Why do few medical students report their experiences of mistreatment to administration?

Introduction: Over 50% of medical students worldwide report experiencing mistreatment and abuse during their clinical education, yet only a small proportion of students report these concerns to administration. It is unknown how medical students make sense of their experiences of mistreatment and come to decide whether to formally report these experiences. Improved understanding of this phenomenon will facilitate changes at the administrative and institutional levels to better support students.

Methods: Using Constructivist Grounded Theory, we interviewed 19 current and former medical students from one institution about their experiences with mistreatment and reporting. Data were analysed in an iterative fashion, using focused and theoretical forms of coding.

Results: The decision of whether to report mistreatment is only one phase in the process that students report experiencing when encountering mistreatment. This process can be understood as a journey consisting of five phases: Situating, Experiencing and Appraising, Reacting, Deciding and Moving Forward. Students move through these phases as they come to understand their position as medical learners and their ability to trust and be safe within this institution. Each experience of mistreatment causes students to react to what has happened to them, decide if they will share their experiences and reach out for support. They choose if they are going to report the mistreatment, at what cost and for what outcomes. Students continue through their training while incorporating their experiences into their understanding of the culture in which they are learning and continually resituating themselves within the institution.

Discussion: Student perceptions of trust or mistrust in their educational institution are highly influential when it comes to reporting mistreatment. Interventions designed to support students and decrease exposure to mistreatment may be best focused on increasing organisational trust between students and the medical school.

Citation: Bell A, Cavanagh A, Connelly CE, Walsh A, Vanstone M. Why do few medical students report their experiences of mistreatment to administration? Med Educ. 2021 Apr;55(4):462-470. doi: 10.1111/medu.14395.

The mind that wanders: Challenges and potential benefits of mind wandering in education.

An examination of Eyal & Hurst’s (2008) framework for promoting retention in resource-poor settings through locally-relevant training: A case study for the University of Guyana Surgical Training Program

Background: Eyal and Hurst proposed that locally relevant medical education can offset the prevalence of physician “brain drain” in resource-poor regions of the world, and presented a framework of the ethical and pragmatic benefits and concerns posed by these initiatives. The present study explored the framework’s utility through a case study of the University of Guyana Diploma in Surgery (UGDS) program.

Methods: The framework’s utility was evaluated using a case study design that included review and analysis of documents and semi-structured interviews with graduates, trainees, faculty members, and policy makers associated with the UGDS program. Data were analyzed from constructivist and interpretivist perspectives, and compared against the benefits and concerns described by Eyal and Hurst.

Results: The framework is a useful template for capturing the breadth of experience of locally relevant training in the Guyanese setting. However, the results suggest that delineating the framework factors as either beneficial or concerning may constrict its applicability. The case study design also provided specific insights about the UGDS program, which indicate that the Program has promoted the retention of graduates and a sustainable culture of postgraduate medical education in Guyana.

Conclusion: It is suggested that the framework be modified so as to represent the benefits and concerns of locally relevant training along a continuum of advantage. These approaches may help us understand retention within a resource-poor country, but also within particularly remote areas and public health care systems generally.

Citation: Prashad AJ, Cameron BH, McConnell M, Rambaran M, Grierson LEM. An examination of Eyal & Hurst’s (2008) framework for promoting retention in resource-poor settings through locally-relevant training: A case study for the University of Guyana Surgical Training Program. Can Med Educ J. 2017 Apr 20;8(2):e25-e36.

Admissions experiences of aspiring physicians from low-income backgrounds

Understanding moral empathy: A verbatim-theatre supported phenomenological exploration of the empathy imperative

Objectives: Several studies have measured a decline in empathy during medical training, speculating that factors within the formal, informal and hidden curricula are responsible for this phenomenon. Although the medical education literature describes the moral domain of empathy as most fundamental to the empathic response, most research into the decline has examined the cognitive, affective and behavioural domains. This study distinguishes itself by focusing on how moral empathy is affected through training.

Methods: Ten medical residents from core education specialties at McMaster University participated in lightly structured interviews concerning their training experiences. Interview transcripts were analysed by way of a descriptive phenomenological approach. Analyses afforded descriptions of the way medical training influences moral empathy. These descriptions were then used to generate a verbatim theatre play that was performed for an audience of residents, educators, learners, researchers and scholars. Following the play, audience participants completed a survey to member-check the descriptions and to glean other reflective experiences in resident training that impact moral empathy. The survey results informed revisions to the codebook that was subsequently used to re-analyse the interview transcripts. This resulted in a final, refined version of the influence of training on learner moral empathy.

Results: The findings suggest that a resident’s sense of moral empathy relies upon the notion of an innate capacity for empathy, and is influenced by their clinical and classroom education, and specific experiences with patients during training. Importantly, these factors are rarely experienced as having a direct deleterious impact on residents’ moral empathy but rather are experienced as challenges to their ability to act on their moral empathy.

Conclusions: The study promotes reflection of what it means to experience empathy in the moral domain. The description offers a new perspective from which to view empathic declines that have been previously reported, while also highlighting a moral-behavioural tension that has implications for competency-based assessment and the way empathy is conceptualised in medical education.

Citation: Pieris D, Jafine H, Neilson S, Amster E, Zazulak J, Lam C, Grierson L. Understanding moral empathy: A verbatim-theatre supported phenomenological exploration of the empathy imperative. Med Educ. 2022 Feb;56(2):186-194. doi: 10.1111/medu.14676.

A literature review on observational learning for medical motor skills and anesthesia teaching

Motor skill practice is very important to improve performance of medical procedures and could be enhanced by observational practice. Observational learning could be particularly important in the medical field considering that patients’ safety prevails over students’ training. The mechanism of observational learning is based on the mirror neuron system, originally discovered in the monkey pre-motor cortex. Today we know that humans have a similar system, and its role is to understand and reproduce the observed actions of others. Many studies conclude that humans are able to plan and to make movements based on visual information by mapping a representation of observed actions, especially when the motor system is committed to do it. Moreover most researchers considered observational learning effective for complex skills, such as medical procedures. Additionally, observational learning could play a relevant role during anesthesia training since the learner works in pairs most of the time (dyad practice). Some teaching approaches should be taken into consideration: an implicit engagement of the observer motor system is required, immediate feedback seems to have an important effect, and a combination of observational and physical practice could be better than physical practice alone. In an environment where effectiveness and efficacy are essential, observational learning seems to fit well.

Citation: Cordovani L, Cordovani D. A literature review on observational learning for medical motor skills and anesthesia teaching. Adv Health Sci Educ Theory Pract. 2016 Dec;21(5):1113-1121. doi: 10.1007/s10459-015-9646-5.

Examining the validity argument for the Ottawa Surgical Competency Operating Room Evaluation (OSCORE): a systematic review and narrative synthesis

The Ottawa Surgical Competency Operating Room Evaluation (OSCORE) is an assessment tool that has gained prominence in postgraduate competency-based training programs. We undertook a systematic review and narrative synthesis to articulate the underlying validity argument in support of this tool. Although originally developed to assess readiness for independent performance of a procedure, contemporary implementation includes using the OSCORE for entrustment supervision decisions. We used systematic review methodology to search, identify, appraise and abstract relevant articles from 2005 to September 2020, across MEDLINE, EMBASE and Google Scholar databases. Nineteen original, English-language, quantitative or qualitative articles addressing the use of the OSCORE for health professionals’ assessment were included. We organized and synthesized the validity evidence according to Kane’s framework, articulating the validity argument and identifying evidence gaps. We demonstrate a reasonable validity argument for the OSCORE in surgical specialties, based on assessing surgical competence as readiness for independent performance for a given procedure, which relates to ad hoc, retrospective, entrustment supervision decisions. The scoring, generalization and extrapolation inferences are well-supported. However, there is a notable lack of implications evidence focused on the impact of the OSCORE on summative decision-making within surgical training programs. In non-surgical specialties, the interpretation/use argument for the OSCORE has not been clearly articulated. The OSCORE has been reduced to a single-item global rating scale, and there is limited validity evidence to support its use in workplace-based assessment. Widespread adoption of the OSCORE must be informed by concurrent data collection in more diverse settings and specialties.

Citation: Spencer, M., Sherbino, J. & Hatala, R. Examining the validity argument for the Ottawa Surgical Competency Operating Room Evaluation (OSCORE): a systematic review and narrative synthesis. Adv in Health Sci Educ (2022). doi.org/10.1007/s10459-022-10114-w

The McMaster Advanced Communication Competencies Model for Psychiatry (MACC Model)

Objective: Communication is a core competency for all physicians in training. In Canada, the importance of communication during residency is recognized through the CanMEDS framework. Although literature exists around teaching communication skills to residents, research in psychiatry residents is lacking. The purpose of this study was to explore how faculty members conceptualize the development of communication skills in psychiatry residents and develop a model reflecting this.

Methods: The authors used a constructivist grounded theory approach. Purposive sampling was used to select 14 faculty educators who regularly supervise psychiatry residents in a single university-based residency training program. Semi-structured interviews were conducted to explore educators’ perceptions of how communication skills develop during residency. Constant comparative analysis occurred concurrently with data collection until thematic theoretical sufficiency was reached and relationships between themes determined.

Results: Five themes underlie the McMaster Advanced Communication Competencies model, describing the progressive development of communication abilities in residents. Three themes identify foundational sets of abilities including: refining common foundational relational abilities, developing foundational specific psychiatric communication abilities, and learning to reflect upon and manage internal reactions. These foundational pillars then allow residents to develop a personalized art of flexible psychiatric interviewing, and skillfully partner with patients in co-creating care plans.

Conclusions: This research describes a preliminary communication competency model for teaching and assessing psychiatry residents. It defines the core communication abilities required for residents to progress to independent practice. Future research could explore and test the model’s validity and transferability.

Citation: Snelgrove N, Zaccagnini M, Sherbino J, McCabe R, McConnell M. The McMaster Advanced Communication Competencies Model for Psychiatry (MACC Model). Acad Psychiatry. 2022 Apr;46(2):210-217. doi: 10.1007/s40596-021-01516-w.

Examining the barriers to meaningful assessment and feedback in medical training

Background: Recent reports from both accreditation bodies in North America highlight problems with current assessment practices in postgraduate medical training. Previous work has shown that educators might be reluctant to report poor performance or fail underperforming trainees. This study explores the barriers perceived by medical educators to providing more meaningful assessment and feedback to trainees.

Methods: Semistructured interviews were conducted with 22 physician educators. Interviews were audiotaped and transcribed verbatim. Three researchers analyzed the transcripts using a grounded theory approach.

Results: Participants expressed a reluctance to provide poor assessments or feedback to trainees. Fifty-five percent of the participants reported passing trainees who could have benefited from additional training. Our data revealed a number of barriers which may account for these findings. Implementing more frequent formative assessments could help educators more effectively evaluate trainees and provide feedback, although a shift in the culture of medicine may be required.

Conclusions: It is imperative that the barriers to effective assessment and feedback identified in this study be addressed to improve postgraduate medical training and enhance patient care.

Citation: McQueen SA, Petrisor B, Bhandari M, Fahim C, McKinnon V, Sonnadara RR. Examining the barriers to meaningful assessment and feedback in medical training. Am J Surg. 2016 Feb;211(2):464-75. doi: 10.1016/j.amjsurg.2015.10.002.