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1.  Using focus groups to understand causes for morale decline after introducing change in an IM residency program 
BMC Medical Education  2014;14:132.
Background
Although program evaluation is a core requirement of Internal Medicine residencies, little is reported in the literature regarding resident satisfaction with training. Most program evaluation consists of numerical rating scales from which it is often difficult to pinpoint exact sources of dissatisfaction.
Methods
Our goal in this work is to evaluate the utility of focus group methodology to uncover in detail the reasons for residents’ deteriorating morale in an IM residency program, as well as to solicit suggestions for correction. This study employed focus groups (FG) in a qualitative research design, in which descriptive statistics from a resident program evaluation survey served to guide an intensive focus group process. Participants were 40 of 45 2nd and 3rd year internal medicine residents enrolled in the IM residency training program. Five chief residents were trained to conduct 5 focus groups with 8 residents in each group. The focus groups examined possible issues contributing to the deterioration of morale noted in the quantitative survey.
Results
Many unexpected themes were uncovered by the FGs. Residents identified the following factors as the major contributors to deteriorating morale: 1) Pace of change 2) Process of change 3) The role of chief residents in change 4) Fear of intimidation and retaliation. Groups also suggested practical recommendations for improving the culture of the residency.
Conclusion
Introducing change in residency training is a challenging process. Respectful attention to resident frustrations and solution-focused discussions are necessary to understand and improve morale. Focus groups proved to be a useful tool in revealing the precise source of pervasive resident concerns as well as providing potential solutions. In addition, FGs methodology can be adapted in a practical manner to residency evaluation.
doi:10.1186/1472-6920-14-132
PMCID: PMC4094667  PMID: 24994046
Education medical graduate; Residency program evaluation; Focus groups; Qualitative research; Morale; Burnout
3.  Reflective Practice Enriches Clerkship Students’ Cross-Cultural Experiences 
Journal of General Internal Medicine  2010;25(Suppl 2):119-125.
AIM
To describe a curriculum incorporating written reflection followed by reflective discussion with the goal of enhancing students’ recognition and handling of cross-cultural and health disparity issues in different healthcare delivery settings.
PROGRAM AND SETTING
This required curriculum was implemented within a 4-week family medicine clerkship (n = 188 students, 6 to 12 per rotation) in 23 successive rotations over 2 years. Electronic submission of a written assignment in response to structured questions was followed by in-class discussion in week 4.
PROGRAM EVALUATION
Outcomes were students’ session evaluations, thematic analysis of student responses, and analysis of faculty facilitators’ reflections about discussion sessions. Students’ cultural knowledge about their patients’ health beliefs around diabetes was assessed using multiple choice questions at the beginning and end of the clerkship.
RESULTS
One hundred percent of students submitted narratives. Student evaluations demonstrated high acceptance, appreciation of sessions and faculty. Analyses of written assignments and in-class discussions identified recurring themes. Students achieved greater synthesis and more nuanced understanding of cross-cultural encounters after discussion. Self-rating of confidence in addressing cultural issues after the curriculum was high at 3.17 ± SD 0.57 (1–4). Cultural knowledge scores improved significantly. Core components for success were clerkship director support, required participation, experienced faculty facilitators without evaluative roles, a structured assignment and formal forum for trigger question discussion
DISCUSSION
Written reflection followed by facilitated peer discussion adds value to simple ‘exposure’ to cross-cultural clinical experiences for medical students.
doi:10.1007/s11606-009-1205-4
PMCID: PMC2847102  PMID: 20352505
reflection; cross-cultural; RP curriculum
4.  Visit to the Radiologist 
doi:10.1007/s11606-010-1601-9
PMCID: PMC3043194  PMID: 21174163
5.  Relationship of creative projects in anatomy to medical student professionalism, test performance and stress: an exploratory study 
Background
The anatomy course offers important opportunities to develop professionalism at an early stage in medical education. It is an academically significant course that also engenders stress in some students.
Methods
Over a three-year period, 115 of 297 students completed creative projects. Thirty-four project completers and 47 non-completers consented to participate in the study. Projects were analyzed for professionalism themes using grounded theory. A subset of project completers and non-completers were interviewed to determine their views about the stress of anatomy and medical school, as well as the value of the creative projects. We also compared test performance of project completers and non-completers.
Results
Projects completed early in the course often expressed ambivalence about anatomy, whereas later projects showed more gratitude and sense of awe. Project completers tended to report greater stress than noncompleters, but stated that doing projects reduced stress and caused them to develop a richer appreciation for anatomy and medicine. Project completers performed significantly lower than non-completers on the first written exam (pre-project). Differences between groups on individual exams after both the first and second creative project were nonsignificant.
Conclusion
For some students, creative projects may offer a useful way of reflecting on various aspects of professionalism while helping them to manage stress.
doi:10.1186/1472-6920-9-65
PMCID: PMC2775735  PMID: 19887011
6.  A focus Group Study of Medical Students’ Views of an Integrated Complementary and Alternative Medicine (CAM) Curriculum: Students Teaching Teachers 
Medical education online  2008;13(3):1-13.
Background
Student views of new curricula can shape training outcomes. This qualitative study elicited student opinions of CAM instruction to examine and distill best strategies.
Methods
49 second, third and fourth year students participated in focus groups using a predefined question route. Interviews were audio taped and transcribed.
Results
Students successfully differentiated CAM curricula from other academic content and were supportive of a longitudinal integrated approach. They had positive disposition toward CAM use for themselves but this did not necessarily translate into patient recommendations. They agreed that goals of the CAM curriculum should center on awareness of patient use and evidence and information relevant to clinical practice. They advocated a case-based, hands-on, experiential strategy vs lectures. Students proposed greater institutional commitment to strengthen curricular effectiveness. The majority did not intend to practice CAM modalities but valued skills to assess them. Patient-centeredness was recognized. As training progressed, students exhibited a growing tendency to evaluate CAM efficacy, and therefore value, exclusively according to evidence.
Conclusions
In-depth student input allowed examination of the effectiveness of a CAM curriculum, permitting improvement and assessment of program effectiveness.
doi:10.3885/meo.2008.Res00252
PMCID: PMC2759094  PMID: 19823690
Curriculum assessment; Complementary and Alternative Medicine (CAM); focus groups; medical students; qualitative
7.  Walking a mile in their patients' shoes: empathy and othering in medical students' education 
One of the major tasks of medical educators is to help maintain and increase trainee empathy for patients. Yet research suggests that during the course of medical training, empathy in medical students and residents decreases. Various exercises and more comprehensive paradigms have been introduced to promote empathy and other humanistic values, but with inadequate success. This paper argues that the potential for medical education to promote empathy is not easy for two reasons: a) Medical students and residents have complex and mostly unresolved emotional responses to the universal human vulnerability to illness, disability, decay, and ultimately death that they must confront in the process of rendering patient care b) Modernist assumptions about the capacity to protect, control, and restore run deep in institutional cultures of mainstream biomedicine and can create barriers to empathic relationships. In the absence of appropriate discourses about how to emotionally manage distressing aspects of the human condition, it is likely that trainees will resort to coping mechanisms that result in distance and detachment. This paper suggests the need for an epistemological paradigm that helps trainees develop a tolerance for imperfection in self and others; and acceptance of shared emotional vulnerability and suffering while simultaneously honoring the existence of difference. Reducing the sense of anxiety and threat that are now reinforced by the dominant medical discourse in the presence of illness will enable trainees to learn to emotionally contain the suffering of their patients and themselves, thus providing a psychologically sound foundation for the development of true empathy.
doi:10.1186/1747-5341-3-10
PMCID: PMC2278157  PMID: 18336719
8.  A focus Group Study of Medical Students’ Views of an Integrated Complementary and Alternative Medicine (CAM) Curriculum: Students Teaching Teachers 
Background:
Student views of new curricula can shape training outcomes. This qualitative study elicited student opinions of CAM instruction to examine and distill best strategies.
Methods:
49 second, third and fourth year students participated in focus groups using a predefined question route. Interviews were audio taped and transcribed.
Results:
Students successfully differentiated CAM curricula from other academic content and were supportive of a longitudinal integrated approach. They had positive disposition toward CAM use for themselves but this did not necessarily translate into patient recommendations. They agreed that goals of the CAM curriculum should center on awareness of patient use and evidence and information relevant to clinical practice. They advocated a case-based, hands-on, experiential strategy vs lectures. Students proposed greater institutional commitment to strengthen curricular effectiveness. The majority did not intend to practice CAM modalities but valued skills to assess them. Patient-centeredness was recognized. As training progressed, students exhibited a growing tendency to evaluate CAM efficacy, and therefore value, exclusively according to evidence.
Conclusions:
In-depth student input allowed examination of the effectiveness of a CAM curriculum, permitting improvement and assessment of program effectiveness.
doi:10.3885/meo.2008.Res00252
PMCID: PMC2759094  PMID: 19823690
Curriculum assessment; Complementary and Alternative Medicine (CAM); focus groups; medical students; qualitative
9.  "That never would have occurred to me": a qualitative study of medical students' views of a cultural competence curriculum 
Background
The evidence is mixed regarding the efficacy of cultural competence curricula in developing learners' knowledge, attitudes and skills. More research is needed to better understand both the strengths and shortcomings of existing curricula from the perspective of learners in order to improve training.
Methods
We conducted three focus groups with medical students in their first year of clinical training to assess their perceptions of the cultural competence curriculum at a public university school of medicine.
Results
Students evaluated the informal curriculum as a more important source of learning about cultural competence than the formal curriculum. In terms of bias in both self and others, the cultural competence curriculum increased awareness, but was less effective in teaching specific interventional skills. Students also noted that the cultural competence curriculum did not always sufficiently help them find a balance between group-specific knowledge and respect for individual differences. Despite some concerns as to whether political correctness characterized the cultural competence curriculum, it was also seen as a way to rehumanize the medical education experience.
Conclusion
Future research needs to pay attention to issues such as perceived relevance, stereotyping, and political correctness in developing cross-cultural training programs.
doi:10.1186/1472-6920-6-31
PMCID: PMC1481591  PMID: 16729888

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