February 2021

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COMSEP Journal Club
February 2021
Editors: Karen Forbes, Randy Rockney and Jon Gold

 

Medical Student Mistreatment: The Students’ Perspectives

Why do few medical students report their experiences of mistreatment to administration? Bell A, Cavanagh A, Connelly CE, Walsh A, Vanstone M. Med Educ. 2020;00:1–9. https://doi.org/10.1111/medu.14395

Reviewed by Daniel Herchline

 

What was the study question?

When medical learners experience mistreatment or abuse in the learning environment, how do they make decisions about reporting that mistreatment?

 

How was the study done?

Using constructivist grounded theory, the authors performed interviews with current and former medical students at one institution in order to answer the research question.

 

What were the results?

The authors conducted 19 interviews with current and former medical students. The authors developed a model that describes how students iteratively experience and process mistreatment over the course of their training. The model is broken down into 5 stages that include: 1) situating, the process during which students come to understand their positions as learners; 2) experiencing and appraising mistreatment; 3) reacting; 4) deciding about course of action while considering potential costs and outcomes; and 5) moving forward. The authors note that students’ trust in the organization/institution played a key role in how students experienced mistreatment and whether or not they subsequently reported the mistreatment.

 

What are the implications?

Medical students continue to experience mistreatment in the clinical learning environment. The decision to report mistreatment is influenced by a number of different factors including organizational trust. Recommended undertakings include explicitly outlining what constitutes inappropriate behavior or mistreatment, improving reporting mechanisms to make them more accessible for students, optimizing transparency and support for students following reporting, and encouraging bystanders to come forward if they have witnessed mistreatment of learners.

 

Editor’s Note: One interesting part of the study was that during the “deciding” stage many students ‘tested the waters’ with preceptors or senior peers to assess the risk of reporting.  As faculty we can support a culture of disclosure by encouraging students to report if we find ourselves in this situation. (JG)

 

 

Gender Differences in Assessments

 

Comparison of Male and Female Resident Milestone Assessments During Emergency Medicine Residency Training: A National Study.  Santen S, Yamazaki K, Holmboe E, Yarris L, Hamstra S. Acad Med. 2020; 95(2):263-268

https://dx.doi.org/10.1097/ACM.0000000000002988

 

Reviewed by Deepikah Singh

 

What was the study question? 

Does gender affect Clinical Competency Consensus (CCC) ratings of residents in a national cohort of Emergency Medicine programs?

 

How was the study done? 

This study examined longitudinal milestone ratings for all EM residents (n = 1,363; 125 programs) reported to ACGME every 6 months from 2014 to 2017. A multilevel linear regression model was used to estimate differences in slope for all sub-competencies. Predicted marginal means between genders were compared at time of graduation.

 

What were the results? 

Males and females were rated similarly at the end of their training for the majority of sub-competencies. However, a small but statistically significant effect of gender was found on milestone ratings. Gender differences in the increase in ratings from initial rating to graduation was observed in 6 sub-competencies. In 4 patient-care sub-competencies (Emergency stabilization, General approach to procedures, Airway management, Vascular access) males were rated as performing better than females at time of graduation with milestone ratings differences ranging from 0.048 to 0.074 on 5-point Likert scale.  Where differences did exist, the extrapolated educational time effect equated to less than 1 month.

 

What are the implications?

While males and females were rated similarly for the majority of sub-competencies, statistically significant but very small absolute differences were noted in patient care. Educational impact of these differences at the program level is unclear and future work to monitor these trends in EM and other specialties is needed. The group function of CCC ratings may help to limit bias since summative decisions were no longer made based upon the individual assessment of the program director. On the other hand, it is also possible that subtle biases which may exist in individual attending-resident evaluations might be masked during the CCC consensus review. Further investigation of gender bias in evaluations from individual evaluations to CCC is needed.

 

Editor’s note: Numerous studies have pointed to differences in the way male and female trainees are rated/evaluated by male and female evaluators. The underlying reasons for these differences are not clear. Going forward it will be interesting to learn the causes of those differences and, of greater importance, what significance they have for education, evaluation, and clinical practice. (RR)

 

 

A Simple Curriculum on Complex Care

 

Visiting Jack: Mixed Methods Evaluation of a Virtual Home Visit Curriculum With a Child With Medical Complexity. Huth K, Amar-Dolan L, Perez JM, Luff D, Cohen AP, Glader L, Leichtner A, Newman LR. Acad Pediatr. 2020 Sep-Oct;20(7):1020-1028. https://dx.doi.org/10.1016/j.acap.2020.05.001

 

Reviewed by  Chelsea Howie and Joanna Holland

 

What was the study question?

What is the impact of a virtual home visit curriculum on pediatric residents’ confidence, knowledge, and knowledge application in complex care, and how does it change perspectives on caring for children with medical complexity (CMC)?


How was the study done?

This was a mixed-methods pre-post intervention study of a 90-minute online curriculum for first year pediatric residents, which included videos and accompanying assessments, followed by an in-person seminar that included facilitated reflection, a videoconference interaction with a family partner, and discussion with interprofessional clinicians involved with CMC. A baseline survey asked about prior experiences and attitudes in complex care.  A postintervention survey explored reactions to the curriculum. Multiple choice and short answer questions assessed knowledge and application to case-based scenarios before and after the curriculum. Interviews and focus groups 5 to 8 weeks later allowed participants to share experiences caring for CMC and reaction to the curriculum.


What were the results?

Twenty-four residents participated in the pre- and post-intervention survey and assessments and 12 residents participated in an interview or focus group. Resident knowledge and knowledge application in all aspects of complex care presented in the curriculum increased, as well as reported confidence on topics including home accessibility, medication safety, enteral tube care, non-invasive ventilation, and post-discharge issues. Four themes emerged across interviews and focus groups: 1) recognizing prior attitudes toward complexity, such as difficulty maintaining a holistic view of the patient and family, 2) new mental framework for complex care at home, e.g. appreciation for the “moving parts and people involved” 3) drivers of behavior change, such as a deeper sense of empathy and 4) commitment to change practice, including inquiring about baseline life at home and assessing caregiver needs.


What are the implications?

A multimodal, virtual curriculum highlighting the care of CMC in the home and community was effective in meeting its objectives. The authors encourage implementation of education in complex care beginning early in residency. Such a curriculum could also be feasibly delivered to senior medical students to support the development of knowledge and opportunity for reflection that will provide tools to future physicians to support informed, comprehensive care for CMC.

 

Editor’s note: The authors of this mixed-methods study did a nice job of aligning the qualitative results with the framework of transformative learning theory. Although a small study, the authors were able to see a shift in learner’s attitudes with even a simple educational intervention, suggesting that a curricular innovation does not need to be big to have a big impact. (KFo)

 

Note: Part of this curriculum is available at https://learn.openpediatrics.org/learn/course/internal/view/elearning/3647/virtual-home-visit-for-a-child-with-medical-complexity-course