Online Learning in Medical Student Clerkship: A Survey of Student Perceptions and Future Directions.

Background The coronavirus disease 2019 (COVID-19) pandemic had a major impact on medical education with clerkship students abruptly removed from clinical activities in 2020 and hastily immersed in online learning to maintain medical education. In 2022, students returned to in-person clinical experiences, but synchronous learning sessions continued online with extensive use of asynchronous online resources. This change offers a unique opportunity to gather information about students' perspectives regarding the acceptability and effectiveness of online learning strategies. This study aims to explore the clerkship student experience with the integration of online learning and in-person learning into formalized educational sessions in clerkship. Methodology The authors administered an online survey to clerkship students at the Cumming School of Medicine at the University of Calgary, Canada in spring 2022. The survey consisted of primarily Likert-style questions to explore the perceived effectiveness of various online learning strategies. Results are reported as the proportion selecting "quite effective" or "extremely effective." Results A total of 89 students responded to the survey (57.4% of graduating class). For synchronous online learning, case-based learning was perceived as the most effective teaching strategy (61.8%), and audience response systems were the most effective strategy for improving audience engagement (70.1%). For asynchronous online learning, interactive cases (84.9%) and student-developed online study guides (83.6%) were perceived as the most effective. Students held varying perceptions regarding how online learning impacted their well-being. When considering future clerkship curricula, the majority of clerkship students preferred a blend of in-person and online learning. Conclusions This study identified that most clerkship students prefer a hybrid of in-person and online learning and that ideal online learning curricula could include case-based learning, audience response systems, and a variety of asynchronous learning resources. These results can guide curriculum development and design at other medical institutions.

Measuring wellbeing: A scoping review of metrics and studies measuring medical student wellbeing across multiple timepoints.

PURPOSE: Studies have demonstrated poor mental health in medical students. However, there is wide variation in study design and metric use, impairing comparability. The authors aimed to examine the metrics and methods used to measure medical student wellbeing across multiple timepoints and identify where guidance is necessary. METHODS: Five databases were searched between May and June 2021 for studies using survey-based metrics among medical students at multiple timepoints. Screening and data extraction were done independently by two reviewers. Data regarding the manuscript, methodology, and metrics were analyzed. RESULTS: 221 studies were included, with 109 observational and 112 interventional studies. There were limited studies (15.4%) focused on clinical students. Stress management interventions were the most common (40.2%). Few (3.57%) interventional studies followed participants longer than 12 months, and 38.4% had no control group. There were 140 unique metrics measuring 13 constructs. 52.1% of metrics were used only once. CONCLUSIONS: Unique guidance is needed to address gaps in study design as well as unique challenges surrounding medical student wellbeing surveys. Metric use is highly variable and future research is necessary to identify metrics specifically validated in medical student samples that reflect the diversity of today's students.

Recommandations pour des soins préventifs pour promouvoir l'équité en matière de santé.

CONTEXTE: Malgré des investissements importants dans un système de soins de santé public qui comprend des services préventifs, on continue d'observer des disparités évitables en matière de santé au Canada. L'équipe avait pour objectif de formuler des recommandations pour des soins de santé préventifs qui puissent améliorer l'équité en matière de santé par la priorisation des interventions efficaces à l'intention des groupes défavorisés. MÉTHODES: La ligne directrice a été élaborée par un comité composé de spécialistes en soins primaires et de membres de la patientèle, avec la contribution d'un groupe de patientes-et patientspartenaires ayant vécu diverses expériences. Après avoir sélectionné les sujets à prioriser, nous avons recensé les revues systématiques, les essais randomisés et contrôlés récents sur les méthodes de dépistage et d'autres études pertinentes sur l'efficacité du dépistage et de la prise en charge. Nous avons utilisé l'approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation) pour formuler les recommandations et avons suivi le guide AGREE II (Appraisal of Guidelines for Research and Evaluation) pour rédiger le rapport. Il en a été de même avec les principes du Guidelines International Network pour la gestion des intérêts concurrents. Les recommandations ont été passées en revue par un comité externe d'experts en contenu avant d'être distribuées à des intervenants à l'échelle nationale pour approbation. RECOMMANDATIONS: Nous avons formulé 15 recommandations concernant le dépistage et d'autres soins préventifs et 1 recommandation de nature politique visant à améliorer l'accès aux soins primaires. Ainsi, nous recommandons de prioriser une stratégie de communication pour le dépistage du cancer colorectal à partir de l'âge de 45 ans et pour l'évaluation du risque de maladie cardiovasculaire pour lutter contre les iniquités en matière de santé et promouvoir la santé. Les interventions particulières qui devraient être déployées pour lutter contre les iniquités comprennent l'autodépistage du virus du papillome humain (VPH) et du VIH, et le test de libération de l'interféron γ pour l'infection tuberculeuse. Le dépistage de la dépression, de la toxicomanie, de la violence conjugale et de la pauvreté devrait également permettre aux personnes touchées d'accéder plus facilement à des interventions éprouvées. Nous recommandons une prise de contact systématique avec des professionnels de la santé en soins primaires pour les personnes défavorisées. INTERPRÉTATION: Les interventions préventives éprouvées peuvent aider à combattre les iniquités en matière de santé si la priorité est accordée aux personnes défavorisées. Les médecins, les organisations de santé et les gouvernements devraient adopter des mesures fondées sur des données probantes et en faire le suivi s'ils veulent promouvoir l'équité en matière de santé partout au Canada.

Design thinking sprints as a facilitation process to enact change in the residency match process and beyond.

Implication Statement: Enacting change in medical education requires effective facilitation processes. Medical education lags behind other fields in systems innovation and radically disruptive approaches to the challenges we encounter. Design thinking "sprints," widely used in many other settings, serve as an opportunity to fill the gap as a facilitation process during periods requiring extensive and/or rapid change. Though resource-intensive, our experience using design thinking sprints for a situation requiring urgent change management with high-stakes implications for Canadian medical education to demonstrate their utility. A more widespread, adoption can contribute to innovation within all aspects of education including curriculum design, policy development, and educational process renewal. Énoncé des implications de la recherche: La mise en œuvre de changements dans la formation médicale exige un processus de facilitation efficace. Comparée à d'autres disciplines, l'éducation médicale est à la traîne en ce qui concerne l'innovation des systèmes et l'adoption d'approches radicalement transformatrices en réponse aux défis rencontrés. Le sprint de conception creative (design thinking sprints), approche largement utilisée dans de nombreux contextes, pourraient permettre de combler le manque de processus de facilitation lorsque des changements importants ou rapides sont à l'œuvre. Notre expérience de l'utilisation de tels sprints dans une situation nécessitant une gestion urgente de changements à enjeux importants pour l'éducation médicale au Canada démontre son utilité, malgré les ressources considérables qui ont dû être mobilisées. Une adoption plus large de cette approche peut contribuer à l'innovation dans tous les aspects de l'éducation, y compris la conception des programmes d'études, l'élaboration de politiques et le renouvellement des processus éducatifs.

Preventive care recommendations to promote health equity.

BACKGROUND: Avoidable disparities in health outcomes persist in Canada despite substantial investments in a publicly funded health care system that includes preventive services. Our objective was to provide preventive care recommendations that promote health equity by prioritizing effective interventions for people experiencing disadvantages. METHODS: The guideline was developed by a primary care provider-patient panel, with input from a patient-partner panel with diverse lived experiences. After selecting priority topics, we searched for systematic reviews and recent randomized controlled trials of screening and other relevant studies of screening accuracy and management efficacy. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to develop recommendations and followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) reporting guidance. We managed competing interests using the Guideline International Network principles. The recommendations were externally reviewed by content experts and circulated for endorsement by national stakeholders. RECOMMENDATIONS: We developed 15 screening and other preventive care recommendations and 1 policy recommendation on improving access to primary care. We recommend prioritized outreach for colorectal cancer screening starting at age 45 years and for cardiovascular disease risk assessment, to help address inequities and promote health. Specific interventions that should be rolled out in ways that address inequities include human papillomavirus (HPV) self-testing, HIV self-testing and interferon-γ release assays for tuberculosis infection. Screening for depression, substance use, intimate partner violence and poverty should help connect people experiencing specific disadvantages with proven interventions. We recommend automatic connection to primary care for people experiencing disadvantages. INTERPRETATION: Proven preventive care interventions can address health inequities if people experiencing disadvantages are prioritized. Clinicians, health care organizations and governments should take evidence-based actions and track progress in promoting health equity across Canada.

Fostering a Health-Promoting Learning Environment in Medical Education: Adapting the Okanagan Charter for Administrators and Medical Educators.

Medical students enter medical school with similar or even better well-being than their age-matched peers in other educational programs, but there is predictable erosion of their well-being following matriculation. Interventions to counter this erosion predominantly focus on the individual level; however, significant systemic issues persist that thwart meaningful change. Effectively reforming the learning environment and more broadly targeting problematic aspects of the culture of medical education are essential steps to advance efforts to improve medical learner well-being. Although a healthy environment may allow learners to be well in the educational setting, a health-promoting learning environment strives to promote and embed well-being across all aspects of the learner's experience. Health-promoting learning environments operate by infusing health principles into all aspects of operations, practices, mandates, and businesses. The Okanagan Charter is a widely adopted international framework with principles for best practices of adoption. This charter has the recent endorsement of the Association of Faculties of Medicine of Canada, representing all faculties of medicine in Canada, and serves as a framework for reassessing work on well-being in medical education. In response to this endorsement, the authors have adapted the 5 strategies from the charter for pragmatic integration into the medical education environment and added a sixth strategy: (1) embed health in all policies; (2) develop sustainable, supportive spaces; (3) create thriving medical communities and culture; (4) encourage, support, and sustain meaningful personal development; (5) review, develop, and strengthen faculty-level health services; and (6) collaborate and invest in continuous improvement and evaluation. For each of these 6 strategic directions, actionable steps for implementation in academic medicine are provided to create sustainable and meaningful change.

Long-Term Non-invasive Ventilation in Children With Down Syndrome: A Systematic Review.

Context: Children with Down syndrome are at risk for obstructive sleep apnea, which may not be resolved by adenotonsillecotmy, as well as other respiratory disorders that may impact breathing during sleep. Long-term non-invasive ventilation, including continuous and bilevel positive airway pressure delivery, is an alternate treatment strategy. Objective: To assess the use and outcomes of long-term non-invasive ventilation in children with Down syndrome including comparison to other children using long-term non-invasive ventilation. Data Sources: The search strategy for the scoping review used Medical Subject Headings (MeSH) and free-text terms for "child" and "non-invasive ventilation." MEDLINE (Ovid), Embase (Ovid), CINAHL (Ebsco), Cochrane Library (Wiley), and PubMed databases were searched (1990-2021). Study Selection: The scoping review results were searched to identify studies including data on at least three children with Down Syndrome using long-term non-invasive ventilation. Data Extraction: Study characteristics, subject characteristics, technology type, and outcome measurements were extracted. Results: A total of 28 articles included 543 children with Down syndrome using long-term non-invasive ventilation. Children with Down syndrome accounted for 18% of children using long-term non-invasive ventilation. Data on efficacy, feasibility, and adherence in children with Down syndrome are comparable to other children. Children with Down syndrome may have greater difficulty initiating long-term non-invasive ventilation, longer time to establish use, and a higher rate of inability to establish use. Outcome data is limited but suggest favorable impact on cardiac function and attention. Limitations: Articles related to long-term non-invasive ventilation use in adolescents and young adults may have been excluded. Conclusions: Children with Down syndrome make up a significant portion of the population of children using long-term non-invasive ventilation. While there is more limited data available with respect to the use and outcomes for children with Down syndrome compared to the other children, long-term non-invasive ventilation is an effective and well-tolerated therapy with no clear differences in the use or outcomes for children with Down syndrome. Additional work is needed to understand potential challenges around establishing long-term non-invasive ventilation use in children with Down syndrome. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=206533, identifier: CRD206533.

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.

Women's experiences of antenatal transfer for threatened premature labour in NSW: A qualitative study.

BACKGROUND: Each year thousands of pregnant women experiencing threatened premature labour are transferred considerable distances across Australia to access higher level facilities but only a small proportion of these women go on to actually give birth to a premature baby. Women from regional areas are required to move away from their home, children and support networks because of a perceived risk of birthing in a centre without neonatal intensive care facilities. AIM: This study examines the experience of women undergoing antenatal transfer for threatened premature labour in New South Wales and the Australian Capital Territory who do not give birth during their transfer admission. METHODS: Thirteen semi-structured in-depth interviews were held with women across five tertiary referral sites across New South Wales and the Australian Capital Territory, and analysed until saturation for themes. FINDINGS: Seven urban and six rural women were interviewed. Women and their families were all negatively affected by antenatal transfer. Factors that helped enable a positive experience were; enhanced sense of safety in the tertiary unit, and individual qualities of staff. Factors that contributed to negative experiences were; inadequate and conflicting information, and no involvement or choice in the clinical decision-making process to move to another facility. CONCLUSIONS: Antenatal transfer is an extremely stressful experience for women and their families. The provision of high quality written and verbal information, and the inclusion of women's perception of risk in the clinical decision making process will improve the experience for women and their families in NSW and the ACT.

The Impact of Partial Factorial Invariance on Cross-Group Comparisons.

This study explored the impact of partial factorial invariance on cross-group comparisons of latent variables, including latent means, latent variances, structural relations (or correlations) with other constructs, and regression coefficients as predicting external variables. The results indicate that the estimates of factor mean differences are sensitive to violations of invariance on both factor loadings and intercepts. Noninvariant factor loadings were also found to influence the cross-group comparisons of factor variances and regression coefficients (slopes, in the raw metric) with external variables. However, cross-group comparisons of standardized slopes and interfactor correlations were not subject to noninvariance. Under conditions of partial invariance, we further compared the performance of four different model specification strategies. In general, fitting partially invariant models with all noninvariant parameters that were freely estimated yielded more accurate estimates of the parameters of interest. The implications of the major findings of this work, as well as recommendations and guidelines for future empirical researchers, are discussed below.

It's a Hard-Knock Life: Game Load, Fatigue, and Injury Risk in the National Basketball Association.

CONTEXT: National Basketball Association (NBA) athletes experience a high rate of injuries. Injury prevention requires identifying observable and controllable risk factors. OBJECTIVE: To examine the relationship among game load, fatigue, and injuries in NBA athletes. DESIGN: Cross-sectional study. SETTING: Game statistics and injury reports over 3 NBA seasons (2012-2015). PATIENTS OR OTHER PARTICIPANTS: Data represented 627 players (height = 200.7 ± 8.9 cm, mass = 100.6 ± 12.1 kg, NBA experience = 4.8 ± 4.2 years, pre-NBA experience = 3.2 ± 1.9 years), 73 209 games, and 1663 injury events. MAIN OUTCOME MEASURE(S): An injury event was defined as a player missing or leaving a game due to injury. Logistic multilevel regression was used to predict injuries from time-lagged fatigue and game load with between-subjects differences explained by demographic variables. RESULTS: The odds of injury increased by 2.87% ( P < .001) for each 96 minutes played and decreased by 15.96% ( P < .001) for each day of rest. Increases in game load increased injury odds by 8.23% ( P < .001) for every additional 3 rebounds and 9.87% ( P < .001) for every additional 3 field-goal attempts. When fatigue and game load were held constant, injury odds increased by 3.03% ( P = .04) for each year of NBA experience and 10.59% ( P = .02) for a 6-cm decrease in height. I observed variability in the intercepts ( P < .001) and the slopes for minutes, rest, field-goal attempts, and rebounds (all P < .001). CONCLUSIONS: Injuries were associated with greater fatigue and game load, more years of NBA experience, and being shorter than average. Both baseline injury risk and the magnitude of the load-injury and fatigue-injury associations varied across individuals. Researchers should explore the nature of these relationships.

Correction: Novel IgG-Degrading Enzymes of the IgdE Protease Family Link Substrate Specificity to Host Tropism of Streptococcus Species.

[This corrects the article DOI: 10.1371/journal.pone.0164809.].

Novel IgG-Degrading Enzymes of the IgdE Protease Family Link Substrate Specificity to Host Tropism of Streptococcus Species.

Recently we have discovered an IgG degrading enzyme of the endemic pig pathogen S. suis designated IgdE that is highly specific for porcine IgG. This protease is the founding member of a novel cysteine protease family assigned C113 in the MEROPS peptidase database. Bioinformatical analyses revealed putative members of the IgdE protease family in eight other Streptococcus species. The genes of the putative IgdE family proteases of S. agalactiae, S. porcinus, S. pseudoporcinus and S. equi subsp. zooepidemicus were cloned for production of recombinant protein into expression vectors. Recombinant proteins of all four IgdE family proteases were proteolytically active against IgG of the respective Streptococcus species hosts, but not against IgG from other tested species or other classes of immunoglobulins, thereby linking the substrate specificity to the known host tropism. The novel IgdE family proteases of S. agalactiae, S. pseudoporcinus and S. equi showed IgG subtype specificity, i.e. IgdE from S. agalactiae and S. pseudoporcinus cleaved human IgG1, while IgdE from S. equi was subtype specific for equine IgG7. Porcine IgG subtype specificities of the IgdE family proteases of S. porcinus and S. pseudoporcinus remain to be determined. Cleavage of porcine IgG by IgdE of S. pseudoporcinus is suggested to be an evolutionary remaining activity reflecting ancestry of the human pathogen to the porcine pathogen S. porcinus. The IgG subtype specificity of bacterial proteases indicates the special importance of these IgG subtypes in counteracting infection or colonization and opportunistic streptococci neutralize such antibodies through expression of IgdE family proteases as putative immune evasion factors. We suggest that IgdE family proteases might be valid vaccine targets against streptococci of both human and veterinary medical concerns and could also be of therapeutic as well as biotechnological use.

Twenty-five years on: outcomes of a longitudinal evaluation of the NSW Rural Resident Medical Officer Cadetship Program.

INTRODUCTION: The New South Wales Rural Resident Medical Officer Cadetship Program began in 1988 as a strategy to increase the numbers of junior doctors in rural hospitals. This article outlines the results of an evaluation undertaken in 2014. Specifically, it will look at where former cadets who entered the program between 1989 and 2010 were working in 2014, what training programs they chose and their attitudes toward the program. METHOD: Data were collected using a semi-structured questionnaire sent to all the former cadets who entered the program from 1989 until 2010. This included self-administered questions relating to background (where the majority of the students' primary schooling was undertaken), vocational training, current role, current work location and attitudes towards the cadetship. Responses were received from 142 of the 211 cadets in the study (67%). RESULTS: Of the 142 former cadets who responded to the questionnaire, 90 had completed a vocational training program and were working as fully qualified medical practitioners. A further 44 were trainees, six were non-specialist hospital doctors and two were no longer practising. Overall, the most popular vocational training programs among fully qualified doctors and trainees combined were general practice, anaesthetics/intensive care and emergency medicine. Over half of the cadets included in the analysis (n=74, 53%) were working in rural areas (Australian Standard Geographical Classification Remoteness Areas 2-5) in 2014 and practice location was significantly (p<0.001) influenced by career choice. Of the cadets working in rural locations, the majority (58%) were working as general practitioners while 38% had chosen other specialties and 4% were working as hospital non-specialists. An equal proportion of cadets came from urban and rural backgrounds while a small proportion grew up overseas. The cadets with rural backgrounds were more likely to choose general practice than those from urban backgrounds. A similar analysis of cadets comparing geographic background and practice location showed cadets of rural background were more likely to be working in a rural location than cadets of urban background. CONCLUSIONS: The cadetship is an effective link between medical school and rural practice. The success of the program relies in part on the mentoring, networking and other educational opportunities available to cadets, which serve to foster their interest and provide a structured pathway to long-term rural practice. It has been demonstrated that targeted incentive based scholarship schemes with a return-of-service component can be beneficial, particularly where they include ongoing support and reinforcement throughout the transition from undergraduate to postgraduate training.

Script-theory virtual case: A novel tool for education and research.

Context/Setting: The script theory of diagnostic reasoning proposes that clinicians evaluate cases in the context of an "illness script," iteratively testing internal hypotheses against new information eventually reaching a diagnosis. We present a novel tool for teaching diagnostic reasoning to undergraduate medical students based on an adaptation of script theory. INTERVENTION: We developed a virtual patient case that used clinically authentic audio and video, interactive three-dimensional (3D) body images, and a simulated electronic medical record. Next, we used interactive slide bars to record respondents' likelihood estimates of diagnostic possibilities at various stages of the case. Responses were dynamically compared to data from expert clinicians and peers. Comparative frequency distributions were presented to the learner and final diagnostic likelihood estimates were analyzed. Detailed student feedback was collected. OBSERVATIONS: Over two academic years, 322 students participated. Student diagnostic likelihood estimates were similar year to year, but were consistently different from expert clinician estimates. Student feedback was overwhelmingly positive: students found the case was novel, innovative, clinically authentic, and a valuable learning experience. DISCUSSION: We demonstrate the successful implementation of a novel approach to teaching diagnostic reasoning. Future study may delineate reasoning processes associated with differences between novice and expert responses.

The effect of education on community nursing practice in improving the patient-carer experience at the end of life.

Successfully completing the 'Foundations in End of Life/Palliative Care' distance-learning module has had a measurable effect on the knowledge, competence and confidence of community nurses in the principles and practice of palliative and end-of-life care. An appropriate practice-based education module can empower community nursing practice and have a direct impact on improving the patient-carer experience at the end of life. This article provides evidence from the quantitative and qualitative data from pre- and post-module self-assessment questionnaires along with the successful completion of an electronic multiple-choice questionnaire and short-answer classroom test to demonstrate this.