The Educational Climate Inventory: Measuring Students' Perceptions of the Preclerkship and Clerkship Settings.

PURPOSE: To develop an instrument to assess educational climate, a critical aspect of the medical school learning environment that previous tools have not explored in depth. METHOD: Fifty items were written, capturing aspects of Dweck's performance-learning distinction, to distinguish students' perceptions of the educational climate as learning/mastery oriented (where the goal is growth and development) versus performance oriented (where the goal is appearance of competence). These items were included in a 2014 survey of first-, second-, and third-year students at six diverse medical schools. Students rated their preclerkship or clerkship experiences and provided demographic and other data. The final Educational Climate Inventory (ECI) was determined via exploratory and confirmatory factor analysis. Relationships between scale scores and other variables were calculated. RESULTS: Responses were received from 1,441/2,590 students (56%). The 20-item ECI resulted, with three factors: centrality of learning and mutual respect; competitiveness and stress; and passive learning and memorization. Clerkship students' ratings of their learning climate were more performance oriented than preclerkship students' ratings (P < .001). Among preclerkship students, ECI scores were more performance oriented in schools with grading versus pass-fail systems (P < .04). Students who viewed their climate as more performance oriented were less satisfied with their medical school (P < .001) and choice of medicine as a career (P < .001). CONCLUSIONS: The ECI allows educators to assess students' perceptions of the learning climate. It has potential as an evaluation instrument to determine the efficacy of attempts to move health professions education toward learning and mastery.

Perspective: deconstructing integration: a framework for the rational application of integration as a guiding curricular strategy.

In response to historical criticism, evolving accreditation standards, and recent reports on curricula, medical educators and medical schools have been eagerly pursuing integration as a goal of curricular reform. The general education literature broadly considers integration to be the deliberate unification of separate areas of knowledge, and it provides support for the concept that integration better meets the needs of adult learners in professional education. The use of integration as a curricular goal is not without its critics, however, nor is it free of difficulties in implementation. In this perspective, the authors propose that most of these difficulties arise from a failure to recognize that integration is a strategy for curricular development rather than a goal in itself, and they argue that adopting a systematic approach to integration offers many potential benefits. They articulate the conceptual and practical issues that they believe are critical to consider in order to achieve successful curricular integration, and they suggest that integration should be approached as a subset of broader curriculum development decisions. They propose a three-level framework for applying integration as a guiding curricular strategy, in which decisions about integration must follow curricular decisions made at the program level, the course level, and then the individual session level.

Effecting curricular change through comprehensive course assessment: using structure and process to change outcomes.

Effective curriculum oversight requires periodic assessment and continuous improvement of individual course offerings as well as their overall integration. The literature indicates that most course review processes do not use the breadth of information available or sufficiently encourage faculty feedback and reflection, limiting the value derived. Suggestions for which data to include in the course evaluations are available in the literature; however, there is little guidance on effective course review structures and processes. In this article, the authors discuss a course review process revised as part of a comprehensive reform of the George Washington University School of Medicine and Health Sciences undergraduate medical school curriculum management structure. The process improvements incorporated evaluation practices grounded in the medical and higher education literatures and included changes to the data reviewed as well as the review timing, participants, and structure. The revised process uses a broad array of information, requires significant faculty participation, and uses questioning, writing, and dialogue to encourage faculty reflection and learning. Course directors indicate that the process helps them focus, and the information and the perspectives of others lead to reflection and new ideas. Through the process, course directors have changed course content and teaching methods, improved assessments of learning, and expanded course integration across the curriculum. The procedural and content elements of the process can be easily transferred to other medical schools and are applicable to other curricular reform projects across the continuum of medical education.

Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain.

OBJECTIVE: The effect of clinical guidelines on resource utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied. We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain. DESIGN: Physician groups were randomized to receive guideline education and individual feedback, supporting patient education materials, both, or neither. The impact on guideline adherence and resource utilization was evaluated during the 12-month period before and after implementation. PARTICIPANTS: Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practices. INTERVENTIONS: Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders. The patient education component included written and videotaped materials on the care of low back pain. MAIN RESULTS: The clinician intervention was associated with an absolute increase in guideline-consistent behavior of 5.4% in the intervention group versus a decline of 2.7% in the control group (P =.04). The patient education intervention produced no significant change in guideline-consistent behavior, but was poorly adopted. Patient characteristics including duration of pain, prior history of low back pain, and number of visits during the illness episode were strong predictors of service utilization and guideline-consistent behavior. CONCLUSIONS: Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline-consistent behavior. Patient education materials did not enhance guideline effectiveness. Implementation barriers could limit the utility of this approach in usual care settings.