Shame in Medical Education: A Randomized Study of the Acquisition of Intimate Examination Skills and Its Effect on Subsequent Performance.

THEORY: Although medical students are exposed to a variety of emotions, the impact of emotions on learning has received little attention so far. Shame-provoking intimate examinations are among the most memorable events for students. Their emotions, however, are rarely addressed during training, potentially leading to withdrawal and avoidance and, consequently, performance deficits. However, emotions of negative valance such as shame may be particularly valuable for learning, as they might prompt mental rehearsal. We investigated the effect of shame on learning from the perspective of cognitive load theory. HYPOTHESES: We hypothesized that (a) training modality determines state shame, (b) state shame directly affects the quality of a clinical breast examination as one example of a shame-provoking exam, and (c) students who experience shame during training outperform those who just discuss the emotion during subsequent performance assessments. METHOD: Forty-nine advanced medical students participated in a randomized controlled, single-blinded study. After a basic, low-fidelity breast examination training, students were randomized to further practice either on a high-fidelity mannequin including a discussion of their emotions or by examining a standardized patient's real breasts. Last, all students conducted a breast examination in a simulated doctor's office. Dependent variables were measures of outcome and process quality and of situational shame. RESULTS: Students training with a standardized patient experienced more shame during training (p < .001, d = 2.19), spent more time with the patient (p = .005, d = 0.89), and documented more breast lumps (p = .026, d = 0.65) than those training on a mannequin. Shame interacted with training modality, F(1, 45) = 21.484, p < .001, η2 = 0.323, and differences in performance positively correlated to decline in state shame (r = .335, p = .022). CONCLUSIONS: Students experiencing state shame during training do reenact their training and process germane load-in other words, learn. Furthermore, altering simulation modality offers a possibility for educators to adjust the affective component of training to their objectives.

A simulated night shift in the emergency room increases students' self-efficacy independent of role taking over during simulation.

BACKGROUND: Junior doctors do not feel well prepared when they start into postgraduate training. High self-efficacy however is linked to better clinical performance and may thus improve patient care. What factors affect self-efficacy is currently unknown. We conducted a simulated night shift in an emergency room (ER) with final-year medical students to identify factors contributing to their self-efficacy and thus inform simulation training in the ER. METHODS: We simulated a night in the ER using best educational practice including multi-source feedback, simulated patients and vicarious learning with 30 participants. Students underwent 7 prototypic cases in groups of 5 in different roles (leader, member and observer). Feeling of preparedness was measured at baseline and 5 days after the event. After every case students recorded their confidence dependent of their role during simulation and evaluated the case. RESULTS: Thirty students participated, 18 (60 %) completed all surveys. At baseline students feel unconfident (Mean -0.34). Feeling of preparedness increases significantly at follow up (Mean 0.66, p = 0.001, d = 1.86). Confidence after simulation is independent of the role during simulation (F(2,52) = 0.123, p = 0.884). Observers in a simulation can estimate leader's confidence independent of their own (r = 0.188, p = 0.32) while team members cannot (r = 0.61, p < 0.001). CONCLUSIONS: Simulation improves self-efficacy. The improvement of self-efficacy is independent of the role taken during simulation. As a consequence, groups can include observers as participants without impairing their increase in self-efficacy, providing a convenient way for educators to increase simulation efficiency. Different roles can furthermore be included into multi-source peer-feedback.

The practial use of the consensus statement on practical skills in medical school--a validation study.

OBJECTIVE: The importance of the acquisition of practical medical skills during medical school is increasing. With the consensus statement "Practical Skills," developed by the GMA as part of the National Competency-Based Learning Objective Catalogue for Medicine (NKLM), a reference frame was created for the procurement of such skills. This frame consists of 290 learning objectives divided by "organ system," type (core or elective learning objective), current stage of medical education and level of instruction. By comparing a large and well evaluated range of student tutorials with the consensus statement, one can analyze the practical benefit of the statement, as well as evaluate the tutorial program for completeness. METHODS: In the first stage, four evaluators in two groups independently classified all consensus statement's learning objectives by each of the 48 tutorials currently offered. The inter-rater reliability among the evaluators of each group was calculated both collectively, and according to each organ system. In the second stage, disagreements in the classification were resolved through discussion and consensus decision-making. The coverage of the learning objectives by the tutorials, in the required level of instruction, was then analyzed separately by learning objective type and organ system. Reasons for any initial dissent were recorded and grouped thematically. RESULTS: The correlation between the classifications of the two evaluators was moderately significant. The strength of this correlation, and thus the precision of individual learning goals wording, varied according to organ system. After a consensus was reached, the results show that the offered tutorials covered 66% of all learning objectives, as well as 74% of the core objectives. The degree of coverage differed according to organ system and stage of medical education. CONCLUSION: The consensus statement is suitable to systematically analyze and develop teaching units. The comparison with established curricula also offers possibilities for further development of the consensus statement, and therefore also of the NKLM.