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Oral health is essential to human health. Conditions associated with poor oral health involve all organ systems and many major disease categories including infectious disease, cardiovascular disease, chronic pain, cancer, and mental health. Outcomes are also associated with health equity. Medical education organizations including the Association of American Medical Colleges and National Academy of Medicine recommend that oral health be part of medical education. However, oral health is not traditionally included in many medical school, physician assistant, or nurse practitioner curricula. Several challenges explain this exclusion including lack of time, expertise, and prioritization; we therefore provide suggestions for integrating oral health education into the health professions school curriculum. These recommendations offer guidance for enhancing the oral health curriculum across institutions. We include key organizational and foundational steps, strategies to link oral health with existing content, and approaches to achieve curricular sustainability.

BackgroundThe purpose of this article is to illustrate the application of an evidence-based, structured performance measurement methodology to identify, prioritize, and (when appropriate) generate new measures of health care quality, using primary care as a case example. Primary health care is central to the health care system and health of the American public; thus, ensuring high quality is essential. Due to its complexity, ensuring high-quality primary care requires measurement frameworks that can assess the quality of the infrastructure, workforce configurations, and processes available. This paper describes the use of the Productivity Measurement and Enhancement System (ProMES) to compile a targeted set of such measures, prioritized according to their contribution and value to primary care.MethodsWe adapted ProMES to select and rank existing primary care measures according to value to the primary care clinic. Nine subject matter experts (SMEs) consisting of clinicians, hospital leaders and national policymakers participated in facilitated expert elicitation sessions to identify objectives of performance, corresponding measures, and priority rankings.ResultsThe SMEs identified three fundamental objectives: access, patient-health care team partnerships, and technical quality. The SMEs also selected sixteen performance indicators from the 44 pre-vetted, currently existing measures from three different data sources for primary care. One indicator, Team 2-Day Post Discharge Contact Ratio, was selected as an indicator of both team partnerships and technical quality. Indicators were prioritized according to value using the contingency functions developed by the SMEs.ConclusionOur article provides an actionable guide to applying ProMES, which can be adapted to the needs of various industries, including measure selection and modification from existing data sources, and proposing new measures. Future work should address both logistical considerations (e.g., data capture, common data/programming language) and lingering measurement challenges, such as operationalizating measures to be meaningful and interpretable across health care settings.

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has had a transformative effect on individuals across the world, including those in healthcare. Transformative learning is an educational theory in which an individual's worldview is fundamentally altered through conscious reflection (Cognitive Rational), insights (Extrarational), or social reform (Social Critique). We utilized transformative learning theory to characterize the experiences of medical trainees during the pandemic.MethodsWe used the Transformative Learning Survey in September and October 2020 to evaluate the processes and outcomes of transformative learning in health professions students and housestaff at an academic medical center during the pandemic. We analyzed survey scores for three process domains and four outcome subdomains. We inductively coded the survey's two open-ended questions and performed qualitative and mixed-methods analyses.ResultsThe most prominent TL outcome was Self-Awareness, Acting Differently was intermediate, and Openness and Worldview Shifts were lowest. Cognitive Rational and Social Critique processes were more prominent than Extrarational processes. Students were more likely than housestaff to undergo transformative learning through the Social Critique process (p = 0.025), in particular the sub-processes of Social Action (p = 0.023) and Ideology Critique (p = 0.010). Qualitative analysis via the aggregation of codes identified four responses to the pandemic: negative change, positive change, existential change, or no change. Negative changes (67.7%) were most common, with students reporting more of these changes than housestaff (74.8% vs 53.6%; p < 0.01). Only 8.4% of reported changes could be defined as transformative.ConclusionsThrough the theoretical lens of transformative learning, our study provides insight into the lives of learners during the pandemic. Our finding that medical students were more likely to use Social Critique processes has multiple parallels in the literature. If leaders in academic medicine desire to create enlightened change agents through transformative learning, such education must continue throughout graduate medical education and beyond.

Abstract Background Audit and feedback has been shown to be instrumental in improving quality of care, particularly in outpatient settings. The mental model individuals and organizations hold regarding audit and feedback can moderate its effectiveness, yet this has received limited study in the quality improvement literature. In this study we sought to uncover patterns in mental models of current feedback practices within high- and low-performing healthcare facilities. Methods We purposively sampled 16 geographically dispersed VA hospitals based on high and low performance on a set of chronic and preventive care measures. We interviewed up to 4 personnel from each location (n = 48) to determine the facility’s receptivity to audit and feedback practices. Interview transcripts were analyzed via content and framework analysis to identify emergent themes. Results We found high variability in the mental models of audit and feedback, which we organized into positive and negative themes. We were unable to associate mental models of audit and feedback with clinical performance due to high variance in facility performance over time. Positive mental models exhibit perceived utility of audit and feedback practices in improving performance; whereas, negative mental models did not. Conclusions Results speak to the variability of mental models of feedback, highlighting how facilities perceive current audit and feedback practices. Findings are consistent with prior research in that variability in feedback mental models is associated with lower performance.; Future research should seek to empirically link mental models revealed in this paper to high and low levels of clinical performance.

Introduction We created a curriculum to help new physicians and nurses develop skills in interprofessional collaboration. This modular, team-based curriculum for early practitioners delivered training in the five following skill areas: listening for meaning, soliciting another's perspective, negotiating a transparent plan of care, attending to nonverbal communication and microaggression, and speaking up the hierarchy. Methods We brought first-year medical and surgical residents and new nurses together for a 2-hour session monthly for 5 months. Each session began with an interactive large-group presentation, followed by small-group activities covering one of the five skill areas above, which had been identified as critical to interprofessional collaboration by national organizations. We measured relational coordination (RC), a validated measure of how well teams work together, before and after the curriculum was administered. We also obtained qualitative data from participant interviews and end-of-session evaluations. Results Participants reported that the program helped them gain an understanding of each other's roles and workflow challenges. They felt that the curriculum allowed for the cultivation of professional relationships outside the clinical environment, which improved collegiality via gains in rapport and empathy towards each other. Nurses noted increased approachability of their physician colleagues after participation. RC scores improved for the entire cohort (p = .0232). Nurses had statistically higher RC gains than interns did (p = .0055). Discussion Curriculum participants demonstrated improved RC scores and reported increased rapport with and empathy for each other. Curriculum development in this area is important because it may lead to better team-based patient care.

Abstract Introduction Research suggests that students become less patient-centered and empathetic in response to both internal and external factors, including the organizational culture, or hidden curriculum, of medical school. Students often feel compelled to make compromises when they experience tension between competing values in clinical teaching environments. To address this, we implemented a modular, longitudinal professionalism curriculum for third-year medical students, based on a conceptual model that highlights a student's ideal, as well as the internal and environmental forces that can either sustain or change their ideal over time. Methods As students progressed through the third year, they participated in various modules linked to different clerkships, each focusing on a different aspect of the conceptual model. Each module includes a reflective writing exercise followed by a faculty-facilitated discussion. Results In general, students rated the group discussions and faculty facilitation as the most useful parts of each session and the writing exercises as the least useful. Written comments were mostly favorable and suggested that the session facilitated self-reflection and provided a safe environment for students to discuss stressors of third-year clerkships. Discussion This curriculum represents a unique approach to fostering professional role formation through its broad potential applicability to multiple types and levels of learners, its adaptability to fit various course lengths and learning environments, and its incorporation of a conceptual model that allows individual learners to address different facets of the sustaining and acculturating forces that impact their personal professional identity formation for future encounters.

Metaphor helps humans understand complex concepts by “mapping” them onto accessible concepts. The purpose of this study was to investigate the effects of using jazz as a metaphor to teach senior medical students improvisational communication skills, and to understand student learning experiences. The authors designed a month-long course that used jazz to teach improvisational communication. A sample of fourth-year medical students (N = 30) completed the course between 2011 and 2014. Evaluation consisted of quantitative and qualitative data collected pre- and post-course, with comparison to a concurrent control group on some measures. Measures included: (a) Student self-reports of knowledge and ability performing communicative tasks; (b) blinded standardized patient assessment of students’ adaptability and quality of listening; and (c) qualitative course evaluation data and open-ended interviews with course students. Compared to control students, course students demonstrated statistically significant and educationally meaningful gains in adaptability and listening behaviors. Students’ course experiences suggested that the jazz components led to high engagement and creativity, and provided a model to guide application of improvisational concepts to their own communication behaviors. Metaphor proved to be a powerful tool in this study, partly through enabling increased reflection and decreased resistance to behaviors that, on the surface, tended to run counter to generally accepted norms. The use of jazz as a metaphor to teach improvisational communication warrants further refinement and investigation.

Abstract Introduction This medication reconciliation clinical case demonstration is used as a classroom instructional tool to assist students in developing a methodology for critically analyzing medications when conducting medication reconciliation, particularly those conducted when patients transition across care settings. Methods A number of medication errors have intentionally been built into the case. In the classroom, students are asked to identify the medication-related problems. After working independently, we discuss their responses as a group. Following the classroom session, students reconcile medications with individuals on their patient panel. At the conclusion of the course, students independently complete a patient case, similar to one that is presented in class, to assess their competency in identifying and resolving medication-related problems. Results Students were asked to rate their opinion of this session as being “helpful and educational.” Using a 5-point Likert scale where 1 = strongly disagree and 5 = strongly agree, the mean rating given by students that responded (n = 11) was 4.18. Discussion Through use of this case as an instructional method, along with the accompanying medication framework and tools provided to the students, student competency at identifying medication-related problems increased substantially in a way that was directly relevant to patient care.

Abstract This standardized patient case and its accompanying sequence of activities are intended to build skill among first-year medical students in recognizing patient clues and eliciting contextual information. Additional activities include a large-group introduction prior to the standardized patient encounter, a stimulated review of the standardized patient encounter, and a small-group reflection and discussion. The standardized patient case embeds three contextual themes (beliefs about treatment, stressful environment, and fear of what symptoms mean) that are each assigned a specific behavioral cue or clue. Standardized patients are trained to drop these clues and then to give further information only if the student interviewer follows up on the clue. Each theme is constructed to yield potentially meaningful differences in physician decision-making if the clue is or is not followed up on. Students and standardized patients then review the video independently and mark moments in the video that they feel represented clues and whether or not the clue was followed up on. Once the moments have been marked, the students view the video a second time to compare their own markings with those of the standardized patient. Lastly, the students meet in small groups with a faculty facilitator to share one exemplar moment and discuss with the group. Students indicated that the stimulated recall video review of their standardized patient encounter was the most effective activity for triggering reflection, followed by the small-group discussion and the review of the merged standardized patient bookmarks. Students felt that the activities were effective overall in promoting reflection on the relevance of context in the medical encounter.

Abstract Problem-based learning (PBL) cases are typically sparse lines of information dispensed in steps. Students do not get a real impression of the patient, and do not have an opportunity to practice note-taking skills during a clinical interview. Our goal is to present a more realistic way to begin a PBL case where these deficiencies could be minimized. A video of a physician and a medical student taking a history and examining a standardized patient was made. Realistic lower leg petechiae and arm bruises were applied to the standardized patient with cosmetic makeup to mimic autoimmune thrombocytopenia. The camera zooms to provide a clear view of the petechiae and bruising. Pauses are built into the video when students need to generate and revise hypotheses. The video is 20 minutes long, not counting the pauses. The first segment shows the physician and student taking the history. The second segment shows the student reporting physical findings (from an off-camera exam) and shows the physician doing the remainder of the exam (on-camera). Following this segment, the physician and student are shown as they discuss the patient, and the medical student developing a differential. Following the video, the laboratory findings, treatment and learning objectives of the case are presented on paper as usual in the PBL session. The submission includes the video and the paper version of the labs and remainder of the case. Signed releases from everyone in the video have been obtained. The video was used for 10 groups of year 2 medical students during the hematology course in the last academic year. Students had not had experience with this type of PBL case previously, so it was a novel experience for them and for the facilitators as well. Instructions were provided for the facilitators. We had students fill out a free text survey evaluation of the experience and the comments we received were overwhelmingly positive. One caveat however, was that it does take a little longer at the beginning of a session and that students felt that they would not like to have a video before every PBL case for that reason. We intend to create more of these experiences and continue to use this one, based on student feedback about the experience.

Abstract Nurses and physicians share responsibility for improving quality and safety in health care systems, which argues for shared learning about these concepts. This 2.5-hour module, one of two on quality improvement (QI) principles, contains materials to use with first-year medical students and senior bachelor's degree nursing students. The module uses the team-based learning (TBL) method and assumes that users are familiar with TBL terminology and procedures. Included in the resource are a suggested time line, student preparation assignment, readiness assurance tests, application activities, and PowerPoint slides. Students are randomly assigned to learning teams, ensuring an even mix of nursing and medical students. Because our students are naive to TBL at the start, we conduct a warm-up readiness assurance test and a warm-up application activity to orient them to TBL processes. Both of these warm-up activities use brief introductory content about QI principles. We follow them with a more in-depth readiness assurance and application phase, which takes proportionately longer to complete. We use the PowerPoint mostly for timekeeping, orientation, and wrap-up points. It does not contain any unique content over that embedded in the readiness assurance and application materials. This module represents an initial attempt to combine TBL, interprofessional education, and QI concepts. TBL may provide an ideal method for teaching QI content in an interprofessional context because it requires students of various backgrounds to work together to solve real-world, application-based problems. Our hope is that by working together on such activities, nursing and medical students can learn how to build relationships across professional boundaries and see opportunities for improvement in the health care system. Although we have implemented this resource mainly with nursing and medical students, we feel that it may also be useful for a variety of other professional students, including physician assistants, pharmacists, nurse practitioners, and others.

Abstract Nurses and physicians share responsibility for improving quality and safety in health care systems, which argues for shared learning about these concepts. This 2.5-hour module, one of two on quality improvement (QI) principles, contains materials to use with first-year medical students and senior bachelor's degree nursing students. The module uses the team-based learning (TBL) method and assumes that users are familiar with TBL terminology and procedures. Included in this resource are a suggested timeline, student preparation assignment, readiness assurance tests, application activities, and PowerPoint slides. Students are randomly assigned to learning teams, ensuring an even mix of nursing and medical students. Because our students are naive to TBL at the start, we conduct a warm-up readiness assurance test and a warm-up application activity to orient them to TBL processes. Both of these warm-up activities use brief introductory content about QI principles. We follow them with a more in-depth readiness assurance and application phase, which takes proportionately longer to complete. We use the PowerPoint mostly for timekeeping, orientation, and wrap-up points. It does not contain any unique content over that embedded in the readiness assurance and application materials. This module represents an initial attempt to combine TBL, interprofessional education, and QI concepts. TBL may provide an ideal method for QI content in an interprofessional context because it requires students of various backgrounds to work together to solve real-world, application-based problems. Our hope is that by working together on such activities, nursing and medical students can learn how to build relationships across professional boundaries and see opportunities for improvement in the health care system. Although we have implemented this resource mainly with nursing and medical students, we feel that it may also be useful for a variety of other professional students, including physician assistants, pharmacists, nurse practitioners, and others.

Abstract Introduction This exercise is a small-group discussion about bias for medical students who have had at least some clinical experience. It is designed to cultivate awareness that bias is inherent in all humans, including physicians, and can impact patient care. The aim is to foster self-reflection through an exercise that challenges assumptions about personal bias. Methods The Implicit Association Test (IAT) is used as a trigger, and a small-group discussion format is used to create reflection about personal biases and their effects on clinical decisions. Students discuss what it was like to take the IAT, how they felt when they got their results, if their results were expected, when bias can be helpful, clinical experiences with bias, and what they will do with their results. The content is presented as a set of guidelines and features materials for training facilitators and conducting the discussion. These materials comprise an outline of the exercise, advance preparation assignments, instructions for students, and a small-group facilitator guide. The materials also include evaluation tools consisting of pre- and postdiscussion student surveys and facilitator postdiscussion surveys. Results As evidence that the IAT does generate meaningful discussion in a facilitated small group, we report the analysis of our pilot data (n = 72). Our exercise resulted in an increase in the perception that personal bias could have an impact on patient relationships (p < .001) among students reporting a lower belief that bias can have impact (n = 6). Among students who rated themselves as having a lower self-awareness prior to the exercise (n = 14), there was an increase in self-awareness of personal bias after the exercise (p < .001). Finally, students reported significant increases (p < .01) in the perception that the IAT was an effective tool for generating small-group discussion about personal bias (p < .001) and that the reflection exercises and small-group discussions were effective tools for raising awareness about personal bias (p < .001) after attending the session. Discussion Our results suggest that the primary value of this exercise lies not simply in taking the IAT but rather in the cognitive processing of the IAT and other potential biases that takes place during the small-group session. The IAT in conjunction with the discussion appears to be what leads to increased self-awareness and self-reflection.