September 2019

posted in: 2019 Journal Clubs | 0

Racism in medical education

The Effects of Racism in Medical Education on Students' Decisions to Practice in Underserved or Minority Communities.  Phelan SM et al. Academic Medicine 2019 94(8) 1178-89

Reviewed by Adwoa Osei



What was study question?

Does racism manifested in medical school training affect medical students' intentions to practice in underserved or minority communities?

How was the study done?

Students from 49 randomly selected US medical schools were longitudinally surveyed using repeated -measure data from the Medical Student Cognitive Habits And Growth Evaluation Study (CHANGE). Web based survey questions were given at the beginning of MS1 and at the end of MS4.

Dependent variables were questions on intentions to practice in an underserved area and planning to work primarily with racial/ethnic minority patients.

Independent variables were:

Manifestations of racism in medical school

  1. Curricula and policies: number of hours on racial disparities and bias, minority health, cultural awareness; recruitment and retention of minority students
  2. Culture and climate: witnessed racial insensitivity from faculty, racial tensions and microaggressions
  3. Attitudes and behaviors: explicit racism, implicit bias, anxiety about treating black patients, attitudes about social justice, desire to behave in unprejudiced way.

What were the results?

The change in intentions from baseline in MS1 to graduation in MS4 in terms of intentions to practice in an undeserved area or intention to work primarily with minority patients were described as transitioning from Yes No or Undecided to Yes No or Undecided in regard to each intention with the associated medical school experiences linked with each change or lack of change. For example, a change from no intention to practice in an underserved area to a positive intention was associated with a stronger medical school commitment to diversity, a school’s orientation toward interracial interactions and number of interactions with black students, faculty and staff. Conversely, a change from a positive to a negative intention was associated with increased medical authoritarianism and negative fourth year explicit racial bias. Other transitions, positive or negative, were likewise linked to positive and negative experiences in medical school related to race.

Why is this important?

Negative explicit racial bias in medical schools was associated with students' choosing not to provide care in and for high need communities.  Prioritizing minority health, commitment to diversity/racial bias training in medical school curricula; increasing minority representation in medical school students, faculty and staff, and facilitating discussions of racial inequity can affect students' intent to practice in underserved/minority communities.

Editor’s note: I graduated from medical school almost 40 years ago at a time when explicit manifestations of racism in medical education were abundant, too awful to recount, and seemingly acceptable to the medical education establishment. There has been a welcome and dramatic change since those days, at least insofar as the omnipresence of overt manifestations of racism, but there is still a long way to go. (RR)


How do we encourage shared decision making?

Promoting Shared Decision-Making Behaviors During Inpatient Rounds: A Multimodal Educational Intervention.

Harman et al. Academic Medicine 2019; 94(7): 1010-1018

Reviewed by: Chelsea Torres & Suzanne Friedman

What was the study question?

What is the effectiveness of a multimodal educational intervention to increase the use of shared decision making behaviours on inpatient rounds?

How was the study done?

Inpatient rounding teams on four distinct adult and pediatric services in two hospitals participated in an 8-week interventional period structured utilizing the Patient Engagement Project (PEP) which was derived from literature review and expert consensus regarding shared decision making (SDM) practices. Intervention techniques involved a four-part education bundle comprised of (1) educational workshops, (2) educational campaign, (3) audit and real-time feedback, and (4) trained observers during patient encounters. SDM was measured using the Rochester Participatory Decision-Making Scale (RPAD) for the 12-week periods before and after the 8-week intervention, scoring 9 behaviors while observing on structured rounds for the four teams.


What were the results?

527 SDM encounters of 175 rounds led by 49 hospitalists were scored and compared for pre and post intervention. Analyses were performed to assess the mean RPAD score improvement on all 9 items. The mean RPAD score went from 3.91 to 5.77 on the 9-point scale, an improvement of +1.86 points (95% CI, 1.33-2.03; P< 0.001; Cohen d = 0.82). There were also associative measurements including mean improvement in RPAD scores of 0.7 to 2.5 points correlating with longer patient encounters and a higher percentage of trainees per team.


What are the implications of these findings?

This study showed a replicable significant improvement in shared decision-making practices during inpatient rounds after PEP intervention. Improved SDM practices were associated with greater number of trainees present on a team and longer patient encounters. A question that arises given these findings is how trainees on a team affect SDM practices. Future studies might explore how education regarding SDM behaviors differs between faculty and trainees, and the benefits of standard SDM education for medical students regarding the incorporation of SDM on inpatient rounds.

Editor’s Comments: Even after this well-designed multimodal intervention, the mean scores were still only 5.77 on a 9-point scale. Of note, the scores were not of individual physicians, but of the “team”, and more learners on the team positively impacts SDM scores. This should push us all to reflect on our own SDM behaviors on rounds and realize that despite what we think about how well we are doing this, we can always do better and furthermore we can always do better as a team. (KFo)



A cheap intervention to build illness scripts

Does providing the correct diagnosis as feedback after self-explanation improve

medical students’ diagnostic performance?Chamberland et al. BMC Medical Education (2019) 19:194

Reviewed by Srividya Naganathan

What was the study question?

What are the effects of giving immediate or delayed content feedback on medical students’ diagnostic performance?

How was the study done?

Third-year medical students from a single institution were randomized into three groups. In the initial learning phase, all the students were given 4 cases and instructed on the use of self-explanation as a learning strategy to answer 3 questions for each case:

  1. What is the most likely diagnosis?
  2. 2. What are the two main arguments supporting this diagnosis?
  3. List two plausible alternative diagnoses

Students in Group 1 were provided the correct diagnosis after each case.  Students in Group 2 were given all the diagnoses after the completion of all 4 cases.  Students in Group 3 did not receive any additional information

In the assessment phase a week later, the students were given 12 cases: 4 with the same diagnoses as the learning cases but different clinical scenarios (near-transfer cases), 4 with the same clinical symptom but different clinical scenarios and different diagnoses (far-transfer cases) and 4 cases with new symptoms and diagnoses.  They were instructed to complete the same questions on each case.

The authors calculated a diagnostic accuracy score based on question 1 and a diagnostic performance score based on all 3 questions.

What were the results?

A total of 94 students participated in the study; There was no difference in the scores at the learning phase between the groups.  In the assessment phase, significant difference was noted for the diagnostic accuracy score between groups for the near-transfer cases (p = .033) but no difference between groups for the far-transfer cases (p = .630). Analysis revealed differences between group 1 and group 3 (p = .048) but not between the group 2 and 3 (p = .081), nor between the group 1 and 2 (p =.974). There was no difference noted in the diagnostic performance score between the groups for both the near and far-transfer cases.


What are the implications of these findings?

Providing feedback (in the form of the correct diagnosis) to students after using self-explanation with clinical cases may improve their diagnostic accuracy but unfortunately, this effect is limited to similar cases. Giving the diagnosis at the end of case discussion may help build illness scripts but does not necessarily promote clinical reasoning when faced with similar initial symptoms but a completely different diagnosis. The diagnostic performance score which is a better measure of clinical reasoning than merely arriving at the correct diagnosis was not different between the groups.

Editor’s Note: The good news—the authors were looking for a cheap intervention that was not faculty resource intensive—and they found one.   The mental practice involved in talking through a simulated case and then connecting it to a diagnosis was enough to make students recognize the correct pattern a week later.  The bad news is that they didn’t seem to be able to apply their thinking to slightly different cases.  For that they might need an actual teacher.  (JG)



Visual arts and reflective medicine

Art as Sanctuary: A Four-Year Mixed-Methods Evaluation of a Visual Art Course Addressing Uncertainty through Reflection.

Gowda D, Dubroff R, Willieme A, Swan-Sein A, Capello C.  Acad Med. 2018 Nov;93(11).

Reviewed by Deepika Singh

What was the study question?

What are the effects of a museum-based course in visual arts on medical students’ observation skills, recognition of uncertainty and cognitive biases and ability to self-reflect?


How was the study done?

An elective museum-based course for first-year medical students was created by two medical schools and led by an art educator experienced in medical education. The course was run and evaluated from 2014 to 2017, with 47 students participating over the 4 years. Before and after the course, students were given the Groningen Reflection Ability Scale (GRAS) for reflective ability, the Tolerance for Ambiguity scale for ambiguity, and the Best Intentions Questionnaire for personal bias awareness.  35 students (74%) completed all the scales. Focus group interviews and narrative post-course evaluations were conducted, coded, and thematically analyzed.

What were the results?

Statistically significant improvement was found in GRAS scores. Qualitative themes included student enhancement of observational skills, awareness of the subjectivity and uncertainty of perception, exploration of multiple points of view, and recognition of the course as a place for restoration and connection to classmates.

What are the implications?

Thoughtful exploration of the subjectivity of perception with the outside world requires reflection, a foundational habit of the skillful practitioner. Incorporating visual art into medical education is an effective pedagogical method for addressing competencies central to training, including observation, reflection, and self-care.

Editor’s Note:  In addition to improving students’ reflection skills, the course evaluations uncovered an unexpected finding highlighted by the article’s title.  The students saw the course as a place of refuge from the breakneck speed of medical school.  The importance of art as sanctuary can not be ignored as we work to create healthy, resilient physicians.  (JG)