Engaging Premedical Students in Medical Education Research: Benefits of Clinical Skills Observation Studies.

PURPOSE: Observations requiring evaluation and critical thinking can be powerful learning experiences. Video-recorded standardized patient encounters are underused resources for evaluation and research. The authors engaged premedical students in medical education research reviewing standardized patient encounters. This study aims to explore participant perceptions of the research experience and how they gained clinical skills. METHOD: This mixed-method study was completed between 2019 and 2022. Premedical participants coded medical students' clinical skills in video-recorded standardized patient encounters. Each participant also completed their own new patient history in a standardized patient encounter at both the beginning and end of their research project. Participants then completed an end-of-program debrief to discuss their experiences coding the clinical skills encounters. The authors coded communication skills implemented in the pre/postencounters and completed a thematic analysis of the debrief transcripts. RESULTS: All 21 participants demonstrated significant clinical skills gain after their research project, which included spending more time with the patient (pre-M=5 minutes, post-M=19 minutes, t=13.2, P<.001) and asking more questions (pre-M=13, post-M=40, t=9.3, P<.001). Prior clinical experience did not influence pre- or postoutcomes, but the number of videos coded was associated with asking more questions in the postencounter. Participants described learning actively and reflected that their clinical skills research project gave them greater insight into patient-care aspects of medical school and how medical students learn. CONCLUSIONS: These data demonstrate that observational studies in which premedical students evaluate standardized patient encounters gave the students context to medical education while enabling them to develop and transfer their own clinical skills. Studies observing standardized patient encounters provide rich insight into clinical skills development, and this work generates both research outcomes and actionable program evaluation data for medical educators. Purposefully engaging premedical students in such experiential learning opportunities benefits the students and helps cultivate early medical education pathways for these learners.

LGBTQ+ Microaggressions in Health Care: Piloting an Observation Framework in a Standardized Patient Assessment.

Microaggressions are subtle derogatory behaviors that unintentionally communicate hostility toward marginalized social groups. This article describes the preliminarily validation of a framework for observing LGBTQ+ microaggressions in health care, which can lead to distrust and disengagement from the healthcare system. Coders used the framework to observe microaggressions in video-recorded clinical-skills assessments with medical students who elicited health histories from standardized patients. Microaggression classifications were reviewed to determine construct reliability and the presence/absence among eight framework categories. Among 177 encounters with sexual and gender minority standardized patients, heteronormative/cisnormative language and assumptions occurred in the largest proportion of encounters (85.3%). Only identity-based referrals decreased significantly after a clinical skills intervention (20.0% to 4.9%, p = .01). These outcomes show that LGBTQ+ healthcare microaggressions are pervasive and will likely require nuanced training to address them. This groundwork can also be used to develop scales for patients and observers to identify microaggressions and assess perceived impact.

Epistemic Peerhood as a Model To Improve Gender-Affirming Care in Medical Education.

Issue: Inadequate training around gender-affirming care is a critical gap in health care and medical education that causes disparities and leads to injury for transgender, nonbinary, and other gender-diverse patients. In contrast to this widespread provider knowledge gap, gender-diverse patients bring critical knowledge from their own experiences to health care. Embracing varied epistemologies, or sources of knowledge, within medical education has the potential to enhance gender-affirming care by intentionally placing value on the lived experiences and emphasizing the credibility of gender-diverse patients. Evidence: In this article, the authors endorse a model of epistemic peerhood in which the embodied knowledge of gender-diverse patients and the authoritative knowledge of providers are each valued for their contribution to care. The authors reflect on experiences developing gender-affirming healthcare curricula and how medical education has not yet adequately addressed gender-diverse care without embracing community knowledge. Implications: The authors identify three vital areas to integrate epistemic peerhood in medical training to address gaps in gender-affirming care: (1) collaborative student training methods that reflect embodied knowledge in the absence of, or in addition to, clinical expertise on gender-affirming care; (2) sustainable partnerships between academic programs and gender-diverse communities that foster continuous engagement from collaborators with lived experience; and (3) broad community input about best practices for representing gender diversity in patient simulation. Embracing epistemic peerhood in each of these areas would result in broader gender-diverse community representation and leadership in medical education, which would ultimately strengthen gender-affirming healthcare training.

Gender Diverse Representation in Patient Simulation: A Scoping Review.

PURPOSE: Despite recent advocacy for transgender and nonbinary (TGNB) health competencies in medical education, there is little guidance on how to represent diverse gender identities for clinical skills training. Published literature is one of few resources available to inform educators' decisions, so this study aims to summarize how medical education scholarship portrays TGNB identities in patient simulation. METHOD: This scoping review used PRISMA guidelines with search strings encompassing diverse gender identities and patient simulation. This search was completed in July 2021, and all years of publication were included. The authors completed a 3-tiered review to identify relevant studies and then extracted data to summarize how TGNB patients were portrayed and training outcomes. RESULTS: After screening 194 total articles, 44 studies met the criteria for full review. Of these, 22 studies involved TGNB simulated patient cases. Within these, 15 (68%) reported the specific gender identities represented in the patient case, revealing mostly binary transgender identities. Sixteen studies (73%) reported the gender identities of all actors who portrayed the patient. The identities of all patients and actors matched in only 10 articles (45%), indicating that most programs portray TGNB identities with cisgender or unspecified standardized patients. Nearly all studies reported desirable learner outcomes. Several noted the advantage of authenticity in recruiting TGNB actors and the need to achieve more accurate representation of TGNB patients. CONCLUSIONS: Educators are increasingly representing TGNB identities in clinical skills training. These results show a lack of nonbinary representation and discrepancies between TGNB patient cases and standardized patient identities. These data also suggest that simulation programs need and desire better recruitment strategies within TGNB communities. Because TGNB communities are not a monolith, reporting out and analyzing gender identities of simulation cases and people hired to portray TGNB patients helps ensure that TGNB care is taught effectively and respectfully.

Improving Medical Student Attitudes Toward Suicide Prevention Through a Patient Safety Planning Clerkship Initiative.

OBJECTIVE: This project aimed to understand medical students' attitudes toward suicide prevention and their experiences in an innovative clerkship training program that engaged students in patient safety planning. METHODS: Medical students were invited to complete the Attitudes to Suicide Prevention (ASP) scale to explore student perceptions of suicide prevention and risk assessment. Seventy-five psychiatry clerkship students also completed a new safety planning training program with at-risk patients on psychiatry inpatient units. Each student observed a patient safety plan being completed, discussed this process with the resident or attending, completed a safety plan with another patient, and then debriefed with the observing physician. Participants completed the ASP before and after the rotation. RESULTS: The cross-sectional data (n=490) showed that student perceptions of suicide prevention were generally positive (M=27.8, SD=6.1) with variation among classes, but many students did not fully recognize the potential effectiveness of suicide risk reduction strategies. After the clerkship intervention, students were significantly more likely to report that working with suicidal patients was rewarding (p=0.035) and less likely to report discomfort assessing patients for suicide risk (p=0.001). CONCLUSIONS: Medical educators can reinforce the process and efficacy of suicide interventions by modeling the described initiative. Psychiatry clerkship training that intentionally engages students in safety planning with patients is generalizable, and these skills could be extended to the student burnout crisis. Longitudinal studies will help determine how individual perceptions change through medical school and whether students apply safety planning skills in psychiatry and other specialties to care for suicidal patients.

Questioning Aid for Rich, Real-Time Discussion (QARRD): A Tool to Improve Critical Thinking in Clinical Settings.

Introduction: Critical thinking skills are crucial for health professionals, especially in clinical settings. However, most health professions educators engage learners with only lower-level concepts such as definitions, fact recall, or basic explanations. Employing strategic questioning methods that require learners to use higher-order thinking can help develop clinical reasoning skills. Methods: The Questioning Aid for Rich, Real-time Discussion (QARRD) was created for health professions educators to purposefully implement concepts from Bloom's taxonomy and hierarchical questioning in clinical settings. The tool was introduced to faculty in a 1-hour, interprofessional workshop that described learning science and evidence-based questioning methods. Participants practiced QARRD questioning strategies and completed a pre/post case-based evaluation in which they developed discussion prompts for learners. Results: Thirty-seven educators participated in two separate workshops. The majority (71%) of preworkshop prompts were lower-order thinking skills (remembering/understanding). After the workshop, the complexity of participants' discussion prompts increased significantly. Most postworkshop prompts (69%) reflected higher-level thinking skills (apply/analyze/evaluate/create). Many participants reported that, despite previously knowing about Bloom's taxonomy, they had not known how to implement this learning framework in clinical instruction until completing the QARRD training. Discussion: The QARRD is a versatile, practical tool for health professions educators to practice promoting higher-level thinking in clinical settings. QARRD strategies allow educators to make small, purposeful adjustments to instructional methods that meaningfully engage learners to help facilitate clinical reasoning. This workshop can be delivered at other institutions and adapted as a virtual grand rounds to broadly enhance strategic questioning in clinical education.

Perspectives of Transgender and Genderqueer Standardized Patients.

Phenomenon: Disparities in health and healthcare for gender minorities (GMs) such as transgender people are significant, and medical educators have a responsibility to ensure trainees master the clinical skills required to provide them with quality care. We implemented a standardized patient (SP) scenario designed to measure students' ability to provide gender-affirming care and sought to understand the experiences and perceptions of the GMs who served as SPs in this case. Our key research question was: how do GM SPs describe the experience of serving as an SP on a gender-affirming care clinical case? Approach: Semi-structured focus groups were conducted with GM SPs (n = 10) to understand their experiences and gauge their perceptions of portraying a patient seeking gender-affirming care. The patient they portrayed matched their own gender identity. Focus groups were transcribed verbatim and analyzed using inductive thematic analysis. Findings: We developed three primary themes in our analysis: personal connection, gap identification, and insight into medical education. The SPs reported a personal connection to this case, enabling them to give nuanced feedback, confront bias they encountered, and foster connection to their broader community. They were able to identify specific gaps related to communication skills, assumptions, and knowledge about gender identity and gender-affirming care. They gained valuable insight into medical education such as the complexity of learning clinical skills and roadblocks to inclusive simulation. Insights: By sharing the perspectives of GMs in patient simulation, this study demonstrates that GMs can also benefit from engagement with medical education, as the SPs in our study described hope, empowerment, and engagement as positive aspects of participation. This study also shows that GMs' lived experiences seeking medical care were instrumental in their ability to note gaps, which provides valuable insight for other institutions attempting to improve students' GM clinical skills. Further, GM SPs' perspectives are valuable to provide a rationale and guidance to other schools implementing gender-affirming education. Efforts to create and implement gender-affirming care curriculum should include GMs in order to build partnerships and prioritize the voices and agency of GMs.

Gender Minorities in Simulation: A Mixed Methods Study of Medical School Standardized Patient Programs in the United States and Canada.

PURPOSE: A provider's ability to translate knowledge about transgender health to affirming patient care is key to addressing disparities. However, standardized patient (SP) programs have little published guidance for gender-affirming care or addressing disparities experienced by transgender and nonbinary patients. METHOD: Between 2018 and 2019, we invited all 208 accredited US and Canadian medical schools to participate in a study to determine how gender minorities are represented in SP encounters. Responding programs (n = 59, response rate = 28%) that represented patients with diverse gender identities were invited to complete semistructured interviews about SP case content, impact, and barriers to this work. Discussions were analyzed using a modified grounded theory method. RESULTS: Fifty nine of 208 eligible programs (response rate = 28.3%) completed our survey and 24 completed interviews. More than half of programs used gender minority SPs (n = 35, 59.3%). More than half of the programs also reported portraying gender minority cases (n = 31, 52.5%). Interviewees described how effective SP simulation required purposeful case development, engaging subject matter experts with lived experience, and ensuring psychological safety of gender minority SPs. Barriers included recruitment, fear of disrespecting gender minority communities, and transphobia. Engaging gender minorities throughout case development, training, and implementation of SP encounters was perceived to reduce bias and stereotyping, but respondents unanimously desired guidance on best practices on SP methodology regarding gender identity. CONCLUSIONS: Many programs have established or are developing SP activities that portray gender minority patients. Effective SP simulation hinges on authenticity, but the decisions around case development and casting vary. Specifically, programs lack consensus about who should portray gender minority patients. This research suggests that input from gender minority communities both to inform best practices at the macro level and in an ongoing advisory capacity at the program level will be essential to teach gender-affirming care.

Compassion cultivation training promotes medical student wellness and enhanced clinical care.

BACKGROUND: Compassionate health care is associated with positive patient outcomes. Educational interventions for medical students that develop compassion may also increase wellness, decrease burnout, and improve provider-patient relationships. Research on compassion training in medical education is needed to determine how students learn and apply these skills. The authors evaluated an elective course for medical students modeled after the Compassion Cultivation Training course developed by the Stanford Center for Compassion and Altruism Research and Education. The elective goals were to strengthen student compassion, kindness, and wellness through compassion training and mindfulness meditation training modeled by a faculty instructor. The research objectives were to understand students' applications and perceptions of this training. METHODS: Over three years, 45 students participated in the elective at the University of Louisville School of Medicine. The course administered a pre/post Kentucky Inventory of Mindfulness Skills that measured observing, describing, acting with awareness, and accepting without judgment. Qualitative analyses of self-reported experiences were used to assess students' perceptions of compassion training and their application of skills learned through the elective. RESULTS: The mindfulness inventory showed significant improvements in observing (t = 3.62, p = 0.005) and accepting without judgment skills (t = 2.87, p = 0.017) for some elective cohorts. Qualitative data indicated that students across all cohorts found the elective rewarding, and they used mindfulness, meditation, and compassion skills broadly outside the course. Students described how the training helped them address major stressors associated with personal, academic, and clinical responsibilities. Students also reported that the skills strengthened interpersonal interactions, including with patients. CONCLUSIONS: These outcomes illuminate students' attitudes toward compassion training and suggest that among receptive students, a brief, student-focused intervention can be enthusiastically received and positively influence students' compassion toward oneself and others. To underscore the importance of interpersonal and cognitive skills such as compassion and mindfulness, faculty should consider purposefully modeling these skills to students. Modeling compassion cultivation and mindfulness skills in the context of patient interactions may address student empathy erosion more directly than stress management training alone. This pilot study shows compassion training could be an attractive, efficient option to address burnout by simultaneously promoting student wellness and enhanced patient interactions.

Engaging the Transgender Community to Improve Medical Education and Prioritize Healthcare Initiatives.

Phenomenon: Transgender patients experience discrimination, limited access to care, and inadequate provider knowledge in healthcare settings. Medical education to address transgender-specific disparities is lacking. Research that engages transgender community members may help address health disparities by empowering patients, increasing trust, and informing medical curricula to increase competence. APPROACH: A 2015 Community Forum on Transgender Health Care was hosted at the University of Louisville School of Medicine, which included healthcare professionals and transgender community members to facilitate dialogue among mixed-participant groups using a World Café model. Fifty-nine participants discussed the status of transgender healthcare and made recommendations for local improvements. A follow-up survey was administered to 100 individuals, including forum participants and their referrals. The forum discussion and survey responses were analyzed to determine common perceptions of transgender healthcare, priorities for improvement interventions, and themes to inform curriculum. FINDINGS: The community forum discussion showed that local transgender care is overwhelmingly underdeveloped and unresponsive to the needs of the transgender community. The follow-up survey revealed that priorities to improve transgender care included a multidisciplinary clinic for lesbian, gay, bisexual, and transgender (LGBT) patients, an LGBT-friendly network of physicians, and more training for providers and support staff. This mutually constructive engagement experience influenced reform in undergraduate curricula and continuing education opportunities. Insights: Community engagement in healthcare disparities research can cultivate improbable discussions, yield innovative insight from marginalized populations, and build relationships with community members for future collaborations and interventions. Societal acceptance of transgender identities, which could be promoted through healthcare providers, could stimulate significant progress in transgender healthcare. Supplemental educational interventions for practicing physicians will improve the current conditions of transgender healthcare, but a comprehensive medical school curriculum specifically for transgender health that includes interactions between the transgender community and medical students could be particularly impactful.

Genomic Resources Notes accepted 1 February 2015 - 31 March 2015.

This article documents the public availability of (i) raw transcriptome sequence data, assembled contigs and BLAST hits of the Antarctic plant Colobanthus quitensis grown in two different climatic conditions, (ii) the draft genome sequence data (raw reads, assembled contigs and unassembled reads) and RAD-tag read data of the marbled flounder Pseudopleuronectes yokohamae, (iii) transcriptome resources from four white campion (Silene latifolia) individuals from two morphologically divergent populations and (iv) nuclear DNA markers from 454 sequencing of reduced representation libraries (RRL) based on amplified fragment length polymorphism (AFLP) PCR products of four species of ants in the genus Tetramorium.

Contrasting patterns of X/Y polymorphism distinguish Carica papaya from other sex chromosome systems.

The sex chromosomes of the tropical crop papaya (Carica papaya) are evolutionarily young and consequently allow for the examination of evolutionary mechanisms that drive early sex chromosome divergence. We conducted a molecular population genetic analysis of four X/Y gene pairs from a collection of 45 wild papaya accessions. These population genetic analyses reveal striking differences in the patterns of polymorphism between the X and Y chromosomes that distinguish them from other sex chromosome systems. In most sex chromosome systems, the Y chromosome displays significantly reduced polymorphism levels, whereas the X chromosome maintains a level of polymorphism that is comparable to autosomal loci. However, the four papaya sex-linked loci that we examined display diversity patterns that are opposite this trend: the papaya X alleles exhibit significantly reduced polymorphism levels, whereas the papaya Y alleles maintain greater than expected levels of diversity. Our analyses suggest that selective sweeps in the regions of the X have contributed to this pattern while also revealing geographically restricted haplogroups on the Y. We discuss the possible role sexual selection and/or genomic conflict have played in shaping the contrasting patterns of polymorphism found for the papaya X and Y chromosomes.

The sex-specific region of sex chromosomes in animals and plants.

Our understanding of the evolution of sex chromosomes has increased greatly in recent years due to a number of molecular evolutionary investigations in divergent sex chromosome systems, and these findings are reshaping theories of sex chromosome evolution. In particular, the dynamics of the sex-determining region (SDR) have been demonstrated by recent findings in ancient and incipient sex chromosomes. Radical changes in genomic structure and gene content in the male specific region of the Y chromosome between human and chimpanzee indicated rapid evolution in the past 6 million years, defying the notion that the pace of evolution in the SDR was fast at early stages but slowed down overtime. The chicken Z and the human X chromosomes appeared to have acquired testis-expressed genes and expanded in intergenic regions. Transposable elements greatly contributed to SDR expansion and aided the trafficking of genes in the SDR and its X or Z counterpart through retrotransposition. Dosage compensation is not a destined consequence of sex chromosomes as once thought. Most X-linked microRNA genes escape silencing and are expressed in testis. Collectively, these findings are challenging many of our preconceived ideas of the evolutionary trajectory and fates of sex chromosomes.