JMIR Publications

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  Medical Education in the Developing...

  Nov 27, 2018

  How Self-Directed e-Learning Contributes to Training for Medical Licentiate Practitioners in Zambia: Evaluation of the Pilot Phase of a Mixed-Methods Study

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  Authors List:

  • Sandra Barteit  
  • Albrecht Jahn  
  • Annel Bowa  
  • Sigrid Lüders  
  • Gregory Malunga  
  • Clemence Marimo  
  • Sigrid Wolter  
  • Florian Neuhann  

  Abstract:

  Background: Zambia faces a severe shortage of health workers, particularly in rural areas. To tackle this shortage, the Medical Licentiate program was initiated at Chainama College of Health Sciences in the capital, Lusaka, in 2002. The objective of the program was to alleviate the shortage of human resources in curative care. On-the-job training is conducted in decentralized teaching hospitals throughout Zambia. However, the program faces significant challenges such as shortages of senior medical instructors and learning materials. Objective: Our aim was to address these challenges by introducing a self-directed, e-learning platform with an offline tablet as part of a collaborative blended-learning intervention to supplement local teaching and training. Methods: The pilot phase of the e-learning platform was evaluated using a mixed-methods approach with a convergent parallel design. Various methods were employed to test the data’s adequacy and potential for generating valid results. Methods included questionnaires according to the technology acceptance model and information system success model by DeLone and McLean, semistructured interviews, learner diaries, pretesting, the collection of usage data, exam results, demographics, and informal feedback. Outcome measures included usage, adoption, efficiency, acceptance, user-friendliness, and gained knowledge and skills. Results: In total, 52 students and 17 medical instructors participated in the pilot evaluation. The questionnaire results showed a high acceptance of the technology (>80%) and high agreement (>75%) with the e-learning platform. Semistructured interview results showed an overall appreciation of the e-learning intervention, but the need for more e-learning materials. Respondents identified a need for multimedia materials that transfer skills such as medical procedure visualization and interactive exercises to practice procedural knowledge. The learning diaries identified the lack of specific learning materials and potential shortcomings of existing learning materials. However, students were satisfied with the current e-learning content. The majority of students used the e-learning platform offline on their tablets; online e-learning was underutilized. Conclusions: The pilot phase of the tablet-based e-learning platform to support the self-directed learning intervention was well received and appreciated by students and medical instructors of Chainama College of Health Sciences. E-learning for knowledge acquisition appears to be adequate and feasible for this low-resource educational environment. Our evaluation results guide the further development of the full implementation of the e-learning platform in this educational setting. E-learning materials should reflect curriculum requirements, and additional multimedia and interactive content is needed, as well as improved integration and active participation from medical instructors in the e-learning processes.

  • JMIR Med Educ 2018;4(2):e10222

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  Student/Learners Perceptions and...

  Nov 26, 2018

  Assessing the Impact of Video-Based Assignments on Health Professions Students’ Social Presence on Web: Case Study

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  Authors List:

  • Jennie C De Gagne  
  • Sang S Kim  
  • Ellen R Schoen  
  • Hyeyoung K Park  

  Abstract:

  Background: Web-based education is one of the leading learning pedagogies in health professions education. Students have access to a multitude of opinions, knowledge, and resources on Web, but communication among students in Web-based courses is complicated. Technology adds a filter that makes it difficult to decipher the emotions behind words or read nonverbal cues. This is a concern because students benefit more from Web-based classes when they have a high perception of social presence. To enhance social presence on Web, we planned to use video-based assignments (VBAs) that encourage students to interact with each other. Objective: This case study examines the impact of VBAs on health professions students and their experiences with the technology. This study aims to provide information to the growing body of literature about strategies to develop social presence on Web. Methods: A total of 88 students from various nursing programs participated in the study. While the control group comprised 36 students who submitted only written-based assignments (WBAs), the experimental group of 52 students submitted VBAs besides WBAs. No enrolled student had previously participated in the course, and there were no repeaters in either of the groups. Both groups participated in a weekly survey comprising 4 open-ended questions and 3 Likert items on a scale of 1-5 (1=strongly disagree and 5=strongly agree). The social presence questionnaire assessed by the experimental group comprised 16 items and a 5-point Likert scale in which higher scores represented higher levels of social presence. While quantitative data were analyzed using descriptive statistics, qualitative responses were analyzed using content analysis. Results: No significant differences were noted between the groups regarding the program (F1,87=0.36, P=.54). Regarding students’ engagement, no statistically significant difference was observed between the 2 groups (t14=0.96, P=.35). However, the experimental group’s average score for engagement was slightly higher (4.29 [SD 0.11]) than that of the control group (4.21 [SD 0.14]). Comparison of the total number of responses to the weekly engagement survey revealed 88.0% (287/326) as either strongly agree or agree in the control group, whereas 93.1% (525/564) in the experimental group. No statistically significant difference was observed between VBAs and WBAs weeks (t6=1.40, P=.21) in the experimental group. Most students reported a positive experience using VBAs, but technical issues were barriers to embracing this new approach to learning. Conclusions: This study reveals that social presence and engagement are positively associated with student learning and satisfaction in Web-based courses. Suggestions are offered to enhance social presence on Web that could generate better learning outcomes and students’ experiences.

  • JMIR Med Educ 2018;4(2):e11390

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  Viewpoint and Opinions on Innovation...

  Nov 12, 2018

  Electronic Health Records as an Educational Tool: Viewpoint

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  Authors List:

  • Yacob Habboush  
  • Robert Hoyt  
  • Sary Beidas  

  Abstract:

  Background: Electronic health records (EHRs) have been adopted by most hospitals and medical offices in the United States. Because of the rapidity of implementation, health care providers have not been able to leverage the full potential of the EHR for enhancing clinical care, learning, and teaching. Physicians are spending an average of 49% of their working hours on EHR documentation, chart review, and other indirect tasks related to patient care, which translates into less face time with patients. Objective: The purpose of this article is to provide a preliminary framework to guide the use of EHRs in teaching and evaluation of residents. Methods: First we discuss EHR educational capabilities that have not been reviewed in sufficient detail in the literature and expand our discussion for each educational activity with examples. We emphasize quality improvement of clinical notes as a basic foundational skill using a spreadsheet-based application as an assessment tool. Next, we integrate the six Accreditation Council for Graduate Medical Education (ACGME) Core Competencies and Milestones (CCMs) framework with the Reporter-Interpreter-Manager-Educator (RIME) model to expand our assessments of other areas of resident performance related to EHR use. Finally, we discuss how clinical utility, clinical outcome, and clinical reasoning skills can be assessed in the EHR. Results: We describe a pilot conceptual framework—CCM framework—to guide and demonstrate the use of the EHR for education in a clinical setting. Conclusions: As EHRs and other supporting technologies evolve, medical educators should continue to look for new opportunities within the EHR for education. Our framework is flexible to allow adaptation and use in most training programs. Future research should assess the validity of such methods on trainees’ education.

  • JMIR Med Educ 2018;4(2):e10306

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  New Methods and Approaches in Medical...

  Nov 7, 2018

  Use of Grading of Recommendations, Assessment, Development, and Evaluation to Combat Fake News: A Case Study of Influenza Vaccination in Pregnancy

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  Authors List:

  • Sidra Zafar  
  • Yacob Habboush  
  • Sary Beidas  

  Abstract:

  Background: The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework is a validated evaluation tool used to assess the quality of scientific publications. It helps in enhancing clinicians’ decision-making process and supports production of informed healthy policy. Objective: The purpose of this report was two-fold. First, we reviewed the interpretation of observational studies. The second purpose was to share or provide an example using the GRADE criteria. Methods: To illustrate the use of the GRADE framework to assess publications, we selected a study evaluating the risk of spontaneous abortion (SAB) after influenza vaccine administration. Results: Since 2004, the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practice have recommended influenza vaccination of pregnant women. Previous studies have not found an association between influenza vaccination and SAB. However, in a recent case-control study by Donahue et al, a correlation with SAB in women who received the H1N1 influenza vaccine was identified. For women who received H1N1–containing vaccine in the previous and current influenza season, the adjusted odds ratio (aOR) for SAB was 7.7 (95% CI, 2.2-27.3), while the aOR for women not vaccinated in the previous season but vaccinated in the current season was 1.3 (95% CI, 0.7-2.7). Conclusions: Our goal is to enable the readers to critique published literature using appropriate evaluation tools such as GRADE.

  • JMIR Med Educ 2018;4(2):e10347

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  Virtual Patients

  Nov 6, 2018

  Improving Shared Decision Making Between Patients and Clinicians: Design and Development of a Virtual Patient Simulation Tool

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  Authors List:

  • Simon Jacklin  
  • Neal Maskrey  
  • Stephen Chapman  

  Abstract:

  Background: Shared decision making (SDM) involves the formation of a collaborative partnership between the patient and clinician combining both of their expertise in order to benefit decision making. In order for clinicians to be able to carry out this skilled task, they require practice. Virtual reality, in the form of a virtual patient, could offer a potential method of facilitating this. Objective: The objective of this study was to create a virtual patient that simulated a primary care consultation, affording the opportunity to practice SDM. A second aim was to involve patients in the design of a virtual patient simulation and report the process of the design. Methods: We employed a multistep design process drawing on patient and expert involvement. Results: A virtual patient, following a narrative style, was built, which allows a user to practice and receive feedback; both clinical and communication skills are required for the simulation. The patient group provided multiple insights, which the academic team had overlooked. They pertained mostly to issues concerning the patient experience. Conclusions: It is possible to design a virtual patient that allows a learner to practice their ability to conduct SDM. Patient input into the design of virtual patient simulations can be a worthwhile activity.

  • JMIR Med Educ 2018;4(2):e10088

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  Viewpoint and Opinions on Innovation...

  Oct 25, 2018

  Blending Gagne’s Instructional Model with Peyton’s Approach to Design an Introductory Bioinformatics Lesson Plan for Medical Students: Proof-of-Concept...

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  Authors List:

  • Richa Tambi  
  • Riad Bayoumi  
  • Peter Lansberg  
  • Yajnavalka Banerjee  

  Abstract:

  Background: With the rapid integration of genetics into medicine, it has become evident that practicing physicians as well as medical students and clinical researchers need to be updated on the fundamentals of bioinformatics. To achieve this, the following gaps need to be addressed: a lack of defined learning objectives for “Bioinformatics for Medical Practitioner” courses, an absence of a structured lesson plan to disseminate the learning objectives, and no defined step-by-step strategy to teach the essentials of bioinformatics in the medical curriculum. Objective: The objective of this study was to address these gaps to design a streamlined pedagogical strategy for teaching basics of bioinformatics in the undergraduate medical curriculum. Methods: The established instructional design strategies employed in medical education—Gagne’s 9 events of instruction—were followed with further contributions from Peyton’s four-step approach to design a structured lesson plan in bioinformatics. Results: First, we defined the specifics of bioinformatics that a medical student or health care professional should be introduced to use this knowledge in a clinical context. Second, we designed a structured lesson plan using a blended approach from both Gagne’s and Peyton’s instructional models. Lastly, we delineated a step-by-step strategy employing free Web-based bioinformatics module, combining it with a clinical scenario of familial hypercholesterolemia to disseminate the defined specifics of bioinformatics. Implementation of Schon’s reflective practice model indicated that the activity was stimulating for the students with favorable outcomes regarding their basic training in bioinformatics. Conclusions: To the best of our knowledge, the present lesson plan is the first that outlines an effective dissemination strategy for integrating introductory bioinformatics into a medical curriculum. Further, the lesson plan blueprint can be used to develop similar skills in workshops, continuing professional development, or continuing medical education events to introduce bioinformatics to practicing physicians.

  • JMIR Med Educ 2018;4(2):e11122

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  Training Tools for Medical Students

  Oct 17, 2018

  A Novel Web-Based Experiential Learning Platform for Medical Students (Learning Moment): Qualitative Study

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  Authors List:

  • Alexander Y Sheng  
  • Andrew Chu  
  • Dea Biancarelli  
  • Mari-Lynn Drainoni  
  • Ryan Sullivan  
  • Jeffrey I Schneider  

  Abstract:

  Background: Experiential learning plays a critical role in learner development. Kolb’s 4-part experiential learning model consists of concrete experience, reflective observation, abstract conceptualization, and active experimentation in a recurring cycle. Most clinical environments provide opportunities for experiences and active experimentation but rarely offer structured means for reflection and abstract conceptualization that are crucial for learners to learn through experience. We created Learning Moment, a novel Web-based educational tool that integrates principles of asynchronous learning and learning portfolios to fulfill the reflection and abstract conceptualization aspects of Kolb’s learning cycle in the modern clinical learning environment. Medical students log concise clinical “pearls” in the form of “learning moments” for reflection, review, and sharing with peers in a community of practice. Objective: We sought to evaluate learners’ experiences with Learning Moment via a qualitative study. Methods: We employed purposive sampling to recruit medical students who used Learning Moment during their rotation. We conducted 13 semistructured interviews (10 individual interviews and one 3-person group interview) between January and March 2017 using an ethnographic approach and utilized a general inductive method to analyze and code for potential themes. Results: A total of 13 students (five in their third year of medical school and eight in their fourth year) voluntarily participated in our qualitative interviews. Five of the 13 (38%) students intended to pursue emergency medicine as their chosen field of specialty. The median number of “learning moments” logged by these students is 6. From our analysis, three key themes emerged relating to the perceived impact of Learning Moment on student learning: (1) logging “learning moments” enhanced memorization, (2) improved learning through reflection, and (3) sharing of knowledge and experiences in a community of practice. Conclusions: Learning Moment was successfully implemented into the educational infrastructure in our department. Students identified three mechanisms by which the application optimizes experiential learning, including enabling the logging of “learning moments” to promote memorization, encouraging reflection to facilitate learning, and fostering the sharing of knowledge and experiences within a community of practice. The Learning Moment concept is potentially scalable to other departments, disciplines, and institutions as we seek to optimize experiential learning ecosystems for all trainees.

  • JMIR Med Educ 2018;4(2):e10657

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  Social Media in Medical Education

  Aug 21, 2018

  Enterprise Microblogging to Augment the Subinternship Clinical Learning Experience: A Proof-of-Concept Quality Improvement Study

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  Authors List:

  • Irsk Anderson  
  • Oliver Hulland  
  • Jeanne M Farnan  
  • Wei Wei Lee  
  • Debra Milton  
  • Vineet M Arora  

  Abstract:

  Background: Although the Clerkship Directors in Internal Medicine (CDIM) has created a core subinternship curriculum, the traditional experiential subinternship may not expose students to all topics. Furthermore, academic institutions often use multiple clinical training sites for the student clerkship experience. Objective: The objective of this study was to sustain a Web-based learning community across geographically disparate sites via enterprise microblogging to increase subintern exposure to the CDIM curriculum. Methods: Internal medicine subinterns used Yammer, a Health Insurance Portability and Accountability Act (HIPAA)–secure enterprise microblogging platform, to post questions, images, and index conversations for searching. The subinterns were asked to submit 4 posts and participate in 4 discussions during their rotation. Faculty reinforced key points, answered questions, and monitored HIPAA compliance. Results: In total, 56 medical students rotated on an internal medicine subinternship from July 2014 to June 2016. Of them, 84% returned the postrotation survey. Over the first 3 months, 100% of CDIM curriculum topics were covered. Compared with the pilot year, the scale-up year demonstrated a significant increase in the number of students with >10 posts (scale-up year 49% vs pilot year 19%; P=.03) and perceived educational experience (58% scale-up year vs 14% pilot year; P=.006). Few students (6%) noted privacy concerns, but fewer students in the scale-up year found Yammer to be a safe learning environment. Conclusions: Supplementing the subinternship clinical experience with an enterprise microblogging platform increased subinternship exposure to required curricular topics and was well received. Future work should address concerns about safe learning environment.

  • JMIR Med Educ 2018;4(2):e18

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  Social Media in Medical Education

  Jul 23, 2018

  Expanding Opportunities for Professional Development: Utilization of Twitter by Early Career Women in Academic Medicine and Science

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  Authors List:

  • Jaime D Lewis  
  • Kathleen E Fane  
  • Angela M Ingraham  
  • Ayesha Khan  
  • Anne M Mills  
  • Susan C Pitt  
  • Danielle Ramo  
  • Roseann I Wu  
  • Susan M Pollart  

  Abstract:

  The number of women entering medical school and careers in science is increasing; however, women remain the minority of those in senior faculty and leadership positions. Barriers contributing to the shortage of women in academics and academic leadership are numerous, including a shortage of role models and mentors. Thus, achieving equity in a timelier manner will require more than encouraging women to pursue these fields of study or waiting long enough for those in the pipelines to be promoted. Social media provides new ways to connect and augments traditional forms of communication. These alternative avenues may allow women in academic medicine to obtain the support they are otherwise lacking. In this perspective, we reflect on the role of Twitter as a supplemental method for navigating the networks of academic medicine. The discussion includes the use of Twitter to obtain (1) access to role models, (2) peer-to-peer interactions, and continuous education, and (3) connections with those entering the pipeline—students, trainees, and mentees. This perspective also offers suggestions for developing a Twitter network. By participating in the “Twittersphere,” women in academic medicine may enhance personal and academic relationships that will assist in closing the gender divide.

  • JMIR Med Educ 2018;4(2):e11140

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  Continuing Medical Education (CME)...

  Jul 19, 2018

  Development of a Web-Based Formative Self-Assessment Tool for Physicians to Practice Breaking Bad News (BRADNET)

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  Authors List:

  • Anne-Christine Rat  
  • Laetitia Ricci  
  • Francis Guillemin  
  • Camille Ricatte  
  • Manon Pongy  
  • Rachel Vieux  
  • Elisabeth Spitz  
  • Laurent Muller  

  Abstract:

  Background: Although most physicians in medical settings have to deliver bad news, the skills of delivering bad news to patients have been given insufficient attention. Delivering bad news is a complex communication task that includes verbal and nonverbal skills, the ability to recognize and respond to patients’ emotions and the importance of considering the patient’s environment such as culture and social status. How bad news is delivered can have consequences that may affect patients, sometimes over the long term. Objective: This project aimed to develop a Web-based formative self-assessment tool for physicians to practice delivering bad news to minimize the deleterious effects of poor way of breaking bad news about a disease, whatever the disease. Methods: BReaking bAD NEws Tool (BRADNET) items were developed by reviewing existing protocols and recommendations for delivering bad news. We also examined instruments for assessing patient-physician communications and conducted semistructured interviews with patients and physicians. From this step, we selected specific themes and then pooled these themes before consensus was achieved on a good practices communication framework list. Items were then created from this list. To ensure that physicians found BRADNET acceptable, understandable, and relevant to their patients’ condition, the tool was refined by a working group of clinicians familiar with delivering bad news. The think-aloud approach was used to explore the impact of the items and messages and why and how these messages could change physicians’ relations with patients or how to deliver bad news. Finally, formative self-assessment sessions were constructed according to a double perspective of progression: a chronological progression of the disclosure of the bad news and the growing difficulty of items (difficulty concerning the expected level of self-reflection). Results: The good practices communication framework list comprised 70 specific issues related to breaking bad news pooled into 8 main domains: opening, preparing for the delivery of bad news, communication techniques, consultation content, attention, physician emotional management, shared decision making, and the relationship between the physician and the medical team. After constructing the items from this list, the items were extensively refined to make them more useful to the target audience, and one item was added. BRADNET contains 71 items, each including a question, response options, and a corresponding message, which were divided into 8 domains and assessed with 12 self-assessment sessions. The BRADNET Web-based platform was developed according to the cognitive load theory and the cognitive theory of multimedia learning. Conclusions: The objective of this Web-based assessment tool was to create a “space” for reflection. It contained items leading to self-reflection and messages that introduced recommended communication behaviors. Our approach was innovative as it provided an inexpensive distance-learning self-assessment tool that was manageable and less time-consuming for physicians with often overwhelming schedules.

  • JMIR Med Educ 2018;4(2):e17

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  Social Media in Medical Education

  Jul 13, 2018

  How an Environment of Stress and Social Risk Shapes Student Engagement With Social Media as Potential Digital Learning Platforms: Qualitative Study

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  Authors List:

  • Becky Hartnup  
  • Lin Dong  
  • Andreas Benedikt Eisingerich  

  Abstract:

  Background: Social media has been increasingly used as a learning tool in medical education. Specifically, when joining university, students often go through a phase of adjustment, and they need to cope with various challenges such as leaving their families and friends and trying to fit into a new environment. Research has shown that social media helps students to connect with old friends and to establish new relationships. However, managing friendships on social media might intertwine with the new learning environment that shapes students’ online behaviors. Especially, when students perceive high levels of social risks when using social media, they may struggle to take advantage of the benefits that social media can provide for learning. Objective: This study aimed to develop a model that explores the drivers and inhibitors of student engagement with social media during their university adjustment phase. Methods: We used a qualitative method by interviewing 78 undergraduate students studying medical courses at UK research-focused universities. In addition, we interviewed 6 digital technology experts to provide additional insights into students’ learning behaviors on social media. Results: Students’ changing relationships and new academic environment in the university adjustment phase led to various factors that affected their social media engagement. The main drivers of social media engagement were maintaining existing relationships, building new relationships, and seeking academic support. Simultaneously, critical factors that inhibited the use of social media for learning emerged, namely, collapsed online identity, uncertain group norms, the desire to present an ideal self, and academic competition. These inhibitors led to student stress when managing their social media accounts, discouraged them from actively engaging on social media, and prevented the full exploitation of social media as an effective learning tool. Conclusions: This study identified important drivers and inhibitors for students to engage with social media platforms as learning tools. Although social media supported students to manage their relationships and support their learning, the interaction of critical factors, such as collapsed online identity, uncertain group norms, the desire to present an ideal self, and academic competition, caused psychological stress and impeded student engagement. Future research should explore how these inhibitors can be removed to reduce students’ stress and to increase the use of social media for learning. More specifically, such insights will allow students to take full advantage of being connected, thus facilitating a richer learning experience during their university life.

  • JMIR Med Educ 2018;4(2):e10069

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  Specialist Training for Doctors

  Jun 15, 2018

  Resident and Attending Physicians’ Perceptions of Patient Access to Provider Notes: Comparison of Perceptions Prior to Pilot Implementation

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  Authors List:

  • Deepa Rani Nandiwada  
  • Gary S Fischer  
  • Glenn Updike  
  • Margaret B Conroy  

  Abstract:

  Background: As electronic health records have become a more integral part of a physician’s daily life, new electronic health record tools will continue to be rolled out to trainees. Patient access to provider notes is becoming a more widespread practice because this has been shown to increase patient empowerment. Objective: In this analysis, we compared differences between resident and attending physicians’ perceptions prior to implementation of patient access to provider notes to facilitate optimal use of electronic health record features and as a potential for patient empowerment. Methods: This was a single-site study within an academic internal medicine program. Prior to implementation of patient access to provider notes, we surveyed resident and attending physicians to assess differences in perceptions of this new electronic health record tool using an open access survey provided by OpenNotes. Results: We surveyed 37% (20/54 total) of resident physicians and obtained a 100% response rate and 72% (31/44 total) of attending physicians. Similarities between the groups included concerns about documenting sensitive topics and anticipation of improved patient engagement. Compared with attending physicians, resident physicians were more concerned about litigation, discussing weight, offending patients, and communicated less overall with patients through electronic health record. Conclusions: Patient access to provider notes has the potential to empower patients but concerns of the resident physicians need to be validated and addressed prior to its utilization.

  • JMIR Med Educ 2018;4(1):e15

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