Clinical Clerkship Research Articles

Measuring the development of a medical professional identity through medical school

Purpose The Professional Identity Essay (PIE) is a theory and evidence-based Medical Professional Identity Formation (MPIF) measure. We describe trajectories of PIE-measured MPIF over a 4-year US medical school curriculum. Methods Students write PIEs at medical school orientation, clinical clerkships orientation, and post-advanced (near graduation) clerkship. A trained evaluator assigns an overall stage score to narrative responses to nine PIE prompts (inter-rater ICC 0.83, 95% CI [0.57 − 0.96], intra-rater ICC 0.85). Distribution of PIE stage scores across time points were analyzed in the aggregate and individual students were classified as Increase, Stable (no score change) or Decrease based on the trajectories of PIE stage scores over time. Results 202 students completed 592 PIEs from 2018-2023. There was a significant change in the proportion of PIEs in stages over time (X2 84.40, p < 0.001), 47% (n = 95) students were categorized in the Increase trajectory, 45.5% (n = 92) as Stable and 7.4% (n = 15) as Decrease. Older age and time-predicted stage scores change within trajectories (p < 0.05). Conclusions Medical students’ PIE stage scores increase over time with three distinctive trajectories. Further study is needed to explore the utility of this method for formative assessment, program evaluation, and MPIF research.

포스트 코로나 시대 준비를 위한 임상실습 교육 고찰

Objectives This study aimed to examine clinical clerkship education in the COVID-19 era and gather fundamental information for setting the direction of clinical clerkship education in the post-COVID era.&#x0D; Methods This study focused on the minutes of the ‘Clinical clerkship Advancement Conference’ held in December 2022 and the ‘2023 Clinical clerkship Improvement Plans’ submitted by each clinical clerkship department at E-Medical School in Seoul. The study employed the Focused Group Interview analysis method.&#x0D; Results First, when examining the factors that influenced clinical clerkship education during the COVID-19 peri-od, a total of 8 categories and 17 subcategories were identified in two domains: positive factors of clinical clerkship education and negative factors of clinical clerkship education. Second, when examining the improvement plans for clinical clerkship education in preparation for the post-COVID era, a total of 6 categories and 23 subcategories were derived from three domains: efforts for pre-implementation education improvement, efforts for operational improvement of clinical clerkship education, and long-term improvement. Third, when exploring the requirements for clinical clerkship in the post-COVID era, a total of 6 categories and 11 subcategories were identified in two do-mains: recommendations for clinical clerkship education in the post-COVID era and necessary support for clinical clerkship education in the post-COVID era.&#x0D; Conclusions This study examined the clinical clerkship education conducted during the COVID-19 period and de-rived implications for improving clinical clerkship in the post-COVID era. The findings of this study will serve as foundational data for future improvements in clinical clerkship education and ultimately contribute to enhancing the quality of clinical clerkship education.

Development and Implementation of Health Systems Science Education in the Clinical Learning Environment

Health systems science is a new medical educational field added to the traditional medical education curricula of basic and clinical sciences. Health systems science emphasizes a more comprehensive approach utilizing systems thinking to care for patients, including interactions between multiple healthcare systems. In this review, I explore how health systems science education can be applied when medical instructors teach students in clinical clerkships through representative case studies. This study first looks at examples of health systems science education in clinical clerkship in the United States and suggests how to develop the curriculum of health systems science for clinical learning environments in Korea by combining Kotter’s 8-step change management model and Kern’s 6-step curriculum development model. Finally, based on practical examples from actual clinical practice education situations, suggestions are made regarding how to develop the entire educational program of a medical school from the stage of applying health systems science at the individual level to clinical practice education.

The influence of Gamification on medical students’ diagnostic decision making and awareness of medical cost: a mixed-method study

BackgroundThe gamification of learning increases student enjoyment, and motivation and engagement in learning tasks. This study investigated the effects of gamification using decision-making cards (DMCs) on diagnostic decision-making and cost using case scenarios.MethodThirty medical students in clinical clerkship participated and were randomly assigned to 14 small groups of 2–3 medical students each. Decision-making was gamified using DMCs with a clinical information heading and medical cost on the front, and clinical information details on the back. First, each team was provided with brief clinical information on case scenarios. Subsequently, DMCs depending on the case were distributed to each team, and team members chose cards one at a time until they reached a diagnosis of the case. The total medical cost was then scored based on the number and contents of cards drawn. Four case scenarios were conducted. The quantitative outcomes including confidence in effective clinical decision-making, motivation to learn diagnostic decision-making, and awareness of medical costs were measured before and after our gamification by self-evaluation using a 7-point Likert scale. The qualitative component consisted of a content analysis on the benefits of learning clinical reasoning using DMCs.ResultConfidence in effective clinical decision-making, motivation to learn diagnostic decision-making, and awareness of medical cost were significantly higher after the gamification. Furthermore, comparing the clinical case scenario tackled last with the one tackled first, the average medical cost of all cards drawn by students decreased significantly from 11,921 to 8,895 Japanese yen. In the content analysis, seven advantage categories of DMCs corresponding to clinical reasoning components were extracted (information gathering, hypothesis generation, problem representation, differential diagnosis, leading or working diagnosis, diagnostic justification, and management and treatment).ConclusionTeaching medical students clinical reasoning using DMCs can improve clinical decision-making confidence and learning motivation, and reduces medical cost in clinical case scenarios. In addition, it can help students to acquire practical knowledge, deepens their understanding of clinical reasoning, and identifies several important clinical reasoning skills including diagnostic decision-making and awareness of medical costs. Gamification using DMCs can be an effective teaching method for improving medical students’ diagnostic decision-making and reducing costs.

Reimagining a pass/fail clinical core clerkship: a US residency program director survey and meta-analysis

Pass/fail (P/F) grading has emerged as an alternative to tiered clerkship grading. Systematically evaluating existing literature and surveying program directors (PD) perspectives on these consequential changes can guide educators in addressing inequalities in academia and students aiming to improve their residency applications.In our survey, a total of 1578 unique PD responses (63.1%) were obtained across 29 medical specialties. With the changes to United States Medical Licensure Examination (USMLE), responses showed increased importance of core clerkships with the implementation of Step 2CK cutoffs. PDs believed core clerkship performance was a reliable representation of an applicant’s preparedness for residency, particularly in Accreditation Council for Graduate Medical Education’s (ACGME)Medical Knowledge and Patient Care and Procedural Skills. PDs disagreed with P/F core clerkships because it more difficult to objectively compare applicants. No statistically significant differences in responses were found in PD preferential selection when comparing applicants from tiered and P/F core clerkship grading systems. If core clerkships adopted P/F scoring, PDs would further increase emphasis on narrative assessment, sub-internship evaluation, reference letters, academic awards, professional development and medical school prestige.In the meta-analysis, of 6 studies from 2,118 participants, adjusted scaled scores with mean difference from an equal variance model from PDs showed residents from tiered clerkship grading systems overall performance, learning ability, work habits, personal evaluations, residency selection and educational evaluation were not statistically significantly different than from residents from P/F systems.Overall, our dual study suggests that while PDs do not favor P/F core clerkships, PDs do not have a selection preference and do not report a difference in performance between applicants from P/F vs. tiered grading core clerkship systems, thus providing fertile grounds for institutions to examine the feasibility of adopting P/F grading for core clerkships.

Predictors of Excellent Urology Residents at the Time of the Urology Match

ObjectiveTo update our experience and report on features predictive of high quality urology residents at the time of the urology match, because data predicting which medical students will mature into excellent urology residents are sparse. MethodsWe reviewed our experience with 84 urology residents who graduated from 2006 to 2023. Residents were independently scored 1-10 based on overall quality by the current and former Program Director. Discrepant scoring by >2 was resolved by an independent review. Associations of features from the medical student application with an excellent score (defined as 8-10) were evaluated with logistic regression. ResultsDiscrepant scoring >2 was noted in only 5 (6%) residents. Among the 84 residents, the median overall score was 7 (range 1-10) and 36 (43%) residents had an excellent score of 8-10. Univariably, higher USMLE step II score (p=0.03), election to AOA (p=0.004), no negative interview comments (p=0.002), honors in OB/Gyn (p=0.048) and psychiatry clerkships (p=0.04), and honors in all core clinical clerkships (p<0.001) were significantly associated with an excellent score. In a multivariable model, no negative interview comments (p=0.003) and honors in all core clinical clerkships (p=0.001) were independently associated with an excellent score (c-index 0.76). There were several notable features (sex, letters of recommendation, USMLE step I, externship at our institution, surgery clerkship grade, and rank list) that were not significantly associated with excellent residents. ConclusionsWe demonstrate features associated with excellent urology residents, most notably no negative interview comments and an honors grade in all core clinical clerkships.

Preparing Preclinical Medical Students for Routine Code Status Discussions: A Mixed-Methods Study

ContextMedical students are expected to gain competency in inquiring about patients’ goals of care, per the Association of American Medical Colleges’ Entrustable Professional Activities. While students may be part of teams that conduct routine code status discussions (CSDs), formal training in this skill prior to clinical clerkships is lacking. ObjectivesWe aimed to address this training gap by designing a curriculum to teach preclinical medical students about routine CSDs. MethodsWe designed and conducted an interactive workshop for preclinical medical students to learn about routine CSDs and practice this skill, using Kern's Six Steps to Curriculum Design. A qualitative and quantitative pre- and postsurvey was administered. A convergent, parallel, mixed methods analysis was performed. ResultsStudents (n = 135) named more options for code status following the workshop (presurvey 1.3 vs. postsurvey 4.3, P < 0.01). There was an increase in the proportion of students reporting that they felt “somewhat comfortable” or “extremely comfortable” conducting a CSD (presurvey 19% vs. postsurvey 64%, P < 0.01), and a decrease in those reporting that they felt “extremely uncomfortable” or “somewhat uncomfortable” (presurvey 53% vs. postsurvey 18%, P < 0.01). Thematic analysis revealed that students were concerned about knowledge gaps, communication tools, personal discomfort, and upsetting patients or family. ConclusionA workshop to train medical students to conduct routine CSDs can be included as part of a preclinical medical education curriculum. Students reported that the workshop increased their confidence in conducting CSDs and demonstrated an increase in corresponding knowledge, preparing them to deliver person-centered care on their clerkships.

The influence of a digital clinical reasoning test on medical student learning behavior during clinical clerkships

Recently, a new digital clinical reasoning test (DCRT) was developed to evaluate students’ clinical-reasoning skills. Although an assessment tool may be soundly constructed, it may still prove inadequate in practice by failing to function as intended. Therefore, more insight is needed into the effects of the DCRT in practice. Individual semi-structured interviews and template analysis were used to collect and process qualitative data. The template, based on the interview guide, contained six themes: (1) DCRT itself, (2) test debriefing, (3) reflection, (4) practice/workplace, (5) DCRT versus practice and (6) ‘other’. Thirteen students were interviewed. The DCRT encourages students to engage more in formal education, self-study and workplace learning during their clerkships, particularly for those who received insufficient results. Although the faculty emphasizes the different purposes of the DCRT (assessment of/as/for learning), most students perceive the DCRT as an assessment of learning. This affects their motivation and the role they assign to it in their learning process. Although students appreciate the debriefing and reflection report for improvement, they struggle to fill the identified knowledge gaps due to the timing of receiving their results. Some students are supported by the DCRT in exhibiting lifelong learning behavior. This study has identified several ways in which the DCRT influences students’ learning practices in a way that can benefit their clinical-reasoning skills. Additionally, it stresses the importance of ensuring the alignment of theoretical principles with real-world practice, both in the development and utilization of assessment tools and their content. Further research is needed to investigate the long-term impact of the DCRT on young physicians’ working practice.

Assessing Correlations Between Competency Ratings and Assessment-Specific Global Rating Scores Across Seven Core Clinical Clerkships at the University of Michigan Medical School.

Assessing Correlations Between Competency Ratings and Assessment-Specific Global Rating Scores Across Seven Core Clinical Clerkships at the University of Michigan Medical School.

Improved Confidence and Clinical Application: The Effects of a Longitudinal Suture Curriculum for Medical Students.

The ability to competently suture is an expected skill for graduating medical students, but many graduates report feeling unprepared to perform this skill. This study aimed to improve student confidence and clinical readiness for third-year clerkships by implementing a novel, mandatory 7.5-hour longitudinal suturing skills curriculum across the first 3 years of medical school. The required suturing skills curriculum was implemented for all medical students throughout the first 3 years of medical school at a large academic health center in the mid-South United States. Precurriculum (n = 167) and postcourse (n = 148) surveys were administered to first-year students in the first year of the curriculum (2017-2018), and a parallel follow-up survey was administered to this cohort in 2020 after students completed their clinical clerkship year (n = 82). Aggregate changes in students' survey responses were analyzed for proper instrument position, simple interrupted sutures, and instrument ties using independent groups Mann-Whitney U tests and Rosenthal correlation coefficients for effect sizes. Statistically significant improvement from pre to post was observed in student comfort in performing three basic skills: proper instrument position (P < 0.001), simple interrupted suture (P < 0.001), and instrument ties (P < 0.001). These pre-post gains were sustained at 2-year follow-up (P < 0.001). Also, the majority of students (66%) reported they were very or completely prepared to suture wounds during their clerkships. Most (83%) also reported they had successfully sutured patient wounds during third-year clerkships without needing significant direction or guidance. We found that a longitudinal suture curriculum with dedicated faculty involvement can improve student confidence in suturing and overall preparedness for third-year clerkships. Although the study is limited to ratings of student comfort and self-reported performance as well as some attrition of responses at postcourse survey and postclerkship survey, the findings highlight the importance of a focused curriculum dedicated to teaching basic suturing skills. Our findings also contribute to the limited body of work examining longitudinal surgical skills development for medical students.

의과대학 임상실습 교육에 대한 학생·교수의 인식 비교 연구

Objectives The purpose of this study was to determine if there is a difference in perceptions of clinical clerkship education between professors, who are the primary decision makers in medical school clinical clerkship education, and medical students, who are taking their first steps as future healthcare providers.&#x0D; Methods A survey was conducted among 66 students and 60 professors who participated in clinical training in the Department of Medicine at Ewha Womans University in Seoul, Korea, and analyzed using independent sample t-tests and cross-over analysis.&#x0D; Results First, the student group perceived the satisfaction and appropriateness of clinical education more positively than the faculty group. Second, the faculty group perceived the clinical education environment sub-component “readiness of the environment” more positively than the student group. Some of the sub-factors such as learning, relationships, and space also showed significant mean differences between the student and faculty groups. Third, when we examined the differences between faculty and students in the achievement of practice skills.&#x0D; Conclusions This study is significant in that it empirically confirms experiential differences in perceptions of the clinical clerkship education process between students and professors, and provides information for the effective implementation of clinical clerkship education.

Clerkship from the Perspective of Medical Students: A Mixed Methods Study

Introduction: One of the most important tasks of medical science universities is the training of qualified and specialized human resources to acquire the necessary skills and efficiency to meet the needs of society. Apprenticeship training is considered a serious issue in education; therefore, examining the current situation, identifying the problems in the trainee training and taking measures to rectify and correct them will lead to the achievement of learning objectives and the improvement of the quality of health services. The aim of the present study was to investigate the status of the clinical clerkship from the perspective of Esfarayen medical students. Method: This quantitative-qualitative study was conducted with 163 public health, nursing and emergency medicine students. In the quantitative phase, a standard questionnaire was used to assess check the status of the students' internships. The qualitative phase was also conducted with the aim of determining identifying the challenges in internships from the students' perspective through individual interviews and targeted group discussions. Results: The educational level of the internship was rated as relatively good with a standard average of 3.47. Although the academic situation of the students' internship was relatively good during the COVID-19 epidemic, there were always challenges in the course of the internship. In the individual interviews and group discussions, the challenges were identified in the form of 6 main codes (challenges related to the instructor, the students, the internship environment, the staff, the training programsand the clients) and 20 sub-codes. Conclusion: Despite the relatively good condition of the clinical clerkship in a quantitative evaluation, these courses showed problems in a qualitative evaluation, such as insufficient experience and motivation of some professors and instructors, psychological problems of students, lack of educational facilities, weak interaction and participation of some staff, insufficient transparency of the training program, and lack of trust of patients in students. It is suggested to solve the challenges identified in this study to improve the quality and quantity of internship courses.

History and physical exam: a retrospective analysis of a clinical opportunity

BackgroundAll learners at the Northern Ontario School of Medicine University complete a longitudinal integrated clerkship experience in their third year, which serves to improve learner experience with community and clinical acute and chronic health needs. Early in the program, Muskoka faculty (two of the 15 LIC sites of NOSM U) became aware that learners never had the occasion to complete a full history and physical exam on a real patient with complex needs. Recognizing this as a critical experience, a program was initiated to provide learners with this opportunity. This manuscript reports on the effectiveness and impact of this novel program and outlines the procedure developed to incorporate a similar program should communities see the relevance.MethodsUsing a mixed method design, feedback was collected from learners and preceptors following the implementation of a novel learning opportunity for clinical clerks. Learners completed a full history and physical exam on volunteer complex patients, with supervision and immediate feedback. Using semi structured surveys, data was collected from each learner and preceptor to determine the program impact and optimize the program. Laurentian University research ethics board, certificate number 6021120.ResultsBoth learners and preceptors agreed this was a valuable experience for learners, a good use of their time and contributed to essential skills including, communication, time management and appropriate data collection. The use of real patients was reported to be very appropriate by learners and faculty and often highlighted gaps in the learner’s knowledge that they were then able to address.ConclusionFeedback collected in this study confirms that providing medical learners the opportunity to complete a full history and physical exam with supervision and feedback was significantly beneficial from both a clinical and a skills-based aspect. Requiring learners to complete this task within the established period forced them to manage their time, focus on clinical consideration and remain on task. Enhancing learning opportunities is associated with improved outcomes and understanding in medical learners. Positive community experience is also related to learner retention, which is paramount for attracting new physicians in a time with significantly limited human health resources.

A Qualitative Analysis of Experiences of Medical Students Serving as Abortion Doulas.

Innovative strategies are needed in clinical education to teach empathetic behavior and communication skills. This study aimed to investigate preclinical medical students' experiences volunteering as abortion doulas and to understand the impact of their participation on their professional training. In this qualitative study, the authors conducted semistructured interviews with medical students who had volunteered as abortion doulas in March to July 2016. The interviews described motivations for participating, experiences volunteering as a doula, approach to caring for patients, and acquisition of communication skills and knowledge of abortion. The authors analyzed interview transcripts using a conventional content analysis approach, and themes were identified. The authors performed 22 interviews. For most participants, this was their first exposure to an abortion procedure or patient care in any capacity. Participants identified acquisition of skills including patient advocacy, communication, and empathy that they were later able to apply throughout their clinical clerkships. This opportunity improved well-being and solidified their decision to apply for residencies in reproductive health fields. After volunteering as abortion doulas, medical students were able to develop communication skills, empathy, and patient advocacy applicable to other areas of patient care. Preclinical students, potentially in other health care professions training, participating in patient care as doulas have the potential to further personal development, professionalism, and activism.

Myocardial Infarction Prevalence and Management at Medical Teaching Institute, Hayatabad Medical Complex, Peshawar, KPK, Pakistan.

Myocardial infarction focuses on the sudden deprivation of circulating blood including variation in myocardial tissue necrosis. Where it is an irretrievable death of ischemia. Annually, compared with other diseases, cardiac disease is the top contributor to human fatalities. The prevalence studies show that the rate has been increased in many countries. To discuss the myocardial infarction prevalence and management in 31 MI-diagnosed patients of Cardiology Ward, MTI, Hayatabad Medical Complex, Peshawar, KPK, Pakistan. A descriptive study was carried out based on clinical clerkship of 31 myocardial infarction diseased patients. The whole data was collected during a six days per week visit routine with the help of proforma containing i.e. questions about the patient’s history. The data was analyzed properly by utilizing SPSS software version 21 and Microsoft Excel to draw results regarding the prevalence and management of myocardial infarction. Discussing the prevalence of myocardial infarction, in 31 MI-diagnosed patients 64.4% were male while in city-wise contribution Peshawar was ranked 1st among other KPK cities with a value of 45.02%. The mean average value was 62 years for all patients. In the management of MI, hypertension was the leading risk factor having a percentage of 48% among others. Chest pain was found in almost all MI-diseased patients. 129.45 mmHg, and 81 mmHg were the systolic and diastolic blood pressure mean values respectively. It was found that the MI rate is higher in males compared to females. AWMI was the most commonly diagnosed type of MI. The suggested drug prescriptions at the said hospital were mostly clopidogrel, aspirin, rosuvastatin, and Enoxaparin. Keywords: Ischemia, tissue necrosis, acute anterior wall myocardial infarction, chest pain, hypertension

Perceived stress, sources of stress and coping strategies among undergraduate medical students of Nepal: a cross-sectional study

Background: Medical students are subjected to significant stressors impacting their physical and mental health. While some students employ positive coping mechanism, others resort to maladaptive coping measures. This study aims to assess prevalence, severity, and sources of stress, as well as coping strategies among medical students of a non-Western low-income country from South Asia. Methods: A self-administered questionnaire-based cross-sectional study was carried out. Demographic variables were collected and stress level was assessed using PSS 14 (Perceived Stress Scale 14). The sources of stress were assessed using MSSQ (Medical Student Stressor Questionnaire) and coping strategies were evaluated using the Brief-Coping Orientation to Problems Experienced. Results: A remarkable response rate of 95% was achieved. Overall, 55% of students were stressed (male 52%, female 60%), the difference among gender was not significant. Initial basic science years students perceived higher levels of stress than later clinical clerkship students. Academic related stressors emerged as leading cause of stress, whereas other variables caused moderate stress. The major stressors were examinations, inadequate time to study, poor marks, extensive amount of learning content, and the need to performing well in the exam. Regarding coping strategies, the study revealed five predominant coping strategies: active coping, acceptance, planning, self-distraction, and instrumental support. Conversely, the least common coping mechanism was substance use. Conclusions: This study reveals a high prevalence of stress level among the medical students, mainly driven by academic pressure. Stressed students were likely to use maladaptive coping strategies. First year medical students require focused support, and promoting healthier coping measures among all medical students is crucial.. Further studies can be done to evaluate the effects of stress on the academic outcomes of students.

Strategies to improve hidden curriculum in nursing and medical education: a scoping review

BackgroundThe importance of hidden curriculum cannot be neglected in education. Despite much research in the field, there have been limited studies on HC improvement in nursing and medical education. This scoping review aimed to determine the scope of strategies to improve HC in nursing and medical education.MethodPubMed, EBSCO/Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Scopus, Web of Science, Proquest and Persian-language databases of Magiran and SID were searched in January 2023 without a time filter. According to the PRISMA flow diagram, two independent reviewers selected the records that fit the inclusion and exclusion criteria via title and abstract screening. Next, the reviewers studied the full texts of the related articles. The data extracted from the selected articles were tabulated and ultimately synthesized.FindingsOut of the eight examined studies, published from 2017 to 2022, only one was in the field of nursing and seven were in medicine. The central strategies were implementing new curricula to replace the previous ones, utilizing team-based clinical clerkship, proposing a HC improvement model, implementation a case-based faculty development workshop, implementation longitudinal and comprehensive educational courses, and incorporating an educational activity into a small group program.ConclusionStudents and faculty members familiarization on the topic of HC, implementing new curricula, utilizing team-based clerkship, and using comprehensive models were among the HC improvement strategies. Focusing on upgrading the learning environment, particularly the clinical settings, can also be helpful in HC improvement.

Acceptance and commitment training for reducing burnout in medical students during a clinical clerkship in psychiatry and palliative care: A pilot study

Physicians are likely to experience burnout early in their medical education, and it only accelerates as their clinical and academic responsibilities expand and they begin clinical practice. However, effective burnout interventions for clinical-year medical students are lacking. Avoidance of unpleasant internal experiences and decreased engagement in value-based behaviors are associated with burnout. This study, an open-label pilot research with a single-center, before-and-after comparative study design and without a control group, aimed to examine the feasibility and effectiveness of brief acceptance and commitment training (ACT) in reducing burnout during psychiatric clinical clerkships at a medical school. The feasibility proved to be good, with all the participants (n = 56) completing the training. There were no significant differences in the emotional exhaustion (EE) and depersonalization (DP) scores of burnout as measured by the Maslach Burnout Inventory (MBI) at the end of the ACT and two months following the intervention. A comparison was made with scores recorded before the intervention, and significant differences were observed. A subsample of medical students with moderate or greater burnout at T0 manifested significant burnout score reductions. The same subsample revealed a significant increase in psychological flexibility as indicated by the progress factor score on the Valuing Questionnaire (VQ) at T1 compared to T0 and a significant reduction in reaction latency to negative words as indicated by the DIRAP score of the Implicit Relational Assessment Procedure (IRAP) for anxiety. We argue that short-term ACT during clinical clerkships of medical students in psychiatry and palliative care is feasible and potentially effective, and a multi-site comparative study using more direct behavioral measures is warranted to further investigate its effectiveness.

Deeper look into feedback practice in an Indonesian context: exploration of factors in undergraduate clinical settings.

The practice of feedback is influenced by the characteristics of students, teachers, and the clinical environment. Most studies on feedback have been conducted in Western settings with different sociocultural backgrounds to Indonesia. This study explores feedback in Indonesian clinical clerkship using a sociocultural lens and aims to provide an exemplar of adaptive practice relevant to non-Western settings. This qualitative study was conducted using an interpretive phenomenology approach. Data were collected through focus groups with students and teachers and interviews with program coordinators. Data were transcribed verbatim and grouped according to data sources, coded, and analyzed thematically. Themes identified from the focus group discussions and interviews were categorized as student, teacher, and environmental factors. Student factors include dependence on feedback, tendencies to use a group approach, difficulties recognizing social rules, a perceived lack of resilience, and tendencies to doubt praise. Factors related to teachers include a high level of expertise, being extremely busy, having a strong commitment, and being unsure of students' acceptance of feedback. Clinical environment factors influence interactions between teachers and learners and include high power distance and collectivistic values. A safe environment is needed to ensure effective feedback interactions. High power distance, collectivism, and generational characteristics of students likely impact feedback practice in clinical settings. Designing a safe environment is essential for effective feedback practice.

The spacing effect: Improving electrocardiogram interpretation.

Accurate electrocardiogram (ECG) interpretation is critical for safe patient care, making this skill a necessary competency for medical school graduation. Improved long-term memory retention with repeated exposure to material is one of the most evidenced-based components of adult learning science. This curricular innovation aimed to determine if implementing spaced repetition and retrieval practice using ECG quizzes during the principal clinical year would improve ECG interpretation skills among medical students enrolled in a Longitudinal Integrated Clerkship (LIC). The curricular innovation applied the spacing effect and retrieval practice. Cognitive science demonstrates enhanced long-term retention through repeated interval exposure to learned material. Studies of spaced retrieval indicate that memory retention is enhanced through tests involving effortful recall. LIC students in an intervention group were exposed to the spacing effect with periodic ECG quizzes throughout their clinical clerkship year. The results of the 17-item post-test for 140 students were analysed: LIC intervention, N= 54; block control, N= 62; and LIC control, N = 24. The ANOVA test was significant (p < 0.001). Games-Howell post hoc testing showed that the mean score in the LIC intervention group was significantly higher compared with the LIC control group (p < 0.001) and the block control group (p < 0.001). There was no significant difference between the LIC control and block control groups (p = 0.59). Spaced repetition of material through ECG quizzes improved ECG interpretation skills on an ECG post-test and mitigates the forgetting curve, maintaining student competency in ECG interpretation.