Cultural Considerations for Patient and Community Education in Global Health: A Qualitative Study in Lesotho.

Background: In global health, international nongovernmental organizations (NGOs) frequently hire, train, and partner with host-country clinicians who manage public outreach and patient care. Purpose and Research Design: We conducted a general interpretivist study of Basotho clinicians hired by NGOs and academic affiliates in Lesotho to identify cultural barriers and facilitators to community and patient education. Data Collection and Analysis: We conducted 13 interviews involving 16 participants (one physician, one nutritionist, 14 nurses). Using an inductive and iterative approach, we analyzed interview transcripts through the lens of social cognitive theory and identified 15 themes. Results: Major findings highlighted: 1) patient and community learners may view Basotho clinicians as authority figures; 2) family and community power dynamics affect healthcare access for vulnerable patient groups; and 3) village leaders may refuse community education when excluded from problem-solving and early planning. Conclusions: Although local clinicians and community members may identify with the same cultural group, clinicians can encounter cultural barriers to patient and community education.

Prioritization and Resource Allocation in Academic Global Health Partnerships.

OBJECTIVE: US-based academic institutions involved in global health (GH) partnerships can have a positive impact on health care systems in low/middle-income countries but lack a consistent approach. Existing priority setting and resource allocation (PSRA) frameworks do not adequately capture the interpersonal and sociopolitical complexity of decision-making in GH work. The authors explored how US-based GH practitioners prioritize and allocate resources for different types of support in academic GH partnerships. METHOD: In 2020 to 2021, the authors invited 36 US-based GH practitioners from the 2015 Pediatric GH Leadership Conference to participate in individual 1-hour semi-structured interviews. Using an iterative and inductive grounded theory approach, the study team analyzed interview transcripts through the lens of Heyse's framework on decision-making in humanitarian aid. RESULTS: The authors interviewed 20 GH practitioners and reached thematic sufficiency. A descriptive conceptual framework, capturing 18 distinct themes in 4 major categories, emerged from the data. In this framework, categories included: 1) stakeholders: those who influence and are influenced by the partnership; 2) goals: vision, mission, aims, and scope of the partnership; 3) implementation strategy: approach to accomplishing goals, categorized as relationship-oriented, task-oriented, context-oriented, or nonprescriptive; and 4) approach to conflict: response when goals and strategies do not align among stakeholders. CONCLUSION: Themes revealed a dynamic process for PSRA. Using our study findings, and building on existing literature, our framework highlights the complex interpersonal relationships, resource limitations, and sociopolitical and economic constraints that affect PSRA in GH partnerships. Finally, themes point to the field's evolution toward a more decolonized approach to GH.

Cultural considerations in health care capacity building: A qualitative study in Lesotho.

International non-governmental organisations (NGOs) and academic institutions support health care capacity building to strengthen health systems in low and middle-income countries. We conducted a phenomenological study of foreign and Basotho clinicians who participated in clinical continuing professional development (CPD) in Lesotho. Clinicians included physicians, nurses, and a nutritionist. We sought to understand, through the lens of social cognitive theory, how cultural differences between foreign and Basotho clinicians affected bidirectional clinical education led by NGOs and academic institutions. We also assessed how Basotho clinical educators considered culture when leading NGO-sponsored clinical CPD for Basotho clinicians. After analysing 17 interviews with 24 total participants (four foreign educators, 11 Basotho educators, and nine Basotho learners), using an iterative and inductive approach, we identified 17 themes within the cognitive, environmental, and behavioural domains. Key findings highlighted: (1) cultural tensions between foreign and Basotho culture, including bias against traditional culture; (2) power structures which affected the efficacy of in-service training strategies; (3) perceptions among foreign educators that technical assistance was more effective than direct service delivery at promoting education and sustainability. Educators should map out key relationships and engage local and foreign stakeholders in culturally-focused targeted needs assessments to improve curricular design in capacity building.

Medical student perspectives on conducting patient experience debrief interviews with hospitalized children and their families.

PURPOSE: To explore how medical students completing a pediatric clerkship viewed the benefits and barriers of debrief interviews with hospitalized patients and families. METHODS: In this study, focus groups were conducted with pediatric clerkship students after completion of a debrief interview. The constant comparative method was used with Mezirow's transformative learning theory as a lens to explore perceptions of the benefits and challenges of performing the interview. RESULTS: Focus groups revealed five benefits and two challenges. The benefits were that the debrief interviews helped students (1) humanize patients and appreciate social and environmental influences on patient health, (2) assess caregiver/patient understanding about care to correct misunderstandings, (3) actively involve caregivers/patients in treatment plan development, (4) engage patients in active expression of questions/concerns, and (5) recognize the value of their own role on the healthcare team. The challenges were that students felt (1) a lack of knowledge to answer caregivers'/patients' questions about diagnoses and (2) discomfort responding to caregiver/patient frustration, anxiety, or sadness. Student feedback on feasibility and implementation led to guidelines for selecting patients and conducting small group discussions after the debrief interviews. CONCLUSIONS: Debrief interviews offer a unique approach for learners to explore patient perspectives during hospitalization through direct patient engagement and dialogue, contributing to professional development, empathy, and potentially more positive patient care experiences.

Pediatric Hospitalists' Performance and Perceptions of Script Concordance Testing for Self-Assessment.

OBJECTIVES: The cognitive expertise of Pediatric Hospitalists (PH) lies not in standard knowledge but in making decisions under conditions of uncertainty. To maintain expertise, PH should engage in deliberate practice via self-assessments that promote higher-level cognitive processes necessary to address problems with missing or ambiguous information. Higher levels of cognition are purported with Script Concordance Test (SCT) questions compared to Multiple Choice Questions (MCQ). To determine if PH use higher levels of cognition when answering SCT versus MCQ questions and to analyze participants' perceptions of the utility of using SCT self-assessment for deliberate practice in addressing clinical problems encountered in daily practice. METHODS: This is a mixed methods study comparing the cognitive level expressed according to Bloom's Taxonomy by PH answering MCQ versus SCT questions using a "think aloud" (TA) exercise, followed by qualitative analysis of interviews conducted afterward. RESULTS: A significantly greater percentage of comments were coded as higher cognitive processes (apply, analyze, evaluate, and create) for SCT versus MCQ (74% vs 19%) compared with lower order (remember, understand); chi-square P < .00001. Analysis of interviews revealed 6 themes. CONCLUSION: SCT questions elicited higher level cognition essential to clinical reasoning compared to MCQ questions. PH-indicated MCQ questions measure standard knowledge, while SCT questions better measure decision-making under conditions of uncertainty. PH-perceived SCT could be useful for deliberate practice in Pediatric Hospital Medicine decision-making if they could compare their rationale in answering questions with that of experts.

The Patient Experience Debrief Interview: How Conversations With Hospitalized Families Influence Medical Student Learning and Reflection.

PURPOSE: To determine the effect of patient debrief interviews on pediatric clerkship student depth of reflection and learning. METHOD: The authors conducted a multi-institutional, mixed-methods, cluster randomized trial among pediatric clerkship students from May 2016 to February 2017. Intervention students completed a debrief interview with a patient-caregiver, followed by a written reflection on the experience. Control students completed a written reflection on a memorable patient encounter. Three blinded authors scored written reflections according to the 4-level REFLECT rubric to determine depth of reflection. Interrater reliability was examined using kappa. REFLECT scores were analyzed using a chi-square test; essays were analyzed using content analysis. RESULTS: Eighty percent of eligible students participated. One hundred eighty-nine essays (89 control, 100 intervention) were scored. Thirty-seven percent of the control group attained reflection and critical reflection, the 2 highest levels of reflection, compared with 71% of the intervention group; 2% of the control group attained critical reflection, the highest level, compared with 31% of the intervention group (χ(3, N = 189) = 33.9, P < .001). Seven themes were seen across both groups, 3 focused on physician practice and 4 focused on patients. Patient-centered themes were more common in the intervention group, whereas physician-focused themes were more common in the control group. CONCLUSIONS: Patient debrief interviews offer a unique approach to deepen self-reflection through direct dialogue and exploration of patient-caregiver experiences during hospitalization.

Promoting Shared Decision-Making Behaviors During Inpatient Rounds: A Multimodal Educational Intervention.

PURPOSE: To estimate the effectiveness of a multimodal educational intervention to increase use of shared decision-making (SDM) behaviors by inpatient pediatric and internal medicine hospitalists and trainees at teaching hospitals at Stanford University and the University of California, San Francisco. METHOD: The 8-week Patient Engagement Project Study intervention, delivered at four services between November 2014 and January 2015, included workshops, campaign messaging, report cards, and coaching. For 12-week pre- and postintervention periods, clinician peers used the nine-point Rochester Participatory Decision-Making Scale (RPAD) to evaluate rounding teams' SDM behaviors with patients during ward rounds. Eligible teams included a hospitalist and at least one trainee (resident, intern, medical student), in addition to nonphysicians. Random-effects models were used to estimate intervention effects based on RPAD scores that sum points on nine SDM behaviors per patient encounter. RESULTS: In total, 527 patient encounters were scored during 175 rounds led by 49 hospitalists. Patient and team characteristics were similar across pre- and postintervention periods. Improvement was observed on all nine SDM behaviors. Adjusted for the hierarchical study design and covariates, the mean RPAD score improvement was 1.68 points (95% CI, 1.33-2.03; P < .001; Cohen d = 0.82), with intervention effects ranging from 0.7 to 2.5 points per service. Improvements were associated with longer patient encounters and a higher percentage of trainees per team. CONCLUSIONS: The intervention increased behaviors supporting SDM during ward rounds on four independent services. The findings recommend use of clinician-focused interventions to promote SDM adoption in the inpatient setting.

Shared Decision-Making During Inpatient Rounds: Opportunities for Improvement in Patient Engagement and Communication.

BACKGROUND: Shared decision-making (SDM) improves patient engagement and may improve outpatient health outcomes. Little is known about inpatient SDM. OBJECTIVE: To assess overall quality, provider behaviors, and contextual predictors of SDM during inpatient rounds on medicine and pediatrics hospitalist services. DESIGN: A 12-week, cross-sectional, single-blinded observational study of team SDM behaviors during rounds, followed by semistructured patient interviews. SETTING: Two large quaternary care academic medical centers. PARTICIPANTS: Thirty-five inpatient teams (18 medicine, 17 pediatrics) and 254 unique patient encounters (117 medicine, 137 pediatrics). INTERVENTION: Observational study. MEASUREMENTS: We used a 9-item Rochester Participatory Decision-Making Scale (RPAD) measured team-level SDM behaviors. Same-day interviews using a modified RPAD assessed patient perceptions of SDM. RESULTS: Characteristics associated with increased SDM in the multivariate analysis included the following: service, patient gender, timing of rounds during patient's hospital stay, and amount of time rounding per patient (P < .05). The most frequently observed behaviors across all services included explaining the clinical issue and matching medical language to the patient's level of understanding. The least frequently observed behaviors included checking understanding of the patient's point of view, examining barriers to follow-through, and asking if the patient has any questions. Patients and guardians had substantially higher ratings for SDM quality compared to peer observers (7.2 vs 4.4 out of 9). CONCLUSIONS: Important opportunities exist to improve inpatient SDM. Team size, number of learners, patient census, and type of decision being made did not affect SDM, suggesting that even large, busy services can perform SDM if properly trained.

Innovation to Dissemination Workshop: Selecting Outcome Measures to Translate Educational Innovations Into Scholarship.

Introduction: Curricular innovations are invaluable to the improvement of medical education programs, and thus, their dissemination to broader audiences is imperative. However, medical educators often struggle to translate innovative ideas into scholarly pursuits due to a lack of experience or expertise in selecting outcome measures that demonstrate impact. A recent national call for increased focus on outcome measures for medical education research highlights the need for more training in this area. Methods: We developed a 2-hour interactive workshop to improve educator ability to identify outcome measures for educational innovations. This workshop was delivered at a national pediatrics educational conference and at three local institutional faculty development sessions. Results: Participants were diverse in terms of experience, expertise, and roles within their educational programs. Participants rated the workshop positively in each setting and identified next steps in developing their own products of educational scholarship. Discussion: This workshop can provide faculty and faculty developers with a template for developing a skill set in identifying outcome measures and pairing them with educational innovations.

Patient Feedback Requirements for Medical Students: Do Perceived Risks Outweigh the Benefits?

Patient feedback has increasingly become part of medical students' training and formative assessment. We conducted a qualitative study using focus groups to explore students' experiences soliciting patient feedback, including the benefits, challenges, and potential strategies to obtain it. Fifteen medical students participated. Thematic analysis revealed students' (1) discomfort soliciting feedback and concern of being viewed as self-serving; (2) concerns about eroding patient trust; (3) indifference to nonspecific, positive feedback; and (4) belief that informally solicited feedback is most helpful for their learning. Strategies for soliciting more useful patient feedback included (1) team-based solicitation, (2) empowering patients as teachers, and (3) development of feedback instruments that allow patients to comment on specific student-identified learning goals. Solicitation of patient feedback is challenging for medical students and provokes discomfort. Strategies to integrate patient feedback into medical student training and assessment must attend to students' needs so the value of patient feedback can be realized.

The SDM 3 Circle Model: A Literature Synthesis and Adaptation for Shared Decision Making in the Hospital.

Patient engagement through shared decision-making (SDM) is increasingly seen as a key component for patient safety, patient satisfaction, and quality of care. Current SDM models do not adequately account for medical and environmental contexts, which may influence medical decisions in the hospital. We identified leading SDM models and reviews to inductively construct a novel SDM model appropriate for the inpatient setting. A team of medicine and pediatric hospitalists reviewed the literature to integrate core SDM concepts and processes and iteratively constructed a synthesized draft model. We then solicited broad SDM expert feedback on the draft model for validation and further refinement. The SDM 3 Circle Model identifies 3 core categories of variables that dynamically interact within an "environmental frame." The resulting Venn diagram includes overlapping circles for (1) patient/family, (2) provider/team, and (3) medical context. The environmental frame includes all external, contextual factors that may influence any of the 3 circles. Existing multistep SDM process models were then rearticulated and contextualized to illustrate how a shared decision might be made. The SDM 3 Circle Model accounts for important environmental and contextual characteristics that vary across settings. The visual emphasis generated by each "circle" and by the environmental frame direct attention to often overlooked interactive forces and has the potential to more precisely define, promote, and improve SDM. This model provides a framework to develop interventions to improve quality and patient safety through SDM and patient engagement for hospitalists.