Exploring medical students' experiences with indigenous patient care: a phenomenological study.

BACKGROUND: Indigenous Peoples in Canada bear a disproportionate burden of disease and experience poorer health outcomes as compared to non-Indigenous populations within Canada; these conditions are said to be mediated and exacerbated by pervasive and uninterrupted anti-Indigenous racism. Third and fourth-year medical students at a Canadian medical school were asked to reflect on their experiences working with Indigenous patients in clinical settings, and how their preclinical Indigenous health curriculum impacted these experiences. METHOD: Phenomenology was used, guided by Goffman's theory of social stigma. Eleven undergraduate medical students were recruited using purposeful sampling. Semi-structured phone interviews were conducted to gain an in-depth understanding of the participants' experiences. Interviews were recorded and transcribed verbatim. Data were analyzed using the four main processes for phenomenological analysis. RESULTS: Four main themes emerged from students' descriptions of clinical experiences involving Indigenous patients: 1) students describe how their Indigenous patients encounter the health care system and their own lack of cultural sensitivity in this context; 2) racism was evident in students' clinical interactions with Indigenous patients, but students do not always perceive these biases nor the impact of this on patient care; 3) identifying the impact of racism on care is complicated by situational clinical encounters; and 4) practicality of preclinical Indigenous health education is desired by students to prepare them for working with Indigenous patients in the clinical setting. CONCLUSIONS: In their clinical experiences, students witness racism against Indigenous peoples yet are unprepared to stand up against it. Findings highlight the importance of enhancing undergraduate medical training to allow students to better understand the unique experiences and perspectives of Indigenous patients. The results support the need for ongoing Indigenous health education, to foster culturally sensitive experiences while learning about Indigenous patients.

Give me a break! Addressing observed structured clinical exam anxiety.

What was the educational challenge? Medical students experience high rates of anxiety; frequent examinations are one contributing source. Students may perceive the observed structured clinical examinations (OSCEs) as particularly stressful. Strategies to reduce anxiety during OSCEs have not been described.What was the solution? We sought to implement and evaluate a simple, in-the-moment intervention aimed at reducing students' OSCE-related anxiety by making stress-reducing activities available during break stations during a summative pediatric OSCE.How was the solution implemented? Three break stations were included in an end-of-rotation, summative OSCE. Students were block-randomized to either control group with standard break stations, or intervention group with stress-reducing activities available in the break room. All participants completed the State-Trait Anxiety Inventory (STAI) before and after the OSCE, and a short questionnaire after OSCE completion.What lessons were learned that are relevant to a wider global audience? Third-year medical students have high levels of stress before and after OSCEs. More than half of students in the intervention group felt their anxiety improved with activities. While the inclusion of stress-reducing activities in break stations did not impact exam performance, some students subjectively felt their performance improved. If OSCE break stations are logistically required, they can be employed to allow students to briefly relax during a high-stress exam without negatively impacting performance.What are the next steps? Next steps include exploration of opportunities for integration of stress-reducing activities during OSCEs with other learner groups, and identification of other stress-inducing aspects of medical training to provide similar opportunities.

Disseminating evidence in medical education: journal club as a virtual community of practice.

BACKGROUND: This study explores the impacts of the Council on Medical Student Education in Pediatrics (COMSEP) Journal Club, a unique means of providing monthly professional development for a large international community of pediatric undergraduate medical educators. In particular, we sought to establish member engagement with the Journal Club, identify factors impacting member contributions to the Journal Club, and determine perceived benefits of and barriers to participation as a Journal Club reviewer. METHODS: Using an established Annual Survey as a study instrument, six survey questions were distributed to members of COMSEP. Items were pilot tested prior to inclusion. Quantitative data were analyzed using descriptive statistics and chi-square analysis.. RESULTS: Of 125 respondents who completed the survey, 38% reported reading the Journal Club most months or always. Level of engagement varied. Reasons for reading included a topic of interest, keeping up to date on medical education literature, gaining practical tips for teaching and implementing new curricula. Motivators for writing a review included keeping up to date, contributing to a professional organization, and developing skill in analyzing medical education literature, with a minority citing reasons of enhancing their educational portfolio or academic promotion. The most commonly cited barriers were lack of time and lack of confidence or training in ability to analyze medical education literature. CONCLUSION: As a strategy to disseminate the latest evidence in medical education to its membership, the COMSEP Journal Club is effective. Its format is ideally suited for busy educators and may help in members' professional development and in the development of a community of practice.

A Team-based Learning Approach During Pediatric Clerkship to Promote Clinical Reasoning.

BACKGROUND: Clinical reasoning skills are essential to medical practice. The problem lies in assuming junior medical students with limited experience develop clinical reasoning and decision-making skills passively and solely through clinical exposure. To prepare learners for independent practice and care for future patients, explicit teaching and assessment of clinical reasoning in low-stakes, collaborative learning environments are needed. METHODS: The key-feature question (KFQs) format is an assessment approach that focuses on the reasoning and decision-making aspects of medical problems rather than knowledge recall. This report describes the development, implementation, and evaluation of a team-based learning (TBL) approach using KFQs to foster clinical reasoning in the third-year pediatric clerkship at our institution. RESULTS: Over the first 2 years of implementation (2017-18, 2018-19), 278 students participated in TBL sessions. Mean individual student scores significantly improved in the group setting for both academic years (P < .001). Individual scores were moderately positively correlated with their total summative Objective Structured Clinical Examination score (r[275] = 0.51; P < .001). The correlation between individual score and their multiple-choice question examination was weaker at 0.29 (P < .001) but remained positive. CONCLUSIONS: A TBL session using KFQs to both teach and assess clinical reasoning in clerkship students may help educators identify students with gaps in knowledge and/or reasoning. The next steps include developing and implementing individualized coaching opportunities, and expanding this approach within the undergraduate medical curriculum. Outcome measures to assess clinical reasoning in authentic patient encounters require further research and development.

Embracing uncertainty: medical student perceptions of a pediatric bootcamp developed in response to mandated changes during the pandemic.

BACKGROUND: The start of the COVID-19 pandemic led to both shortened clinical rotations and consequent loss of embedded formal teaching time. In response to these learning gaps, a novel, virtual pediatric bootcamp was developed to provide a consolidated 3-week learning opportunity for clinical medical students. Pre-clinical students were encouraged but not required to participate, given the suspension of clinical patient experiences for all undergraduate medical learners and the uncertainty of when clinical rotations would resume. This group of students were particularly challenged with adapting their learning in response to the pandemic while also preparing to apply their pre-clinical knowledge to solve clinical problems. METHODS: A qualitative thematic analysis was used for this study. Ten semi-structured phone interviews were conducted with second-year medical students to explore their experiences and perceptions of the pediatric bootcamp. The six phases of thematic analysis proposed by Braun and Clark guided data analysis. To ensure rigour, the three aspects of rigour-credibility, transferability and confirmability were utilized throughout the project. RESULTS: Qualitative exploration from semi-structured phone interviews of second-year medical students' perceptions and experiences of this new and unanticipated learning experience revealed four main themes: (a) clinical relevance, describing how students were pushed to think about clinical problems in a new way; (b) timing, which explored conflicts related to competing interests, mental preparedness, and the interval between learning and application; (c) teaching strategies, describing how active learning and interaction were facilitated and challenges that arose; and (d) learning resources, highlighting the curated and accessible resources made available to the students, as well as those resources that learners develop for themselves. CONCLUSIONS: A novel three-week online case-based pediatric bootcamp fostered application of knowledge for clinical reasoning at a time when students were transitioning from preclinical to clinical learning. Students were stretched to balance competing priorities, and the bootcamp curated synchronous and asynchronous learner opportunities while allowing them to reflect on their own learning styles and effective virtual learning strategies. While bootcamps are often used to prepare learners for transitions between clinical stages, our findings suggest the bootcamp format can also facilitate transition from preclinical to clinical roles.

From vision to implementation: Building a national undergraduate paediatric curriculum.

Objective: There are many challenges in ensuring medical students learn paediatrics. Medical educators must develop and maintain curricula that meet learners' needs and accreditation requirements. Paediatricians and family physicians, practicing and teaching in busy clinical environments, require Canadian-relevant curricular guidance and resources to teach and assess learners. Students struggle with curricular cohesion, clear expectations, and resources. Recognizing these challenges and acknowledging the need to address them, the Paediatric Undergraduate Program Directors of Canada (PUPDOC) created canuc-paeds, a comprehensive competency-based undergraduate curriculum that teachers and students would actually use. Methods: Curriculum development included the following: utilization of best practices in curriculum development, an environmental scan, development of guiding principles, Delphi surveys, in-person meetings, and quality improvement. All Canadian paediatric undergraduate educator leaders and other stakeholders were invited to participate. Results: The curriculum, based on the RCPSC CanMEDS Framework, includes 29 clinical presentations, each with key conditions, foundational knowledge objectives, and learning resources. Essential paediatric-specific physical examination and procedural skills that graduating medical students are expected to perform are identified. Objectives specific to Intrinsic Roles of Collaborator, Communicator, Professional, Leader, Health Advocate and Scholar that can be assessed in the field of paediatrics at the undergraduate level are articulated. The national curriculum has been implemented widely at Canadian medical schools. Online, open-access clinical resources have been developed and are being used world-wide. Conclusion: This curriculum provides overarching Canadian-specific curricular guidance and resources for students and for the paediatricians and family physicians who are responsible for teaching and assessing undergraduate learners.

Physician experiences implementing antimicrobial stewardship rounds in pediatric hospital medicine: An exploratory, qualitative study.

Objectives: An antimicrobial stewardship intervention was implemented for pediatric medicine units using an in-person rounds-based approach to provide stewardship recommendations and education from an antimicrobial stewardship physician and antimicrobial stewardship pharmacist. Design Setting Participants and Methods: In this exploratory qualitative study, purposeful sampling was used to recruit participants for individual interviews at a tertiary- and quaternary-care referral center. Pediatricians and residents who attended ≥1 stewardship round were included. A semistructured interview guide was created focusing on perceptions of antimicrobial stewardship, personal experiences at stewardship rounds, and perceived impacts on patient care. Using a constant comparative analysis approach, codes were developed and collapsed into themes. Results: Overall, 8 pediatricians and 10 residents completed interviews. Qualitative analysis yielded 3 themes: insights into clinical reasoning, opportunity for growth and learning, and establishing and exploring professional relationships. The handshake-rounds approach encouraged participants to critically evaluate antimicrobial choices and to engage in discussion with the antimicrobial stewardship team. Participants felt validated at stewardship rounds and gained confidence prescribing antimicrobials. Face-to-face interaction reduced reluctance for some participants to consult infectious disease (ID) service; however, others worried that physicians may avoid ID consultation because of stewardship rounds. Conclusions: Participants found stewardship rounds to be an effective strategy for education and development of clinical reasoning skills for optimal antimicrobial prescribing-choosing wisely or choosing rightly. The effects of stewardship rounds on timing and frequency of ID consultation are interesting. Further research into important patient outcomes and consultation practices are needed locally, but our experiences may help others to reflect on the power of conversation and relationships in antimicrobial stewardship.

The paediatrician as a leader: A resident educational intervention for high-value care.

The American College of Physicians defines high-value care (HVC) as health care that balances clinical benefit with costs and harms with the goal of improving patient outcomes. We present a novel 2-hour workshop developed for general paediatric residents designed to promote reflective practice on resource stewardship and raise awareness of costs of medical care in hospitalized children. The workshop impact was assessed quantitatively and qualitatively. Preworkshop, 2-week postworkshop, and 6-month postworkshop electronic surveys were completed by 18 of 43 workshop participants (42% survey participation rate, 100% follow-up in postworkshop surveys) revealing increased knowledge and retention. Thematic analysis performed on 'lessons learned' and 'action plans' provided by participants at the end of the workshop yielded rich data with key findings from learners that included critical thinking about their management and reflecting on nonmonetary costs. Future directions include faculty development and assessment of impact on patient care.

How Educators Conceptualize and Teach Reflective Practice: A Survey of North American Pediatric Medical Educators.

OBJECTIVE: The objectives of this study were to explore pediatric undergraduate medical educators' understanding of reflective practice, the barriers they face in teaching this, the curricular activities they use, and the value they assign to reflective practice. METHODS: Nine survey questions were sent to members of the Council on Medical Student Education in Pediatrics, an international pediatric undergraduate medical educator group. Quantitative data were analyzed using descriptive statistics. Open-ended responses were analyzed qualitatively through an iterative process to establish themes representing understanding of reflective practice and barriers in teaching this. RESULTS: Respondents representing 56% of all North American schools answered at least 1 survey question. Qualitative analysis of understanding of reflection revealed 11 themes spanning all components of reflective practice, albeit with a narrow view on triggers for reflection and a lower emphasis on understanding the why of things and on perspective-taking. The most frequent barriers in teaching this were the lack of skilled educators and limited time. Most respondents valued reflective skills but few reported confidence in their ability to teach reflection. Several curricular activities were used to teach reflection, the most common being narrative writing. CONCLUSIONS: Pediatric undergraduate medical educators value reflection and endorse its teaching. However, many do not have a complete understanding of the construct and few report confidence in teaching this. Implementing longitudinal curricula in reflective practice may require a culture change; opportunities exist for faculty development about the meaning and value of reflective practice and how best to teach this.

Family bedside orientations: An innovative peer support model to enhance a culture of family-centred care at the Stollery Children's Hospital.

This paper presents family bedside orientations, an innovative bedside peer support model for families of paediatric patients piloted in one unit at the Stollery Children's Hospital in Edmonton, Alberta. The model invites family members of former patients back to the hospital as volunteer peer mentors responsible for meeting one-on-one with current inpatient families to provide a listening presence, discuss patient safety practices and encourage families to participate in their child's care. Using qualitative and quantitative data collection methods, the model was evaluated over 1 year (December 2014 to December 2015). Data sources included peer mentor field notes (from 163 visits) detailing the number of family bedside orientations completed by peer mentors and how they interacted with families, as well as post-visit family (n=35) surveys, Hospital-Child Inpatient Experience Survey data, peer mentor (n=6) questionnaires, focus groups with unit staff (n=10) and interviews with members of the project leadership team (n=5). Our findings indicated that family bedside orientations became an established practice in the pilot unit and positively impacted family care experiences. We attribute these successes to championing and support from unit staff and our multidisciplinary project leadership team. We discuss how our team addressed family privacy and confidentiality while introducing peer mentors in the unit. We also highlight strategies used to integrate peer mentors as part of the staff team and enhance peer support culture in the pilot unit. Practical considerations for implementing this model in other paediatric environments are provided.