Leave of Absence and Medical Student Placement Into Graduate Medical Education by Race and Ethnicity.

This study examines the association between taking a leave of absence from medical school and placement into graduate medical education (GME) by race and ethnicity.

Evaluating the Role of Competency-Based Behavioral Interviewing in Holistic Medical School Admissions.

PROBLEM: Holistic review is a multifaceted concept that aims to increase diversity and applicant fit with program needs by complementing traditional academic requirements with appraisal of a wider range of personal characteristics and experiences. Behavioral interviewing has been practiced and studied in human resources, business, and organizational psychology for over 50 years. Its premise is that future performance can be anticipated from past actions. However, many of the interview approaches within the holistic framework are resource intensive and logistically challenging. APPROACH: The Vanderbilt University School of Medicine instituted a competency-based behavioral interview (CBBI) to augment the selection process in 2012. Behavioral interviews are based on key competencies needed for entering students and require applicants to reflect on their actual experiences and what they learned from them. The authors reviewed 5 years of experience (2015-2019) to evaluate how CBBI scores contributed to the overall assessment of applicants for admission. OUTCOMES: The final admission committee decision for each applicant was determined by reviewing multiple factors, with no single assessment determining the final score. The CBBI and summary interview scores showed a strong association (P < .005), suggesting that the summary interviewer, who had access to the full applicant file, and the CBBI interviewer, who did not, assessed similar strengths despite the 2 different approaches, or that the strengths assessed tracked in the same direction. Students whose 2 interview scores were not aligned were less likely to be accepted to the school. NEXT STEPS: The review raised awareness about the cultural aspects of interpreting the competencies and the need to expand our cultural framework throughout interviewer training. Findings indicate that CBBIs have the potential to reduce bias related to over-reliance on standardized metrics; however, additional innovation and research are needed.

Challenges Facing First-Generation College Graduates in Medical School: A Qualitative Analysis.

Importance: First-generation (FG) medical students remain underrepresented in medicine despite ongoing national efforts to increase diversity; understanding the challenges faced by this student population is essential to building holistic policies, practices, and learning environments that promote professional actualization. Although FG students have been extensively studied in the undergraduate literature, there is little research investigating how FG students experience medical education or opportunities for educators to intervene. Objective: To explore challenges that FG students experience in undergraduate medical education and identify opportunities to improve foundational FG support. Design, Setting, and Participants: This qualitative study was conducted using an online platform with 37 FG students enrolled in 27 US medical schools. An interprofessional team of medical educators and trainees conducted semistructured interviews from November 2021 through April 2022. Participants were recruited using a medical student listserv. Data were analyzed from April to November 2022. Main Outcomes and Measures: After conducting a preliminary analysis using open coding, a codebook was created and used in a thematic analysis; the codebook used a combination of deductive and inductive coding. Results: Among the 37 students recruited for this study, 21 (56.8%) were female; 23 (62.2%) were in the clinical phase of training; 1 (2.7%) was American Indian or Alaska Native, 7 (18.9%) were Hispanic, Latino, or of Spanish origin, 8 (21.6%) were non-Hispanic Asian or Asian American, 9 (24.3%) were non-Hispanic Black or African American, and 23 (32.4%) were non-Hispanic White; mean (SD) age was 27.3 (2.8) years. Participants described 4 major themes: (1) isolation and exclusion related to being a newcomer to medicine; (2) difficulty with access to basic resources (eg, food, rent, transportation) as well as educational (eg, books); (3) overall lack of faculty or institutional support to address these challenges; and (4) a sense of needing to rely on grit and resilience to survive. Conclusions and Relevance: Although grit and resilience are desirable traits, results of this study suggest that FG medical students face increased adversity with inadequate institutional support, which forces them to excessively rely on grit and resilience as survival (rather than educational) strategies. By applying the holistic model often used in admissions to the postmatriculation educational process, targeted and flexible initiatives can be created for FG students so that all students, regardless of background, can achieve robust professional actualization.

Clinical use of artificial intelligence requires AI-capable organizations.

Artificial intelligence-based algorithms are being widely implemented in health care, even as evidence is emerging of bias in their design, problems with implementation, and potential harm to patients. To achieve the promise of using of AI-based tools to improve health, healthcare organizations will need to be AI-capable, with internal and external systems functioning in tandem to ensure the safe, ethical, and effective use of AI-based tools. Ideas are starting to emerge about the organizational routines, competencies, resources, and infrastructures that will be required for safe and effective deployment of AI in health care, but there has been little empirical research. Infrastructures that provide legal and regulatory guidance for managers, clinician competencies for the safe and effective use of AI-based tools, and learner-centric resources such as clear AI documentation and local health ecosystem impact reviews can help drive continuous improvement.

Master clinical teachers and personalised learning.

Clinical history taking and physical examination are two of the most important competencies of physicians. In addition to informing diagnoses, these activities build rapport and establish relationships between caregivers and patients. Despite this, emphasis on the assessment of bedside clinical skills is declining. To prepare our students for clinical work, we began a clinical competency, personalised teaching programme in which students perform a history and physical examination in front of a master clinical teacher (MCT) approximately every 2 weeks throughout their core clerkship year. The MCT works with the student in a clinical encounter, providing personalised bedside instruction on all features of being a clinician including bedside manner, history-taking skills, physical examination skills, and clinical reasoning. The MCT then provides an assessment of student's competency development and gives feedback to the student about what they do well and where they have opportunities for growth. Assessment data are collected and tracked longitudinally across the clerkship phase to ensure that each student is progressing developmentally. With over 6000 observations of student performance, we are able to discern competency development and growth over time. We can identify if a student is not improving as expected during their clerkship phase and intervene by providing extra practice and training. This core clerkship teaching programme has been well received by both students and instructors and has led us to pilot this approach during the post-clerkship phase of our medical training.

Competencies for the Use of Artificial Intelligence-Based Tools by Health Care Professionals.

PURPOSE: The expanded use of clinical tools that incorporate artificial intelligence (AI) methods has generated calls for specific competencies for effective and ethical use. This qualitative study used expert interviews to define AI-related clinical competencies for health care professionals. METHOD: In 2021, a multidisciplinary team interviewed 15 experts in the use of AI-based tools in health care settings about the clinical competencies health care professionals need to work effectively with such tools. Transcripts of the semistructured interviews were coded and thematically analyzed. Draft competency statements were developed and provided to the experts for feedback. The competencies were finalized using a consensus process across the research team. RESULTS: Six competency domain statements and 25 subcompetencies were formulated from the thematic analysis. The competency domain statements are: (1) basic knowledge of AI: explain what AI is and describe its health care applications; (2) social and ethical implications of AI: explain how social, economic, and political systems influence AI-based tools and how these relationships impact justice, equity, and ethics; (3) AI-enhanced clinical encounters: carry out AI-enhanced clinical encounters that integrate diverse sources of information in creating patient-centered care plans; (4) evidence-based evaluation of AI-based tools: evaluate the quality, accuracy, safety, contextual appropriateness, and biases of AI-based tools and their underlying data sets in providing care to patients and populations; (5) workflow analysis for AI-based tools: analyze and adapt to changes in teams, roles, responsibilities, and workflows resulting from implementation of AI-based tools; and (6) practice-based learning and improvement regarding AI-based tools: participate in continuing professional development and practice-based improvement activities related to use of AI tools in health care. CONCLUSIONS: The 6 clinical competencies identified can be used to guide future teaching and learning programs to maximize the potential benefits of AI-based tools and diminish potential harms.

Considering Clinician Competencies for the Implementation of Artificial Intelligence-Based Tools in Health Care: Findings From a Scoping Review.

BACKGROUND: The use of artificial intelligence (AI)-based tools in the care of individual patients and patient populations is rapidly expanding. OBJECTIVE: The aim of this paper is to systematically identify research on provider competencies needed for the use of AI in clinical settings. METHODS: A scoping review was conducted to identify articles published between January 1, 2009, and May 1, 2020, from MEDLINE, CINAHL, and the Cochrane Library databases, using search queries for terms related to health care professionals (eg, medical, nursing, and pharmacy) and their professional development in all phases of clinical education, AI-based tools in all settings of clinical practice, and professional education domains of competencies and performance. Limits were provided for English language, studies on humans with abstracts, and settings in the United States. RESULTS: The searches identified 3476 records, of which 4 met the inclusion criteria. These studies described the use of AI in clinical practice and measured at least one aspect of clinician competence. While many studies measured the performance of the AI-based tool, only 4 measured clinician performance in terms of the knowledge, skills, or attitudes needed to understand and effectively use the new tools being tested. These 4 articles primarily focused on the ability of AI to enhance patient care and clinical decision-making by improving information flow and display, specifically for physicians. CONCLUSIONS: While many research studies were identified that investigate the potential effectiveness of using AI technologies in health care, very few address specific competencies that are needed by clinicians to use them effectively. This highlights a critical gap.

Becoming Active Bystanders and Advocates: Teaching Medical Students to Respond to Bias in the Clinical Setting.

INTRODUCTION: Incidents of bias and microaggressions are prevalent in the clinical setting and are disproportionately experienced by racial minorities, women, and medical students. These incidents contribute to burnout. Published efforts to address these incidents are growing, but gaps remain regarding the long-term efficacy of these curricular models. We developed and longitudinally evaluated a workshop that taught medical students a framework to respond to incidents of bias or microaggressions. METHODS: In October 2019, 102 Vanderbilt core clerkship medical students participated in an hour-long, interactive, case-based workshop centered around the 3 D's response behavior framework: (1) direct, (2) distract, and (3) delegate. Participants were surveyed before and after the training, and both qualitative and quantitative data were collected. A refresher workshop was offered 8 months later, which added two additional D's: delay and display discomfort. RESULTS: After the workshop, respondents' knowledge of the assessed topics improved significantly, as did their confidence in addressing both personally experienced and witnessed incidents. Respondents initially indicated a high likelihood of using response behaviors to address incidents. The workshop did not consistently modify behavioral responses to experienced or witnessed incidents. Ninety-one percent of respondents agreed the workshop was effective. DISCUSSION: This workshop provided an effective curriculum to sustainably improve participant knowledge and confidence in responding to incidents of bias and microaggressions. This resource can be adopted by educators at other institutions.

Development and Pilot Testing of a Multidimensional Learning Environment Survey.

BACKGROUND: Multiple, complex factors comprise the learning environment and influence student learning outcomes, yet comprehensive evaluation of the learning environment in nursing schools is limited. PURPOSE: The Learning Environment Survey (LES) was developed to facilitate nursing students' report of perceptions of the complex learning environment in nursing education. METHODS: Systematic exploration of the literature, conceptual operationalization of the learning environment, and development of an item pool were completed. Content validity was established with expert assessment, student testing for clarity, and calculation of scale-content validity index/average (S-CVI/Ave). Pilot testing was completed at 1 school of nursing with baccalaureate-equivalent prelicensure and advanced practice master's level students, and doctor of nursing practice students. RESULTS: The CVI (S-CVI/Ave) was 0.92. Domain scores demonstrated Cronbach's α reliabilities of 0.67 or higher with most being > 0.85. CONCLUSION: The LES establishes a mechanism for eliciting comprehensive learning environment data for systematic assessment and national comparison of multiple nursing learning environments.

Assessing medical student performance of Entrustable Professional Activities: A mixed methods comparison of Co-Activity and Supervisory Scales.

Introduction: Observations of medical student participation in entrustable professional activities (EPAs) provide insight into the student's ability to synthesize competencies across domains and effectively function in different clinical scenarios. Both Supervisory and Co-Activity Assessment Scales have been recommended for use with medical students.Methods: Students were assessed on EPAs during Acting Internships in Medicine and Pediatrics. Two rating scales were modified based on expert review and included throughout the 2017-18 academic year. Statistical analysis was conducted to clarify relationships between the scales. Raters were interviewed to explore their interpretations and response processes.Results: The results of the McNemar test suggest that the scales are different (p-value <.01). Co-activity and Supervisory EPA ratings are related, but not interchangeable. This finding concurs with themes that emerged from response process interviews: (1) the scales are not directly parallel (2) rater preference depends on diverse factors and (3) rater comments are crucial for guiding students' future learning.Conclusion: The modified Chen Supervisory Scale and the modified Ottawa Co-Activity Scales are measuring different aspects of the entrustable professional activity landscape. Both scales can provide useful information to the learner and the assessment system, but they should not be treated as interchangeable assessments.

Development of an interprofessional clinical learning environment report card.

Multiple factors in the learning environment can encourage or impede student learning. Unanswered questions regarding the shared learning environment for graduate nursing and medical education and the desire for an ongoing improvement process drove creation of an interprofessional collaborative and development of an Interprofessional Clinical Learning Environment Report Card (I-CLERC) at one U.S. academic medical center. The I-CLERC offers a process and a product for institutionalizing a shared assessment tool to inform improvement efforts, track progress and promote accountability. In addition, it enhances interprofessional collaboration, with students and faculty from both nursing and medicine working together to define excellence, monitor performance, and identify areas for improvement in the shared clinical learning environment. The purpose of this manuscript is to describe development and implementation of an interdisciplinary, institutional collaborative for ongoing evaluation of the shared clinical learning environment.

Increasing RN Perceived Competency With Substance Use Disorder Patients.

BACKGROUND: Although behavioral health and substance use disorder patients visit hospitals in significant numbers, nurses are often ill-prepared to care for them. METHOD: The purpose of this quasi-experimental preclass-postclass design was to determine the effects of an educational intervention on the perceived competency of 57 nurses who care for patients with behavioral and substance abuse disorders. The nurses who chose to participate were asked to respond to a demographic questionnaire and a survey designed to measure perceived competency. Survey data were analyzed to determine whether any differences (alpha = .05) existed between participants' attitudes and knowledge preclass and postclass. RESULTS: Immediately following the educational intervention, a statistically significant increase was found in perceived competency related to self-confidence, attitudes, communication, and knowledge of resource availability among participating nurses. CONCLUSION: Nurses working in acute care hospitals, particularly those without addiction and psychiatric services, may benefit from continuing education on this important topic. J Contin Nurs Educ. 2017;48(4):175-183.

Competency milestones for medical students: Design, implementation, and analysis at one medical school.

Competency-based assessment seeks to align measures of performance directly with desired learning outcomes based upon the needs of patients and the healthcare system. Recognizing that assessment methods profoundly influence student motivation and effort, it is critical to measure all desired aspects of performance throughout an individual's medical training. The Accreditation Council for Graduate Medical Education (ACGME) defined domains of competency for residency; the subsequent Milestones Project seeks to describe each learner's progress toward competence within each domain. Because the various clinical disciplines defined unique competencies and milestones within each domain, it is difficult for undergraduate medical education to adopt existing GME milestones language. This paper outlines the process undertaken by one medical school to design, implement and improve competency milestones for medical students. A team of assessment experts developed milestones for a set of focus competencies; these have now been monitored in medical students over two years. A unique digital dashboard enables individual, aggregate and longitudinal views of student progress by domain. Validation and continuous quality improvement cycles are based upon expert review, user feedback, and analysis of variation between students and between assessors. Experience to date indicates that milestone-based assessment has significant potential to guide the development of medical students.

How do we understand the determinants of health? An exploration of distributed knowledge and interprofessional health sciences education.

It is acknowledged that interprofessional communication and teamwork are foundational for high-quality, safe medical practice. The theory of distributed knowledge posits that each person has unique knowledge and experiences that can contribute to a broader group perspective. Patient care can be positively influenced by a robust and interprofessionally shared understanding of the complexities of health and illness. One would expect a variety of perspectives to be evident in all healthcare providers, including incoming health science students from different professional fields. To examine this notion, medical, nursing, and pharmacy students (n = 24) at the start of an interprofessional training experience were asked to write an essay on factors that contribute to health and/or illness. Their essays were thematically coded to generate a list of factors considered key to health/illness and compare responses across fields to better understand how knowledge is distributed across entering learners. Results show that students from different professional backgrounds emphasise some shared and some divergent factors. This distributed knowledge can be a rich source of understanding and shared thinking across professions. It is also a critical source of individual power to contribute to the construction of an ongoing, collaborative discourse about health.