4th-year Medical Students Research Articles

Medical students\u2019 perceptions of a career in family medicine

BackgroundIn Israel, there is a shortage of family medicine (FM) specialists that is occasioned by a shortage of students pursuing a FM career.MethodsA questionnaire, based on methods adapted from marketing research, was used to provide insight into the medical specialty selection process. It was distributed to 6th-year medical students from two Israeli medical schools.ResultsA response rate of 66% resulted in collecting 218 completed questionnaires. Nineteen of the students reported that they were interested in FM, 68% of them were women. When compared to students not interested in FM, the selection criteria of students interested in FM reflected greater interest in a bedside specialty which provides direct long-term patient care. These latter students were also more interested in a controllable lifestyle that allowed time to be with family and children and working outside the hospital especially during the daytime. These selection criteria aligned with their perceptions of FM, which they perceived as providing them with a controllable lifestyle, allowing them to work limited hours with time for family and having a reasonable income to lifestyle ratio. The students not interested in FM, agreed with those interested in FM, that the specialty affords a controllable lifestyle and the ability to work limited hours Yet, students not interested in FM more often perceived FM as being a boring specialty and less often perceived it as providing a reasonable income to lifestyle ratio. Additionally, students not interested in FM rated the selection criteria, academic opportunities and a prestigious specialty, more highly than did students interested in FM. However, they perceived FM as neither being prestigious nor as affording academic opportunitiesConclusionThis study enriches our understanding of the younger generation's attitudes towards FM and thus provides administrators, department chairs and residency program directors with objective information regarding selection criteria and the students’ perceptions of FM. We identified the disconnect between the selection criteria profiles and the perceptions of FM of students not inclined to pursue a residency in FM. This allowed for recommendations on how to possibly make FM more attractive to some of these students.

A cross-sectional study to assess knowledge, attitude, and awareness of forensic odontology among medical students: An emergency concern

Background: Medical professionals are important in treating and management of victims of mass disasters, abuse, and organized crimes. Although the forensic odontologist has a pivotal role in the investigation, health-care provider in the emergency medicine should have the potential to detect, inform, and interact with the dentist for further applications in legal issues. We aimed to conduct the present study on the knowledge, awareness, and attitude among the medical students. Materials and Methods: With informed consent, we conducted a cross-sectional study among 194 4th-year medical students. A structured questionnaire consisting of 17 items relating to forensic odontology to assess the knowledge, awareness, and attitude among medical students and data were collected and reviewed. Results: On analyzing the collected data of 194 participants, the percentage of participants who knew: the meaning of forensic odontology, forensic odontology a part of forensic medicine, and role of forensic odontology in the criminal analysis were 172 (87%), 192 (99%), and 181 (93%), respectively. A total of 183 (94%) were aware of bite mark patterns, 171 (88%) would examine for bite marks in child abuse, 89 (46%) the lip prints, DNA as accurate and sensitive method of comparison and teeth as source of DNA was 128 (66%) and 122 (63%), respectively. A total of 127 (65%) agreed that forensic odontologist as experts, 101 (52%) had opted for dental evidence, and 139 (72%) had agreed that postmortem unit should include a dental laboratory facility. However, only 79 (41%) knew the tooth as the choice of evidence in mass disaster. 101 (52%) stated dentist as expert witness. The awareness of the role of teeth in age and gender estimation was 147 (76%) and 79 (41%), respectively. Forty-nine (25%) had handled forensic dentistry case in emergency medicine and importance of maintaining dental records were known to 85 (44%). Conclusions: Medical students had inadequate knowledge of forensic odontology. As a health-care provider, medical professionals should understand the implications of forensic odontology.

Assessment of toxicology knowledge in the fourth-year medical students: Three years of data.

Pharmacology and toxicology are core content knowledge for physicians. Medical students should demonstrate understanding of general pharmacology and basic treatment of poisoning. The objective of this study was to measure the knowledge of the 4th-year medical students (MS4) on these topics over 3 years. A multiple-choice exam (15 questions) was administered to MS4 students in spring of 2010, 2011, and 2012. Questions were developed by medical toxicologists to evaluate basic knowledge in three areas: pharmacologic effects (PE), treatment of poisoning (TOP), and pharmacokinetics (PK). The students were grouped by intended specialties into pharmacologic intense (anesthesia, emergency medicine, internal medicine, pediatrics, and psychiatry), less pharmacologic intense specialties (dermatology, OB/GYN, ophthalmology, pathology, physical medicine and rehabilitation, radiology, and surgery) and by completion of a pharmacology or toxicology elective. Mean group scores were compared using ANOVA. Totally 332 of 401 (83%) students completed the survey. Mean scores were stable over the three years, higher for students completing a toxicology rotation and for students entering a pharmacologically intense specialty. The external validity is limited to a single medical school with incomplete participation and content was limited by the survey length. Consistent results over the three-year period and correlation of performance with completing a toxicology rotation and intent to enter a pharmacology intensive specialty suggest this survey may correlate with toxicology knowledge. Implementation of required core courses focused on toxicology may improve core content knowledge in fourth year medical students.

Medical Students' Views of Medicine as a Calling and Selection of a Primary Care-Related Residency.

With the US health care system facing a primary care physician shortage, we evaluated whether medical students who saw medicine as a calling were more likely to enter a family medicine, internal medicine, or pediatrics residency program. Of the 591 4th-year medical students who responded to a survey item on medicine as a calling, 237 strongly agreed that the "practice of medicine is a calling." Students who strongly agreed that medicine was a calling had higher odds (P=.003) of selecting a primary care-related residency. Identifying with medicine as a calling may increase the likelihood of pursuing a primary care career.

Medical students’ perspectives on the anatomy course at the University of Zimbabwe

Background. Traditional academic-led anatomy teaching methods, such as didactic lectures and cadaver dissections, are on the decline, as more student-led teaching methods are being adopted. Objectives. To assess medical students’ perspectives on the teaching objectives achieved by traditional teaching methods (lectures, cadaver dissections and tutorials) used in the anatomy course. Methods. A cross-sectional survey comprising a matrix questionnaire was performed among selected 1st-year - 5th-year medical students, using stratified random sampling. The students were requested to select a score between 0 and 5 to represent the fit between the learning outcome and the teaching method, with 0 being no fit and 5 representing a perfect fit. Results. Lectures had the highest mean score of 3.871 for the ability to provide medical vocabulary. Cadaver dissection had the highest mean score of 3.488 for its ability to develop team skills. The highest mean score of 3.415 for all three teaching methods combined was recorded for the learning outcome relating to imparting an anatomical foundation, while the lowest mean score of 2.731 was recorded for the development of skills in order to follow complicated instructions. However, no teaching method had an excellent fit (mean ≥4.5) with any of the teaching objectives. Conclusion. The study showed that the three teaching methods being used in the anatomy course were, to a great extent, useful to impart the skills and content base. However, other teaching methods, such as problem-based and team-based learning, have to be considered to achieve the other important learning outcomes.

Developing Empathy: Does Experience Through Simulation Improve Medical-Student Empathy?

This study used a role-play experience of stroke to improve student empathy for patients with neurological deficits. Participants were 4th- and 5th-year medical students (n = 62). Students worked in pairs, one as patient, and the other as carer/observer. To simulate middle cerebral artery infarction, the patient was fitted with a leg splint, their arm was placed in a sling with the hand taped closed, and they wore glasses that blocked half of their visual field in each eye to simulate homonymous hemianopia. The patient then attended to their daily duties and completed a list of tasks. All participants completed the Jefferson Scale of Physician Empathy (student version) before and after the role-play exercise and wrote a reflection about their experience. There was a statistically significant increase in mean empathy scores from baseline to post-participation. Students found the experience valuable and reported increased recognition of the time taken to complete tasks, receiving odd looks and stares, feeling judged, and greater understanding of stigma and of the experiences of people with disabilities. This role-play of a stroke experience improved medical-student empathy. Role-play experiences could be used more widely in clinical education.

A Needs Assessment Report for Development of an Obstetrics and Gynecology Skills Elective

OBJECTIVE: We completed a needs assessment for obstetrics and gynecology exam and procedural skills to inform a 4th-year exam and procedural skills elective. METHODS: We surveyed 4th-year medical students matching in ob-gyn and junior ob-gyn residents about what skills should be included in a 4th-year procedure elective. We created a 15-question survey of ob-gyn exam and procedural skills using APGO Medical Student Educational Objectives and Year One Milestones, with answers on a Likert scale. RESULTS: Ten (7%) 4th-year medical students who matched into ob-gyn residency and 18 (48%) ob-gyn residents at the University of Colorado completed the survey. They identified basic ultrasound skills (96%), postoperative care (96%), and surgical preparation (93%) as the most valuable procedural skills to include in a 4th-year medical school elective for students entering into an obstetrics and gynecology residency. The procedural skills with the lowest support for to inclusion in an elective were hysteroscopy (32%), laparoscopy (43%), and colposcopy (61%). CONCLUSION: Students entering ob-gyn and junior ob-gyn residents desire training in ultrasound skills, basic surgical preparation, and postoperative care education over more complex ob-gyn procedural skills before residency. We will use these results to create a 4th-year medical student elective that includes these skills.

Medical Student Attitudes on Abortion Reflect Professionalism: A Qualitative Exploration

OBJECTIVE: In medical education we must train learners to be competent in aspects of professionalism. It is challenging to assess an individual’s professionalism. The goal of this study was to examine the extent that medical students' attitudes toward abortion, as captured through vignettes and interviews, reflect their overall general professionalism attitudes. METHODS: We conducted qualitative interviews with 4th-year medical students who had applied for ob/gyn residency programs between 2012 and 2014. Semi-structured interviews explored factors that influenced their attitudes toward abortion before medical school, any transition in attitudes that occurred during medical school, and how they perceive abortion to be relevant to their future training and medical practices. Narratives were analyzed for meaningful patterns regarding professionalism tenants as outlined in the Charter for Medical Professionalism based on an analytical approach. RESULTS: The final sample included 74 students enrolled in 39 medical schools in 25 states and the District of Columbia. Within-transcript content related to abortion attitudes, three themes emerged. First, students reflected on abortion care as a primacy of patient welfare. Second, students recognized patient autonomy was preserved when abortion was offered as a pregnancy option. Lastly, students advocated that availability of abortion services fell within the preview of social justice to be afforded to their future patients. CONCLUSION: The investigation of attitudes toward abortion through a qualitative approached provides an assessment of professionalism tenants in medical students. This finding may inform professionalism curricula that utilize pregnancy options and abortion case-based scenarios to facilitate medical student learning and assessment.

Preparing Fourth-Year Medical Students to Collaborate With Nurses: An Innovative Paging Curriculum

BACKGROUND: Effective communication and collaboration between physicians and nurses improves patient care outcomes, decreases costs, and is a crucial aspect of new interns' responsibilities. However, little formal training is provided to graduating medical students. METHODS: A simulated paging curriculum was administered to 4th-year medical students participating in an OBGYN residency preparation elective. Certified Nurse Midwives administered the pages, and simulated the role of a floor nurse. Students completed a survey before and after the curriculum. Students indicated on a 100 mm visual analogue scale (1=not comfortable at all, 100=extremely comfortable) their comfort gathering information, their comfort providing patient care management, and their comfort collaborating on patient care with a nurse. Pre- and postresponse means were compared utilizing paired t tests. RESULTS: Eleven students completed the paging curriculum, and eight (72%) responded to the survey. After the curriculum, students felt more comfortable gathering information from a nurse (before 57.1, after 87.5; P=.0071), providing patient care management with a nurse (before 47.8, after 85.6; P=.0038), and collaborating on patient care with a nurse (before 66.1, after 93.6; P=.0015). DISCUSSION: Medical students felt more comfortable collaborating with nurses on patient care after participating in a simulated paging curriculum. Although a limitation of our study is the small sample size, these pilot data suggest that improvement in the nursing-resident interaction can be made with innovative simulated paging curricula.

Fifth-year medical students’ perspectives on rural training in Botswana: A qualitative approach

Background. The curriculum of the Faculty of Medicine at the University of Botswana includes rural community exposure for students throughout their 5 years of training. In addition to community exposure during the first 2 years, students complete 16 weeks of family medicine and 8 weeks of public health medicine. However, as a new faculty, students’ experiences and perceptions regarding rural clinical training are not yet known. Objective. To describe the experiences and perceptions of the 5th-year medical students during their rural training and solicit their recommendations for improvement. Methods. This qualitative study used face-to-face interviews with 5th-year undergraduate medical students ( N =36) at the end of their family medicine rotation in Mahalapye and Maun villages. We used a phenomenological paradigm to underpin the study. Voice-recorded interviews were transcribed and analysed using Atlas TI version 7 software (USA). Results. Three main themes were identified: ( i ) experiences and perceptions of the rural training environment; ( ii ) perceptions of the staff at rural sites; and ( iii ) perceptions of clinical benefits and relevance during rural training. While the majority of students perceived rural training as beneficial and valuable, a few felt that learning was compromised by limited resources and processes, such as medical equipment, internet connectivity and inadequate supervision. Conclusion. While the majority of students perceived rural training as beneficial, students identified limitations in both resources and supervision that need to be improved. Understanding students’ rural training experiences and perceptions can help the Faculty of Medicine, stakeholders and site facilitators to guide future rural training implementation.

Epileptic seizure or not? Proportion of correct judgement based only on a video recording of a paroxysmal event

PurposeOur study was intended to measure the proportion of correct seizure recognition among different medical and non-medical groups based on only a video recording. MethodsVideo recordings about paroxysmal movements of 15 very young infants (2days − 5 months of age) were displayed for six groups: 159 1st-year medical students, 65 4–5th-year medical students, 52 paediatric residents, 18 paediatric neurologists from different European countries, 43 adult neurologists and 37 parents whose children were treated at our Department. All participants were asked to decide which recording they considered as of epileptic origin or a non-epileptic event. Correct answer rate (CAR) was calculated in each group for every video. ResultsThe average CAR was the lowest in the group of 1st-year medical students (36.6%), the best results were reached by paediatric neurologists (67.4%). The CAR was significantly different between the groups of 1st-year medical students and paediatric neurologists (p=0.02), and between the groups of 1st-year medical students and residents (p=0.045). The CAR of the most deceptive epileptic seizure was only 18.2%. The judgement of parents proved to be better than that of the 1st-year medical students. ConclusionsRecognising epileptic seizures in very young infants without EEG is extremely inaccurate. Even trained paediatric neurologists were able to judge correctly the different movement types in only 67.4% of the cases. The role of education and experience is clearly indicated by the increase in CAR from 1st-year medical students through well–trained paediatric neurologists.

Developing capability through peer-assisted learning activities among 4th-year medical students and community health workers in community settings

Background. The Longitudinal Community Attachment programme for Students (L-CAS) is an activity by means of which each student is exposed to primary healthcare learning and practice in communities. Capability has been described as ‘an integration of knowledge, skills, personal qualities and understanding used appropriately and effectively … but in response to new and changing circumstances’. Within this paradigm, peer-assisted learning (PAL) has been used to support the development of student capability during L-CAS activities. Objective. To evaluate the impact of PAL sessions on student and community health worker (CHW) capability development. Methods. Study participants comprised 4th-year medical students and CHWs. Student data were drawn from the rotation reflective reports (RRRs) and CHW data from semi-structured interviews. Results. The main themes that emerged from the RRRs and interviews were the impact on the personal and professional development of participants; the creation of awareness and understanding of the context of the communities; relationship building; and the impact of peer learning activities on the knowledge, skills and attitudes of participants. Conclusion. In the process of addressing the challenge of preparing capable professionals, PAL was found to be a very effective way of positioning peers in relation to each other as resources. PAL activities enhanced the abilities of students and CHWs to learn from experience and to achieve the goals of critical reflection and experiential learning.

Brain Death: Knowledge of Future Brazilian Physicians

BackgroundThousands of people die on the waiting list for transplants. The shortage of organs and tissues for transplantation is considered a serious global problem. Brain death (BD) is the main source of organs for transplantations. ObjectiveGiven that BD is assessed by medical staff and that this diagnosis is ethically relevant, the goal of this work was to analyze the knowledge of 5th- and 6th-year medical students of Southern Brazil regarding the process of determining BD. MethodThis observational, cross-sectional study was conducted between September 2013 and March 2014. ResultsA total of 635 students participated in the study, with 337 (53.1%) from public and 298 (46.9%) from private schools. Approximately 333 (52.4%) attended the 6th year of the medical program. The mean age of the students was 25.4 ± 3.56 years, with a prevalence of females of 54.6% (347) and a prevalence of Catholic religion of 61.7% (392); 84.2% of the students reported not feeling confident performing the BD protocol. A low percentage (15.7%) correctly answered 75% or more of the questions about BD, a criterion used to determine sufficient knowledge of BD. Approximately 45% (282) of respondents were not able to identify the patients who were candidates for the BD protocol. Analyzing the medical students' knowledge at the end of the program can provide information about the quality of undergraduate education on the topic of determining BD. ConclusionIt was concluded that 5th- and 6th-year medical students of Paraná State have little knowledge about the BD protocol.

Erratum to: The effect of self-explanation of pathophysiological mechanisms of diseases on medical students' diagnostic performance.

Self-explanation while diagnosing clinical cases fosters medical students’ diagnostic performance. In previous studies on self-explanation, students were free to self-explain any aspect of the case, and mostly clinical knowledge was used. Elaboration on knowledge of pathophysiological mechanisms of diseases has been largely unexplored in studies of strategies for teaching clinical reasoning. The purpose of this two-phase experiment was to investigate the effect of self-explanation of pathophysiology during practice with clinical cases on students’ diagnostic performance. In the training phase, 39 4th-year medical students were randomly assigned to solve 6 criterion cases (3 of jaundice; 3 of chest pain), either self-explaining the pathophysiological mechanisms of the findings (n = 20) or without self-explaining (n = 19). One-week later, in the assessment phase, all students solved 6 new cases of the same syndromes. A repeated-measures analysis of variance on the mean diagnostic accuracy scores showed no significant main effects of study phase (p = 0.34) and experimental condition (p = 0.10) and no interaction effect (p = 0.42). A post hoc analysis found a significant interaction (p = 0.022) between study phase and syndrome type. Despite equal familiarity with jaundice and chest pain, the performance of the self-explanation group (but not of the non-self-explanation group) on jaundice cases significantly improved between training and assessment phases (p = 0.035) whereas no differences between phases emerged on chest pain cases. Self-explanation of pathophysiology did not improve students’ diagnostic performance for all diseases. Apparently, the positive effect of this form of self-explanation on performance depends on the studied diseases sharing similar pathophysiological mechanisms, such as in the jaundice cases.

The effect of self-explanation of pathophysiological mechanisms of diseases on medical students' diagnostic performance.

Self-explanation while diagnosing clinical cases fosters medical students' diagnostic performance. In previous studies on self-explanation, students were free to self-explain any aspect of the case, and mostly clinical knowledge was used. Elaboration on knowledge of pathophysiological mechanisms of diseases has been largely unexplored in studies of strategies for teaching clinical reasoning. The purpose of this two-phase experiment was to investigate the effect of self-explanation of pathophysiology during practice with clinical cases on students' diagnostic performance. In the training phase, 39 4th-year medical students were randomly assigned to solve 6 criterion cases (3 of jaundice; 3 of chest pain), either self-explaining the pathophysiological mechanisms of the findings (n=20) or without self-explaining (n=19). One-week later, in the assessment phase, all students solved 6 new cases of the same syndromes. A repeated-measures analysis of variance on the mean diagnostic accuracy scores showed no significant main effects of study phase (p=0.34) and experimental condition (p=0.10) and no interaction effect (p=0.42). A post hoc analysis found a significant interaction (p=0.022) between study phase and syndrome type. Despite equal familiarity with jaundice and chest pain, the performance of the self-explanation group (but not of the non-self-explanation group) on jaundice cases significantly improved between training and assessment phases (p=0.035) whereas no differences between phases emerged on chest pain cases. Self-explanation of pathophysiology did not improve students' diagnostic performance for all diseases. Apparently, the positive effect of this form of self-explanation on performance depends on the studied diseases sharing similar pathophysiological mechanisms, such as in the jaundice cases.

Medical students' perceived educational needs to prevent and treat childhood obesity.

Medical schools are challenged to incorporate more prevention-based education into curricula, offering an opportunity to revisit approaches to nutrition education. The objective of this study was to explore United States (US) medical students' understanding of childhood obesity, specifically barriers to childhood obesity prevention and treatment and students' perceived educational deficits. The research team conducted phone interviews with 78 3rd- and 4th-year medical students, representing 25 different medical schools across the US. Using a semi-structured interview guide, researchers asked students to describe the etiology of childhood obesity and reflect on where they acquired knowledge of the etiology and what additional resources they would need to treat obese children. Using a phenomenological approach to analysis, researchers identified five dominant emergent themes. Student-perceived barriers to childhood obesity prevention and treatment in clinical care included student-centered (e.g., lack of knowledge), patient-centered (e.g., lack of access), and healthcare system-centered barriers (e.g., limited time). Students requested more applicable nutrition information and counseling skills relevant to preventing and treating childhood obesity; however, they tended to identify others (e.g., parents, schools), rather than themselves, when asked to describe how childhood obesity should be prevented or treated. To provide students with an understanding of their role in preventing and treating childhood obesity, US medical schools need to provide students with childhood obesity-specific and general nutrition education. To build their self-efficacy in nutrition counseling, schools can use a combination of observation and practice led by skilled physicians and other healthcare providers. Increasing students' self-efficacy through training may help them overcome perceived barriers to childhood obesity prevention and treatment.

High-fidelity anesthesia simulation in medical student education: Three fundamental and effective teaching scenarios

Simulation is a vital tool in the assessment and training of medical professionals and those in high-risk fields. Simulation-based education provides medical students an opportunity to learn crisis management and team-building skills in an environment that poses no risk to actual patients. Students are given exposure to high-intensity medical scenarios which require and encourage critical thinking and advanced interpersonal communication skills. They are also provided with immediate feedback through debriefing and an opportunity to apply new skills through the reproducibility of rare cases. The benefits of simulation in the training of medical students during their rotations through their anesthesia electives are infrequently assessed. We expose 3rd- and 4th-year medical students to our MetiMan Prehospital model mannequin for simulation. The simulations included pulmonary embolism, airway fire, and malignant hyperthermia. We used these simulated scenarios as tools for practical teaching and exposure to uncommon events. As assessed in follow-up evaluations, the medical students found the simulations useful in the immediate application of clinical skills during their patient encounters through their rotation. The purpose of this article is to review the benefits of simulation in high-risk fields and highlight its value in the medical education of students during their anesthesiology elective. The following core competencies sare addressed in this article: Patient care, Practice-based learning and improvement, Medical knowledge, Interpersonal and communication skills.

Personality traits predict a medical student preference to pursue a career in surgery.

In this study, we examined the impact of personality traits, assessed with the psychopathic personality inventory revised version (PPI-R), on medical students' likelihood of selecting a surgical specialty. This is a cross-sectional questionnaire-based study of 360 4th-year medical students at a single university. We used the PPI-R previously developed to evaluate "adaptive" traits within nonclinical (student) populations. Students were asked to express their specialty of choice. Medical specialties were categorized as surgical and nonsurgical. Logistic regression was used to identify predictors and appropriate adjustments were made for demographic factors. The survey was completed by 335 out of 360 students. The prevalence of students aspiring to a surgical career was 23.6%. They exhibited higher PPI-R total score, self-centered impulsivity (SCI) factor score, Machiavellian egocentricity, social influence, and fearlessness content scale scores. Logistic regression showed that SCI score was a significant predictor for the likelihood of expressing interest toward a surgical career. Our findings expand previous research on the usefulness of the nonclinical use of psychopathic personality traits to investigate career choice.

Development and Pilot of a 4th-Year Medical Student Elective in Antimicrobial Stewardship

Development and Pilot of a 4th-Year Medical Student Elective in Antimicrobial Stewardship

Medical Students' Understanding of Directed Questioning by Their Clinical Preceptors

ABSTRACTPhenomenon: Throughout clerkship, preceptors ask medical students questions for both assessment and teaching purposes. However, the cognitive and strategic aspects of students' approaches to managing this situation have not been explored. Without an understanding of how students approach the question and answer activity, medical educators are unable to appreciate how effectively this activity fulfills their purposes of assessment or determine the activity's associated educational effects. Approach: A convenience sample of nine 4th-year medical students participated in semistructured one-on-one interviews exploring their approaches to managing situations in which they have been challenged with questions from preceptors to which they do not know the answer. Through an iterative and recursive analytic reading of the interview transcripts, data were coded and organized to identify themes relevant to the students' considerations in answering such questions. Findings: Students articulated deliberate strategies for managing the directed questioning activity, which at times focused on the optimization of their learning but always included considerations of image management. Managing image involved projecting not only being knowledgeable but also being teachable. The students indicated that their considerations in selecting an appropriate strategy in a given situation involved their perceptions of their preceptors' intentions and preferences as well as several contextual factors. Insights: The medical students we interviewed were quite sophisticated in their understanding of the social nuances of the directed questioning process and described a variety of contextually invoked strategies to manage the situation and maintain a positive image.