Journal of Advances in Medical Education & Professionalism

Abstract Introduction: Despite its healthcare advantages and expanded use during the COVID-19 pandemic, telehealth is not included in many medical school curricula.
Methods: In this prospective mixed methods study (n=52), we created a novel Telehealth Education Curriculum (TEC) for the third year Obstetrics and Gynecology (Ob/Gyn) rotation at New York Medical College during COVID-19. The TEC included supervised telehealth patient encounters via video conference [and a virtual Objective Structured Clinical Encounter (vOSCE)] designed to simulate a telehealth encounter (Zoom Video Communications, Inc.). We measured student perceptions of the
TEC via two 4-point Likert surveys, which included free response questions, administered via SurveyMonkey between April and June 2020. Participation was voluntary and responses were deidentified. We computed means and response distributions across survey questions using SPSS; IBM version 19.
Results: The response rate was 92% for both the Telehealth (33/36) and vOSCE (48/52) surveys. Seventy-six percent (25/33) strongly or moderately agreed that telehealth and in-person patient
encounters have similar educational value. Eighty-three percent (40/48) strongly or moderately agreed the vOSCE provided a valuable patient interaction. Ninety-seven percent (32/33) strongly
or moderately agreed the telehealth encounters should continue during COVID-19 restrictions versus 82% (27/33) agreeing they should be incorporated into the curriculum post COVID-19.
Conclusion: Almost all students responded that the TEC should continue during COVID-19 and most agreed it should be incorporated into the Ob/Gyn clerkship permanently, after COVID-19. We found vOSCEs to be an effective method for teaching telehealth to medical students. Key challenges identified by students included adjusting to a virtual format, lack of body language, and communicating empathy virtually. Positive takeaways included practice with telemedicine and an opportunity for continued clinical education during COVID-19.

Abstract Introduction: As part of its Next Accreditation System, the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine describe 6 competencies containing 23 sub-competencies graded by milestones ranging from level 1 (expected of an incoming intern) to level 5 (demonstrates abilities of an attending) that are used to track resident training progression. To the best of our knowledge, there have been no studies introducing a milestones-based curriculum to medical students prior to their introduction to the wards, so we sought to determine the effects that a pre-clinical Emergency Medicine Interest Group (EMIG) Milestones Elective would have on preparing the students interested in Emergency Medicine (EM) as a specialty to meet the
level 1 milestones prior to their intern year.
Methods: The elective hosted 15 events throughout the academic year, and pre- and post-curriculum surveys were administered. Thirteen first- and second-year medical students at our institution who completed the elective self-reported their perception of preparedness for each level 1 milestone in the 19 sub-competencies. A repeated measures design was used through identical pre- and post-curriculum surveys to determine any changes in self-reported preparedness for meeting level 1 milestones after completing the elective using Wilcoxon Signed Ranks Test.
Results: There was a significant increase in the median scoring from 1 to 2 (P=0.027) in overall self-reported preparedness for meeting the level 1 milestones included in the elective, as well as significant increases in subcategories across competencies 1-4 outlined by the ACGME. There was no significant increase in preparedness for professionalism or interpersonal communication
competencies. There was no significant increase in interest in EM as a result of the elective.
Conclusion: Implementing a milestones-based curriculum during the pre-clinical years shows improved self-reported preparedness of students interested in pursuing EM for meeting level 1 milestones prior to residency. Additionally, a specialtybased elective such as this one offered through EMIG may further increase interest in the field during pre-clinical years.

Abstract Introduction: Coronavirus disease-2019 (COVID-19) has disrupted clinical services and postgraduate training across the world. Hence, this survey was conducted to understand the impact of pandemic on Physiotherapy post-graduate (PG) education.
Methods: It was a cross-sectional, observational study. A total of 254 Physiotherapy PG trainees were recruited through snowball sampling from Physiotherapy colleges across the state of Maharashtra. A 34-item structured questionnaire was developed, based on available literature, to evaluate the impact of COVID-19 pandemic on four domains: academic training, clinical training, research activities, and concerns faced by a PG trainee. The face validity of this questionnaire was assessed by six academicians and their suggestions were examined. Subsequently, it was piloted
on five PG trainees before administering it to the participants. The validated questionnaire was then circulated via various social media platforms and personal contacts using Google form. Descriptive statistics were summarized as frequencies/percentages. McNemar’s test was used to determine the differences on a dichotomous dependent variable between the two related groups using SPSS software.
Results: Overall 131 trainees provided complete responses. Although 85% (n=111) of them claimed they attended PG teaching activities through online mode, almost 67% (n=101) disagreed to
have achieved their learning objectives. A vast majority (91%,n=119) of them felt that their  specialty related practical training was severely affected, and 98% (n=129) reported that reduced caseload had impacted their clinical learning. Also, 70% (n=54) of final year PGs had difficulty in recruiting new participants for their dissertation. Spread of infections to family (98%), commuting in
public transport (98%), uncertainty about exam dates (91%), and competency development in specialty areas (96%) were some of their concerns.
Conclusion: COVID-19 pandemic had impacted various domains of Physiotherapy PG program such as academic, clinical and research areas. Regulatory authorities should take serious consideration and devise strategies to overcome it.

Abstract Introduction: Didactic lectures lead to lack of attention and limited independent thinking with limited self-assessment, crossword puzzles having shown promising results and substantial usability. A thorough literature search showed that most of the studies done were on the introduction of crosswords as a tool of assessment in either medical or allied health sciences; hence, we planned this study to know the acceptability of crossword puzzles as a method of assessment.
Methods: The subjects of this cross-sectional study to assess the acceptability of crossword puzzles were 5th semester students of the second professional MBBS (Bachelor of Medicine and Bachelor of Surgery). The study was conducted for three consecutive batches over a period of three months at the same time of the year from 2018 to 2020. The students had appeared for formative assessment and gave written informed consent. The crossword puzzles were given to the students, being followed by an anonymous feedback questionnaire and formative examination one week later. The feedback questionnaire was analyzed for coefficient of reliability by Cronbach’s Alpha, giving an internal consistency of 0.841.
Results: A total of 425 students participated in the study. The crossword puzzles had an average percentage score of 62.7% across all the three years, which was significantly higher (p <0.05),
as compared to the formative examination score of 45.2%. The same set of students appeared for both types of evaluation and the results were compared. The feedback given was that majority
of the students agreed that crosswords enhanced their knowledge of drugs, promoted active learning, and helped in remembering the topic.
Conclusion: Crossword puzzles were an acceptable and effective tool for assessment as they gave better results and provided better understanding in comparison to the conventional formative
assessment as the feedback questionnaire showed. Most students agreed that the crosswords enhanced their knowledge of drugs, promoted active learning and helped in remembering the topic.

Abstract Introduction: Disruptive behaviors among nursing educators are a globally recognized problem. They have detrimental effects on nursing educators, the nursing profession, students and patients. This study aimed to explore nursing educators’ experiences with disruptive behaviors in the professional work environment.
Methods: The current study was conducted in 2019 and used a qualitative content analysis approach. Participants were selected purposely from nursing schools. Data was collected using semi-structured interviews with 20 nursing educators, and then analyzed according to the Graneheim and Lundman method.
Results: Through analysis of the transcribed interviews, 4 categories and 10 subcategories were extracted. The categories include disrespectful interactions, inaccurate feedback on work
performance, low acceptance in the clinical setting and perceived unfairness.
Conclusion: Disruptive behaviors among nursing educators can affect professionalism as well as the quality of education provided by them. Therefore, considering factors that lead to disruptive
behaviors in the professional work environment is necessary.

Abstract Introduction: There is no formal education or training course about daily progress note writing in Iranian medical interns’curriculum. The current study aimed to assess the effectiveness of a training intervention on daily progress note writing by Iranian medical interns.
Methods: This quasi-experimental study (pre- and post-test) was conducted on 150 medical interns selected through the census method at Razi Hospital of Rasht, north of Iran from October-2018
to May-2019. In the baseline, daily progress notes written by 150 medical interns were assessed using a Subjective, Objective, Assessment, and Plan (SOAP)-based questionnaire by the expert
panel. Content validity of the questionnaire was confirmed by experts and internal consistency was determined using Cronbach’s alpha coefficient. In the intervention phase, training sessions (4
one-hour sessions) on how to write the daily progress note, based on SOAP format and its importance, were held for the interns. All medical interns were given a week to meet the SOAP standards. Then, the same expert panel reviewed and assessed the newly written daily progress notes of the same medical interns. Finally, the scores from the evaluation of progress note writing, before and after the intervention, were compared with paired sample t-test.
Results: The mean age of the medical interns was 23.1±5.2 years. The majority of them were male (56%). There was a significant improvement in all SOAP notes’ components written by medical
interns between the pre- and post-intervention periods (general rules: 52.7±24.5 vs. 85.4±18.2, p <0.001; subjective: 21.2±18.3 vs. 61.7±24.3, p <0.001; objective: 25.3±18.3 vs. 71.3±25.2, p <0.001; assessment: 10.7±13.0 vs. 51.4±29.6, p <0.001; plan: 11.2±15.2 vs.
49.6±27.5, p <0.001; total: 21.9±13.0 vs. 61.8±23.0, p <0.001). But the scores were still far from the desirable level after the training intervention.
Conclusion: The finding of the present research suggests that a training intervention can lead to some improvements in the daily progress notes written by Iranian medical interns.

Abstract Introduction: The COVID-19 pandemic has caused a significant toll on healthcare across the globe. The pandemic caused many other consequences, including economic implications and teaching consequences, notably in higher education throughout the world. COVID-19 and the resulting closure of university campuses have had many impacts on Health Professions Education (HPEd), affecting all aspects, including teaching methods, assessment methods, curricula, student-teacher relationships,
student selection processes, and student well-being. It has had significant effects on the setting in which students are required to learn more skills such as psychomotor skills. This manuscript aims to investigate the changes implemented in medical education during the pandemic and describe one medical school’s response to medical education changes during the pandemic.
Methods: This study was a combination of a case study done by in-depth investigation of the current context at one medical school during the pandemic and action research done by gathering
information to change a condition in a particular place.
Results: Many changes were implemented in medical education, including online teaching for basic science courses (first two years of the program) and online assessments (video-based remote proctoring) in the program’s first two years. Such courses as Clinical Skills are using telemedicine/telehealth concepts in training. There were changes such as video-based remote
proctoring of NBME shelf-examinations even in the assessments of clerkships/clinical rotations.
Conclusions: Adaptations of medical education during this pandemic is highly dependent on technology. Most of the changes will be practiced until the campuses are open. We need to
understand that these changes were made over this unprecedented period, i.e. the pandemic as an emergency rather than as a normal change process.

Abstract Psychomotor skills training includes three stages of learning. In the cognitive stage, there is a creation of awareness regarding the items to be learned; in the associative stage, the refining of skills takes place, and in the autonomous stage, the proficiency in the skills is developed (1). One of the ways by which novice surgeons acquire mastery standards, before proceeding to perform surgical skills independently, is by practicing in cadavers. In contrast to the conventional pattern of learning,
i.e. apprenticeship model whereby the trainees learn by ‘see one, do one and teach one’ adage,
cadaveric skill lab ascertains the transformation/change of individual abilities in a structured
environment in pursuit of a task goal. The above statement could be substantiated by the study conducted by Zendejas et al. (2), where  residents trained under simulated settings were able to complete the task goal, i.e. total extraperitoneal repair in lesser time and with reduced intra-operative and post-operative complications compared to the traditional training group.
When we mean acquiring mastery standards, it means that all learners should attain the prescribed
competency standards required for deliberate practice without much variation in the defined
outcomes. Nevertheless, it is well known that each individual does not necessarily have the same
motor learning dynamics, and they need not learn the same pattern even in similar task conditions
(3). Notably, the surgical skill can be deciphered as a sequential motor skill learning, involving a
combination of explicit and implicit processes, operating in a schema in order to accomplish the
task (4). Besides, this should be complemented by proprioceptive feedback, which harnesses
the motor accuracy and enables making quick adjustments in the authentic environment. In this
context, we wish to throw light upon two pertinent learning theories which medical educators shall
reconcile while planning surgical skill programs.
Let us consider the sequence of learning taking place while learning a surgical skill, for example, arthrocentesis in the cadaveric knee model. Comparing the Kovacs’ steps for procedural skill training (5), we could envisage that skill acquisition passes through four distinct stages. In the first step, the novice gains the cognitive knowledge required for the procedure (‘learn’ step). Secondly, he/she visualizes and contextualizes the procedure by observing while being performed by an expert (‘see’ step).
Thirdly, the step of imitation begins where the participant performs the movements required for the skill with a certain degree of confidence, and this could be considered as trial and error (‘practice’ step). Finally, upon multiple cycles of practice, the trainee would master the movement patterns, tailor it according to tricky situations, and, if needed, create a new pattern of movements
(‘do’ step). Subsequently, we shall reiterate upon two theories, which could be attributed to motor
learning in the cadaveric skill lab.
Schmidt’s schema theory is an open-loop controlled method of motor learning which does not involve feedback mechanism (6). It postulates the mechanism by which a novice learns a specific motor task which he or she has not performed previously. During the ‘learn’ and ‘see’ phase, a trainee observes a lot of co-ordinated movement patterns that get stored as schemas in a short memory system. When they practice, they learn by committing multiple errors, which also gets coded as schemas. For example, while performing laparoscopic procedures in cadavers, a surgeon needs to learn how to anticipate where and how far the instrument will pass through employing perceptual decisions made on the moment-moment basis. From short term memory, the information goes to a recall schema, where the specific response is selected, and then the recognition schema, where the response will
be evaluated, errors are realized, and followed by the generation of information on the correct
response. This process helps in deciding a critical move or use a certain degree of force in specific situations for a co-ordinated motor pattern. This can be analogized to a cricketer who recalls the mistakes after the innings, interprets the sequence of movements, and corrects his future performances. Besides, schema theory emphasizes the value of variability in practice conditions for honing the learned skills in simulated settings. Thus, schema theory could still be considered to have a significant role in skill learning despite the criticism placed on it.
Another major theory that has been posited for motor skill acquisition is Adam’s theory of learning, which is essentially a closed-loop method relying upon the sensory/perceptual feedback on the ongoing sequence of skilled movements (7).
It involves a stimulus (input) that generates a perception of input resulting in a memory trace to
decide as to which movement should be initiated. This will be followed by a perception trace, which
is an amalgamation of sensory consequences of previous similar movements and, finally, a motor
action (output). This can be compared with gaining experience of driving a car in crowded places
where the driver learns negotiation and adjustment abilities in stimulus-response reacting manner.
The crux of this theory that supports the need for formative feedback in ‘practice’ sessions whereby
making the learners know about the results is that it facilitates the identification/rectification of errors. To exemplify, a workshop where the placement of the endotracheal tube in cadaver by
the novice is confirmed by visualizing using the ultrasound transducer, the learners could assess the
end-point by themselves and rectify accordingly.
Performing the prescribed movement repetitively enables the learners to gain the correct perceptual
trace over time with the actual accomplishment of end-point, similar to hitting the bull’s eye during
shooting practice. Nevertheless, this motor theory of learning does not take into consideration the
salience of variability in practice while mastering a procedure.
With the advent of soft embalming techniques, cadavers are increasingly used for teaching
procedural skills owing to their relatively higher fidelity, haptic parameters, and life-like
simulation compared to mannequins and virtual reality simulator. On the flip side, many cadaverbased workshops suffer a lack of structuring and sophisticated feedback. Feedback from cadaveric skill workshops should be structured to provide feedback regarding the knowledge of results and knowledge of performance to aid the mastery of standards. In this context, we emphasize the importance of knowledge about the theories involved in motor learning, which ideally should
be incorporated while designing surgical skill cadaveric workshops and in the absence of which
procedural skill training might not effectively translate to the clinical environment. Supplementing
the established framework with learning theories will suffice the long-term outcomes of the skill
training sessions, which is reaching mastery standards in performing that particular procedure.

Abstract Our informal survey prompted us to suggest a more radical approach; whereby, at peak levels of stress, students are screened with validated anxiety and depression scores. This would work two-fold: firstly by encouraging the student to reflect on their own, perhaps ignored symptomatology; but secondly, by providing universities with information, and trends, to identify and approach students who might be at risk. Utmost sensitivity and confidentiality are paramount in making this successful, but we are unaware of any previous implementation of this technique. We urge its consideration when renewing school health policy.

Abstract We read and appreciated the article by Kasalaei et al. titled 'Barriers of critical thinking in medical students' curriculum from the viewpoint of medical education experts: A qualitative study' . As current medical students at King’s College London, we would like to discuss how our medical school has addressed some of the barriers mentioned and has consequently enhanced our critical thinking skills.