|Two heads are better than one?|
|Three visions of doctoring: a Gadamerian dialogue|
Medicine in the twenty-first century faces an 'identity crisis,' as it grapples with the emergence of various 'ways of knowing,' from evidence-based and translational medicine, to narrative-based and personalized medicine. While each of these approaches has uniquely contributed to the advancement of patient care, this pluralism is not without tension. Evidence-based medicine is not necessary individualized; personalized medicine may be individualized but is not necessarily person-centered. As novel technologies and big data continue to proliferate today, the focus of medical practice is shifting away from the dialogic encounter between doctor and patient, threatening the loss of humanism that many view as integral to medicine's identity. As medical trainees, we struggle to synthesize medicine's diverse and evolving 'ways of knowing' and to create a vision of doctoring that integrates new forms of medical knowledge into the provision of person-centered care. In search of answers, we turned to twentieth-century philosopher Hans-Georg Gadamer, whose unique outlook on "health" and "healing," we believe, offers a way forward in navigating medicine's 'messy pluralism.' Drawing inspiration from Gadamer's emphasis on dialogue and 'practical wisdom' (phronesis), we initiated a dialogue with the dean of our medical school to address the question of how medical trainees and practicing clinicians alike can work to create a more harmonious pluralism in medicine today. We propose that implementing a pluralistic approach ultimately entails 'bridging' the current divide between scientific theory and the practical art of healing, and involves an iterative and dialogic process of asking questions and seeking answers.
|Learning climate positively influences residents' work-related well-being|
An optimal learning climate is crucial for the quality of residency training and may also improve residents' well-being and empathy. We investigated the associations of learning climate with residents' work-related well-being. A multicenter questionnaire study was performed among 271 surgery and gynaecology residents in 21 training programs from September 2012 to February 2013. Residents were asked to complete work-related well-being measurements: work engagement (Utrecht Work Engagement Scale), job and specialty satisfaction (measures from Physician Worklife Study), and physician empathy (Jefferson Scale of Physician Empathy). The Dutch Residency Educational Climate Test was used to evaluate learning climate. Multivariate adjusted linear regression analyses were used to estimate associations of learning climate with work-related well-being measures. Well-being measures were completed by 144 residents (53.1%). Learning climate was evaluated by 193 residents, yielding 9.2 evaluations per training program on average. Overall learning climate score was positively associated with work engagement [regression coefficient b = 0.58; 95% confidence interval (CI) 0.18–0.98; p = 0.004] and job satisfaction (b = 0.80; 95% CI 0.48–1.13; p < 0.001). No associations were found between learning climate and empathy and specialty satisfaction. Residents' work engagement and job satisfaction are positively related to the learning climate and may be further enhanced by improved learning climates of training programs.
|Early identification of first-year students at risk of dropping out of high-school entry medical school: the usefulness of teachers' ratings of class participation|
Dropping out from undergraduate medical education is costly for students, medical schools, and society in general. Therefore, the early identification of potential dropout students is important. The contribution of personal features to dropout rates has merited exploration. However, there is a paucity of research on aspects of student experience that may lead to dropping out. In this study, underpinned by theoretical models of student commitment, involvement, and engagement, we explored the hypothesis of using inferior participation as an indicator of a higher probability of dropping out in year 1. Class participation was calculated as an aggregate score based on teachers' daily observations in class. The study used a longitudinal dataset of six cohorts of high-school entry students (N = 709, 67% females) in one medical school with an annual intake of 120 students. The findings confirmed the initial hypothesis and showed that lower scores of class participation in year 1 added predictive ability to pre-entry characteristics (Pseudo-R2 raised from 0.22 to 0.28). Even though the inclusion of course failure in year 1 resulted in higher explanatory power than participation in class (Pseudo-R2 raised from 0.28 to 0.63), ratings of class participation may be advantageous to anticipate dropout identification, as those can be collected prior to course failure. The implications for practice are that teachers' ratings of class participation can play a role in indicating medical students who may eventually drop out. We conclude that the scores of class participation can contribute to flagging systems for the early detection of student dropouts.
|Challenging encounters as experienced by registered nurses new to the emergency medical service: explored by using the theory of communities of practice|
The aim of this study was to explore challenging encounters experienced by registered nurses (RN) during their first year in the emergency medical service by using the social learning theory of communities of practice. During the first year in a new professional practice, a new RN experiences a transition during which the new professional identity is being formed. This is a challenging and demanding period of time. According to the learning theory of communities of practice by Lave and Wenger, individuals' learning and development in a new professional practice occurs through participation in social activity and is influenced by context. This study is based on the qualitative data from semi-structured interviews. Thirty-two RNs working in the Swedish emergency medical service were interviewed via telephone during the spring of 2017. A qualitative content analysis with deductive reasoning of the interviews was used. The analysis process generated the main category; New RNs participation is challenged by unpredictability and uncertainty in practice. The main category was based on three generic categories; Loneliness in an unpredictable context, Uncertainty about the team, and Uncertainty in action. The challenges new RNs encounter during the first year relate to all three dimensions of a community of practice; mutual engagement, joint enterprise and shared repertoire. The encountered challenges also relate to the EMS context. Taking into account all these aspects when designing support models for RN's professional development may be advantageous for creating positive development for RNs new to the EMS and/or similar practices.
|Associations between motivational factors for studying medicine, learning approaches and empathy among medical school candidates|
Previous research highlighted associations between students' motivation for medical studies and their learning approaches on the one hand and empathy on the other. Internal motivational factors for studying medicine (e.g., care for patients, save lives) coupled with a deep approach to learning have been positively related to empathy in contrast to external motivational factors (e.g., future earning potential, prestige) and surface learning. However, assessments of these assumptions among medical school candidates are scarce. This study examined the relationship between different motivational factors and empathy among students enrolled in a selection year in medicine by testing the mediating role of learning approaches. A sample of 572 candidates for medical studies answered a self-reported questionnaire half way through their selection year. Measures included internal and external motivational factors for studying medicine, deep and surface learning approaches and empathy. Path-analysis tested the mediation effects of deep and surface approaches to learning on the relationship of internal and external motivational factors with empathy. The deep learning approach partially mediated the significant positive association between internal motivational factors and empathy, while the surface learning approach fully mediated the significant negative association between external motivational factors and empathy. These results suggest that learning approaches could be a pathway by which internal and external motives for studying medicine are related to empathy among medical school candidates. Pedagogical strategies and educational environments accounting for individual differences in motivation and learning may contribute to training students to become professional and caring doctors in the future.
|Fostering medical students' clinical reasoning by learning from errors in clinical case vignettes: effects and conditions of additional prompting procedures to foster self-explanations|
The present study aims at fostering undergraduate medical students' clinical reasoning by learning from errors. By fostering the acquisition of "negative knowledge" about typical cognitive errors in the medical reasoning process, we support learners in avoiding future erroneous decisions and actions in similar situations. Since learning from errors is based on self-explanation activities, we provided additional prompting procedures to foster the effectiveness of the error-based instructional approach. The extent of instructional support in a web-based learning environment with erroneous clinical case examples was varied in a one-factorial design with three groups by either presenting the cases as (a) unsupported worked examples or by providing the participants with (b) closed prompts in the form of multiple-choice tasks or (c) with open reflection prompts during the learning process. Despite significant learning progress in all conditions, neither prompting procedure improved the learning outcomes beyond the level of the unsupported worked example condition. In contrast to our hypotheses, the unsupported worked example condition was the most effective with respect to fostering clinical reasoning performance. The effects of the learning conditions on clinical reasoning performance was mediated by cognitive load, and moderated by the students' self-efficacy. Both prompting procedures increased extraneous cognitive load. For learners with low self-efficacy, the prompting procedures interfered with effective learning from errors. Although our error-based instructional approach substantially improved clinical reasoning, additional instructional measures intended to support error-based learning processes may overtax learners in an early phase of clinical expertise development and should therefore only be used in moderation.
|Supporting self-regulation in simulation-based education: a randomized experiment of practice schedules and goals|
Self-regulated learning is optimized when instructional supports are provided. We evaluated three supports for self-regulated simulation-based training: practice schedules, normative comparisons, and learning goals. Participants practiced 5 endoscopy tasks on a physical simulator, then completed 4 repetitions on a virtual reality simulator. Study A compared two practice schedules: sequential (master each task in assigned order) versus unstructured (trainee-defined). Study B compared normative comparisons framed as success (10% of trainees were successful) versus failure (90% of trainees were unsuccessful). Study C compared a time-only goal (go 1 min faster) versus time + quality goal (go 1 min faster with better visualization and scope manipulation). Participants (18 surgery interns, 17 research fellows, 5 medical/college students) were randomly assigned to groups. In Study A, the sequential group had higher task completion (10/19 vs. 1/21; P < .001), longer persistence attempting an ultimately incomplete task (20.0 vs. 15.9 min; P = .03), and higher efficiency (43% vs. 27%; P = .02), but task time was similar between groups (20.0 vs. 22.6 min; P = .23). In Study B, the success orientation group had higher task completion (10/16 vs. 1/24; P < .001) and longer persistence (21.2 vs. 14.6 min; P = .001), but efficiency was similar (33% vs. 35%; P = .84). In Study C, the time-only group had greater efficiency than time + quality (56% vs. 41%; P = .03), but task time did not differ significantly (172 vs. 208 s; P = .07). In this complex motor task, a sequential (vs. unstructured) schedule, success (vs. failure) orientation, and time-only (vs. time + quality) goal improved some (but not all) performance outcomes.
|Impact of funding allocation on physical therapist research productivity and DPT student graduates: an analysis using panel data|
Financial support for institutional research is relatively stagnant, and thus institutions are likely to seek tuition revenue to offset the costs of research and teaching. It is likely that this has led to increases in tuition driven activities, and thus has limited research activities of academic physical therapy (PT) programs in particular. However, the relationships between sources of program revenue, the number of graduates from PT programs, and the scholarly production of PT faculty have not been studied. The purpose of this paper is to study the effects of types of funding—including research grants and tuition—on the number of physical therapy graduates from each program and the research productivity of physical therapy faculty. Data from 2008 to 2016 were utilized to perform a fixed-effects panel analysis. Panel models created predictions for the number of graduates and the number of peer-reviewed publications for programs from grant funding, annual tuition, and number of funded faculty members. In any given program, a 1% increase in annual tuition is associated with 24% more graduates per year, but a single percentage point increase in the mix of NIH grant funding over other funding types is associated with 8% fewer graduates, all else equal. For every 1% increase in annual tuition, a program can expect to have 41% fewer publications per year. Those institutions with higher numbers of graduates tended to have higher numbers of publications. Higher annual program tuition appears to be associated with both higher numbers of physical therapy graduates and lower levels of publications. Different funding sources have variable effects on degree production and scholarly productivity. Data are self-reported by programs on the Annual Accreditation Report, and cause and effect cannot be established through observational design.
|Student participation in governance of medical and veterinary education: experiences and perspectives of student representatives and program directors|
Student participation in governance of education is of growing interest. However, it remains unclear what factors render this participation in institutional governance a success or a failure. Another question is: what are the perceived benefits for schools and students? We empirically explored experiences and perspectives of student representatives and program directors of all (8) medical and (1) veterinary schools in the Netherlands on factors that influence student participation in institutional governance and its values and challenges for schools and student representatives. A constructivist grounded theory study was performed. A theoretical sample of student representatives was invited to fill out an explorative, qualitative questionnaire. Next, focus groups with student representatives and interviews with all program directors were conducted. Data was analyzed using open, axial and selective coding by all authors. Experiences and perspectives of students and program directors were remarkably similar in both perceived influences and values. Four main categories of influences could be distinguished in student participation: (1) individual student characteristics, (2) individual staff characteristics, (3) the organization of student representatives and (4) the school's organization, including its culture and policy regarding student participation. A cohesive, well-organized and independent student organization has crucial impact on student participation in educational governance processes. For representatives, major benefits of participation are personal and career development. Challenges are low effectiveness and efficiency of their actions. A clear school policy on student participation and better introduction, feedback and coaching of representatives should be provided to improve student participation in governance processes.