Medical School Experience Research Articles

Race, Ethnicity, and Medical Student Well-being in the United States

Little is known about the training experience of minority medical students. We explore differences in the prevalence of burnout, depressive symptoms, and quality of life (QOL) among minority and nonminority medical students as well as the role race/ethnicity plays in students' experiences. Medical students (N = 3080) at 5 medical schools were surveyed in 2006 using validated instruments to assess burnout, depression, and QOL. Students were also asked about the impact of race/ethnicity on their training experience. The response rate was 55%. Nearly half of students reported burnout (47%) and depressive symptoms (49%). Mental QOL scores were lower among students than among the age-matched general population (43.1 vs 47.2; P < .001). Prevalence of depressive symptoms was similar regardless of minority status, but more nonminority students had burnout (39% vs 33%; P < .03). Minority students were more likely to report that their race/ethnicity had adversely affected their medical school experience (11% vs 2%; P < .001) and cited racial discrimination, racial prejudice, feelings of isolation, and different cultural expectations as causes. Minority students reporting such experiences were more likely to have burnout, depressive symptoms, and low mental QOL scores than were minority students without such experiences (all P < .05). Symptoms of distress are prevalent among medical students. While minorities appear to be at lower risk for burnout than nonminority students, race does contribute to the distress minority students do experience. Additional studies are needed to define the causes of these perceptions and to improve the learning climate for all students.

Musculoskeletal Medicine Educational Reform in the Bone and Joint Decade*

The burden of musculoskeletal disease is vast. Although these diseases may lack the cachet of more immediately life-threatening conditions (such as cancer or stroke), musculoskeletal problems are worthy of increased attention, as the amelioration of bone and joint disease can certainly enhance life, if not extend it. Buoyed by the accomplishments of the Decade of the Brain (1990-2000), the international community of musculoskeletal physicians and scientists came together in Sweden in 1998 to found the Bone and Joint Decade1,2. The specific purpose of this group was to confront the growing burden of musculoskeletal disorders through raising public awareness of the problem and improving prevention, treatment, and research. The United Nations, the World Health Organization, and others announced public support. In the United States, President Bush, joined by the governors of all fifty states, declared the years 2002 through 2011 to be the National Bone and Joint Decade in the United States. The international organization for the Bone and Joint Decade as well as its American counterpart have worked on many fronts, among them achieving recognition for the burden of musculoskeletal disease within the World Health Organization, successfully advocating for public health policy innovations, raising public awareness, and nurturing young clinical investigators in musculoskeletal basic and clinical sciences. One area of particular focus within the United States Bone and Joint Decade is the improvement of medical school education in musculoskeletal medicine. As co-chairs of the medical school education committee (J.B. and G.V.L.) and executive director (T.K.) of the Decade, we welcome the chance now, at the Decade's five-year mark, to share a description of the problems and challenges we face, a detailing of the progress we have made, and a delineation of the future work to be done. The Decade proposes that the medical school experience in …

Student Body Diversity: Relationship to Medical Students’ Experiences and Attitudes

Multiple studies of undergraduate college students have demonstrated the effects of cross-cultural interaction and exposure to diverse ideas on a variety of educational outcomes. The current study was designed to extend this work into medical education, examining student body diversity and school-supported cross-cultural experiences on students' attitudes about diversity. Four-hundred forty-one rising fourth-year medical students from three schools with differing levels of student body diversity completed a 55-item questionnaire on their background, experiences, and attitudes related to cross-cultural diversity. Medical students' attitudes about culture and health and their perspectives on societal issues related to diversity were influenced by their medical school experiences. Informal instructional interactions seem to have been most influential in shaping these beliefs. The opportunity for students from diverse backgrounds to interact as part of the curriculum is an important means of promoting positive attitudes toward diversity in educational and social environments.

Musculoskeletal medicine educational reform in the bone and joint decade

The burden of musculoskeletal disease is vast. Although these diseases may lack the cachet of more immediately life-threatening conditions (such as cancer or stroke), musculoskeletal problems are worthy of increased attention, as the amelioration of bone and joint disease can certainly enhance life, if not extend it. Buoyed by the accomplishments of the Decade of the Brain (1990-2000), the international community of musculoskeletal physicians and scientists came together in Sweden in 1998 to found the Bone and Joint Decade1,2. The specific purpose of this group was to confront the growing burden of musculoskeletal disorders through raising public awareness of the problem and improving prevention, treatment, and research. The United Nations, the World Health Organization, and others announced public support. In the United States, President Bush, joined by the governors of all fifty states, declared the years 2002 through 2011 to be the National Bone and Joint Decade in the United States. The international organization for the Bone and Joint Decade as well as its American counterpart have worked on many fronts, among them achieving recognition for the burden of musculoskeletal disease within the World Health Organization, successfully advocating for public health policy innovations, raising public awareness, and nurturing young clinical investigators in musculoskeletal basic and clinical sciences. One area of particular focus within the United States Bone and Joint Decade is the improvement of medical school education in musculoskeletal medicine. As co-chairs of the medical school education committee (J.B. and G.V.L.) and executive director (T.K.) of the Decade, we welcome the chance now, at the Decade's five-year mark, to share a description of the problems and challenges we face, a detailing of the progress we have made, and a delineation of the future work to be done. The Decade proposes that the medical school experience in …

Culturally Competent Care Education: Overview and Perspectives

Health care disparities are a serious problem in the United States, for which an immediate and multifaceted response is required. A critical component in addressing these disparities is culturally competent care education. To that end, Harvard Medical School has established a Culturally Competent Care Education Committee, which drives key efforts in curriculum and faculty development. Although Harvard Medical School has substantial ongoing culturally competent care education practices, pedagogic methods for achieving the formidable objectives of culturally competent care education are not yet fully defined or developed. It is hoped that this report of current Harvard Medical School practices,perspectives, and experiences will help others institute or continue to develop culturally competent care education-related plans and activities. With time and study, the best and most efficient practices will emerge.

Attitudes of Preclinical and Clinical Medical Students Toward Interactions with the Pharmaceutical Industry

Medical school is a critical time for physicians in training to learn the professional norms of interacting with the pharmaceutical industry, yet little is known about how students' attitudes vary during the course of training. This study sought to determine students' opinions about pharmaceutical industry interactions with medical students and whether these opinions differ between preclinical and clinical students. The authors surveyed medical students at Harvard Medical School (HMS) from November 2003 through January 2004 using a six-question survey. The authors then analyzed how responses differed among the classes. Out of 723 questionnaires, 418 were returned--an overall response rate of 58%. A total of 107 (26%) students believed that it is appropriate for medical students to accept gifts from pharmaceutical companies, and 76 (18%) agreed that the medical school curriculum should include events sponsored by the pharmaceutical industry. Many students--253 (61%)--reported that they do not feel adequately educated about pharmaceutical industry-medical professionals' interactions. Preclinical and clinical students had similar opinions for the majority of their responses. Finally, students who reported feeling better educated about pharmaceutical industry interactions tended to be less skeptical of the industry and more likely to view interactions with the industry as appropriate. Students' opinions about interactions with the pharmaceutical industry were similar between preclinical and clinical students, suggesting that the current medical school experience may have limited impact on students' views about interactions with the pharmaceutical industry.

“Throwing in the Spatula”: A qualitative study examining pharmacists' decisions to become physicians

Objectives: To describe and examine the experiences of pharmacists who had become physicians. Method: A key informant approach was utilized to identify potential participants in this study, which involved a semi- structured interview. Field notes and transcripts were produced, coded and categorized, and an inductive analysis method was used to generate themes that were confirmed with subsequent interviews. Results: A total of 32 pharmacist-physicians participated in this study. All participants had practiced as pharmacists prior to beginning medical school. For most participants, intrinsic motivational factors to study medicine were very strong, while extrinsic motivational factors were cited as reasons to study pharmacy. The experience of medical school, and approaches to medical education were compared and contrasted with pharmacy; while pharmacy was described as more collegial, friendly and supportive, medical (particularly practice-based) education was described as more relevant and focused. Striking differences emerged between male and female participants regarding satisfaction with the decision to pursue medicine as a career; male participants were generally positive about their decision, while female participants were somewhat more nuanced or ambivalent regarding change in their profession. Conclusions: Examining the experiences of individuals who are both physicians and pharmacists provides an informative vehicle for examining differences and similarities in professional education, training and culture. While further work is necessary to more clearly examine these issues, this study provides an important insight into the ways in which pharmacists and physicians relate to one another and their own professional cultures.

Smoothing Out Transitions: How Pedagogy Influences Medical Students’ Achievement of Self-regulated Learning Goals

Medical school is an academic and developmental path toward a professional life demanding self-regulation and self-education. Thus, many medical schools include in their goals for medical student education their graduates' ability to self-assess and self-regulate their education upon graduation and throughout their professional lives. This study explores links between medical students' use of self-regulated learning as it relates to motivation, autonomy, and control, and how these influenced their experiences in medical school. Subjects were medical students in two distinct medical school environments, "Problem-based learning" and "Traditional." PBL students described a rough transition into medical school, but once they felt comfortable with the autonomy and control PBL gave them, they embraced the independence and responsibility. They found themselves motivated to learning for learning's sake, and able to channel their motivation into effective transitions from the classrooms into the clerkships. Traditional students had a rougher transition from the classrooms to the clerkships. In the first two years they relied on faculty to direct and control learning, and they channeled their motivation toward achieving the highest grade. In the clerkships, they found faculty expected them to be more independent and self-directed than they felt prepared to be, and they struggled to assume responsibility for their learning. Self-regulated learning can help smooth out the transitions through medical school by preparing first and second year students for expectations in the third and fourth years, which can then maximize learning in the clinical milieu, and prepare medical students for a lifetime of learning.

Evaluation of an Innovative Physical Activity Collaboration between Medical Students and Masterʼs Exercise Physiology Students

PURPOSE: US medical schools report a lack of physical activity (PA) and exercise instruction in their existing curricula. Practicing physicians cite lack of knowledge as a barrier to PA counseling. We designed and evaluated an innovative PA curriculum that was a collaborative effort between practicing exercise physiologists, physicians, educators and students in each discipline. METHODS: Preventive Medicine and Nutrition (PMN) is a 14-week course taught at Harvard Medical School (HMS). Each PMN session consists of a 60-minute lecture followed by a 75-minute tutorial held in groups of eight medical students. In 2004–5, we established a collaborative project in which a 60-minute lecture covering epidemiology, physiology, patient counseling, and exercise prescription was co-taught by a practicing physician and a practicing exercise physiologist. Exercise physiology graduate students from Northeastern University (NU) were invited to join and contribute to the 75-minute tutorial session on the case of a sedentary man at high risk for diabetes. The NU students received dedicated training sessions for the tutorial prior to their attendance. At the conclusion of the tutorial session, HMS and NU students completed anonymous surveys that assessed their own PA habits and rated the lecture and tutorial. RESULTS: 118 HMS and 18 NU students completed surveys. The HMS students were 53% female and 49% non-white, whereas the NU students were 72% female and 33% non-white. 86% of HMS and 100% of NU students reported regular (i.e., ≥ 3 days/ week) PA, with median group values of 210 and 269 minutes/week respectively. 34% of HMS students indicated that this was their first PA learning experience in medical school. 35% of HMS and 28% of NU students wanted more discussion of physiology and 34% and 39% (respectively) wanted more exercise prescription content. 86% of HMS and 94% of NU students thought the tutorial effectively reinforced the concepts presented in the lecture. 81% of HMS students said that the NU students were a helpful addition to the case discussion, and 94% of NU students felt they made a valuable contribution. However, both student groups indicated they wanted more opportunity to interact, particularly to learn about ways to collaborate in the future (46% of HMS and 50% of NU students). CONCLUSIONS: Our curriculum was a successful innovative collaboration between medicine and exercise physiology. Future iterations of this curriculum may include increased tutorial time and formalizing the role of the NU students. Further study is needed to determine the long-term impact of such a curriculum on the practice habits and resource sharing of both student groups.

Prior experiences associated with residents’ scores on a communication and interpersonal skill OSCE

Objective This exploratory study investigated whether prior task experience and comfort correlate with scores on an assessment of patient-centered communication. Methods A six-station standardized patient exam assessed patient-centered communication of 79 PGY2-3 residents in Internal Medicine and Family Medicine. A survey provided information on prior experiences. t-tests, correlations, and multi-factorial ANOVA explored relationship between scores and experiences. Results Experience with a task predicted comfort but did not predict communication scores. Comfort was moderately correlated with communication scores for some tasks; residents who were less comfortable were indeed less skilled, but greater comfort did not predict higher scores. Female gender and medical school experiences with standardized patients along with training in patient-centered interviewing were associated with higher scores. Residents without standardized patient experiences in medical school were almost five times more likely to be rejected by patients. Conclusions Task experience alone does not guarantee better communication, and may instill a false sense of confidence. Experiences with standardized patients during medical school, especially in combination with interviewing courses, may provide an element of “deliberate practice” and have a long-term impact on communication skills. Practice Implications The combination of didactic courses and practice with standardized patients may promote a patient-centered approach.

Factors that Influence Prescribing Decisions among Turkish Physicians

Appropriate prescribing implies the maximizing of effectiveness and the minimizing of risks and costs, while respecting patients' choices. Physicians' experiences in medical school and residency are formative in establishing patterns of prescribing. Today, pharmaceutical representatives also exert influence in the drug selection process among practicing physicians. Although physicians often state that peer-reviewed publications of clinical trials are their main source of information about drugs, the research literature has shown that this is actually one of the least important sources. The purpose of this study is to identify factors that influence prescribing decisions among physicians in Turkey. This study is important because the factors that influence physicians' prescribing behaviors are difficult to quantify and have rarely been acknowledged here. For the purpose of the study, 156 physicians in a Ministry of Health Hospital in Ankara were surveyed. The majority of the participants reported that phar...

Everyday classism in medical school: experiencing marginality and resistance

To explore the medical school experiences of students who self-identify as coming from a working-class or impoverished family background. A questionnaire was administered to Year 3 medical students at a Canadian medical school and in-depth interviews were held with 25 of these students (cohort 1). The same methods were repeated with another Year 3 class 3 years later (cohort 2). While having (or not having) money was the most obvious impact of social class differences, students also discussed more subtle signs of class that made it easier or more difficult to fit in at medical school. Students from working-class or impoverished backgrounds were significantly less likely to report that they fitted in well, and more likely to report that their class background had a negative impact in school. They were also more likely to indicate awareness that a patient's social class may affect their health care treatment. Students from working-class or impoverished backgrounds may experience alienation in medical school. Through the commonplace interactions of 'everyday classism' they may experience marginalisation, isolation, disrespect and unintentional slights. At the same time, they suggest that their experiences of exclusion may strengthen their clinical practice.

Preparation of residents for death pronouncement: A sensitive and supportive method

To identify factors associated with internal medicine interns' self-assessed competency in death pronouncement and to evaluate the effectiveness of a 10-minute death pronouncement module and pocket card guidelines. In June 2003 at the Birmingham VAMC, Alabama, 48 internal medicine interns completed a survey of medical school education, training, and experience in death pronouncement and a self-assessment of death pronouncement competency. In September 2003, 33 of the 48 interns completed a follow-up training/education survey and rated their post-intervention competency. Using chi-square and paired t-tests, we identified factors associated with variations among baseline and post-intervention variables and examined pre-post changes in self-assessed competency levels. At baseline, less than 30% of the interns had medical school instruction in the process of death pronouncement. More than 70% reported needing basic instruction/close supervision. Post-intervention, close to 90% interns needed minimal or no assistance. Over 50% reported using pocket card guidelines. We found significant pre-post increases in mean rankings in each of the 5 self-assessed competencies (p < .001). Factors associated with differences in baseline and post-intervention assessments included medical school training/experience and use of the pocket card guidelines. When interns began training, most had no instruction in death pronouncement and felt unprepared for this task. With brief instruction, pocket card guidelines, and 3-months experience, the majority of interns reported needing minimal/no assistance in pronouncing death. A larger sample from multiple sites is needed to confirm these findings.

Short Reports

The University of Hawaii, John A. Burns School of Medicine has offered community-based, interdisciplinary training (CBIT) since 1992 with the stated intention of producing physicians who would choose primary care specialties, practice in under-served communities and work well in interdisciplinary settings. At present, a minority of first-year medical students (15 – 20 out of 63) self-select to participate in CBIT. These medical students, together with nursing, medical technology, food science, social work and public health students, work together in interdisciplinary teams led by communitybased faculty at four community health centers located in under-served areas. At two sites the student teams provide health education to local primary and secondary schools. At the other two sites student teams provide case-management services for chronically ill patients. To date, 111 medical students and over 170 students from the other health professions have completed this program. A study was undertaken to explore the effects CBIT on the choice of career path for those medical students who participated in the program. Twenty-five graduates who participated in CBIT and 23 graduates who participated in standard community medicine experiences when they were first-year medical students from 1992 to 1996 were interviewed in 2002 as graduates. Informed consent was obtained from participants. A research assistant, not affiliated with the program and unaware of the graduates’ involvement in CBIT, conducted semi-structured telephone interviews. The graduates were told that the study was concerned with the effect of medical school experiences on their practice choices. Each of the four authors independently analysed notes from the interviews from which identifiers had been removed. They then met to discuss and negotiate a consensus interpretation of common and significant themes. Many of the CBIT graduates noted that the program had given them intimate access and close bonds to local communities. Those who completed the CBIT program believed that it increased their comfort with working in interdisciplinary teams. However, it was found that a number of factors influenced specialty choice and practice location.

Identification with the role of doctor at the end of medical school: a nationwide longitudinal study

Given the sparse literature on the topic, there is a need to know more about student identification with the role of doctor, particularly with respect to the possible impact of pre-existing and medical school factors. Medical students at all 4 Norwegian universities (n = 421) were mailed questionnaires on entry to their medical course (T1). Respondents were surveyed again halfway through (T2) and at the end (T3) of their 6-year courses. The study sample comprised the 236 students who responded on all 3 occasions. No significant variation occurred between medical schools in the level of student identification with the role of doctor, except for a significant gender difference at 1 university. Among pre-existing factors, interpersonal problems and confidence in one's own knowledge had independent impact on role identification controlled for gender, age, parental relationships, personality and mental health. This impact was mediated through perceived stress and perceived recording skills, while confidence in knowledge also maintained impact in the final model. Women had a lower level of role identification, with the strongest impact coming from pre-existing factors like interpersonal problems, fear of encountering demanding work, and confidence in own knowledge. For men, change in perceived medical school stress from T2 to T3 and perceived recording/clinical skills had significant impact on the level of role identification. Pre-existing factors, partly mediated through skill acquisition and stressful medical school experiences, influenced role identification. In women, pre-existing factors had a significant impact upon role identification, contrasting with men, whose role identification was more influenced by medical school factors.

The Value of the Subinternship: A Survey of Fourth Year Medical Students

:Background: Although the subinternship is often regarded as an important part of many fourth year curricula it is rarely studied.Purpose: We aimed to understand the how well the subinternship prepared medical students to perform core clinical skills.Methods: Senior medical students at Boston University School of Medicine rated their perception of the effectiveness of the subinternship and “medical school overall” in preparing them to perform core clinical skills using a written survey.Results: Overall, 69% (101) of students responded. Students believe that the subinternship prepares them to perform most key skills involved in day-to-day medical care. However, students feel less prepared by either their subinternship or overall medical school experience to carry out some complex patient communication skills including delivering “bad news” and discussing endof- life wishes.Conclusions: The subinternship appears to be effective in preparing students for many of the challenges they will face as an intern and beyond. However, students identified several complex communication skills that could be addressed in part by the subinternship for which they felt unprepared. Student learning would likely be enhanced by creating a longitudinal program to teach these higher-level communication skills during medical school and by integrating practice and feedback of these skills into the subinternship.

Assessing the neurology clerkship: The value of student feedback

A Neurology Clerkship Core Curriculum was recently approved by the American Academy of Neurology, the American Neurological Association, and the Association of University Professors of Neurology.1 This curriculum has been considered a landmark effort because it represents a broad consensus of “virtually every leading neurologist teaching medical students” in the United States.2 The objective of this curriculum is to address the educational needs of future physicians, regardless of whether they pursue neurology as a specialty. The proposed curriculum is assumed to include a required, 4-week clerkship placed in the 3rd year of the medical school experience. Although the curriculum has been defined, “almost nothing about evaluation of achieving the goals of the clerkship” is available.2 We decided to elicit feedback from students to determine whether the goals of our clerkship were being achieved. We also reasoned that our predominantly 4th year clerkship would provide a more experienced perspective on the question of 3rd year vs 4th year placement of the clerkship. Our 4-week clerkship is offered at multiple sites. The numbers of students in each placement during the 4 years of this study (1999 to 2003) were University Hospital (111), Veterans Administration …

Students and teachers prefer early experience

Medical students and teachers favour having early clinical experience in medical school, a study in the BMJ has found (2004;329:834-7). Tim Dornan, consultant physician, and Chris Bundy, senior lecturer in health psychology, from Manchester University led group discussions with 64 students, staff, and curriculum leaders from three medical schools in the United Kingdom. Results indicated that without early experience, the medical curriculum …

Western medical ethics taught to junior medical students can cross cultural and linguistic boundaries.

BackgroundLittle is known about teaching medical ethics across cultural and linguistic boundaries. This study examined two successive cohorts of first year medical students in a six year undergraduate MBBS program.MethodsThe objective was to investigate whether Arabic speaking students studying medicine in an Arabic country would be able to correctly identify some of the principles of Western medical ethical reasoning. This cohort study was conducted on first year students in a six-year undergraduate program studying medicine in English, their second language at a medical school in the Arabian Gulf. The ethics teaching was based on the four-principle approach (autonomy, beneficence, non-malfeasance and justice) and delivered by a non-Muslim native English speaker with no knowledge of the Arabic language. Although the course was respectful of Arabic culture and tradition, the content excluded an analysis of Islamic medical ethics and focused on Western ethical reasoning. Following two 45-minute interactive seminars, students in groups of 3 or 4 visited a primary health care centre for one morning, sitting in with an attending physician seeing his or her patients in Arabic. Each student submitted a personal report for summative assessment detailing the ethical issues they had observed.ResultsAll 62 students enrolled in these courses participated. Each student acting independently was able to correctly identify a median number of 4 different medical ethical issues (range 2–9) and correctly identify and label accurately a median of 2 different medical ethical issues (range 2–7) There were no significant correlations between their English language skills or general academic ability and the number or accuracy of ethical issues identified.ConclusionsThis study has demonstrated that these students could identify medical ethical issues based on Western constructs, despite learning in English, their second language, being in the third week of their medical school experience and with minimal instruction. This result was independent of their academic and English language skills suggesting that ethical principles as espoused in the four principal approach may be common to the students' Islamic religious beliefs, allowing them to access complex medical ethical reasoning skills at an early stage in the medical curriculum.

University of South Carolina School of Medicine.

University of South Carolina School of Medicine.