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Introduction: Increasing the diversity of medical students, or widening participation (WP), is critical for social justice and healthcare delivery, and many governments are setting policies to encourage WP. However, establishing policy is only the first step in an educational change process: we also need to know "how" policy is enacted or how medical schools interpret and put into practice WP policy. Addressing this gap, the aim of this study was to examine policy enactment in six new UK medical schools with an explicit WP mandate., Methods: This qualitative study, underpinned by social constructivism, used semi-structured interviews to explore the experiences of key actors (6 Deans and 14 Admissions staff) of putting policy into practice when setting up a new medical school. Data coding and analysis were initially inductive, using thematic analysis. We then applied Ball's theory of policy enactment to organise the data into four contextual dimensions of 'situation', 'professional', 'material' and 'external'., Results: On the surface, there were many similarities across the six schools in terms of the four dimensions. However, how these dimensions interacted illuminated tensions and differences. For example, some schools found themselves increasingly subjected to local and extra-local rule systems, including pressure to follow host university norms and hosts struggling to accept that medical schools are heavily regulated. There were also tensions between the new medical schools and the medical education "establishment", including lack of power and being judged by overly narrow outcomes., Discussion: Different contexts seem to influence the enactment of WP to medicine in different places, even in the same country, even in medical schools established at the same time. That policy enactment is a complex, non-linear process of enactment is important to acknowledge: context is critical. Our findings will inform future policies and practices that aim to increase WP in medicine., (© 2024 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Test-enhanced learning (TEL) is an impactful teaching and learning strategy that prioritises active learner engagement through the process of regular testing and reviewing. While it is clear that meaningful feedback optimises the effects of TEL, the ideal timing of this feedback (i.e. immediate or delayed) in a medical education setting is unclear., Method: Forty-one second-year medical students were recruited from the University of Melbourne. Participants were given a multiple-choice question test with a mix of immediate (i.e. post-item) and delayed (i.e. post-item-block) conceptual feedback. Students were then tested on near and far transfer items during an immediate post-test, and at a one-week follow-up., Results: A logistic mixed effects model was used to predict the probability of successful near and far transfer. As expected, participants in our study tended to score lower on far transfer items than they did on near transfer items. In addition, correct initial response on a parent question predicted subsequent correct responding. Contrary to our hypotheses, the feedback timing effect was non-significant-there was no discernible difference between feedback delivered immediately versus delayed feedback., Discussion: The findings of this study suggest that the timing of feedback delivery (post-item versus post-item-block) does not influence the efficacy of TEL in this medical education setting. We therefore suggest that educators may consider practical factors when determining appropriate TEL feedback timing in their setting., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Objective: This study explored how the Syrian crisis, training conditions, and relocation influenced the National Medical Examination (NME) scores of final-year medical students., Methods: Results of the NME were used to denote the performance of final-year medical students between 2014 and 2021. The NME is a mandatory standardised test that measures the knowledge and competence of students in various clinical subjects. We categorised the data into two periods: period-I (2014-2018) and period-II (2019-2021). Period-I represents students who trained under hostile circumstances, which refer to the devastating effects of a decade-long Syrian crisis. Period-II represents post-hostilities phase, which is marked by a deepening economic crisis., Results: Collected data included test scores for a total of 18 312 final-year medical students from nine medical schools (from six public and three private universities). NME scores improved significantly in period-II compared with period-I tests (p < 0.0001). Campus location or relocation during the crisis affected the results significantly, with higher scores from students of medical schools located in lower-risk regions compared with those from medical schools located in high-risk regions (p < 0.0001), both during and in the post-hostilities phases. Also, students of medical schools re-located to lesser-risk regions scored significantly less than those of medical schools located in high-risk regions (p < 0.0001), but their scores remained inferior to that of students of medical schools that were originally located in lower-risk regions (p < 0.0001)., Conclusion: Academic performance of final year medical students can be adversely affected by crises and conflicts, with a clear tendency to recovery upon crises resolution. The study underscores the importance of maintaining and safeguarding the infrastructure of educational institutions, especially during times of crisis. Governments and educational authorities should prioritise resource allocation to ensure that medical schools have access to essential services, learning resources, and teaching personnel., (© 2024 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Health professions education curricula are undergoing reform towards social accountability (SA), defined as an academic institution's obligation to orient its education, service and research to respond to societal needs. However, little is known about how or which educational experiences transform learners and the processes behind such action. For example, those responsible for the development and implementation of undergraduate medical education (UGME) programs can benefit from a deeper understanding of educational approaches that foster the development of competencies related to SA. The purpose of this paper was to learn from the perspectives of the various partners involved in a program's delivery about what curricular aspects related to SA are expressed in a UGME program., Methods: We undertook a qualitative descriptive study at a francophone Canadian university. Through purposive convenience and snowball sampling, we conducted 16 focus groups (virtual) with the following partners: (a) third- and fourth-year medical students, (b) medical teachers, (c) program administrators (e.g., program leadership), (d) community members (e.g., community organisations) and (e) patient partners. We used inductive thematic analysis to interpret the data., Results: The participants' perspectives organised around four key themes including (a) the definition of a future socially accountable physician, (b) socially accountable educational activities and experiences, (c) characteristics of a socially accountable MD program and (d) suggestions for curriculum improvement and implementation., Conclusions: We extend scholarship about curricular activities related to SA from the perspectives of those involved in teaching and learning. We highlight the relevance of experiential learning, engagement with community members and patient partners and collaborative approaches to curriculum development. Our study provides a snapshot of what are the sequential pathways in fostering SA among medical students and therefore addresses a gap between knowledge and practice regarding what contributes to the implementation of educational approaches related to SA. We emphasise the need for educational innovation and research to develop and align assessment methods with teaching and learning related to SA., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Self-monitoring of clinical-decision-making is essential for health care professional practice. Using certainty in responses to assessment items could allow self-monitoring of clinical-decision-making by medical students to be tracked over time. This research introduces how aspects of insightfulness, safety and efficiency could be based on certainty in, and correctness of, multiple-choice question (MCQ) responses. We also show how these measures change over time., Methods: With each answer on twice yearly MCQ progress tests, medical students provided their certainty of correctness. An insightful student would be more likely to be correct for those answers given with increasing certainty. A safe student would be expected to have a high probability of being correct for answers given with a high certainty. An efficient student would be expected to have a sufficiently low probability of being correct when they have no certainty. The system was developed using first principles and data from one cohort of students. A dataset from a second cohort was then used as an independent validation sample., Results: The patterns of aspects of self-monitoring were similar for both cohorts. Almost all the students met the criteria for insightfulness on all tests. Most students had an undetermined outcome for the safety aspect. When a definitive result for safety was obtained, absence of safety was most prevalent in the middle of the course, while the presence of safety increased later. Most of the students met the criteria for efficiency, with the highest prevalence mid-course, but efficiency was more likely to be absent later., Discussion: Throughout the course, students showed reassuring levels of insightfulness. The results suggest that students may balance safety with efficiency. This may be explained by students learning the positive implications of decisions before the negative implications, making them initially more efficient, but later being more cautious and safer., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Medical educators aim to understand why students differ in performance and stress. While performance and stress are associated with student demographics, school factors and aspects of self-regulated learning (SRL), it remains unclear how these elements interact within individuals. This multi-cohort study identified SRL profiles among medical students and explored their associations with performance and stress. Additionally, we examined the identified profiles' associations with gender, migration status and assessment policy., Methods: We used latent profile analysis (LPA) to identify profiles on Motivated Strategies for Learning Questionnaire (MSLQ) scores of six cohorts (2014-2019) of Year 1, first semester medical students (n = 1894) in a Dutch medical school. We used nine MSLQ subscales that measure test anxiety (TA), self-efficacy, deep learning, resource management and value. The university's assessment policy varied, demanding students to obtain 100% or 75% of Year 1 credits to remain enrolled. We defined optimal performance as obtaining all credits at the end of Year 1. Two cohorts completed the Perceived Stress Scale (PSS-14, n = 409) in the 2nd semester., Results: We identified three distinct student profiles: 693/1894(36.6%) were classified as TA high SRL high , 661/1894(34.9%) as TA low SRL high and 540/1894(28.5%) as TA moderate SRL low . Females were more likely to belong to TA high SRL high profiles compared to males (effect size [ES] Cramer's V = .13, small). Migration background was not associated with these profiles. The TA high SRL high profile was more prevalent under the 100% assessment policy (ES Cramer's V = .10, negligible). TA low SRL high students demonstrated lower stress levels (PSS = 23.9 out of 56) compared to TA high SRL high students (PSS = 28.7, ES Cohen's d = .62, medium) and TA moderate SRL low students (PSS = 28.2, ES Cohen's d = .51, medium). Performance differed among the three profiles (ES Cramer's V = .16, small): 82.5% optimal performance in the TA low SRL high , 71.9% in the TA high SRL high and 65.2% in the TA moderate SRL low profile., Discussion: Three distinct SRL student profiles associated with gender, academic performance and perceived stress were identified. Test anxiety had additional value in distinguishing subgroups with differential academic performance and stress. These profiles may aid educators to inform personalised support strategies for novice learners., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Differential attainment is a well-known phenomenon in medical education. Despite a strong impetus for institutions and researchers to move away from a 'student deficit model' when exploring the attainment gap, little attention has been given to understanding the experiences of Black, Asian and Minority Ethnic (BAME) medical students. Informed by the social construction of learning theory, this is the first national study to explore how multiple dimensions of the medical school environment impact academic performance of BAME undergraduate medical students across the UK., Methods: Using a sequential explanatory mixed-methods approach, the authors conducted a survey and facilitated three focus groups across medical schools in the UK between 2020-2021. Participants self-identified as being from BAME backgrounds. Quantitative analyses included descriptive statistics and bivariate analyses. Qualitative data were analysed using thematic analysis, subsequently identifying inductive themes., Results: Three hundred sixty-two respondents completed the Phase 1 survey, and 17 participants participated in the Phase 2 focus groups. Although both survey and focus group participants identified facilitators to learning such as supportive relationships, students reported facing numerous barriers that they felt impeded their learning and performance. These barriers included limited access to educational resources, and undiversified curricula and medical school populations. Students also described both experiencing and witnessing various forms of racism throughout their educational journeys., Discussion: Students encountered various difficulties throughout their medical training that they felt impacted their learning and performance. This study offers novel insights into the experiences of BAME students and builds upon previous research. It also reveals the pervasive nature of racism within medical schools, highlighting the urgent need for institutional changes. Educators and institutions must go beyond merely recognising these barriers and facilitators; they must proactively innovate and adapt. In doing so, they pave the way for inclusive learning environments that truly foster a sense of belonging for BAME students., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: The slow pace of change in respect of increasing the diversity of medical students suggests powerful actors are reproducing practices to support the status quo. Opening up medicine to embrace diversity thus requires the deconstruction of entrenched processes and practices. The first step in doing so is to understand how the actor-network of widening participation and access to medicine (WP/WA) is constructed. Thus, here we examine how the connections among actors in WP/WA in two different networks are assembled., Methods: A comparative case study using documents (n = 7) and interviews with staff and students (n = 45) from two medical schools, one United Kingdom and one Australian, was used. We used Callon's moments of translation (problematisation, interessement/operationalisation, enrolment, mobilisation) to map the network of actors as they are assembled in relation to one another. Our main actant was institutional WP to medicine policy (actor-as-policy)., Results: Our actor-as-policy introduced five other actors: the medical school, medical profession, high schools, applicants and medical school staff. In terms of problematisation, academic excellence holds firm as the obligatory passage point and focal challenge for all actors in both countries. The networks are operationalised via activities such as outreach and admissions policy (e.g., affirmative action is apparent in Australia but not the UK). High schools play (at best) a passive role, but directed by the policy, the medical schools and applicants work hard to achieve WP/WA to medicine. In both contexts, staff are key mobilisers of WP/WA, but with little guidance in how to enact policy. In Australia, policy drivers plus associated entry structures mean the medical profession exerts significant influence., Conclusions: Keeping academic excellence as the obligatory passage point to medical school shapes the whole network of WP/WA and perpetuates inequality. Only by addressing this can the network reconfigure., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Identity threats, such as stereotype threat and microaggressions, impair learning and erode well-being. In contrast to identity threat, less is known about how learners experience feelings of safety regarding their identity. This exploratory study aims to develop a theory of identity safety in the clinical learning environment., Methods: This multi-institutional, qualitative interview study was informed by constructivist grounded theory and critical pedagogy. Participants were clinical students at three public medical schools in the United States in 2022. Investigators purposively sampled participants for interviews based on their responses to an 11-item survey with an open-ended question soliciting students' personal identities and responses to both the racial/ethnic and gender Stereotype Vulnerability Scales. The investigators interviewed, coded, constantly compared and continued sampling until the codes could be developed into categories, then concepts and finally into a theory. The team engaged in critical reflexivity throughout the analytic process to enrich data interpretations., Results: Sixteen diverse students were interviewed. We organised their identity-salient experiences into identity threat, threat mitigation and identity safety. Participants experienced identity threat through unwelcoming learning environments, feeling compelled to change their behaviour in inauthentic ways or sociopolitical threat. Threat mitigation occurred when a participant or supervisor intervened against an identity threat, dampening but not eliminating the threat impact. Participants characterised identity safety as the ability to exist as their authentic selves without feeling the need to monitor how others perceive their identities. Identity safety manifested when participants demonstrated agency to leverage their identities for patient care, when others upheld their personhood and saw them as unique individuals and when they felt they belonged in the learning environment., Discussion: Attending to identity safety may lead to educational practices that sustain and leverage team members' diverse identities. Identity safety and threat mitigation may work together to combat identity threats in the learning environment., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Within medical school's holistic review of applicants includes a review of their distance travelled to get to this point in their education. The AAMC defines distance travelled (DT) as, 'any obstacles or hardships you've overcome to get to this point in your education or any life challenges you've faced and conquered'. What medical students consider as their distance travelled has not been explored. The authors sought to identify the factors medical students perceive are important for medical school admissions to consider when assessing someone's 'distance travelled' by asking current medical students to share their DT experiences along with the barriers and facilitators they encountered on their medical school journey., Methods: The authors conducted semi-structured interviews with US medical students through purposeful sampling methods. The social-ecological model framework was used to develop questions to elicit participants' experiences that contributed to their distance travelled. Interviews were conducted in 2021 and ranged from 60-75 minutes. Transcribed interviews were qualitatively analysed using interpretive description., Results: A total of 31 medical students from seven medical schools were included in the study. Overall, participants defined distance travelled as an applicant's hardships (e.g. being the primary caregiver for a family member) and privileges (e.g. having physician parents) they experienced. Three major themes were identified: (1) individual-level characteristics and factors, (2) interpersonal relationships and (3) aspects of the participants' community and society., Discussion: Our findings show that medical school applicants considered DT to be a valuable component of a holistic medical school admission process. Participants' experiences of DT were varied and complex. Our research suggests that admissions teams for medical schools should incorporate more comprehensive recruitment practices and inclusive methodological frameworks to accurately capture the diversity of identities and experiences of medical school applicants and to consider the factors that shape their journey to medical schools., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Practical wisdom is considered a multidimensional virtue of enduring relevance to medicine. Though it has received increasing attention in recent years, proposed frameworks for practical wisdom can differ, and little is known about how medical students and physicians describe its dimensions and relevance., Methods: We used structured interviews, employing open-ended and closed-ended questions, to describe how medical students and physicians understand practical wisdom and identify the kinds of clinical situations they believe require practical wisdom. We interviewed 102 participants at two US medical schools in 2021, comprising a voluntary response sample of 40 pre-clinical medical students and 40 clinical medical students and a purposive sample of 22 nominated physicians. Interviews were conducted by videoconference using a structured interview guide. Open-ended responses were coded using qualitative content analysis (directed and conventional) and tabulated; closed-ended responses were tabulated. Quotations provided qualitative illustrations, and frequencies were used for summative results., Results: Participants considered practical wisdom clinically meaningful, broadly relevant and multidimensional. Most described it as deliberative, goal-directed, context-sensitive, integrated with ethics and marked by integrity and motivation to act. Many described it as experience-based, person-centred or problem-solving. Participants also selected an average of 15.6 (SD = 4.9) additional virtues as being essential for practical wisdom in medicine and described a broad range of clinical situations that require practical wisdom in medicine., Conclusions: Participants described practical wisdom as a multidimensional capacity that entails deliberation, depends on a constellation of other virtues and is broadly applicable to medicine. Most agreed it is goal-directed and context-sensitive and involves ethics, integrity and motivation. Efforts to teach practical wisdom in medical education should clarify its dimensions and highlight its relationship to virtue ethics, professionalism, clinical judgement and the individualised care of patients as persons., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Assessment plays a key role in competence development and the shaping of future professionals. Despite its presumed positive impacts on learning, unintended consequences of assessment have drawn increasing attention in the literature. Considering professional identities and how these can be dynamically constructed through social interactions, as in assessment contexts, our study sought to understand how assessment influences the construction of professional identities in medical trainees., Methods: Within social constructionism, we adopted a discursive, narrative approach to investigate the different positions trainees narrate for themselves and their assessors in clinical assessment contexts and the impact of these positions on their constructed identities. We purposively recruited 28 medical trainees (23 students and five postgraduate trainees), who took part in entry, follow-up and exit interviews of this study and submitted longitudinal audio/written diaries across nine-months of their training programs. Thematic framework and positioning analyses (focusing on how characters are linguistically positioned in narratives) were applied using an interdisciplinary teamwork approach., Results: We identified two key narrative plotlines, striving to thrive and striving to survive, across trainees' assessment narratives from 60 interviews and 133 diaries. Elements of growth, development, and improvement were identified as trainees narrated striving to thrive in assessment. Neglect, oppression and perfunctory narratives were elaborated as trainees narrated striving to survive from assessment. Nine main character tropes adopted by trainees with six key assessor character tropes were identified. Bringing these together we present our analysis of two exemplary narratives with elaboration of their wider social implications., Conclusion: Adopting a discursive approach enabled us to better understand not only what identities are constructed by trainees in assessment contexts but also how they are constructed in relation to broader medical education discourses. The findings are informative for educators to reflect on, rectify and reconstruct assessment practices for better facilitating trainee identity construction., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: The mistreatment or abuse (maltreatment) of medical learners by their peers and supervisors has been documented globally for decades, and there is significant research about the prevalence, sequelae and strategies for intervention. However, there is evidence that learners experience maltreatment as being less clear cut than do researchers, educators and administrators. This definitional ambiguity creates problems for understanding and addressing this issue. The objective of this study was to understand how medical learners and educators make sense of less-than-ideal interactions in the clinical learning environment, and to describe which factors influenced their perception that the encounter constituted maltreatment., Methods: Using constructivist grounded theory, we interviewed 16 medical students, 15 residents or fellows, and 18 educators associated with a single medical school (n = 49). Data collection began with the most junior learners, iterating with analysis as we progressed through the project. Constant comparative analysis was used to gather and compare stories of 'definitely', 'maybe' and 'definitely not' maltreatment across a variety of axes including experience level, clinical setting and type of interaction., Results: Our data show that learners and educators have difficulty classifying their experiences of negative interpersonal interaction, except in the most severe and concrete cases. While there was tremendous variation in the way they categorised similar experiences, there was consistency in the elements drawn upon to make sense of those experiences. Participants interpreted negative interpersonal interactions on an individual basis by considering factors related to the interaction, initiator and recipient., Conclusions: Only the most negative behaviour is consistently understood as maltreatment; a complex process of individual sense-making is required to determine the acceptability of each interaction. The differences between how individuals judge these interactions highlight an opportunity for administrative, research and faculty development intervention., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Increasing recognition of autism is reflected in the growing awareness of autistic health care providers. Regulatory bodies including the UK General Medical Council and the UK Medical Schools Council have published guidance fostering inclusion. Whilst many autistic doctors and students are thriving, many may not disclose their diagnosis unless difficulties arise, which perpetuates stereotypes. No studies have explored the experiences of autistic medical students. We aimed to do this., Methods: This was an interpretive phenomenological study. Autistic medical students were recruited using Facebook announcements. Participants underwent audio-recorded, loosely structured interviews. Recordings were transcribed verbatim and underwent an interpretive phenomenological analysis., Results: Five participated from five different UK medical schools. Constructed themes included: Autistic profiles and stereotypes-'I'm a lot better with patients than I am with my peers, with staff, which is hard for a lot of people to understand'; sensory processing and the learning environment-'noises really hurt my ears … It actually hurts'; me, myself and masking-'so, medicine's hard. But I'm also studying myself and I'm figuring myself out and that degree is harder'; the social world-'I always feel like I'm watching my back'; and navigating the system-'[they say] "but you're going to be a doctor one day, so you need to get used to it"'., Conclusion: Participants longed for understanding and support from their medical schools. They reported experiences of isolation, bullying and anxiety. Most felt themselves to be victims of the system, whereby they were expected to adapt themselves in order to appear non-autistic. When participants reported not coping due to being autistic, most were advised to 'take time out'. None were offered personalised adjustments to their learning environment. All reported strengths associated with being autistic. This supports the assertion that autistic people can be safe, effective and skilled doctors., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Medical students from affluent and highly educated backgrounds remain overrepresented in Canadian medical schools despite widespread efforts to improve diversity. Little is known of the medical school experiences of students who are first in their family (FiF) to attend university. Drawing on Bourdieu and a critically reflexive lens, this study explored the experiences of FiF students in a Canadian medical school to better understand the ways in which the medical school environment can be exclusive and inequitable to underrepresented students., Methods: We interviewed 17 medical students who self-identified as being FiF to attend university. Utilising theoretical sampling, we also interviewed five students who identified as being from medical families to test our emerging theoretical framework. Participants were asked to discuss what 'first in family' meant to them, their journey into medical school and their experiences at medical school. Bourdieu's theories and concepts were used as sensitising concepts to explore the data., Results: FiF students discussed the implicit messages they received about who belongs in medical school, challenges in shifting from their pre-medical lives to a medical identity and competing with peers for residency programmes. They reflected on the advantages they perceived they had over their fellow students due to their less 'typical' social backgrounds., Conclusion: While medical schools continue to make strides when it comes to increasing diversity, inclusivity and equity require increased attention. Our findings highlight the ongoing need for structural and cultural change at admissions and beyond-change that recognises the much-needed presence and perspectives that underrepresented medical students, including those who are FiF, bring to medical education and healthcare. Engaging in critical reflexivity represents a key way that medical schools can continue to address issues of equity, diversity and inclusion., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Newer electronic differential diagnosis supports (EDSs) are efficient and effective at improving diagnostic skill. Although these supports are encouraged in practice, they are prohibited in medical licensing examinations. The purpose of this study is to determine how using an EDS impacts examinees' results when answering clinical diagnosis questions., Method: The authors recruited 100 medical students from McMaster University (Hamilton, Ontario) to answer 40 clinical diagnosis questions in a simulated examination in 2021. Of these, 50 were first-year students and 50 were final-year students. Participants from each year of study were randomised into one of two groups. During the survey, half of the students had access to Isabel (an EDS) and half did not. Differences were explored using analysis of variance (ANOVA), and reliability estimates were compared for each group., Results: Test scores were higher for final-year versus first-year students (53 ± 13% versus 29 ± 10, p < 0.001) and higher with the use of EDS (44 ± 28% versus 36 ± 26%, p < 0.001). Students using the EDS took longer to complete the test (p < 0.001). Internal consistency reliability (Cronbach's alpha) increased with EDS use among final-year students but was reduced among first-year students, although the effect was not significant. A similar pattern was noted in item discrimination, which was significant., Conclusion: EDS use during diagnostic licensing style questions was associated with modest improvements in performance, increased discrimination in senior students and increased testing time. Given that clinicians have access to EDS in routine clinical practice, allowing EDS use for diagnostic questions would maintain ecological validity of testing while preserving important psychometric test characteristics., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Patient-student relationships are at the heart of Longitudinal Integrated Clerkships (LICs). Outcomes for students and preceptors are beneficial, but patient outcomes remain unclear. This systematic literature review explored the current evidence base of patient outcomes in an LIC. Patient outcomes were defined as issues related to patient safety, clinical effectiveness or patient experience., Methods: Seven bibliographic databases were searched. A wider search strategy included a hand search of three medical education journals' previous issues and backward/forward citation searching of included studies and of a relevant systematic review. Included studies were quality appraised and assessed for their strength and level of evidence. A qualitative data synthesis was performed., Results: Databases searches identified 7237 titles. Following the removal of duplicates, titles and abstracts were reviewed against the inclusion criteria. Forty-eight studies had a full-text review. Nineteen met the inclusion criteria. Seven studies were included from the wider search strategy. From the 26 included studies, two major themes were identified. (1) 'A trusting patient-student relationship' contains the sub-themes: 'care and compassion', 'patient education and empowerment' and 'the loss of the student as 'my' doctor'. (2) 'The student acts as an agent of change for the patient' contains the sub-themes: 'patient advocacy', 'supporting the patient to navigate the healthcare system', 'communication between patient and healthcare professional' and 'enhancement of preceptors' care, healthcare services and communities'., Conclusions: LICs provide educational continuity allowing the creation of a trusting patient-student relationship. This relationship leads to students becoming agents of change for patients by enhancing patient outcomes. This review provides further evidence on the benefits of having an LIC as part of the medical education curricula and implications for its successful delivery. Further research is needed to explore educationally induced benefits for patients and look at objective assessments of patient health outcomes., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)