Background: Current literature promotes a student-centred approach with an active learning design, as such curricula have demonstrated improvements in outcomes such as critical thinking and clinical competence. Current literature demonstrates success in North America and Europe. However, research in low-resource countries have highlighted resource- and satisfaction-related issues due to such shifts. This study implements a case-based learning (CBL) intervention at Kasturba Medical College Mangalore Campus (KMCMG), India. Faculty and undergraduate medical student perceptions are explored in order to understand the contextual factors that will lead to an effective, acceptable and feasible medical curriculum. Methods: This cross-sectional, mixed-methods study employed a Likert scale questionnaire and semi-structured focus groups to 3rd year medical students (n=248), as well as semi-structured interviews with faculty (n=10) in the Department of Community Medicine. Cases were created through a co-development process with KMCMG faculty. Questionnaire data was analyzed by descriptive statistics and qualitative data was analyzed primarily by an inductive-iterative approach. Results: Both faculty and students find CBL to be more valuable than the traditional lecture-based method, and find CBL meaningful for students as future physicians. Comments highlighted the importance of student preparedness and of trained facilitators in order to enhance the learning experience. A significantly larger proportion of Indian schooled students, versus those who studied abroad, felt that CBL helped acquire new information (p=0.016), enhanced their clinical approach (p=0.008), and believed the role of the facilitator was important (p=0.001). Conclusion: Feedback towards CBL was found to be satisfactory in all aspects, and both students and faculty would like to see more CBL sessions in the future. Limitations such as faculty shortage and the inability to use informational technology at this time should be taken into consideration when moving forward. It is recommended that a resource-light version of CBL be considered, to provide robust orientations to faculty and students, and to further engage with faculty and students in order to enhance the CBL experience. / Thesis / Master of Science (MSc)

BACKGROUND: Many patients face chronic pain, which can be debilitating and dramatically impair patient's quality of life. These patients often seek treatment from their primary care physicians, who may utilize a wide range of options to manage their chronic pain, including opioids. Opioids provide analgesia while potentially leading to other adverse effects, including misuse, addiction and overdose. Therefore there is a need for clinicians to develop safe opioid prescribing practices. This has been recognized by the development of national guidelines and recommendations to improve the training and education of physicians in this domain. However, a gap in medical education and training for safe opioid prescribing skill exists, creating physicians who may feel ill prepared to treat this patient population. To remedy this problem, an educational intervention was designed that utilized a didactic session with or without an immediate or delayed observed structured clinical exam (OSCE) to improve safe opioid prescribing skills among internal medicine residents at an academic medical center. The specific aims of this thesis are to understand both quantitative and qualitative impacts of this educational intervention, specifically to describe participant characteristics, quantitatively evaluate within and between group changes at 8-months in safe opioid prescribing knowledge, confidence and self-reported practices and qualitatively describe participants' experience of the OSCE as a learning tool. METHODS: Using a quasi-experimental design, 39 internal medicine residents were assigned to either a control or intervention groups. The intervention groups received a didactic session alone, a didactic session and immediate OSCE or a didactic session and a delayed OSCE. Participants were surveyed at baseline, 4- and 8-month follow-up to assess their safe opioid prescribing knowledge, confidence, and self-reported practices. RESULTS: Participants in the didactic followed by immediate OSCE group significantly improved both within group confidence and practices at 8-month follow-up. Additionally, participants in this group improved their confidence at 8-month follow-up significantly compared to the control group. Participants from the other educational intervention groups (didactic followed by delayed OSCE and didactic only) also saw improvements in confidence and practice, but the effect was not as robust. OSCE participants found the OSCE to be a useful learning tool and both participants in the immediate and delayed OSCE groups highlighted the need to receive the didactic session immediately prior to the OSCE session. DISCUSSION: Despite many barriers in safe opioid prescribing facing internal medicine residents including limited faculty mentorship and difficult inherited patients, this educational intervention still improved their safe opioid prescribing knowledge, confidence and practice. The use of OSCEs as an education tool is an innovative approach to develop clinical skills and can be adapted in a variety of ways to accommodate institutional and learners' needs. / 2017-05-01T00:00:00Z

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Background: Empathy is essential to forming strong patient-physician relationships that enable physicians to provide better healthcare. In the medical education literature, empathy consists of cognitive, affective, behavioural, and moral domains. Studies have measured declines in empathy during medical training. Researchers speculate that factors within formal, informal, and hidden curricula contribute to empathic decline. Several frameworks suggest that empathy in the moral domain (i.e., the inner motivation to accept patients unconditionally, commit to understanding patients, and help patients achieve their needs) is the most fundamental to the empathic response. Studying the factors that influence moral empathy during training is important to developing insights into the reasons for the demonstrated declines in resident empathy. Methods: Descriptive phenomenology was used to address the research objective. Medical residents from various specialties participated in lightly structured interviews concerning their experiences. Interview transcripts were inductively and collaboratively analyzed to construct a preliminary set of factors that influence moral empathy. These factors informed the creation of a script for a verbatim theatre play that was performed for an audience of residents, educators, learners, researchers, and scholars. Following the play, audience participants completed a survey that served as a member-check of the factors that contributed to the final construction of factors. Results: The results were constructed as three categories under which seven factors are nested. These categories are: Innate Capacity, Previous Personal Encounters, and Specific Patient Encounters. With the exception of a few, most factors do not directly influence residents’ moral empathy but rather challenge their ability to act on their moral empathy. Discussion: These results offer unique insights into the declines in empathy that have been previously reported in the medical education literature, while also highlighting a moral-behavioural tension that has implications for competency-based medical education, the four-factor model of empathy, and the assessment of empathy in medical education. Future work may build on the results of this study to develop an assessment tool for moral empathy and to elucidate the relationships between the domains of empathy in order to arrive at a more refined conceptualization of the construct. / Thesis / Master of Science (MSc) / Empathy—the ability to comprehend the experiences of others—is an important tool that enables physicians to build relationships with patients, which helps them provide better healthcare. Studies have shown that empathy declines during medical training due to a variety of factors. Frameworks describing the empathic response suggest that one’s inner motivation to accept patients unconditionally, commit to understanding patients, and help patients achieve their needs may be fundamental to providing clinical care with empathy. As such, the goal of this study was to explore the factors that influence these inner motivations of residents in order to gain insights about the evidence that purports residents to demonstrate less empathy as they progress in their training. To address this objective, 10 medical residents from various specialties were interviewed about their experiences, the data were analyzed by way of a descriptive phenomenological methodology, and the initial findings were presented as a verbatim theatre play as a means of member-checking the proposed results. After viewing the play, an audience of medical residents, educators, learners, researchers, and scholars provided feedback through a survey that contributed to the final conclusions of the study. In this regard, the study shows that, apart from a few factors, residents’ inner motivations to be empathic are not significantly influenced during medical training. Rather, certain factors associated with residency affect their ability to deliver on their inner motivations. This study offers insights into the role of motivation in empathic decline, assessment of empathy during medical training, and potential significance of a tension between one’s motivation to be empathic and the opportunities that they are afforded to be empathic during residency.

Introduction: In medical education, communication is recognized as a core competency for physicians. In Canada, medical students are taught core communication abilities. The importance of communication in postgraduate training is recognized in the CanMEDS competency framework. Although robust literature exists on teaching communication abilities to medical students, research in communication abilities for psychiatry residents is lacking, despite the fact that the clinical interview is frequently the only diagnostic tool available and often a key part of patient treatment. Given the transition to competency-based education in Canadian postgraduate medical education, it is critical that the psychiatric profession gains an improved understanding of the progression of communication abilities in psychiatry training. This study seeks to understand the progression of communication skills development in psychiatry. Methods: This study used a constructivist grounded theory approach. This study used purposive sampling and conducted semi-structured interviews with 14 faculty educators who regularly supervise psychiatry residents at two sites affiliated with one university-based residency program. Constant comparative analysis occurred concurrently with iterative data collection until thematic sufficiency was reached and all relationships between themes were determined. Results: Five themes outlining the progressive development of communication abilities were identified. Three themes identified three foundational sets of abilities, including refining pre-existing relational abilities, developing a repertoire of specific psychiatric communication abilities, and learning to reflect upon and manage one’s own internal reactions. These competencies served as foundational pillars for the final two themes, in which residents develop the personalized art of flexible psychiatric interviewing, which then allows them to skillfully partner with their patients in co-creating care plans. Conclusion: This research represents a first step in defining a communication competency framework for psychiatry residents. It includes defining the core abilities required for progression to unsupervised practice. Future research should explore generalizability, test the framework, and determine teaching and assessment methods. / Thesis / Master of Science (MSc) / In contemporary medical education, the ability to communicate well with patients is a fundamental competency. This set of abilities is taught in medical schools and reflected in residency training competence frameworks, such as the CanMEDS framework. In psychiatry residency training, communication is fundamental as the clinical interview is typically the only diagnostic tool available and frequently part of the treatment of psychiatric illness (e.g., psychotherapy). However, the development of psychiatric communication competency remains understudied. With the shift to competency-based education across Canadian psychiatry postgraduate residency education, understanding the development of patient communication abilities in psychiatry residents is critical for teaching and assessment. This research examines psychiatry educators’ perceptions of the developmental model of psychiatry resident competence in communication. The results of this study highlight five clear themes that emerge to explain how residents achieve the abilities to communicate with their patients at a level of competence that is compatible with independent practice. This framework brings clarity to the unique set of abilities that psychiatrists use to communicate with and help their patients. It will also serve as a foundation for developing teaching and assessment methods in psychiatry residency education and will serve as a basis for further research on the development of communication abilities in psychiatry residents.

A thesis submitted to the school of graduate studies in partial fulfilment of the requirements for the degree doctor of philosophy. / Experiencing intimate partner violence (IPV) is associated with a wide range of mental and physical health conditions that often have profound and enduring consequences in the lives of people, families and communities who are affected. Evidence suggests that many of these health concerns can be mitigated with timely access to medical care which addresses patient safety and needs for support. This has led to health policymakers framing IPV as a “health issue” which physicians are uniquely situated to address. Previous research suggests, however, that many physicians are ill-equipped to respond to patients who have experienced IPV, giving rise to questions about how physicians learn about IPV in the course of their training and how this training might be enhanced in order to improve medical care for people affected by IPV. This dissertation is comprised of three original studies that lie at the nexus of health policy and health professions education scholarship. The first study combines environmental scanning and critical discourse analysis to examine how physicians’ roles related to IPV are represented in training resources created for a Canadian medical audience. The second study uses qualitative description to identify physicians’ perceptions of their own roles in caring for patients affected by IPV and highlights the sites and sources of insight that are impactful in shaping these perceptions. The third study integrates key informant technique and interpretive description to synthesize recommendations from stakeholders outside of medicine about physicians’ roles in addressing IPV, and opportunities to improve medical education and practice in the future. Together, these studies offer a critical perspective on broader implications of constructing IPV as a “health issue” that informs practice for physicians, medical educators, researchers, policymakers, and organizers working to improve health care for people affected by IPV. / Dissertation / Doctor of Philosophy (PhD) / People who experience intimate partner violence (IPV) are at a higher risk of experiencing a wide range of serious and long-lasting health issues. Politicians and other policymakers framing IPV as a “health issue” have suggested that doctors are well-placed to address these concerns and to support patients who are dealing with IPV, but research suggests that many doctors lack knowledge or skills that are needed to address IPV with appropriate sensitivity. This dissertation examines how doctors learn about IPV in the course of their medical training by 1) analyzing how doctors’ roles related to IPV are presented in educational resources and policy documents, 2) interviewing doctors about their perceptions of IPV and their related training, and 3) talking to people who do work related to IPV outside of medicine about their suggestions for improving medical education in the future. Taken together, the studies that make up this dissertation can help to inform educators, politicians, and other policymakers working to improve health care for people affected by IPV.

Feedback has long been used and studied in medical education. To acknowledge the complexity of the feedback process, the term feedback literacy has been introduced into the medical education literature. This thesis attempted to explore feedback literacy in the undergraduate medical education context by aggregating a comprehensive body of evidence and using different research methodologies. It focused on providing a more complete understanding of feedback literacy, identifying factors and learning strategies that could improve medical students’ feedback literacy skills, and direct further research on this topic. Results showed that little is known on how to teach feedback literacy and educational interventions to increase students’ feedback literacy skills are still not well established. When exploring factors that could improve students’ feedback literacy skills, this thesis’ results identified that being more intrinsically goal oriented, having strong self-regulated learning traits, and seeking help when needed were positively associated to having better feedback literacy skills. Strategies that students could use to improve their own feedback literacy included self-reflection about the feedback received and how to be more proactive in the feedback process, take small steps when applying the feedback received, and actively discuss the feedback with the giver. Additionally, self-reflections on ones’ motivational beliefs and interests, combined with actions such as creating and implementing strategies to manage motivations, could help students to adjust their learning goal orientation and, consequently, improve their feedback literacy skills. Students should encourage themselves to regulate their learning in the areas of planning, monitoring, and making adjustments in learning strategies to adapt to new situations whenever needed. Lastly, students should seek assistance from others by bringing concerns up, asking questions, and asking clarifications about the feedback received. Taken together, the findings of this thesis support students’ empowerment in the feedback process to help them to make the most of their feedback opportunities in medical school. / Dissertation / Doctor of Philosophy (PhD)

The study explored the learning experiences of first-year resident physicians during the first year of graduate medical education. The experiences of four intern physicians in the first year of residency training at an urban academic health system provided the site for the research. An exploratory case study research design was employed to examine the learning experiences of these new physicians. A qualitative approach was used to analyze data from interviews and ethnographic observations. The findings of this research study provide evidence surrounding how and what these physician trainees learned regarding professionalism during the first year of residency training. The findings indicate these first-year resident physicians experienced significant learning related to professionalism through incidental learning in the clinical environment, particularly from role models and the hidden curriculum. The interns learned both positive and negative professional behaviors from attending physicians. The findings illustrate the increases and decreases of confidence due to the development of clinical skills, increase in responsibilities, and increase in autonomy experienced by all four participants across the first year of residency training. Additionally, the findings highlight the important role of critical incidents, particularly memorable patient encounters, as potentially transformative learning experiences for these interns. Finally, the findings enumerate the pervasive influence of the hidden curriculum of graduate medical education on what these new physicians learned about professionalism, particularly the unprofessional social norms transmitted through attending physicians and others within the context of clinical learning. The findings of the research study support the conclusions that a) incidental learning experiences during the first year of residency education directly influenced how and what these new physicians learned regarding professionalism; b) these intern physicians experienced non-transformative learning during the first year of residency, but critical reflection and critical self-reflection after critical incidents did hold the potential to result in learning that was transformative; and c) the ubiquitous nature of the hidden curriculum significantly impacted what these first-year residents learned about professionalism. These conclusions contribute to the literature related to the development of professionalism in the new physician and the power of the hidden curriculum in medical education to influence professional identity development. Implications for medical educators and recommendations for future research are also identified.