Strategies for enhancing medical student resilience: student and faculty member perspectives.

OBJECTIVES: To improve programs aimed to enhance medical student resiliency, we examined both medical student and faculty advisor perspectives on resiliency-building in an Asian medical school. METHODS: In two separate focus groups, a convenience sample of 8 MD-PhD students and 8 faculty advisors were asked to identify strategies for enhancing resilience. Using thematic analysis, two researchers independently examined discussion transcripts and field notes and determined themes through a consensus process. They then compared the themes to discern similarities and differences between these groups. RESULTS: Themes from the student suggestions for increasing resilience included "Perspective changes with time and experience", "Defining effective advisors," and "Individual paths to resiliency". Faculty-identified themes were "Structured activities to change student perspectives," "Structured teaching of coping strategies", and "Institution-wide social support". Students described themselves as individuals building their own resilience path and preferred advisors who were not also evaluators. Faculty, however, suggested systematic, structural ways to increase resilience. CONCLUSIONS: Students and advisors identified some common, and many distinct strategies for enhancing medical student resilience. Student/advisor discrepancies may exemplify a cultural shift in Singapore's medical education climate, where students value increased individualism and autonomy in their education. As medical schools create interventions to enhance resilience and combat potential student burnout, they should consider individually-tailored as well as system-wide programs to best meet the needs of their students and faculty.

Experiences with a clinical reasoning and evidence-based medicine course.

BACKGROUND: Although clinical reasoning (CR) and evidence-based medicine (EBM) are taught in some medical schools, the curricular details and students' clinical use of these skills are unknown. A detailed description of, and student experiences with, a practical CR and EBM curriculum delivering recommended content and pedagogy in an emerging academic environment may be broadly informative. PURPOSE: To describe and characterise student experiences with a CR and EBM curriculum at a newly formed Academic Medical Centre (AMC). METHODS: Applying expert recommended content and pedagogy, we developed a CR and EBM curriculum for final-year medical students delivered by existing clinical faculty members. We evaluated the course content by delineating the CR elements and EBM steps taught, and characterised student CR and EBM classroom and clinical experiences using a self-reported survey (1, strongly disagree; 5, strongly agree). RESULTS: Clinical faculty members, presenting real cases using active learning techniques, delivered all six recommended CR elements and three EBM steps throughout the course. Thirty-nine (89%) students completed a survey and agreed that the course added value to their clinical practice (3.90). Students agreed that they practised CR in the classroom (3.93) and in the clinical setting (3.78) similarly (p = 0.21). Their agreement differed for EBM practice (classroom 3.78, clinical 3.35; p = 0.002). Exploring factors that inhibit the application of EBM in a clinical setting [is] important CONCLUSIONS: Our curriculum addressed recommended CR and EBM elements, used clinical faculty members efficiently and was valued by students. Although our students practised these skills in the classroom and the clinical setting, exploring factors that inhibit the application of EBM in a clinical setting will be important in optimising both student learning and patient care.

Factors associated with medical student clinical reasoning and evidence based medicine practice.

OBJECTIVES: To identify the factors associated with medical students' clinical reasoning (CR) use and evidence-based medicine (EBM) use in the clinical setting. METHODS: Our cross-sectional study surveyed 44 final-year medical students at an emerging academic medical center in Singapore. We queried the students' EBM and CR value and experiences in the classroom and clinical settings. We compared this to their perceptions of supervisors' value and experiences using t-tests. We developed measures of teaching culture and practice culture by combining relevant questions into summary scores. Multivariate linear regression models were applied to identify factors associated with the students' CR and EBM clinical use. RESULTS: Eighty-nine percent of students responded (n=39). Students reported valuing CR (p=0.03) and EBM (p=0.001) more than their supervisors, but practiced these skills similarly (p=0.83; p=0.82). Clinical practice culture and classroom CR experience were independently associated with students' CR clinical use (p=0.05; p=0.04), and classroom EBM experience was independently associated with students' EBM clinical use (p=0.03). Clinical teaching culture was not associated with students' CR and EBM clinical use. CONCLUSIONS: Our study found that medical students' classroom experience and the clinical practice culture influenced their CR and EBM use. The clinical teaching culture did not. These findings suggest that in order to increase student CR and EBM use, in addition to providing classroom experience, medical educators may need to change the hospital culture by encouraging supervisors to use these skills in their clinical practice.

Academic Medicine Education Institute (AM·EI): Transforming the Educational Culture of Health Professionals.

INTRODUCTION: The Academic Medicine Education Institute (AM∙EI), jointly established by Duke-NUS Graduate Medical School (Duke-NUS) and Singapore Healthcare Services (SingHealth), is a newly formed health professions education academy designed to cultivate best education practices and create a community of health professions educators. To achieve the aims of AM∙EI, the needs of SingHealth educators have to be understood. Therefore, this study was carried out to assess educators' perceptions towards the current education climate and their academic needs. MATERIALS AND METHODS: A 28-item questionnaire consisting of free-response, Likert-type and ranking questions was developed. The questionnaire was electronically distributed to 200 medical and nursing educators, and made available to attendees of the 2012 Singhealth Duke-NUS Scientific Congress through hardcopies. RESULTS: A total of 150 completed questionnaires were received (94 from electronic survey and 56 from Congress). Five themes emerged from the analysis of responses to free-response questions: 1) faculty development, 2) development of a community of educators, 3) recognition for educational efforts, 4) institutional support, and 5) better communication about SingHealth educational activities. Respondents were in highest agreement with the statements (rating of 3.7 out of 5): "The SingHealth education programmes are high quality", "New learning or teaching methods are welcomed in this institution/hospital", and "An academic appointment is important to me". The competencies that respondents felt to be the most important were facilitating discussions, presentation skills, and providing feedback (respective means = 5.1, 5, 5 of 7). CONCLUSION: This needs assessment provided us with important insights regarding SingHealth medical educators' perceptions of their education environment and established key priorities for the AM∙EI's programming efforts.

What do medical students learn when they follow patients from hospital to community? A longitudinal qualitative study.

CONTEXT: Although longitudinal community-based care of patients provides opportunities for teaching patient centredness and chronic disease management, there is a paucity of literature assessing learning outcomes of these clerkships. This study examines learning outcomes among students participating in longitudinal community based follow-up of patients discharged from the hospital. METHODS: The authors conducted a thematic analysis of 253 student narratives written by 44 third-year medical students reflecting on their longitudinal interactions with patients with chronic medical illnesses. The narratives were written over three periods: after acute hospital encounter, after a home visit and at the end of the 10-month follow-up. Analysis involved coding of theme content and counting of aggregate themes. RESULTS: The most frequent theme was 'chronic disease management' (25%) followed by 'patient-centred care' (22%), 'health care systems' (20.9%), 'biomedical issues' (19.7%), 'community services' (9.5%) and 'student's role conflict' (2.3%). There was a shift in the relative frequency of the different themes, as students moved from hospital to community with their patients. Biomedical (44.3%) and health systems (18.2%) were the dominant themes following the acute hospitalization encounter. Chronic disease management (35.1%) and patient centredness (31.8%) were the dominant themes after the 10-month longitudinal follow-up. CONCLUSION: Longitudinal community-based interaction with patients resulted in learning about chronic disease management, patient centredness and health care systems over time. Students shifted from learning biomedical knowledge during the acute hospitalization, to focus on better understanding of long-term care and patient centredness, at the end of the module.

An innovative residency program designed to develop leaders to improve the health of children.

Physician-leaders are needed to address the widening gap in health disparities in an increasingly complex health care system. To be effective leaders, physicians need specific training; yet despite its importance, leadership training is rarely addressed during graduate medical education. As a result, most physician leadership training occurs after residency training. To address this gap in medical education, in 2004 the authors developed the Pediatric Leadership for the Underserved (PLUS) program at the University of California, San Francisco. The PLUS program incorporates leadership development into the framework of standard clinical training by providing specific sessions in personal leadership development and in related skills such as team building, negotiation, and conflict management. Leadership training is explicitly tied to clinical experiences to maximize relevance and opportunities for "real-time" application of new skills and knowledge. In addition, the curriculum includes sessions to develop and implement a three-year longitudinal child health project. Trainees are organized into advising groups to provide structured faculty and peer-peer advising. Key lessons learned in the implementation include the importance of having a skill-based, rather than a topic-based curriculum, and of exposing trainees to concrete examples of the many career paths of physician-leaders. Early outcomes from 2004 to 2009 include program evaluation data, trainee accomplishments, and postgraduate careers. This paper aims to inform other training programs about the development and feasibility of a residency program that incorporates leadership and underserved medicine curricula into the framework of standard clinical training.

A global partnership in medical education between Duke University and the National University of Singapore.

Duke University and the National University of Singapore (NUS) have partnered to launch a new medical school that brings the American style of postbaccalaureate medical education to Asia. The new institution, called the Duke-NUS Graduate Medical School (GMS) and located in Singapore adjacent to the Singapore General Hospital, admitted its inaugural class of students representing citizens of seven nations in August 2007. The project represents an investment of more than $350 million from three ministries of the Singapore government, and a commitment on Duke's part to provide senior leadership and recruit faculty from Duke, from other international locales, and from within Singapore itself. Graduating students who complete the four-year Duke curriculum will receive an MD degree awarded jointly by Duke and NUS, thereby distinguishing this school from medical education in most Asian institutions that award an MBBS degree after a five-year period of study that follows directly from secondary school. The emphasis of the Duke-NUS GMS is to prepare physician-scientists for academic careers, with plans for 20% of each class to complete a combined MD/PhD degree. This article describes events leading up to this partnership and details of the relationship, including curriculum, organizational structure, milestones, and goals.

Using the PRACTICE mnemonic to apply cultural competency to genetics in medical education and patient care.

Medical education curricula increasingly are incorporating courses on cultural competency and skills development in working with ethnically diverse patient populations as well as courses on genetics and genomics. The authors support these efforts and believe the next step is integration of genetics into cultural competency programs and similarly, cultural competency into genetics curricula. In this paper, the authors describe the work of the Genetics in Primary Care Faculty Development Working Group on Cultural Competency, a federally-funded initiative to prepare generalist faculty to teach genetics as part of ambulatory education. Over a 12-month period, this team wrote a module on cultural competency and nine new clinical cases, and developed the PRACTICE mnemonic (prevalence, risk, attitude, communication, testing, investigation, consent, empowerment) to help health care professionals integrate cultural competency skills in genetics into primary care. More specifically, the PRACTICE mnemonic integrates information emerging from experts in health disparities and doctor-patient communication to build a comprehensive model for addressing the relevance of culture and ethnicity in the delivery of genetic services. Lastly, this paper illustrates a systematic method of covering key areas of cultural competency through discussion of a patient with a genetic disorder as well as presents an argument as to why cultural competency is highly relevant to the delivery of genetic services especially as part of generalists' clinical practice.

Evening continuity clinic: preserving primary care education in the face of duty hour limitations?

OBJECTIVE: Residency programs with postcall afternoon continuity clinics violate the new Accreditation Council for Graduate Medical Education (ACGME) limitations on resident duty hours. We evaluated housestaff experience with a pilot intervention that replaced postcall continuity clinics with evening continuity clinics. METHODS: We began this pilot program at one continuity clinic site for pediatric residents. Instead of postcall clinics, residents had evening continuity clinic added to a regular clinic day when they were neither postcall nor on call. At 5 and 11 months, we surveyed housestaff satisfaction and experience with the evening clinics, particularly in comparison to postcall clinics. RESULTS: Nineteen of 23 pediatric residents participated in the pilot program. Twenty-two and 17 residents completed the 5- and 11-month follow-up surveys, respectively. A significantly greater proportion of residents rated their overall satisfaction with evening clinic as good/outstanding (16/18, 89%) compared with postcall clinic (2/19, 11%) at the 5-month survey (P<.01). Resident preference for evening clinic over postcall clinic persisted but was not statistically significant at 11 months (P =.05), and overall satisfaction with evening clinic was unchanged from the 5- and 11-month surveys (P =.64). All areas of patient care, medical education, and clinic infrastructure were better or equal in evening clinic in comparison to postcall clinic except for continuity of preceptors and access to medical services. CONCLUSION: Housestaff had greater satisfaction and a better clinic experience with evening clinic versus postcall clinic. Evening continuity clinic is a viable solution to meeting the ACGME work hour limitations while preserving housestaff primary care education.

Residency is not a race: our ten-year experience with a flexible schedule residency training option.

PURPOSE: To evaluate the Flexible Option (FO), a residency training schedule offered by the University of California, San Francisco, Pediatric Residency Program. METHOD: In 2002, structured telephone interviews were conducted with residents who participated in the FO between 1992 and 2002. Twenty-four of the 284 pediatrics residents during this time participated in the FO. Descriptive interview data were analyzed. A Web-based questionnaire was sent to 72 regularly scheduled (RS) residents at the end of 2001-02. FO and RS residents' specialty board performances were compared. RESULTS: Twenty-one FO residents participated in the telephone interviews. The majority reported that the FO was critical to their success as residents. Most requested the FO for personal and family reasons; over 40% would otherwise have requested leaves from the residency. The most common perceived disadvantages were delay in graduation and financial concerns. Forty-two RS residents completed the online questionnaire. Seventeen percent considered the FO an important factor in program selection; 43% had considered participating in the FO. Seventy-nine percent felt that the FO had a positive effect on the general morale of the program. RS residents perceived that the FO increased workload (43%) and created scheduling problems (52%). However, 88% of RS residents encouraged the program to continue offering the FO. Specialty board scores were similar across FO and RS residents. CONCLUSIONS: Participants perceived that the FO's advantages outweighed the disadvantages. There were no concerning academic disadvantages identified in FO participants. Wide-spread support was found throughout the residency program to sustain the FO. More residency programs should consider creating and offering flexible scheduling options.

Evaluating a Residency Program Using Reflections of Recent Resident Graduates and their Pediatric Colleagues.

BACKGROUND AND PURPOSES: In response to the new Accreditation Council for Graduate Medical Education (ACGME) mandate for residency programs to use feedback to improve its educational program, we piloted a novel evaluation strategy of a residency program using structured interviews of resident graduates working in a primary care practice and their physician associates. METHODS: A research assistant performed a structured telephone interview. Quantitative data assessing the graduate's self-assessment and the graduate's clinical practice by the associate were analyzed. In addition, we performed a qualitative analysis of the interviews. RESULTS: Thirteen resident graduates in primary care practice and seven physician practice associates participated in the study. Graduate self-assessment revealed high satisfaction with their residency training and competency. The associates judged our graduates as highly competent and mentioned independent decision-making and strong interpersonal skills (such as teamwork and communication) as important. They specifically cited the graduate's skills in intensive care medicine and adolescent medicine as well as communication and teamwork skills as important contributions to their practice. CONCLUSIONS: The ACGME Outcomes Project, which increases the emphasis on educational outcomes in the accreditation of residency education programs, requires programs to provide evidence of its effectiveness in preparing residents for practice. Direct assessment of the competency of our physician graduates in practice using structured interviews of graduates and their practice associates provide useful feedback information to a residency program as part of a comprehensive evaluation plan of our program's curriculum and can be used to direct future educational initiatives of our training program.