Priority In Medical Education Research Articles

Infection prevention in medical education - results of a descriptive cross-sectional study in Germany.

The aim of the study was to assess the current curricular status of content on infection prevention in hospitals during medical education prior to the development of a serious game on infection prevention in hospitals. In addition, the data collected was to be contrasted with the training for a specialist nurse in hygiene and infection prevention (FKHI). In an online survey, persons in charge of medical degree programs and continuing education centers for FKHI, SkillsLabs and professional associations in Germany were asked to answer 28 questions on framework conditions, teaching, examinations, and gamification. Data was collected for 22 medical degree programs and 5 FKHI continuing education centers. Due to the low response rate, the data for the FKHI was only analyzed in summary form. On average, 13.5 teaching units (median) are available in medical studies. Six degree programs have a longitudinal curriculum. In 7 of the 22 degree programs, teaching is based on the National Competency-Based Learning Objectives Catalogue (NKLM). Almost all locations teach this content in lectures (n=18) and/or in internships (n=13). Teaching and examinations are most common in the third year of study (n=12). In addition to practical OSCE examinations (n=5), written (n=12) and computer-based (n=8) examinations are used in particular. Gamification is known as a didactic approach to some extent but is not used for teaching infection prevention. Infection prevention in hospitals is given relatively low priority in medical education. Teaching and examinations are based on traditional knowledge-oriented formats, although practical teaching and practical examinations are established at some locations. In contrast to the FKHI, learning objectives currently appear to be less standardized. Further interprofessional development of teaching would be desirable in the future.

P12 A periorbital and upper back rash on a female patient of West African descent: a case of NXP2 dermatomyositis initially misdiagnosed as an allergic reaction

Abstract Introduction Idiopathic inflammatory myopathies (IIM) are a group of conditions characterised by immune-driven muscular inflammation, often in the presence of specific autoantibodies. NXP2 dermatomyositis is a subtype of IIM characterised by antibodies to nuclear matrix protein 2. NXP2 dermatomyositis is associated with calcinosis, especially in younger patients and with malignancy, especially in older patients. We report a case of NXP2 dermatomyositis in a female patient of West African descent presenting with a periorbital and upper back rash which was initially misdiagnosed as an allergic reaction. Images of darker skin are underrepresented in medical education around dermatomyositis. Case description A 49-year-old female office worker presented to A&E with a two-week history of arthralgia and fatigue. Over the past two days, she had also noticed the development of periorbital swelling and a rash on her eyelids and her upper back. On examination in A&E, the rash was considered minor and it was noted that she had difficulty taking off her coat due to pain in her arms. She was discharged home with a working diagnosis of an allergic reaction, with advice to see her GP if symptoms persisted. She was reviewed by her GP, who suspected a vasculitic rash. She was found to have a significantly raised ANCA-MPO antibody titre and was referred to the acute medical take where she was seen urgently by rheumatology on-call. On assessment, she was noted to have pain and morning stiffness in her hands and wrists, with swollen DIPJ, MCPJ and wrists on examination. On assessment by a rheumatologist aware of the skin manifestations of dermatomyositis, she was also noted to have a heliotrope rash, shawl sign, periungual erythema, and a V sign rash and was suspected to have dermatomyositis. Her CK was raised at 3000, and she was found to have NXP2 autoantibodies which confirmed the diagnosis. She was started on hydroxychloroquine whilst an MR scan of her arms and legs was organised, which revealed evidence of myositis in the proximal muscles. Following MR scanning, she was started on high dose corticosteroids. Azathioprine was subsequently initiated as a steroid sparing agent, but was not tolerated due to nausea and so she was switched to subcutaneous methotrexate. Her CK has now normalised, and her skin lesions are healing. Discussion One of the key issues highlighted by this case is the lack of awareness of rashes associated with dermatomyositis generally, and especially in diverse skin types. We suspect this is because of a lack of education and exposure to skin rashes in diverse skin types, especially in highly melanated skin types. On her initial assessment in A&E, her rash was misdiagnosed as an allergic reaction. We suspect a lack of familiarity with skin rashes in darker skin types contributed to this initial misdiagnosis. However, we believe it was clear that the patient’s rash and history on initial presentation were not in keeping with urticaria, or an allergic skin rash. However, a further point to consider is that dermatomyositis is rare, and so those working in primary care are less familiar with its manifestations. Medical resources have historically had a tendency to use images of people with lighter skin tones to demonstrate skin diseases. Over the last few years, several textbooks and online resources have become available specifically showing skin conditions in different skin tones, for example, the Mind the Gap handbook. These resources are generally excellent; however, they tend to focus on common skin disorders. In addition, images of dermatomyositis in medical textbooks are predominantly of white skin. If medical education resources were to include examples of dermatomyositis in a variety of skin tones it is possible that diagnostic confidence and proficiency would improve, and racial disparities would be reduced. This is especially important in a multicultural society like the United Kingdom. Key learning points Lack of awareness of skin rashes in diverse skin types contributes to misdiagnosis and worse outcomes for patients with ethnic minority backgrounds, including those with dermatomyositis. Increasing awareness and education surrounding the skin manifestations in diverse skin types is a key priority for medical education, including in rheumatology. New initiatives aimed at improving our understanding of skin manifestations in diverse skin types are underway.

COVID-19 vaccine registry for pregnant women: policy to control complications of vaccination in pregnant women in 2021–2022

BackgroundData management related to COVID-19 vaccination in pregnant women is vital to improve the treatment process and to establish preventive programs. Implementing a registry to manage data is an essential part of this process. This study aims to design a national model of the COVID-19 vaccination registry for pregnant women in Iran.MethodsThe present study is an applied descriptive study conducted in 2021 and 2022 in two stages. In the first stage, the coordinates of the National Registry of COVID-19 vaccination of pregnant women from related references and articles, as well as the comparative study of the National Registry of COVID-19 vaccination of pregnant women in the United States, Canada, and the United Kingdom was done. In the second stage, the preliminary model was designed. The model was validated using the Delphi technique and questionnaire tools and analyzing the data.ResultsThe presented national COVID-19 vaccination registry model of pregnant women’s main components consist of objectives, data sources, structure, minimum data set, standards, and registry processes, all of which received 100% expert consensus.ConclusionThe vaccination registry of pregnant women has a major role in managing COVID-19 vaccination data of pregnant women and can be one of the Ministry of Health and Medical Education priorities.

Outcomes of the 2021-2022 APDS General Surgery Recruitment Process Recommendations

In recent years, mounting challenges for applicants and programs in resident recruitment have catapulted this topic into a top priority in medical education. These challenges span all aspects of recruitment-from the time an applicant applies until the time of the Match-and have widespread implications on cost, applicant stress, compromise of value alignment, and holistic review, and equity. In 2021-2022, the Association of Program Directors in Surgery (APDS) set forth recommendations to guide processes for General Surgery residency recruitment. This work summarizes the APDS 2021-2022 resident recruitment process recommendations, along with their justification and program end-of-cycle program feedback and compliance. This work also outlines the impact of these data on the subsequent 2022-2023 recommendations. After a comprehensive review of the available literature and data about resident recruitment, the APDS Task Force proposed recommendations to guide 2021-2022 General Surgery resident recruitment. Following cycle completion, programs participating in the categorical General Surgery Match were surveyed for feedback and compliance. About 122 of the 342 programs (35.7%) participating in the 2022 categorical General Surgery Match responded. Based on available data in advance of the cycle, recommendations around firm application and interview numbers could not be made. About 62% of programs participated in the first round interview offer period with 86% of programs limiting offers to the number of slots available; 95% conducted virtual-only interviews. Programs responded they would consider or strongly consider the following components in future cycles: holistic review (90%), transparency around firm requirements (88%), de-emphasis of standardized test scores (54%), participation in the ERAS Supplemental application (58%), single first round interview release period (69%), interview offers limited to the number of available slots (93%), 48-hour minimum interview offer response time (98%), operationalization of applicant expectations (88%), and virtual interviews (80%). There was variability in terms of the feedback regarding the timing of the single first round offer period as well as support for a voluntary, live site visit for applicants following program rank list certification. The majority of programs would consider implementing similar recommendations in 2022-2023. The greatest variability around compliance revolved around single interview release and the format of interviews. Future innovation is contingent upon the ongoing collection of data as well as unification of data sources involved in the recruitment process.

Variation in medical humanities program mission statements in United States and Canadian Medical Schools

Purpose In 2019, the American Association of Medical Colleges (AAMC) identified the discipline of medical humanities as a priority in medical education. Although medical humanities programs have existed in medical and osteopathic schools in the U.S. and Canada since the late 1960’s, this interdisciplinary field remains difficult to define. We studied the mission statements of medical humanities programs to identify core themes and priorities. Materials and methods We conducted a content analysis of U.S. and Canada medical humanities MD and DO mission statements and associated descriptions (n = 56). We compared themes across programs whose directors had a clinical degree versus a terminal research degree, conducted comparisons between medical humanities programs housed in medical schools ranked in Top 20 U.S. News and World Report for Research or Primary Care, and conducted a word frequency analysis. Results Content analysis revealed five themes: improving patient care, improving the provider experience, generating scholarship, cultivating community relationships, and promoting diversity/sociocultural awareness. 70% of programs emphasized patient care and provider experience. Only 34% included the promotion of diversity/sociocultural awareness as a theme. Word frequency analysis corroborated our findings. Conclusions U.S. and Canada medical humanities programs focus primarily on improving patient care and provider wellness.

ATTITUDES, WORK ROLES AND BARRIERS TO NUTRITION CARE - INTERVIEWS WITH AUSTRALIAN AND UK-BASED MEDICAL DOCTORS.

Poor diet is implicated in multiple chronic diseases. Although doctors may be well placed to facilitate nutrition care, nutrition remains a low priority in medical education internationally. Consensus is required on nutrition competencies as a benchmark for education with a regulatory framework to ensure implementation. The aim of this qualitative study was to explore work roles, attitudes, barriers and enablers in the delivery of nutrition care among a cohort of Australian and UK doctors. Semi-structured interviews were conducted with primary care doctors/general practitioners (n = 14) and medical specialists (n = 8) based in Australia and the United Kingdom to explore work roles, attitudes, barriers and enablers in the delivery of nutrition care. Framework analysis identified five key themes: (1) knowledge and skills in nutrition to support medical nutrition care, (2) the delivery of nutrition education, (3) multidisciplinary and interdisciplinary care, (4) systemic barriers and facilitators to care and (5) the need for a paradigm shift. Participants acknowledged nutrition as an important component of medical care but recognised they are currently ill-equipped to support such care, identifying limitations to the systems supporting integrated care. Participants identified that nutrition sits within both a health promotion and medical/treatment model, but they currently work only within the latter. Participants highlighted a lack of knowledge and training regarding nutrition, without which change is not possible. Efforts to improve the nutrition capacity of the medical workforce must be matched by increased investments in primary prevention, including nutrition - a paradigm shift from the medical model.

A Targeted Interest Survey of Preclinical Medical Students for Implementation of Exposure Opportunities in Multidisciplinary Oncology Education

<h3>Background</h3> With the growing prevalence of cancer, fostering multidisciplinary interest in oncology is an important priority in medical education. However, medical student interest in radiation oncology has declined in recent years (1) in part due to a lack of exposure. Efforts have been made to increase formal radiation oncology lectures within didactics. Additionally, preclinical extracurricular activities can provide unique opportunities for meaningful exposure to oncology, including radiation oncology. This study aims to assess current interest for oncology-related activities in preclinical medical students to facilitate innovative integration of radiation oncology-related curricula. <h3>Methods</h3> An anonymous web-based survey was created and distributed to the first-year class at a single academic institution. The survey included questions exploring interest in oncology-related talks, mentorship, shadowing at tumor board discussions, and participation in a longitudinal cancer patient advocacy program. <h3>Results</h3> The survey was distributed to 169 students, with a response rate of 33.1% (n = 56). Among responders, the highest interest activities were lectures (100%, n=56), tumor boards (89.2%, n=50), mentorship (60.7%, n=34), and volunteering (57.1%, n=32). For lectures, students were most interested in surgical oncology (42.9%, n=24), followed by medical oncology (41.1%, n=23) and radiation oncology (32.1%, n=18). Among topic-based talks, 69.6% (n=27) were interested in "how to break bad news", 62.5% (n=35) in cancer disparities, and 48.2% (n=27) in multidisciplinary panels. Respondents reported interest in tumor board discussions, with lung cancer receiving the most interest (53.7%, n=29), followed by breast (48.1%, n=26) and head and neck (40.7%, n=22). In addition, 57.1% (n=32) were interested in volunteering for a longitudinal patient advocacy program. Lastly, there was interest in oncology-specialty mentorship from residents/fellows (Medical=21.2%, n=11, Surgical=10.6%, n=7, Radiation=4.3%, n=2, and any specialty=26.9%, n=11). A significant proportion of surveyed first-year medical students at a single institution are interested in oncology-related talks, tumor boards, mentorship, and volunteering. However, there was disproportionately lower student interest in radiation oncology specific topics and mentorship. <h3>Discussion</h3> These results support invested development of robust, sustainable, extracurricular oncology programs during preclinical years. This helps guide areas to focus our efforts to cultivate and solidify interest in oncology with unique opportunities to integrate radiation oncology curricula. Similar interest surveys can be distributed at other institutions to assess what opportunities would garner interest and delineate activities that would present a meaningful perspective on radiation oncology and oncology as a whole.

Application of the Case Study Method in Medical Education

Reducing the gap between professional opportunities of graduates of medical education institutions and needs of patients is the priority of medical education. The introduction of interactive methods, in particular the case study method, can help solve this problem. The aim of this study was to investigate how the application of the case method in medical education affects the learning outcomes of students and acquisition of practical experience. Case method was used to identify its impact on the acquisition of practical skills, abilities and clinical experience by future physicians. Students’ opinions on the effectiveness of the case method in gaining practical experience were surveyed. The study showed that the case method helped students find solutions required by clinical situations, as they used not only theoretical knowledge, but also acquired practical skills and clinical experience. The case method also increases students’ confidence in their professional abilities. This experimental study proved the high efficiency of using the case method in medical education to gain practical experience by students in the education institution. It can be useful for scholars and educators who are looking for, developing and implementing effective teaching methods that allow students to acquire the necessary competencies.

Giving Moral Competence High Priority in Medical Education. New MCT-based Research Findings from the Polish Context

Nowadays, healthcare and medical education is qualified by test scores and competitiveness. This article considers its quality in terms of improving the moral competence of future healthcare providers. Objectives. Examining the relevance of moral competence in medico-clinical decision-making despite the paradigm shift and discussing the up-to-date findings on healthcare students (Polish sample). Design and method. N=115 participants were surveyed with a standard Moral Competence Test to examine how their moral competence development was affected by the learning environment and further important factors. Results. The sample allowed the identification of a regress in moral competence during students’ pre-clinical curriculum, and progress during their clinical curriculum. A gender-related bias, a segmentation effect, and a pronunciation effect were noticed. Explanations. Scholarly literature usually reports a linear decrease of medical students’ C-scores resulting from, e.g., competitive trends in education. We identified such trends in terms of gender-specific competitive tactics. Religious and ethical affiliations were discussed to explain the unexpected gender bias and the related segmentation and pronunciation effects. The findings can be regarded as predictive for similar developments in educational institutions regardless of cultural contexts as the sample examined in this article represents medical education in a country facing a transition from a non-competitive to competitive tertiary education model, and between presecular and monocultural to secular and pluralist social ethics.

The University of Vermont Larner College of Medicine.

The University of Vermont Larner College of Medicine.

Lung Cancer Screening Knowledge Among Internal Medicine Residents in a University Program.

Lung cancer remains the main cause of cancer-related death. Even though several societies recommend that certain populations may benefit from lung cancer screening with low-dose computed tomography (LDCT), its nationwide adoption has been slow. Practices in primary care are closely linked to residency training. Recognizing gaps in knowledge during training may translate into increased utilization of life-saving measures. Sixty internal medicine residents training at a university-based program were presented with an anonymous online-based survey designed to measure their knowledge about lung cancer screening. In the second phase, residents were presented with an infographic containing the answers to the initial survey. They were surveyed again 30days after this intervention. The average correct response rate among all years was 42%. PGY-1 residents performed better compared with PGY-2 and PGY-3 residents (p= 0.015). Ninety-two percent of residents did not think screening improved all-cause mortality. Less than half thought screening had a lung cancer-specific mortality benefit. Fifty-three percent rated their self-perceived knowledge above 50%. There was no difference in knowledge after the intervention. Specific populations may benefit from LDCT screening. Even if these benefits do not directly translate to population settings, the burden and mortality of lung cancer calls for urgent measures to attempt an earlier diagnosis. Internal medicine residents in this program may have several concerns about lung cancer screening including coverage, benefit, and false positive rate. Educational methods such as infographics may not be effective in improving knowledge among residents. Lung cancer screening should be a priority in medical education, especially in states with high smoking rates and lung cancer mortality.

It’s important, but not important enough: eHealth as a curriculum priority in medical education in Australia

Information and communications technology has become central to the way in which health services are provided. Technology-enabled services in healthcare are often described as eHealth, or more recently, digital health. Practitioners may require new knowledge, skills and competencies to make best use of eHealth, and while universities may be a logical place to provide such education and training, a study in 2012 found that the workforce was not being adequately educated to achieve competence to work with eHealth. We revisited eHealth education and training in Australian universities with a focus on medical schools; we aimed to explore the progress of eHealth in the Australian medical curriculum. We conducted a national interview study and interpretative phenomenological analysis with participants from all 19 medical schools in Australia; two themes emerged: (i) consensus on the importance of eHealth to current and future clinical practice; (ii) there are other priorities, and no strong drivers for change. Systemic problems inhibit the inclusion of eHealth in medical education: the curriculum is described as ‘crowded’ and with competing demands, and because accrediting bodies do not expect eHealth competence in medical graduates, there is no external pressure for its inclusion. Unless and until accrediting bodies recognise and expect competence in eHealth, it is unlikely that it will enter the curriculum; consequently the future workforce will remain unprepared.

Evaluation of a Case-Based, Community-Engaged LGB-TGNC Health Training Module for Trainees in Obstetrics and Gynecology

BACKGROUND: OB/GYN providers are frontline in providing care to LGB-TGNC people. Limited curricula specific to OB/GYN trainees exist. Deficits in competency limit access and quality of care. The AAMC and APGO/CREOG mandate inclusion of population-specific curricula. METHODS: Curriculum consisted of two 1-hour modules meeting APGO/CREOG learning objectives, developed in partnership with an LGB-TGNC community health center. Modules integrated role-play, small groups, and cases, focusing on culturally humble vocabulary, disparities, and best practices. We measured learner satisfaction and anticipated behavior change using Likert scales. Knowledge acquisition was assessed using a pre/post survey in a subgroup (n=14). Feedback was elicited using semi-structured questions. Responses were tabulated and de-identified. Statistical analyses was performed in STATA 13.0. Qualitative responses were coded for theme. Learners were residents and 4th-year students at three institutions. RESULTS: Eighty-two percent (82/100) participants responded. Eighty-one percent (67/82) highly agreed that stated objectives were worthwhile, 71% (58/82) strongly agreed that objectives were adequately met, 37% (30/82) strongly agreed that curriculum dispelled myths held, and 52% (43/82) strongly agreed and 38% (31/82) agreed that curriculum would impact their work as an OB/GYN. Gradients in pre/post knowledge acquisition were greatest for transgender health-related content. Participants wanted further training on gender-affirming hormone therapy, and legislative context. DISCUSSION: LGB-TGNC health is a priority in medical education. We describe an innovative curriculum with high learner satisfaction and knowledge acquisition. Next steps will address curricular limitations and evaluate impact on observed skills and health outcomes.

Developing a Team‐Based Learning Module for Large Classes in Medical School

In addition to early exposure to clinically relevant topics and integration of various disciplines, teaching team skills has become a priority in medical education. Many forms of small‐group teaching, which promote the development of team skills, require a large number of teaching personnel. This can be problematic when these activities are to be implemented in the large classes (i.e., more than 100 students) typical of many Medical Schools. Team‐based learning (TBL) is considered to be a strategy for active learning that enables a single teacher to facilitate learning in multiple small groups simultaneously in the same room. We have developed a TBL module for medical students in the pre‐clerkship period that integrates embryology, anatomy, and radiology of the head and neck region. The TBL module was developed initially in 2015 for a class of 234 students and has been used in 2016 for the second time with a class of comparable size (231 students). Here, we describe the resources available through our institution's Office of Medical Education, and how they were used to adapt TBL for a large class: (1) Various tools of the school's online learning management system, MoodleRooms, were utilized to deliver the pre‐reading material and to present the applications to the students. (2) The computer‐based testing tool, ExamSoft, was used to deliver the questions for the readiness assurance tests (RATs). While the individual RAT was completely performed in ExamSoft, the answers for the group RAT questions were recorded with Immediate Feedback Assessment Technique scratch cards. (3) A dedicated room had been built to accommodate the entire class engaged in small‐group activities (in particular TBL). The room includes 40 tables; each is seating a TBL group and is equipped with a microphone and a monitor the students can connect to wirelessly. There are additional monitors on the walls, and a central instructor station enables the facilitator to control all monitors in the room.A student survey was performed after each of the TBLs; in both years the students evaluated the TBL positively, with even better results in the second year. In our experience, exact time management and aiming for a seamless transition between activities during a TBL session are important to keep students motivated and engaged. In conclusion, TBL with large classes has specific challenges, most of which can be overcome with appropriate measures including institutional support and careful planning.

Development of a Comprehensive Communication Skills Curriculum for Pediatrics Residents.

Effective communication is an essential element of medical care and a priority of medical education. Specific interventions to teach communication skills are at the discretion of individual residency programs. We developed the Resident Communication Skills Curriculum (RCSC), a formal curriculum designed to teach trainees the communication skills essential for high-quality practice. A multidisciplinary working group contributed to the development of the RCSC, guided by an institutional needs assessment, literature review, and the Accreditation Council for Graduate Medical Education core competencies. The result was a cohesive curriculum that incorporates didactic, role play, and real-life experiences over the course of the entire training period. Methods to assess curricular outcomes included self-reporting, surveys, and periodic faculty evaluations of the residents. Curricular components have been highly rated by residents (3.95-3.97 based on a 4-point Likert scale), and residents' self-reported communication skills demonstrated an improvement over the course of residency in the domains of requesting a consultation, providing effective handoffs, handling conflict, and having difficult conversations (intern median 3.0, graduate median 4.0 based on a 5-point Likert scale, P ≤ .002). Faculty evaluations of residents have also demonstrated improvement over time (intern median 3.0, graduate median 4.5 based on a 5-point Likert scale, P < .001). A comprehensive, integrated communication skills curriculum for pediatrics residents was implemented, with a multistep evaluative process showing improvement in skills over the course of the residency program. Positive resident evaluations and informal comments from faculty support its general acceptance. The use of existing resources makes this curriculum feasible.

Practising what we preach: using cognitive load theory for workshop design and evaluation.

Theory-based instructional design is a top priority in medical education. The goal of this Show and Tell article is to present our theory-driven approach to the design of instruction for clinical educators. We adopted cognitive load theory as a framework to design and evaluate a series of professional development workshops that were delivered at local, national and international academic conferences in 2014. We used two rating scales to measure participantsʼ cognitive load. Participants also provided narrative comments as to how the workshops could be improved. Cognitive load ratings from 59 participants suggested that the workshop design optimized learning by managing complexity for different levels of learners (intrinsic load), stimulating cognitive processing for long-term memory storage (germane load), and minimizing irrelevant distracters (extraneous load). Narrative comments could also be classified as representing intrinsic, extraneous, or germane load, which provided specific directions for ongoing quality improvement. These results demonstrate that a cognitive load theory approach to workshop design and evaluation is feasible and useful in the context of medical education.

Changes in Young Adult Primary Care Under the Affordable Care Act.

We sought to describe changes in young adults' routine care and usual sources of care (USCs), according to provider specialty, after implementation of extended dependent coverage under the Affordable Care Act (ACA) in 2010. We used Medical Expenditure Panel Survey data from 2006 to 2012 to examine young adults' receipt of routine care in the preceding year, identification of a USC, and USC provider specialties (pediatrics, family medicine, internal medicine, and obstetrics and gynecology). The percentage of young adults who sought routine care increased from 42.4% in 2006 to 49.5% in 2012 (P < .001). The percentage identifying a USC remained stable at approximately 60%. Among young adults with a USC, there was a trend between 2006 and 2012 toward increasing percentages with pediatric (7.6% vs 9.1%) and family medicine (75.9% vs 80.9%) providers and declining percentages with internal medicine (11.5% vs 7.6%) and obstetrics and gynecology (5.0% vs 2.5%) providers. Efforts under the ACA to increase health insurance coverage had favorable effects on young adults' use of routine care. Monitoring routine care use and USC choices in this group can inform primary care workforce needs and graduate medical education priorities across specialties.

Teaching Quality Improvement in Graduate Medical Education: An Experiential and Team-Based Approach to the Acquisition of Quality Improvement Competencies.

An emerging priority in medical education is the need to facilitate learners' acquisition of quality improvement (QI) competencies. Accreditation bodies in both Canada and the United States have included QI and patient safety in their core competencies. In 2010, the Department of Family Medicine at Queen's University designed a graduate medical education curriculum to engage residents in a clinical QI program that would meet accreditation requirements. Monthly didactic sessions were combined with an experiential, team-based QI project that aligned with existing clinic priorities. The curriculum spans the first year of residency and is divided into three stages: (1) Engaging, (2) Understanding, and (3) Improving and translating. In Stage 1, teams of residents select a clinical QI topic, engage stakeholders, and collect baseline data related to their topic. In Stage 2, they focus on understanding their problem, interpreting their results, and applying QI tools. In Stage 3, they develop change ideas, translate their knowledge, and prepare to hand over their project. This QI curriculum aided residents in effectively acquiring QI competencies and allowed them to experience real-world challenges, such as securing project buy-in, negotiating with peers, and developing solutions to problems. Unlike in many QI programs, residents learned how to improve quality rather than about QI; thus, they formed the necessary foundation to carry out QI work in the future. The curriculum will be evaluated using a knowledge assessment and satisfaction tool and postproject resident interviews. Facilitators will focus more on improving faculty develop ment in QI.

Integrated Learning in Medical Education: Are Our Students Ready?

Integration in medical education means breaking the barriers between individual disciplines. As stated by Bradley and Mattick [1], Bintegrated curriculum aims to provide students with better learning opportunities that will facilitate the development of knowledge that is relevant and meaningful to clinical practice, is deep and retrievable and which is amenable to alteration, updating and development as a part of an ongoing process of lifelong learning.^ The expected outcomes of an integrated medical curriculum are undoubtedly admirable but are we overly optimistic? We are not voting for or against it, rather, in agreement with the medical education fraternity. Integration is essential to avoid the information overload that is associated with the traditional curriculum where information was delivered as a series of disciplinary blocks that is more focused on detail with little emphasis on the links between subjects and its clinical relevance. BIntegration seeks to deal more with principles and concepts that can be used to explore and understand problems and develop new solutions^ [1]. From the time Flexner’s report of 1910 on medical education [2] was published, medical school curricula around the world underwent a major evolution. Most medical schools adopted the B2+2^ curriculum in which the first 2 years of early foundational basic science education are separate from two later years of clinical training [3, 4]. This curriculum format however is viewed as an inadequate system to prepare future physicians for twenty-first century medicine [5, 6]. A number of commentaries, curriculum maps, and guidelines centered on integration have since been published. However, recent major education reports [7, 8] continue to outline integration as a strategic priority for medical education suggesting that integration is a problem yet to be solved. Although the innovations and attempts to integrate basic sciences and clinical knowledge by the medical schools are significant and commendable, most aremade at the level of programs, courses, and teaching sessions. We feel that the Blearners^ are sidelined in the process. Integration of the multiple domains of knowledge should depend on the cognitive activity that occurs within the learner. Simply creating an integrated curriculumwill not mechanically lead to cognitive integraion. A number of possible reasons could be implicated for unsatisfactory outcomes of integration in medical schools. First, the institutions seem to expect that making logistical changes will lead to active integration of basic sciences and clinical knowledge. Creating an integrated curriculum and delivering it in a coordinated manner do not automatically establish integration. Integrated sessions should ideally be given by teachers from one scientific realm (foundational or applied/ clinical) with academic knowledge of the other or collaboratively by teachers from both realms. Trans-disciplinary cooperation among educators must be emphasized by the management or the schools should utilize staff with academic knowledge of both (basic and clinical) realms to deliver the integrated curriculum. Second, it is innovation(s) in curriculum that are loosely referred as integrated curriculum. Examples include introduction of medical ethics and law into the firstyear courses and integrating clinical exposure from the commencement phase of medical education. Third, there is a constant pressure to increase applied knowledge from the early years of the medical school. This has dramatically decreased the number of hours spent on theoretical/foundational * Amudha Kadirvelu amudha.kadirvelu@monash.edu

Needs, expectations, and concerns of medical students regarding end-of-life issues before the introduction of a mandatory undergraduate palliative care curriculum.

In the past, implementation of effective palliative care curricula has emerged as a priority in medical education. In order to gain insight into medical students' needs and expectations, we conducted a survey before mandatory palliative care education was introduced in our faculty. Seven hundred nine students answered a questionnaire mainly consisting of numeric rating scales (0-10). Participants attributed a high importance to palliative care for their future professional life (mean, 7.51 ± 2.2). For most students, symptom control was crucial (7.72 ± 2.2). However, even higher importance was assigned to ethical and legal issues (8.16 ± 1.9). "Self-reflection regarding their own role as a physician caring for the terminally ill along with psychological support" was also regarded as highly important (7.25 ± 2.4). Most students were moderately concerned at the prospect of being confronted with suffering and death (5.13 ± 2.4). This emotional distress was rated significantly higher by female students (5.4 ± 2.4 versus 4.6 ± 2.4; p < 0.001). Seventeen percent of all students rated their distress as being 7 of 10 or higher, which indicates a considerable psychological strain in terms of dealing with end-of-life issues in the future. Professional or personal experience with terminally ill persons lowered these anxieties significantly (4.99 ± 2.34 versus 5.47 ± 2.5, p < 0.05). Medical students stated a remarkably high interest in learning palliative care competencies. Responding to their specific concerns and needs-especially with regard to the acquisition of emotional coping skills-may be key for the development of successful palliative care curricula.