January 2019

posted in: 2019 Journal Clubs | 0

Ready, Willing and Disabled “Being on Both Sides”: Canadian Medical Students’ Experiences With Disability, the Hidden Curriculum, and Professional Identity Construction. Stergiopoulos E, Fernando O & Martimianakis MA. Academic Medicine (2018); 93(10): 1550-9.


Reviewed by Angela Punnett



What was the study question?

Under-reporting of student disabilities to accessibility services is a well-documented phenomenon in medical schools. This study sought to understand the experience of medical students with disabilities as both trainees and patients and to explore the institutional context contributing to this experience.

How was the study done?

This was a qualitative study consisting of 2 components. First, semi-structured interviews were conducted with a purposive sampling of 10 students from one Canadian medical school across all years of training who had self-identified disabilities. Second, a textual analysis of publicly available materials (policies, student services, student blogs) related to student wellness from all 13 English-speaking Canadian medical schools was conducted. Data was analysed using a critical discourse analysis.

What were the results?

The researchers identified two competing discourses in exploring the experience of students with disabilities – the notion of the ‘good student’ versus the ‘good patient’. The ‘good student’ is successful academically, clinically and socially with significant self-sacrifice in order to do so. This may be supported at the institutional level where wellness is often situated as an undertaking to optimize performance.  Students who may have inability to perform the expected student role may be perceived as lazy or incompetent. Thus, the ‘good student’ role may be in conflict with the ‘good patient’ who prioritizes health and self-care. Students also shared the challenges and opportunities that come with their dual roles as student and patient, most notably for the latter, their increased ability to act compassionately and communicate and advocate with and for their patients. Institutional language and policies around accommodations and accesses to those, varied significantly among the 13 medical schools.

What are the implications of these findings?

If we are to develop and support a diverse physician workforce, we must address the hidden curriculum around disability in medical training.  As the authors note, curriculum and faculty development are critical, and our students are well poised to contribute as experts. Institutional policies and practices must be carefully reviewed with a renewed focus on accessibility.

Editor’s Comments: The immense pressure to excel in everything (including ‘wellness’) is ever more apparent in our students – but at what cost?  This is captured in one exemplar quote from the study, where a student blogged “I don’t know what the rules of being a medical student are, besides the obvious ones – like study, be professional, be confident, be perfect.”  Now imagine the student who struggles with physical, mental, or psychological disabilities – it’s no wonder students fear disclosure will make them vulnerable (KFo).

The How and Why of Medical Student Suffering

The suffering medical students attribute to their undergraduate education. Egnew TR, Lewis PR, Myers KR, Phillips WR.  Fam Med 2018;50(4):296-9.


Reviewed by Virginia Randall

What was the study question?

What are the perceptions of medical students about their personal suffering attributable to medical school?

How was the study done?

The authors  conducted focus groups involving a total of 51 students from all four classes at two US medical schools.  They then analyzed transcripts of the focus groups to look for themes using standard qualitative procedures including constant comparison.

What were the results?

While the study was originally designed to explore medical students’ perception  of their education about suffering, some students reported personal suffering attributed to their medical education. They attributed their own suffering to the culture of medical education and to the personal transformation to physicianhood.

Students described suffering related to isolation from connections to family and friends, the culture of medical education that encourages stoicism, and  unclear expectations in the clinical years. Their professional identify became confused with their personal identity and their work performance equated to their personal worth.

“…in medicine…your career is you.”

The consequences of their suffering were distress, dehumanization, powerlessness, and disillusionment.  They were

“too tired to show empathy” and “the emotional distress of just feeling ‘I can’t handle                      the pain I’m seeing every day.’”

They adapted to the stress by distraction, suppression, compartmentalization, and reframing.

“we want to put on that face that it is going okay…because we just keep going and we keep going and we keep going.”

They identified supportive mechanisms as small groups where it was safe to discuss, opportunities for protected venting, and some guidance from mentors about sharing.

“having a group where you could talk about things like this would be amazing”

What are the implications of the findings?

Although this was a small study, the authors suggest that some degree of suffering is inherent in the personal and professional development of future physicians.  Faculty can facilitate opportunities to ameliorate suffering by guiding students in processing their suffering in small safe groups, encourage reflective writing, and helping students find meaning by sharing some of their [faculty] own experiences. Faculty can examine the culture of medicine that promotes suffering and provide alternate messages to the students.

Editor’s Note:  Another contribution to the growing literature on student wellness, this study doesn’t focus on depression or burnout but instead focuses on the experiences of the typical medical student.  Because the participants came from all four years of medical school, the solutions suggested above should likely be implemented across the medical school continuum as well. (JG)




Supplementary curricula to assure mastery of EPAs

A Mastery Learning Capstone Course to Teach and Assess Components of Three Entrustable Professional Activities to Graduating Medical Students. Salzman DH, McGaghie WC, Caprio TW, Hufmeyer KK, Issa N, Cohen ER, Wayne DB. Teaching and Learning in Medicine 2018


Reviewed by Janet Meller

What was the study question?

Can mastery learning improve performance of 3 components of the Entrustable Professional Activities (EPAs) to graduating medical students?

How was the study done?

All graduating students of a single medical school class were required to participate in a 4th year mastery learning capstone course to teach and assess 3 EPA based skills:  obtain informed consent; develop a differential diagnosis and write admission orders; write discharge prescriptions. Students were assessed by a pre-test/post- test design with a simulation –based mastery learning intervention.

What were the results?

130/134 graduating students participated in the study.  Baseline test data showed variable ability to perform the studied skills.  At the conclusion, all students met minimum passing standards for the EPA skills studied.  All students improved their scores in the three skills significantly following the simulation and feedback. Of the 130 medical students polled in an exit survey, 88% responded and all responses were favorable.

What are the implications?

It will soon be incumbent upon medical schools to ensure that their graduates are prepared for residency and that the EPA’s developed by the AAMC will need to be embedded in the curricula.  As this study demonstrated, current clinical education does not adequately prepare students for at least 3 of the EPA’s.  A mastery learning capstone course may fill that gap.  Alternatively, such activities may be integrated earlier in the curriculum.

Editor’s note: A capstone course or revision of the traditional curricula? Assuring mastery of EPAs will of necessity involve significant changes to the way students and residents are educated but I guess that’s the point. (RR)


Clerkship lengths: how much time matters?

Does Reducing Clerkship Lengths by 25% Affect Medical Student Performance and Perceptions?

Monrad SU, et al.  Academic Medicine 2018 Dec; 93(12).


Reviewed by Chas Hannum

What was the study question?

Does a reduction in clerkship lengths lead to a change in clerkship performance, clinical skills performance, clerkship evaluations and perceptions of the learning environment?

How was the study done?

During a curriculum change at a single US medical school, all core clerkships were decreased by 25% for one academic year to avoid an overlap in clerkship cohorts. The two preceding years of “regular” length clerkship data (NBME performance, clerkship evaluations), standardized end-of-year clinical skills exams, and scales to measure wellness and the perception of the learning environment were compared against the same metrics for the shortened clerkship year.

What were the results?

There was no significant difference in NBME exam scores between the year preceding the change and the reduced clerkship year, though, over the three years, pediatrics NBME exam scores declined significantly. All other subject exams had no difference. End-of-year clinical skills exam had no significant difference in total overall scores, but the three-year trend was significantly different in some domains. Clerkship evaluations for pediatrics, internal medicine and psychiatry had an increase in clerkship quality for the shortened year compared to traditional years, and no clerkship had a significant drop in perceived quality. Lastly, well-being indices remained stable during the change, while year-over-year perceptions were statistically significant, but not worse for the reduced year vs. traditional years.

What are the implications of these findings?

The ideal length of core clerkships and the structure of clinical rotations are rooted in strong opinion, not robust evidence. At a time where major changes are happening to medical school curricula, this study provides evidence in support of flexibility within the length of clinical clerkships. Limitations for this study are many, including reduced generalizability and the difficulty in comparing clerkship structure between one single class cohort. Future studies can at least be reassured that experimenting with clerkship length is feasible.

Editor’s note: A long time ago I approached a former department chair with the idea that the length of that department’s core clerkship might be reduced to accommodate other changes in the curriculum. That chair had four words for me: “Over my dead body.” As Dr. Hannum points out, “The ideal length of core clerkships and the structure of clinical rotations are rooted in strong opinion, not robust evidence.” This study (and I am aware of other similar studies) supports the idea that what might on the surface look like radical changes in a traditional medical school curriculum ought not to be feared and educational outcomes are little affected by phenomenon like clerkship length. (RR)


If this article looks familiar to you, you have an excellent memory—it was reviewed by Amy Creel in September 2018.  It was my mistake not to catch it earlier—and in no way detracts from the excellent review by Dr. Hannum (JG)