Exploring the learning environment in undergraduate medical school curricula: A literature review

Chee, Jessica; Martin, Sonya; Pavalagantharajah, Sureka; Sivapatham, Gajanee; Profetto, Jason

Introduction
During their undergraduate medical education (UGME), students learn fundamental skills that inform their attitudes, behaviours, and knowledge that will be carried forward into their medical careers. Learning of these fundamental skills is informed by the formal curriculum taught to students but must be understood within the context of the learning environment. Gruppen et al. (2018) define a learning environment as “the dynamic, co-constructed perceptions, experiences and behaviors of participants in the physical and virtual spaces within which learning occurs.” Therefore, to fully understand the UGME we must understand the medical culture that is informing students’ attitudes, behaviour, and knowledge of certain topics. 

This study aims to identify aspects of the learning environment and culture of medical school, and how these impact learning of the medical curriculum.

Methods
A search was conducted on Ovid Medline with the search terms “(culture OR relationships OR learning environment) AND (medical education OR curriculum) AND (medical school)”. A title/abstract screen was conducted by one reviewer. A full-text screen was conducted independently by two reviewers; discrepancies were reconciled by discussion. A thematic analysis will be done to identify common components of the culture and learning environment of UGME and how they impact the medical curriculum.

Results
An initial search resulted in 460 articles identified through database searches. This has been narrowed to 36 articles through title/abstract and full-text screening. Common themes that have been identified through an initial reading of these papers include the following: impacts of informal and formal curricular components on learning; problem-based learning compared to traditional learning; changes in perceptions based on beginning clinical rotations; diversity of the student population on learning social justice curricula; and the impact of preceptor-student relationships.

Conclusion
The results of this literature review will be used to better understand the learning environment in UGME curricula. The results of this literature review emphasize a very important part of the conversation in curricular development and delivery: the nuances of the hidden curriculum matter. We have identified multiple themes that are critical to understand and consider when developing and evaluating the effectiveness of medical school curricula.  

“Make a New Old Friend”: An Experiential Education Program Fostering Care of the Elderly

Correia, Rebecca; Klea, Lindsay; Campbell, Graham; Costa, Andrew

Introduction: Canada’s aging population calls for more healthcare professionals with skills to care for the elderly. Research demonstrates that experiential learning improves the relevance, attitudes, and retention of classroom material. Intergenerational, experiential learning should be leveraged to create pathways between students in health-related disciplines and the care of older adults.
The Waterloo Regional Campus of the McMaster University DeGroote School of Medicine established “Make a New Old Friend” in January 2018 to increase student competencies in caring for older adults. This program fosters mutual benefits for students and older adults by facilitating intergenerational knowledge exchange and companionship.
Methods: In the first two program iterations, eight pre-clerkship medical students and four geriatric specialists participated. Students and older adults are paired and meet monthly basis to facilitate relationship-building. In-person visits occur at the LTC residence to expose students to the daily challenges and rewards experienced by older adults. Faculty mentors who practice geriatric medicine are matched with students to share insights and arrange shadow days.
Results: Learning outcomes are consolidated with evaluations based on Kolb’s Experiential Learning Cycle. Semi-structured interviews are conducted with students, older adults, and faculty mentors to gain insights from all perspectives. Students and older adults report high levels of satisfaction with this learning experience in follow-up interviews. Lessons learned from previous program iterations have informed planning and coordination of the current (third) program iteration in 2020. 
Conclusion: Students with various educational backgrounds can benefit from intergenerational programs because our aging population suggests that more of these interactions will occur. The evaluation criteria can be adapted to assess competencies essential to different education or career paths.

Understanding medical students’ perspectives of plastic surgery – Are we teaching correctly?

Leveille, Cameron; Crimi, Nicole; Dunn, Emily; Coroneos, Christopher; Voineskos, Sophocles; McRae, Mark; McRae, Matthew

Despite the need for physician’s referral to plastic surgeons, plastic surgery teaching has declined in undergraduate medical education curriculum. This has led to a further decrease in understanding of plastic surgery’s scope of practice. We utilized a mixed-method approach to evaluate the effectiveness of current plastic surgery teaching at the undergraduate medical education level. A quiz to identify plastic surgical procedures and a 13-item questionnaire utilizing a Likert scale was administered to two cohorts of students: one cohort at the beginning of their clerkship and one cohort at the end of their clerkship. The pre- and post- questionnaire were given to students before and after attending their clerkship plastic surgery education session. These aimed to assess students’ confidence in their understanding of plastic surgery’s scope of practice, as well as their ability to correctly identify which procedures may be conducted by a plastic surgeon. We found that there was no difference in student’s perception of their understanding of plastic surgery before and after their academic session and for those starting clerkship compared to those ending (Z= -0.576, p=0.565). However, students at the end of clerkship demonstrated an improved ability to identify procedures within the plastic surgery domain after attending the education session (t= -2.94, p=0.022). Since this improvement is limited to students at the end of clerkship, these findings suggest that the current plastic surgery teaching might require a more tailored medical education intervention that is more successful in knowledge translation. Furthermore, the lack of change in students’ perception of plastic surgery’s scope of practice across clerkship suggest that there is a lack of exposure to plastic surgery for students. As such, future directions should include the creation of a multi-level education session co-created by students, residents, and faculty to help increase the effectiveness of knowledge translation for students of all educational levels.

Using conversations to help Canadians make better decisions during end-of-life or health crises situations

Dombroski, Jill

When sudden or unexpected critical illness occurs to us or our loved ones, the decision-making task surrounding Advance Care Planning or end-of-life choices can be challenging for the entire health care team, including the family members.
Over the course of one month, interviews with physicians in London, Ontario, graduate students at Western University, and members within the community will be surveyed about their Personal Death Awareness and their own or a loved ones, potential health emergency. Through this qualitative method of surveys, participants will be asked to further participate in focus groups. The data from these surveys and interviews will be conducted under a lens of constructed grounded theory. The results of this study would be beneficial for physicians  to become aware within their own profession when dealing with patients, and the community as patients to have some autonomy if they could not speak for themselves.

Point of care ultrasound in urology: building a feasible introductory training program

Uy, Michael; Lovatt, Catherine (Kate); Hoogenes, Jen; Bernacci, Carol; Matsumoto, Edward

Introduction
Point of care ultrasound (PoCUS) is a widely used bedside tool in urology. Applications include the assessment of an undifferentiated acute scrotum, renal colic, and the guidance of suprapubic catheter placement. However, the user-dependent nature of this modality necessitates appropriate use and competence. The objective of this study was to develop a feasible introductory PoCUS course for urology residents.

Methods
Urology residents of all years completed a 3-hour online course, followed by a 3-hour hands-on seminar involving kidney, bladder, and testicular sonographic scanning. Low cost simulated testicular phantoms were constructed and utilized. Course material was developed by licensed ultrasound technologists, based on the Sonography Canada National Competency Profiles. Pre- and post-course surveys focused on residents’ user-confidence, while pre- and post-course multiple-choice questionnaires (MCQ) assessed theoretical knowledge.

Results
Fourteen urology residents (n = 14) participated in the course. Theoretical knowledge in PoCUS improved significantly (52.8% versus 72.3%, p < 0.001). Self-rated confidence in manipulation of ultrasound controls, doppler imaging, and PoCUS of the kidney, bladder, and testicles also improved (all p < 0.001). All participants indicated that the course increased their likelihood of PoCUS use in clinical practice, and that POCUS training should be integrated into a urology training curriculum.

Conclusion
This study developed and executed a feasible foundational PoCUS course for urology residents based on national ultrasound training guidelines. Following the course, residents significantly improved in user confidence and theoretical knowledge. This easily modifiable and reproducible course can be utilized as an introductory tool for urology residents to begin developing competency in ultrasound, and may act as a stepping stone for further competency-based training programs.

Development and Evaluation of Interprofessional growth assessment tool for students in Problem-Based Learning (PBL) classroom

(Eliya, Yousif), (Padwal, Manreet), (Mishra, Anamika), (Shammas, Rafaella), (Anjum, Khatija), (Nawar, Khaled), (Yazdanshenas, Parichehr), (Hayat, Aaron), (Vierhout, Megan), (Patel, Hemisha), (Yousof, Tamana), (Abed, Soumeya), (Saqib, Zarwa), (Adegoirite, Wale), (Sehmi, Roma), (Bridgewater, Darren), (Labiris, Renee), (Arias, Irwin), and (Ask, Kjetil)

Background: The McMaster Demystifying Medicine Program is an undergraduate course and seminar series that uses a translational approach to develop understandings of how advances in biological and biomedical knowledge can apply to human disease and enhance capacity for knowledge translation and communication. Throughout the course, students are required to think critically, give and receive feedback, take the lead on their learning, independently appraise the literature, work in an interdisciplinary team, resolve conflict, and develop skills in written and oral communication orally and written and so on. In this process, we developed a Teamwork, Science and Communication Observation Tool which is a 32-item scale designed to assess student perception of interpersonal growth in areas related to teamwork, communication, feedback, critical appraisal of literature and knowledge translation. The scale was designed to assess the fundamental knowledge of student-driven Problem-Based Learning (PBL) classrooms and soft-skills which the Demystifying Medicine course aims to teach and enhance. In 2017, six more items were added to the scale to better understand student perception and behaviour during problem-solving assignments within the course. All items were organized using Likert-scale responses in which each item is equally weighted across and within subscales.

Method and results: In this study, we will aim to evaluate content validity using experts’ ranking and rating methods. We are establishing a priori that items falling below 70% of respondent ranking as “extremely relevant” or “somewhat relevant” will be omitted from the scale. Furthermore, exploratory factor analysis using Varimax rotation matrix and factor loading between 0.3-0.7 will be used to further asses included factors (i.e., Item domains). Reliability will also be tested through internal consistency assessment and test-retest. Internal consistency will be presented using coefficient alpha and its variance, test-retest will be represented using Pearson’s correlation coefficient for continuous data and Intraclass Correlation coefficient (ICC) for dichotomous data.

Conclusion: Teamwork, Science and Communication Observation Tool is the first-ever educational tool that measure student interprofessional development in a student-driven classroom. 

Developing a Curriculum to Address the Medicine/Psychiatry Interface for PGY-1 Psychiatry Residents

Snelgrove, Natasha; Westcott, Sandra; Brown, Michael; Pardhan, Kaif; Pardhan, Alim; Harms, Sheila

Introduction: Until 2019, PGY-1 psychiatry residents at McMaster University participated in generic, didactic academic learning sessions along with learners from other specialties. Psychiatry residents felt that these sessions lacked applicability to their own learning. Due to changes at the postgraduate level, the psychiatry program at McMaster developed an independent PGY-1 medical psychiatry curriculum to address resident needs and their identified learning gaps.

Methods: A scoping assessment was completed by collating focus group feedback and rotation assessments from the previous curriculum. In response, a unique, case-based curriculum rooted in the interface between medicine and psychiatry was developed by experienced educators from psychiatry, internal medicine, and emergency medicine with contributions from senior psychiatry residents.  This curriculum was launched for PGY-1 residents in the 2019-2020 academic year. Evaluations are being collected for all sessions and evaluations are available for 7 sessions thus far, with response rate to evaluations ranging from 3 to 7 residents per session, of a total of 9 PGY-1 residents. A focus group will be held in April 2020, at the conclusion of the curricular sessions to further evaluate the curriculum.

Results: 15 case-based sessions including simulation sessions were created focusing on core topics including cardiac emergencies, seizures, neurological issues, and chronic health issues situated within psychiatric settings. Emerging data from session evaluations show that residents highly value the case-based and active learning components of this curriculum and the interdisciplinary teachers. The focus group planned for April will add depth to the evaluations received to date and allow a more nuanced curricular evaluation, including both content and format.

Conclusion: This session will discuss the cross-disciplinary collaborative process involved in curriculum and case development. It will also further discuss the results of the evaluations to date as well as changes planned for the upcoming academic year.

Evaluation of Point of Care Ultrasound (POCUS) Training for Midwives

Johnston, Bronte; Darling, Liz; Malott, Anne; Bernacci, Carol; Thomas, Laura; Murray-Davis, Beth  

In 2018, the College of Midwives of Ontario expanded the scope of practice for registered midwives to include performing point of care ultrasound (POCUS) which can aid an obstetric clinical exam. This project will evaluate for the first time a POCUS curriculum developed for midwives and learner skill acquisition as well as future improvements. The course includes a wide variety of educational methods to teach POCUS including online modules, hands-on training, and a clinical practicum. Assessment of learners will include module specific quizzes, objective structured clinical examination (OSCE), demonstration of skills and completion of a clinical practicum.

A concurrent triangulation with mixed-methods approach will be used, all data will be collected concurrently. The outcomes of interest include knowledge and skill acquisition, acceptability of the course and educational impact. There are three components of this study: 1. Surveys - Three surveys, a pre-course, post-course, and four months post-course, will evaluate how midwives apply POCUS in their practice following training and gather feedback on the POCUS course content. Five- and seven-point Likert scale will be described statistically. Open-ended questions will be qualitatively analyzed using thematic analysis. 2. Interviews - Semi-structed interviews will be conducted to better understand their knowledge, attitudes, behaviours, and how well they integrated POCUS within their clinical practice. Interviews will be coded and analyzed using selective and axial coding following grounded theory principles using NVivo12. 3. Prospective cohort study- a comparison between those with a portable ultrasound device and without will be conducted to compare their on-going POCUS skill development. These participants will complete a logbook, a series of ultrasound images, and an OSCE. These assessments will be compared between the two cohorts using tests of statistical significance and distribution.

The findings of this project will have a direct and meaningful impact on how registered midwives in Ontario learn POCUS. There will be a better understanding of how midwives are integrating POCUS into their practice to improve patient care. This research will highlight educational methods that can be applied to POCUS across Canada as well as the shifting scope of practice of midwives in Canada and internationally.

Radiology and Anatomy Knowledge Among Medical Students in a Problem–Based Learning Curriculum

Walker, Danielle; Larocque, Natasha; Gunaseelan, Senthujan; Ramadan, Sherif; Fong, Crystal; Leung, Vincent; Lee, Stefanie

Introduction: Until recently, no formal undergraduate radiology curriculum has existed at McMaster University. We performed an assessment of the radiology knowledge of the last graduating class who received no formal radiology teaching. This data will serve as a baseline to gauge the longitudinal impact of a new curriculum, which includes a partnership with the Anatomy Department to improve the teaching of radiologic anatomy.

Methods: A 50-question multiple-choice quiz was administered to graduating medical students covering the topics of radiologic anatomy, imaging interpretation and appropriate imaging ordering. The validated questions were obtained through an international database provided by the Alliance of Medical Student Educators in Radiology (AMSER). The web-based platform used to create/administer the quiz (Radiology ExamWeb) provides detailed statistical analysis on each question; as such, scores of McMaster students could be compared to international results.

Results: A total of 172 (83.5%) McMaster students completed the quiz. The mean score for
McMaster students was 64.5% vs.72.8% (international average) (p=0.02). McMaster students had lower scores on the radiologic anatomy (61.0% vs.79.1%; p=0.01) and imaging interpretation (51.7% versus 67.4%; p=0.04) sections. There was no difference between the groups on the questions involving appropriate imaging ordering (73.8% versus 71.8%; p=0.71).

Conclusion: This study noted deficiencies in the knowledge of McMaster graduates in the areas of radiologic anatomy and image interpretation. Based on our quiz findings and student feedback, our new curricular initiatives will focus on strengthening these areas. This includes new integrated Radiology-Anatomy lectures that thus far have been well received based on student evaluations.

Musculoskeletal Medicine in Undergraduate Medical Education

McNeill, Kestrel (1); Bryant, Dianne (1); Peterson, Devin (2); Sonnadara, Ranil (1)(2)

Introduction
Musculoskeletal (MSK) diseases are responsible for some of the most prevalent conditions affecting population health in the world. Despite their prevalence, many medical students are not comfortable treating MSK conditions, and lack the knowledge to diagnose and manage these disorders effectively. This lack of comfort and knowledge has been directly linked to deficiencies in the undergraduate medical education curriculum. The purpose of this research was to explore and describe faculty and student perceptions of the current MSK curriculum in the DeGroote School of Medicine.

Methods
A qualitative interpretive description study was conducted. Purposive, maximum variation sampling was employed to recruit faculty (n=6) and students (n=10) from the DeGroote School of Medicine for semi-structured interviews. Participants were interviewed until data saturation and convergence were reached. The transcribed data from interviews were analyzed for emergent themes using an inductive approach.

Results
Students identified case-based tutorials and clinical skills sessions as being useful in learning the general approach to MSK conditions, but suggested lectures were inefficient and ineffective for learning MSK. Indeed attendance was generally low at MSK lectures. Students described MSK as a low priority topic unless they were interested in pursuing “MSK heavy” specialties and reported that anatomy exposure prior to the beginning of their medical education was necessary to keep up with the pace of the material.  Faculty members identified inadequate foundational anatomy knowledge as a barrier to their clinical teaching, and reported that MSK was an under-appreciated area amongst students. Both faculty and students reported a lack of time allocated in the curriculum to teaching MSK anatomy and clinical topics, and insufficient diversity in clinical cases as barriers in effective MSK teaching and learning. Lack of integration of MSK concepts throughout the curriculum made it difficult to consolidate knowledge and retain the material needed to manage MSK conditions effectively in clinical settings.

Conclusion
Both faculty and students identified similar barriers to teaching and learning MSK effectively. Current approaches to the MSK curriculum are insufficient. Future work will address the issues identified by both faculty and students.

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