Self-regulated learning and performance in medical school

We are always worrying about medical student performance. Measures of performance, including grades and standardized test scores, are monitored and discussed regularly. After sitting on an academic performance committee for several years, I have noticed that some students that struggle are a surprise to the faculty. Oh sure, there are some students who have lower pre-matriculant variables (undergraduate science GPA, MCAT, performance in upper level science courses) prior to starting medical school. In those students we might expect a lower performance in medical school. But there are regularly, students who did well during undergraduate studies, they have MCAT scores that are fine, and they are coming before the academic committee because of poor performance-usually failing a course or multiple courses.  Why does this happen?

Educational researchers in the Netherlands (ErasmusUniversity Medical Centre) and the Centre for Research and Innovation in Medical Education) have tried to tackle this question. (1) Their research question was: what is the relationship between motivation, learning strategies, participation, and performance in medical school. They are interested in the concept of self-regulated learning (SRL) which can be thought of as a learner that uses meta-cognition, motivation, and behavioral proactivity to improve their own learning. Several things that can be seen in self-regulated learners (and I would say in high-performing medical students): they monitor their progress towards their own goals; they are interested in learning for the sake of learning; and they develop and utilize effective learning behaviors.

This study was done in a medical school in Rotterdam, the Netherlands which has a six-year medical curriculum. First year students in 2008 and 2009 were included in the study. There were 303 students in 2008 (32% male) and 369 students in 2009 (37% male). Students were given a questionnaire that was about their study techniques and were given immediate feedback and recommendations for ways to improve. An 81 item survey with six motivation subscales and nine strategies subscales was given to measure their Self-regulated Learning. The survey used a Likert scale (1=not at all true of me to 7=very true of me). The questions were things like “understanding the subject matter of this course is very important to me” and “I ask myself questions to make sure I understand the material I have been studying for this course” and “I make sure I keep up with the weekly readings and assignments for this course.” Students also rated their attendance in lecture, clinical skills training, and assignments

The authors found that Participation (lecture attendance, completing study assignments, and skill training attendance) was positively associated with Year 1 Performance and improvements in the mean GPA. Deep learning strategies were negatively associated with Year 1 performance. So students who utilized deep learning strategies more frequently as their study method, had more difficulty in the preclinical (Year 1) curriculum.

So why does participation affect performance? Is it just because people that go to lecture are able to learn things and get explanations that are not in the available written information? Or is it because of the repetition of the material? They have heard it more times- a concept known as distributed practice (study effort is distributed over several study sessions). Or is it differential repetition? Material is presented in lecture, on-line modules, tutorials, small groups, skills training, and independent study which gives more opportunity to absorb and integrate the information into a structured knowledge base.

Is it just because people that go to lecture are more in tune with the material covered and how it will be tested? Since they go to lecture, they know what is going to be on the test based on the cues and clues from the faculty. This is an area that needs more research. We want students to utilize deep learning strategies because information that is learned this way are more likely to retain that information. We don’t want students that do better on the test just because they show up, unless showing up leads to deeper learning and retention of information.

References

(1) Stegers-Jager KM, Cohen-Schotanus J, Themmen APN. Motivation, learning strategies, participation and medical school performance. Medical Education 2012: 46: 678–688.

Physician burnout: is there anything that we can do?

A recent post by Pauline Chen, MD on the New York Times Wellblogspeaks about the nation-wide epidemic of physician burnout. She quotes a recent study published in the Archives of Internal Medicine by Shanafelt, et al (2) that measured the symptoms of burnout using a validated survey instrument (Maslach Burnout Inventory) (3). There were huge differences based on the specialty of the physicians. The highest rates of burnout were found in doctors at the front line of access to medical care: emergency medicine (OR 3.18), general internal medicine (OR 1.64), and family medicine (OR 1.41). These differences remained even after adjusting for age, sex, call schedule, relationship status, primary practice setting, hours worked per week, and years since graduation from medical school.  When compared to a probability-based sample of working adults in the US, physicians had a higher risk for emotional exhaustion (32.1% v. 23.5%), depersonalization (19.4% v. 15.0%), and overall burnout (37.9% v. 27.8%). Overall, 45.8% of physicians had at least one symptom of burnout.

Wow! That is scary! These are practicing physicians who are working themselves to a state of emotional and physical exhaustion. When physicians feel like this they are more likely to make mistakes and medical errors. So, bringing this back to medical education, is there evidence about burnout in learners? Well, a recent article in AcademicMedicine by Dyrbye, et al (4) addressed this question. The authors found that positive mental health had a protective effect on burnout.

In this study, 4,400 medical students from seven medical schools (Mayo College of Medicine; Uniformed Services University of the HealthSciences; University of Alabama School of Medicine; University of California,San Diego; University of Chicago Pritzker School of Medicine; University ofMinnesota Medical School; University of Washington School of Medicine) were surveyed. The students’ mental health was measured using a validated instrument that measures emotional, psychological, and social well-being. The symptoms of burnout were measured using the same Maslach Burnout Inventory that was used in the practicing physician survey.

What the authors found was not surprising: medical students also had high levels of burnout. 42.1% of the students had high scores in emotional exhaustion, 52.5% had a positive depression screen, and 17.4% reported suicidal ideation. When they asked about mental health, interestingly, most students were doing well. 53.1% were flourishing and 42.5% were moderately healthy, while only 4.3% were languishing. Students that were described as languishing reported a low frequency (“never” or “once or twice” in the past month) on more than one of the emotional well-being items and a low frequency on at least six of the signs of positive functioning.

48.2% of students who were languishing reported suicidal thoughts in the past 12 months compared to 25.1% who were moderately mentally healthy (p< 0.001). The scary part was that those who were flourishing still had a 9% rate of suicidal ideation. Students who were languishing were more likely to cheat, more likely to display other dishonest behaviors, less likely to endorse altruistic beliefs, and less likely to care for medically underserved patients.

This is scary stuff! It suggests that a lower, more negative mental attitude in a medical student is correlated with not only their personal feelings about themselves (ie: suicidal ideation) but also how they act within the professional environment (dishonesty and cheating). It may be that if we could identify those students who are languishing, we could intervene to help them improve their mental health. Interventions could impact their professional behavior and quite possibly their performance in the academic realm of medical school. The question is: what are those interventions? More research will be needed to figure out what can be done and what works best.

References

(1) Chen PW. The Widespread Problem of Doctor Burnout.  New YorkTimes.  August 23, 2012
(2) Shanafelt TD, Boone S, Tan L, et al.  Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population.  Arch Intern Med. Published online August 20, 2012.
(3) Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, Calif: Consulting Psychologists Press; 1996.
(4) Dyrbye LN, Harper W, Moutier C, et al.  A Multi-institutional Study Exploring the Impact of Positive Mental Health on Medical Students’ Professionalism in an Era of High Burnout. Academic Medicine  2012;87(8):1024-1031.

Career outcomes of graduates who initially failed Step 1

I know that I have been gone for a while. Sorry about that...

I saw a really interesting article in Advances in Health Sciences Education (1) this month.  The authors decided to study the career outcomes of graduates of six Midwestern medical schools who had initially failed USMLE Step 1. In this retrospective study, the authors sought to determine the academic and professional career outcomes of medical school graduates who failed Step 1 on the first attempt. They took a cohort of students who graduated from the Ohio State University College of Medicine, Michigan State University College of Human Medicine , Washington University School of Medicine, SouthernIllinois University School of Medicine, University ofIowa Roy J. and Lucille A. Carver College of Medicine, and the University of Michigan School of Medicine. In this cohort of 2,003 graduates from 1997-2002 were 50 (2.5%) students who initially failed Step 1 and these students were compared to the 1,953 students who passed Step 1 on the first attempt.

There were several interesting findings in this study. The authors used information from the MSQ (Medical Student Questionnaire), the GQ (Graduate Questionnaire), the AMA Physician Masterfile, ABMS Board certification, and the AAMC Faculty Roster System. Data was gathered from all six schools and merged into a single database. Some of this data has issues, for example the MSQ and the GQ both rely on student self-report. The AMA Masterfile may mis-categorize some doctors and the cohort only includes students who made it to graduation and for whom they had complete data available (about 43% of the total graduates). But with that being said, this is a pretty good study with a large cohort of graduates.

So, what did they find?  As you would guess, passing USMLE Step 1 on the first attempt has major repercussions for medical students. Most students (94%) pass the test, but not all. Students who fail Step 1 are less likely to pass Step 2 and less likely to ultimately graduate from medical school. (2) But this group of students had all graduated so are they still impacted? There is not a lot of evidence that medical school test performance is correlated to residency clinical performance, but Program Directors still put too much emphasis on Step 1. In fact, a national survey of Program Directors (3) found that 84% would seldom or never interview a student who had failed Step 1 even if they eventually passed Step 1.

In this study, those who failed were more likely to be women, minorities, and older. In fact, there were significant differences between these groups. When compared to men who graduated, women were 3.2 times more likely to have failed Step 1 on the first attempt (p < 0.001). African Americans were 13.4 times more likely to fail when compared to whites (p < 0.0001), and Latinos were 7.4 times more likely (p < 0.0001) to fail when compared to whites. They are more likely to end up in primary care residencies, to be older, and to come from families of lower income.

This data obviously has huge implications. Every medical school has a few failures on Step 1 and should be concerned about the implications. Are we willing to tolerate this difference in the relative risk of failing a nationally standardized high stakes examination? There may be pre-matriculate variables that explain some of the differences, but there also may be ways to identify and intervene in high-risk students’ academic career in ways that can decrease their risk of failure.

Take a look at the programs that are in place at the University of Texas Medical Branch in Galveston and Southern Illinois University. They have been successful in helping students that were identified as at-risk students. Unfortunately, but many schools would rather try to decrease the number of at-risk students that they admit.

The method that is often used is to try to admit students with higher MCAT scores and higher undergraduate GPAs. The problem with this strategy is that in doing this the school will also increase the number of rich, white, male students who come from urban backgrounds. This leads to a student body that is less diverse. That is something that our schools should not tolerate.

References

(1) McDougle L, et al.  Academic and professional career outcomes of medical school graduates who failed USMLE Step 1 on the first attempt. Adv in Health Sci Edu.  7 April 2012 (Online First).

(2) Biskobing DM, et al. Study of selected outcomes of medical students who fail USMLE Step 1. Medical Education Online  2006;11(11):1–7.

(3) National Resident Matching Program, Data Release and Research Committee. Results of the 2008 NRMP Program Director Survey. Washington, DC: National Resident Matching Program. 2008

Impact of medical school tuition

In my blog, How much should medical school cost?, I wrote about an innovative proposal by Peter Bach and Robert Kocher to make medical school free. Dr. Bach is the director of the Center for Health Policy and Outcomes at Sloan-Kettering Cancer Center. Dr. Kocher is a special assistant to President Obama on health care and economic policy. Their proposal has gotten a lot of press. It seems that many people have an opinion about the cost of medical education. Dr Joshua Freeman wrote in his blog, Medicine and Social Justice Would free medical schools increase primary care?.  Dr Kenny Lin, in his blog the Common Sense Family Doctor wrote Strengthening the primary care pipeline.  Dr Pauline Chen wrote in the New Times Health blog about The Hidden Cost of Medical Student Debt. 

I was thinking about another aspect of the cost of medical school.  It is something that I have not heard people talking about. Most of the negative aspects that have been talked about are related to the negatives to the student and the impact on their future career choices. There is also some (important) talk about the societal negative of less students choosing primary care and family medicine.

But what about students who never graduate from medical school?  Medical schools try very hard to keep students in school because of the big investment in that individual student. If you get into medical school in the US, your chances of graduating are extremely high. Something like 96 percent.¹  But what happens if you don't graduate? At most schools, the student would be on the hook for the cost of their education.  Wow!  Saddling a medical school graduate with $150,000 in debt is bad, but we say--they are going to be doctors, they can afford it. But if a student leaves school or is dismissed from medical school for academic reasons, they are still going to have that debt of $150,000.

It is a big deal. When the faculty are talking about the academic performance of a medical student, they should not have to worry about the financial ramifications of their decision. But, honestly, how can they not consider the implications. They are essentially condemning someone to financial ruin by saddling them with a debt that rivals that of a new home. And state schools are relatively cheap. If they are at a private medical school or one of the osteopathic schools, their debt may be as much as $300,000. 

The faculty on a dismissal committee are given an unenviable task. They are acutely aware of their responsibility to the public and society. They do not want to graduate a student who is not qualified to be a physician. By the time a student gets to this point they have been on the dean's office radar for a long time. These students have generally failed several courses or national standardized examinations, they have been through a lot of remediation, and there has been an enormous effort to salvage their medical career. The faculty have invested a lot of time and effort into the student. The faculty really care about the students. The school has invested a lot of money in them. A position in the medical school class can never be regained, so if a student is dismissed that spot is gone forever. The faculty feel that they have failed when a student is dismissed. The financial ramifications just make it worse.

So, I would like medical schools to consider a no-fault system.  If a student is dismissed from medical school, their tuition and fees are refunded to them. Let's take the financial part completely out of the discussion.  This will be better for the students and for the faculty. An potential effect of this policy, would be to encourage schools to take a chance on more at-risk students.  Some of these students might be from disadvantaged backgrounds, some might be underrepresented minorities, and some might be from rural areas. These students are less likely to apply to medical school and even when they apply, less likely to graduate.¹ Disadvantaged students may choose to not even try medical school because of the financial consequences of failure. A no-fault system would eliminate those consequences.

What do you think?

References

1) Garrison G, Mikesell C, Matthew D. Medical School Graduation and Attrition Rates [https://www.aamc.org/download/102346/data/aibvol7no2.pdf]. Analysis in Brief AAMC.  2007. Vol 7 Number 2.

Research in medical education

I had a crazy thought the other day,  why don't we do more research in medical schools. I know you're saying that there is a ton of research going on in the modern medical school.  But I bet if you are reading this you don't care that much about most of the research that is going on. Sure, there is plenty of basic science research. For instance, my good friend and co-conspirator/ co- director of our first medical school module is the famous Joe Fontes. He is in the Department of Biochemistry and he has two RO1s from the NIH.  Pretty impressive!  We also do some clinical research. One of my partners has an RO1 from the NIH to study colon cancer screening in minority populations.

But I am talking about research on and about the educational process. How much of what we do on a daily basis is evidence based?  I don't mean the knowledge content that is being delivered but the way that the information is delivered.  Is a lecture better than a small group?  Is an experienced lecturer better than one who is young and inexperienced?  Is a preceptor visit a better way to learn about professional behavior than lecturers. Are preceptorship visits better for teaching clinical skills or faculty physicians or trained patients?

These are all important questions. Why don't we know the answers to them?  

You might say that we know the answer to some of those questions. I would say that we probably know part of the answer to some but we don't know the whole answer to any of them. But does that matter? I think it does. We talk all the time about how we think evidence-based medicine is important but do we apply the same standard to the education of our students? I don't think so. I am not even sure that we could all agree on the definition of "better".

But don't you think we should have an evidence-based standard for educational practice just like we have for clinical practice?  This is what I propose. We need a medical school that is totally based on the best available educational research. Wait a minute, that won't work, will it?  We already know that there is not enough evidence for most of what we do. So, if we can't do it now maybe we could in the future. But how can we get there? Here is the radical part. We need to experiment on our students. (a big gasp was heard!)

The funny part is that I think we already do this. But right now we are not getting their permission.  Every time that we use an unproven educational method in our teaching, we are experimenting on them. We just don't get their consent.  I propose that we start asking for consent and randomize them to the standard educational method or to a well thought out intervention that is based on sound educational theory. This will require us to have a good grounding in educational theory which most physicians don't. And it will require an acknowlegement by us that our methods may not be right. We might need to change.

If I was a med student, I would be excited by this. Our students in Salina (see my blog about Salina) were told at the beginning that they would be the innovators, not guinea pigs. It was and is exciting to them. They were excited to be the first to prove that a medical school could be run in a small town in rural Kansas.  I think that the same would be true on other campuses with other methods. Let's be innovators.  

What do you think?

Empathy

A recent study Rosenthal, et al (1) in the journal Academic Medicine, studied the Jefferson Empathy Scale in medical students at the Robert Wood Johnson Medical School . This study was born out of a committee that included medical students, residents, and faculty. Their purpose was to design a curricular intervention that could be done in the third year of medical school that would help to preserve empathy throughout the year. 

The purpose of the study was "to evaluate JSPE-MS scores of two consecutive medical school classes in order to assess the impact of an empathy-preserving curricular innovation". At RWJ Med school they believed that there is a decrease in empathy across the third year of medical school. Anecdotally, I think that most medical educators know this to be true.

Wiggleton and colleagues (2) found moral distress, burnout, and depression in third year students. In this study, the authors described 50 potentially distressing situations which medical students might encounter in clinical rotations. Situations included: a patient had very advanced disease because they faced barriers to accessing care; a member of the team was disrespectful to someone below them in team ranking; optimal care was not provided as a result of alcoholism, drug use or homelessness; and our team provided care that only prolonged a patient's suffering. Over half of these situations had been experienced at least once. 35% of the situations caused mild to moderate distress.  

Diseker and Michielutte (3) found that empathy decreased before and after clinical experiences in the third year. The author's administered the Hogan empathy scale to all medical students. They found the empathy scale to be negatively correlated to MCAT scores. (see my previous blog about the MCAT). And they found that there was a significant decline in the empathy score from the beginning of medical school to the end.

Hojat and colleagues (4) found empathy significantly declined across the third year of medical school. They found that empathy did not really change that much in the first and second year, but the decline during the third year persisted until graduation. Interestingly, 27% of the students did not have any decline in empathy.

So, in this study the authors designed a curricular intervention that was given in the clinical year. Their intervention was six interactive sessions that were given during each of the required third-year clerkships. The sessions were one hour long and included time for debriefing on intense experiences, reflective essays/blogs,  and discussions of role models, patient care, morally distressing events, and the students' reactions.

This intervention seems fairly simple and similar to a longitudinal experience that our school has in the third year of medical school. The authors were able to document a lack of change in empathy across the third year. There was no statistically significant change in pretest/posttest empathy scores (pre = 115.4, post = 113.9, p =.135). One interesting fact was that student who entered family medicine, internal medicine and pediatrics had significantly higher empathy scores than those entering other specialties such as surgery, urology, otolaryngology, and anesthesiology.

Hopefully, there will be more interventions designed to help our students during the third year. It is hard. They are vulnerable and are often treated like crap. Dr. Steven Kanter (5) in his opening editorial in the March issue of Academic Medicine, reminds us that we need to think with our head as well as our heart to provide the best patient care. If we damage our students they will no longer have the ability to think with their heart, to care for their patients.  OK, I will get off the soap box for a while.

REFERENCES

(1) Rosenthal S, et al Humanism at Heart: Preserving Empathy in Third-Year Medical Students. Acad Med 2011;86(3):350-358.

(2) Wiggleton C, et al. Medical students' experiences of moral distress. Acad Med 2010; 85:111-117.

(3) Diseker RA, Michielutte R. An analysis of empathy in medical students before and following clinical experiences. J Med Educ. 1981;56:1004–1010.

(4) Hojat M, et al. The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84:1182–1191.

(5) Kanter S. Think With Your Head and With Your Heart. Acad Med  2011;86(3):273.

Professional dress: does it matter any more?

Sorry, I have been absent for a couple of weeks.

We started a new class of students off on their medical journey last month. The first year students arrive on campus bright-eyed and bushy tailed as it were. At our school most are fresh out of college. They have spent the last four or five years as Biology or Chemistry majors. They went to class or maybe they didn't. Most college courses don't have attendance requirements. They are generally allowed to dress however they want, this time of year shorts, flip flops and ball caps are the norm.

In 2005, there was a big flap (or should I say flip/flap) when the national championship women's Lacrosse team from Northwestern University was invited to the White House to meet President George Bush.  The scandal began when several people noticed that a picture taken of the ladies showed four of the nine players in the front row wearing flip flops.  Now these ladies were dressed up in skirts and nice clothes. After all they were meeting the President, but dressing up apparently did not include changing shoes.

 

So here we are with another class of new medical students. I am the co-director of the first module so I am sitting there in class most every day. The students are polite, they almost always address me as Dr Delzell, and so far I have not seen any rude behavior in class. But at least half the class is wearing flip flops. T-shirts are the norm. Many extolling their undergraduate school or their fraternity/sorority. Many of the guys wear ball caps. 

Now don't get me wrong, I like to dress casual. As soon as I get home from work I put on shorts and a t-shirt. I love to wear flip flops. I would love to have a job at a medical school that is located on the beach so I could wear casual Hawaiian-style shirts and flip flops every day.  But I don't.  And neither do our students. 

I know that there are some schools that require professional dress whenever the students are on campus. Dr. David Steele, Senior Associate Dean for Medical Education at the Paul L Foster Texas Tech School of Medicine in El Paso has told me that at their new medical school the faculty decided to require students to dress professionally every day. Even during the basic science lectures. And last year, we were invited to be visiting professors at the Yerevan State Medical University in Yerevan Armenia. We visited the campus and toured one of their large lecture halls that would hold about 600 first year medical students. It had hard wooden benches and no air conditioning and the students were required to dress up (suit and tie for the men) each day for lecture.

I don't know if it makes a difference. We talk all the time about how Millennials-Generation Y is different from past generations. I am sure that in the sixties when the hippies started their first day of medical school, they were wearing bell bottoms and tie-dye shirts. I am sure the professors were concerned about the lack of professionalism that those students displayed.  This is to some extent a generational issue that is seen every year. But where is the line?  When is it a generational issue-where the younger generation have a different set of internal rules and values that guide them in different ways than a previous generation? And when is it a maturation issue-where you need to learn behavior from those that are your teachers and mentors?