PROBLEM:Reflective practice is associated with personal and professional development, including enhanced well-being and improved quality of patient care. Although medical education typically relies on narrative or text-based exercises for reflection, the visual arts are well suited to fostering reflective practice in ambiguous learning environments, such as medical school. Incorporating the visual arts with written reflections can enhance creativity and observation while engaging metacognitive skills, such as perspective-taking and self-awareness of biases. The authors describe an innovative reflection tool that integrates photographs with brief written reflections on meaningful learning from early clinical encounters in undergraduate medical education. APPROACH:The authors developed a health humanities reflection tool-the Photo/Tiny Story (PTS)-that combines taking a photograph with writing a corresponding 55-word story. Introduced in a first-year course at the University of Rochester School of Medicine and Dentistry, the tool facilitates students to critically reflect on their experiential learning from one meaningful clinical encounter and represent this in a PTS. Students subsequently discussed their assignments in facilitated small groups. Assignment evaluations from May of the academic year 2021 to 2022 were examined, and the PTSs were thematically analyzed using an inductive approach. OUTCOMES:Seventy-six of 102 students (75%) reported that the PTS was a valuable tool for reflection, with 72 (71%) reporting that it helped them examine assumptions and biases. Additionally, 91 (89%) acknowledged its effectiveness in facilitating reflection on the affective elements of their patient encounter. Qualitative analysis of the PTSs identified 4 key themes: clinical challenge of biopsychosocial practice, awareness of uncertainty, recognizing discrepancies between clinical expectations and reality, and skills application. NEXT STEPS:Results indicate that the PTS is an effective, resource-efficient tool for reflecting on experience and complex skills acquisition in emotionally charged clinical environments. Next steps include analyzing PTS assignments across all 4 years of undergraduate medical education.

Background and Objectives:As standardized metrics in residency selection change, residency program directors increasingly rely on narrative components of the Medical Student Performance Evaluation (MSPE) clerkship summaries. However, wide variability in structure, language, and transparency limits their usefulness for high-stakes decision making. The aims of this study were to explore neurology and child neurology program directors' perspectives on the utility of MSPE neurology clerkship summaries and to identify features that enhance or undermine their value in residency selection. Methods:We conducted a qualitative study using semistructured interviews with US neurology and child neurology residency program directors. Participants reviewed and discussed 4 constructed MSPE neurology clerkship summary cases developed from deidentified authentic MSPE excerpts and designed to reflect variation in structure and content. Interviews were audio recorded, transcribed verbatim, and analyzed using reflexive thematic analysis informed by theories of narrative assessment and discourse. Trustworthiness was supported through analytic memos, peer debriefing, and investigator triangulation. Results:Thirteen program directors participated, and 6 themes emerged: (1) Participants valued honest and transparent narratives but perceived candid discussion of limitations as risky for students; (2) institutional variability in grading systems, access to neurology experiences, and evaluator practices limited fair comparison of applicants; (3) narratives were most useful when clearly structured, concise, and transparent about how evaluations were synthesized; (4) comparative information was viewed as essential for decision making, despite its susceptibility to bias; (5) program directors consistently reported that coded language was difficult to interpret and should be avoided; and (6) nonspecific laudatory comments diminished narrative value, whereas brief, concrete behavioral examples enhanced credibility and interpretability. Discussion:Neurology clerkship summaries in the MSPE remain influential yet imperfect tools for residency selection. Program directors favor narratives that are structured and specific and avoid coded or vague language. Targeted faculty development and adoption of shared narrative frameworks represent actionable strategies to improve fairness, clarity, and trust in narrative assessment within neurology education.

BackgroundImproving clinical reasoning education has been identified as an important strategy to reduce diagnostic error-an important cause of adverse patient outcomes. Clinical reasoning is fundamental to each specialty, yet the extent to which explicit instruction in clinical reasoning occurs across specialties in the clerkship years remains unclear.MethodThe Alliance for Clinical Education (ACE) Clinical Reasoning Workgroup and the Directors of Clinical Skills Courses (DOCS) Clinical Reasoning Workgroup collaborated to develop a clinical reasoning needs assessment survey. The survey questionnaire covered seven common clinical reasoning topics including illness scripts, semantic qualifiers, cognitive biases and dual process theory. Questionnaires were delivered electronically through ACE member organizations, which are primarily composed of clerkship leaders across multiple specialties. Data was collected between March of 2019 and May of 2020.ResultsQuestionnaires were completed by 305 respondents across the six organizations. For each of the seven clinical reasoning topics, the majority of clerkship leaders (range 77.4% to 96.8%) rated them as either moderately important or extremely important to cover during the clerkship curriculum. Despite this perceived importance, these topics were not consistently covered in respondents' clerkships (range 29.4% to 76.4%) and sometimes not covered anywhere in the clinical curriculum (range 5.1% to 22.9%).ConclusionsClerkship educators across a range of clinical specialties view clinical reasoning instruction as important, however little curricular time is allocated to formally teach the various strategies. Faculty development and restructuring of curricular time may help address this potential gap.

Teaching and learning of clinical reasoning are core principles of medical education. However, little guidance exists for faculty leaders to navigate curricular transitions between pre-clerkship and clerkship curricular phases. This study compares how educational leaders in these two phases understand clinical reasoning instruction. Previously reported cross-sectional surveys of pre-clerkship clinical skills course directors, and clerkship leaders were compared. Comparisons focused on perceived importance of a number of core clinical reasoning concepts, barriers to clinical reasoning instruction, level of familiarity across the undergraduate medical curriculum, and inclusion of clinical reasoning instruction in each area of the curriculum. Analyses were performed using the Mann Whitney U test. Both sets of leaders rated lack of curricular time as the largest barrier to teaching clinical reasoning. Clerkship leaders also noted a lack of faculty with skills to teach clinical reasoning concepts as a significant barrier (p < 0.02), while pre-clerkship leaders were more likely to perceive that these concepts were too advanced for their students (p < 0.001). Pre-clerkship leaders reported a higher level of familiarity with the clerkship curriculum than clerkship leaders reported of the pre-clerkship curriculum (p < 0.001). As faculty transition students from the pre-clerkship to the clerkship phase, a shared understanding of what is taught and when, accompanied by successful faculty development, may aid the development of longitudinal, milestone-based clinical reasoning instruction.

Purpose: Medical schools increasingly incorporate ultrasound into preclinical curricula but face barriers including financial constraints, shortages of qualified instructors, and limited curricular space. This study explored how integrating ultrasound co-teaching into an existing first-year clinical skills course influenced preceptors' teaching experiences and characterized areas for curricular improvement. Methods: Ultrasound instructors rotated through classrooms during small-group physical examination skills sessions with 110 medical students, joining physical examination preceptors who taught remaining session content. Twelve ultrasound and traditional preceptors' experiences were characterized through focus group interviews paired with inductive thematic analysis. Results: Four themes were identified. First, the shared classroom fostered vicarious learning and novel instruction techniques but could feel disruptive to teaching. Second, ultrasound integration prompted physical examination preceptors to adopt a learner role. Third, students appeared to associate ultrasound with anatomy and physiology more than physical examination. Finally, ultrasound integration carries multiple logistical considerations. Conclusions: Co-teaching ultrasound within clinical skills courses can promote learning and was associated with multiple effects on faculty preceptors and the teaching process. Those planning similar initiatives should consider strategies to optimize preceptor experiences, minimize disruptive potential, and promote connections between ultrasound and physical examination content.

Purpose: Narrative assessment of trainees can provide meaningful and valid representations of performance,1 yet significant barriers remain to their quality.2 Although the literature offers promising accounts of interventions to improve the quality of faculty members’ narratives,3,4 these studies largely document improvements at a population level, and the extent to which they improve quality at the individual level remains unclear. Thus, a more complete understanding of the measurement characteristics and behavioral processes underlying faculty members’ narratives is critical to informing valid assessment decisions as well as faculty development and research initiatives designed to improve their quality. To this end, we sought to (1) examine attributable facets of variance in the quality of faculty members’ narrative assessments and (2) identify optimal conditions to maximize the reliability of narrative assessment quality scores. Method: Data comprised 62 faculty members who provided 254 narrative assessments on 51 medical students in their neurology and medicine clerkships. We measured quality of narrative assessments using the Narrative Evaluation Quality Instrument (NEQI).5 Our analysis was informed by generalizability theory, a flexible statistical framework for examining the dependability of behavioral measurements. We used generalizability analyses (G- and D-studies) to explore sources of variance in narrative assessment quality scores and project how reliability estimates change under different measurement conditions—namely, an increase or decrease in the number of faculty narrative assessments. Secondary analyses examined potential differences in reliability estimates by faculty gender. Results: Differences across faculty accounted for 59.3% of variability in NEQI scores. Conversely, the quality of narrative assessments of students within faculty contributed relatively little to total variance (0.9%), suggesting high internal consistency within faculty. For each faculty member, 3 narrative assessments scored with the NEQI were required to reach a dependability coefficient of at least 0.80. A subsequent increase in the number of narrative assessments per faculty member resulted in improved reliability; however, the relative gains depreciated beyond 5 comments. Reliability estimates were consistent by faculty gender. Discussion: Variations in the quality of narrative assessment scores were primarily attributed to systematic differences across faculty. Further, faculty were highly stable in the quality of narratives across the students they assessed. Our findings suggest that as few as 3 narrative assessments are necessary to render a quality score that is reasonably consistent for a given faculty member. Additionally, these estimates were similar across faculty gender. Significance: Our work provides a more complete understanding of the measurement characteristics and behavioral processes underlying the quality of faculty members’ narrative assessments. More specifically, this work fills a notable gap in the literature regarding the minimum number of narrative assessments that are needed to provide a reliable estimate of faculty members’ proficiency in this critical assessment domain. Findings provide additional validity evidence of the NEQI and have practical implications for designing and studying the impact of faculty development interventions to improve the quality of faculty members’ narrative assessments. Acknowledgments: The authors wish to acknowledge Robert L. Strawderman, ScD, for his analytical guidance and support.

To examine whether a multi-pronged faculty development effort could improve the quality of neurology clerks' narrative evaluations.

Purpose: Prior work has established validity evidence of narrative assessments 1 and suggests that constructivist–interpretivist assessment approaches provide more meaningful 2 and potentially, more valid representations of trainee performance than numeric-based assessments. 3 Yet, narratives are frequently perceived as vague, nonspecific, and low quality. 4 Evidence also points to consistent patterns of bias in narrative evaluations by factors including student gender and underrepresented minority status. 5 To date, there is little research examining factors associated with narrative evaluation quality, particularly in the undergraduate medical education setting. Thus, the purpose of this work was to examine associations of faculty- and student-level characteristics with the quality of faculty members’ narrative evaluations within in-training evaluation reports. Method: We reviewed faculty narrative evaluations of 50 randomly selected students who completed their medicine and neurology clerkships, resulting in 165 and 87 unique evaluations in the neurology and medicine clerkships, respectively. We evaluated narrative evaluation quality using the Narrative Evaluation Quality Instrument (NEQI). We used linear mixed effects modeling to predict total NEQI score (maximum 12 points). Explanatory covariates included: time to evaluation completion, number of weeks spent with student, faculty total weeks on service per year, total faculty years in clinical education, student gender, faculty gender, and an interaction term between student and faculty gender. Secondary analyses explored association of explanatory covariates with NEQI subcomponent scores: performance domains, specificity, and usefulness. The study was approved as exempt by our institutional committee on human subjects research. Results: Significantly higher narrative evaluation quality was associated with a shorter time to evaluation completion, with NEQI scores decreasing by approximately .3 points every 10 days following students’ rotations (b = −0.03, P = .004). Additionally, female faculty had statistically higher-quality narrative evaluations with NEQI scores 1.81 points greater than their male counterparts (b = 1.81, P = .012). All other covariates were not significant. The “pseudo R2” or estimated proportion of variance accounted for within faculty (R21) was 0.08, and 0.09 between faculty (R22), with the latter suggesting the model explained about 9% of between-faculty differences in NEQI scores. Secondary analyses showed that none of the covariates predicted the performance domain subcomponent score. For the specificity subcomponent score, only faculty gender was statistically significant (b = 0.52; P = .006). However, time to evaluation completion, (b = −0.02, P < .001), time evaluator spent with student (b = 0.40; P = .04), and faculty gender (b = 1.02, P = .005) were all statistically significant predictors of the usefulness subcomponent score. Discussion: We found that time to narrative evaluation completion and faculty gender were associated with overall narrative evaluation quality. Conversely, factors reflecting continuity of supervision and faculty clinical teaching experience were not related to overall narrative evaluation quality. Importantly, there was not an association between faculty and student gender. Significance: Findings from this study advance understanding on ways to improve the quality of narrative evaluations, which are imperative given programmatic assessment models that will increase the volume and reliance on narrative assessments. Additionally, the recent elimination of the USMLE Step 2 Clinical Skills examination further increases the importance of narrative assessments as residency programs look for alternative means to discriminate between levels of trainee performance. Findings can also inform faculty development efforts to improve the quality of student evaluation by promoting processes that facilitate timely completion of narratives. In addition, further investigation should explore the narrative quality disparity by faculty gender and its impact on faculty professional development.

PURPOSE:Research methodologies represent assumptions about knowledge and ways of knowing. Diverse research methodologies and methodological standards for rigor are essential in shaping the collective set of knowledge in health professions education (HPE). Given this relationship between methodologies and knowledge, it is important to understand the breadth of research methodologies and their rigor in HPE research publications. However, there are limited studies examining these questions. This study synthesized current trends in methodologies and rigor in HPE papers to inform how evidence is gathered and collectively shapes knowledge in HPE.METHOD:This descriptive quantitative study used stepwise stratified cluster random sampling to analyze 90 papers from 15 HPE journals published in 2018 and 2019. Using a research design codebook, the authors conducted group coding processes for fidelity, response process validity, and rater agreement; an index quantifying methodological rigor was developed and applied for each paper.RESULTS:Over half of research methodologies were quantitative (51%), followed by qualitative (28%), and mixed methods (20%). No quantitative and mixed methods papers reported an epistemological approach. All qualitative papers that reported an epistemological approach (48%) used social constructivism. Most papers included participants from North America (49%) and Europe (20%). The majority of papers did not specify participant sampling strategies (56%) or a rationale for sample size (80%). Among those reported, most studies (81%) collected data within 1 year.The average rigor score of the papers was 56% (SD = 17). Rigor scores varied by journal categories and research methodologies. Rigor scores differed between general HPE journals and discipline-specific journals. Qualitative papers had significantly higher rigor scores than quantitative and mixed methods papers.CONCLUSIONS:This review of methodological breadth and rigor in HPE papers raises awareness in addressing methodological gaps and calls for future research on how the authors shape the nature of knowledge in HPE.

Prior research has suggested that art-based interventions may reduce anxiety in cancer patients and enhance dialogue in the healthcare setting. Through implementing Art at the Bedside, an art-based hospital visitation program, we sought to examine whether dedicated art observation sessions, and varying formats (with and without guided discussion), could have therapeutic effects on cancer patients’ mental wellbeing. This randomized controlled pilot study evaluated the effects of bedside art observation on anxiety in a sample of 73 hematologic cancer inpatients. We compared state anxiety, as measured by an abbreviated form of the Spielberger State-Trait Anxiety Inventory (STAI Y-6), across three groups (participants who observed an electronic selection of artwork with and without guided discussion, and a control group that did not engage in either dedicated art observation activity). We found that mean anxiety scores were significantly lower among those who participated in guided art observation, compared to those who did not (8.92 versus 12.1, scored on a scale of 6 to 24, p = 0.009, with a medium effect size (η2 = 12.7)). The majority of participants who engaged in art observation felt that the activity provided positive distraction (85.7%) and decreased boredom (79.6%), and many noted that it reduced feelings of anxiety (46.9%) and depression (24.5%). These findings suggest that bedside art observation, particularly with guided discussion, may be a promising complementary therapy for reducing cancer-related anxiety and improving the patient experience in the inpatient hematology/oncology setting, and would benefit from further inquiry.

To explore the emotional burden of a chronic neurological illness diagnosis on neurologists and patients.

Background and Objectives:Narrative-based evaluations are increasingly used to discriminate between levels of trainee performance, yet barriers to high-quality narratives remain. Prior evidence shows mixed results regarding the effectiveness of faculty development efforts on improving narrative evaluation quality. Methods:We used a quasi-experimental study incorporating a historical control group to examine the effectiveness of a pragmatic, multipronged, 4-year faculty development initiative on narrative evaluation quality in a neurology clerkship. We evaluated narrative evaluation quality using the narrative evaluation quality instrument (NEQI) in random samples of narrative evaluations from a historical control and intervention group. We used multilevel modeling to compare NEQI scores (and subscale scores) across groups. Informed by the theory of deliberate practice, our faculty development initiative included (1) annual grand rounds sessions focused on developing high-quality narratives and reporting evaluation metrics, (2) restructuring the clerkship assessment form to simplify and prioritize narratives, (3) recruiting key faculty to rotate on the clerkship grading committee to gain experience with and practice developing quality narratives, and (4) instituting a narrative evaluation excellence award to faculty and residents. Results:The faculty development initiative was associated with improvements in the quality of students' narrative evaluations. Specifically, the intervention group was a significant predictor of NEQI score, with means of 6.4 (95% CI 5.9-6.9) and 7.6 (95% CI 7.2-8.1) for the historical control and intervention groups, respectively. In addition, the intervention group was associated with significant improvement in the specificity and usefulness NEQI subscale scores, but not the performance domain subscale score. Discussion:A long-term, multipronged faculty development initiative can facilitate improvements in narrative evaluation quality. We attribute these findings to 2 factors: (1) pragmatic, solution-oriented efforts that balance focused didactics with programmatic shifts that promote deliberate practice and skill improvement and (2) departmental resources that prioritize and convey a commitment to improving trainee assessment.

Introduction Narrative approaches to assessment provide meaningful and valid representations of trainee performance. Yet, narratives are frequently perceived as vague, nonspecific and low quality. To date, there is little research examining factors associated with narrative evaluation quality, particularly in undergraduate medical education. The purpose of this study was to examine associations of faculty- and student-level characteristics with the quality of faculty member's narrative evaluations of clerkship students. Methods The authors reviewed faculty narrative evaluations of 50 students' clinical performance in their inpatient medicine and neurology clerkships, resulting in 165 and 87 unique evaluations in the respective clerkships. The authors evaluated narrative quality using the Narrative Evaluation Quality Instrument (NEQI). The authors used linear mixed effects modelling to predict total NEQI score. Explanatory covariates included the following: time to evaluation completion, number of weeks spent with student, faculty total weeks on service per year, total faculty years in clinical education, student gender, faculty gender, and an interaction term between student and faculty gender. Results Significantly higher narrative evaluation quality was associated with a shorter time to evaluation completion, with NEQI scores decreasing by approximately 0.3 points every 10 days following students' rotations (p = .004). Additionally, women faculty had statistically higher quality narrative evaluations with NEQI scores 1.92 points greater than men faculty (p = .012). All other covariates were not significant. Conclusions The quality of faculty members' narrative evaluations of medical students was associated with time to evaluation completion and faculty gender but not faculty experience in clinical education, faculty weeks on service, or the amount of time spent with students. Findings advance understanding on ways to improve the quality of narrative evaluations which are imperative given assessment models that will increase the volume and reliance on narratives.

Knowledge of embryology is foundational for understanding normal anatomy and birth defects, yet, embryology is a notoriously difficult subject for medical students. Embryonic lateral folding in particular is one of the most challenging concepts in embryology. Highly effective teaching methods that promote active engagement with dynamic, three‐dimensional models may be helpful for teaching this content. The aim of this study was to determine whether a hands‐on modeling activity utilizing premade crocheted pieces constructed from durable, inexpensive yarn helped medical students enrolled in a pre‐matriculation course to understand embryonic lateral folding. Change in knowledge was assessed using a pre–post design. Students also completed subjective evaluations regarding their satisfaction with the activity. Quiz scores in means (±SD) increased from 62.7 (±24.1) % before the activity to 77.0 (±17.1) % after the activity (P = 0.0495, two‐tailed paired t test; d = 0.68). Generally, students reported that the activity was helpful and enjoyable, and the model pieces were easy to manipulate. These promising results suggest that hands‐on activities with dynamic, three‐dimensional models constitute an effective method for teaching embryology.