Early Introduction of the Multidisciplinary Team by Student Schwartz Rounds: A Mixed Methods Study | BMC medical training


Given the small cohort of students available for the study (not = 29) and the voluntary nature of the rounds, presence in the first round (not = 18) to was surprisingly high. A significant drop occurred for the second round (not= 11), although the presence of other groups of students meant that the number of student audiences for the two rounds was similar (not= 19, not= 16). One possible explanation for the deposit is the consent procedure. This was done face-to-face in the week leading up to the first round, thus also serving as a reminder to the students. The timing of the second round, which occurred 12 days after the first round, as opposed to the POCF recommended month interval, may also be relevant. [6]. Dropout may also be due to prioritizing self-study over attendance, as for many students this was their last placement before exams. The high first-round feedback scores suggest that the dropout was not due to dissatisfaction with the experience. One might also expect that the students who participate in both cycles would be those most interested in SR as a concept, or those who benefited the most from the first cycle. The data actually suggests the opposite since the scores of the dual participants were mostly lower, although the presence of MDT may be the cause.

Quantitative data

Our study used quantitative data for two purposes; evaluate the success of each cycle and compare the student experience between the two. The independent variable in this comparison was the presence of multiple student disciplines. This study is the first to attempt a direct comparison in this way.

Median means showed uniform agreement with each positive POCF statement. The statements can be seen in Fig. 1 and cover relevance, participant benefits and future attendance or referral. This overall evidence of round success is supported by the overall median rating for each round, which was “excellent” for both. The statement that elicited the lowest response in both areas was “I have gained knowledge that will help me meet patient needs”. This may reflect content raised by panelists and the public, which has been kept confidential. Since audience participation is spontaneous, improvement in this rating can be achieved by more clinically focused panels. This should be weighed against the goals of SR, which is not intended as a clinical teaching session.

Lower scores in the MDT cycle may be related to contribution anxiety elicited by the presence of strangers in the meeting. Reflection is a deeply personal process, and medical students are still in their infancy. This argument is discussed later in the thematic analysis. We also need to consider whether the short gap between rounds diluted the impact of the second round. In addition, there is the students’ familiarity with the concept of SR. Only one student in the paired group had experienced SR before attending the first round, which of course cannot be said in the second round. This variation creates the potential for response bias.

Thematic analysis

This study used thematic analysis to explore students’ understanding of and response to SRs, yielding four main themes.

Concerns about the current reflection program

The group was generally frustrated with the rigidity of the mandatory written reflection, which for some had resulted in disengagement from the process. Motivating students to reflect is a challenge [23], and the subjective nature of motivation makes consensus difficult to find. An international focus group study by Sargeant et al. [24] consistently found that student engagement correlated with the quality of feedback they received, whether from supervisors or peers. A better understanding of reflective motivation can be found in a 2007 study by Driessen et al. who reviewed the portfolios of medical students [25]. The results suggest that understanding the thinking reasoning is a more important predictor of engagement than the thinking method itself. Given this, student frustrations here may represent two issues: an aversion to the rigidity of the written form and, second, a problem with the medical school’s communication of its own reflective agenda. The findings here also relate directly to findings from a previous SR pilot study, which found a strong preference for SRs over written reflection. [15]. Written reflection in general fails to engage the full range of student learning styles, ignoring both the pragmatic and active learner [26]. The requirement for a set number of separate trials also does not allow for a cycle of reflection, instead creating multiple separate linear paths. This contradicts the seminal theory developed by Kolb [27] which sees reflection as a process that must progress in a cyclical and logical manner. The GCM document The reflective practitioner [13] explains thinking as a subjective variable process, openly drawing on the established theories of Honey Mumford and Kolb [26, 27]. If medical schools intend to improve student reflective engagement, they also need to consider how their future assignments can incorporate insights from these established theories. It begins by appealing to all types of learners, as well as encouraging individuals to reassess and revalidate their own development. It also requires that students be given the opportunity to think in a way that they themselves find most effective, be it an SR or otherwise. Perhaps the answer is that those who set assignments become more flexible and creative. A successful example of this comes from Brown University in the United States, where surgical students were asked to submit “tweet” style reflections (140 characters) throughout their rotation, resulting in more impactful and actionable insights. [28].

Current exposure to multidisciplinary team

Consensus was uniform that greater integration of MDT is needed in medical school. The presence of MDTs in these cycles provided students with insight into and appreciation for other healthcare roles, and was also seen as a potential tool for improving inter-specialty communication within the NHS. This is a particularly significant finding when considering the NHS’s long-term plan, which sees collaborative working as a central tenet of its overhaul. [29]. The fact that students saw MDT integration as a pathway to culture change is particularly important for an institute like the NHS, which is no stranger to the concepts of bullying and harassment. [30]. There was also consensus on the need for earlier integration of PCT into medical school. This was a more general point about current curricular inadequacies, rather than specifically advocating SRs as a solution, although student tours are a means of ensuring early integration.

Normalize negativity and move on

The third theme of normalizing negativity and self-doubt builds directly on similar findings from previous student pilots [15, 17]. Our participants expand on these themes, viewing them as potential pathways to future change. This is in accordance with the GMC document The Reflective Practitioner,which proposes that the clinician “think analytically…using lessons learned to maintain good practice or make improvements” [13]. The reflective practitionergoes on to recommend group reflections as a mechanism for implementing complex systemic change. Interestingly, some participants already knew each other from previous courses, but this was the first time they heard their peers doubt themselves. This is perhaps indicative of the unique sharing space that SRs can offer. Critically appraising these shared apprehensions was also seen as a potential mechanism for systemic change. Further exploration of this idea may be limited by one of the core tenets of POCF – rounds exist to share but not to solve problems. [6].

Contribution anxiety

The size of the group has been highlighted as one of the causes of these anxieties. Only one previous pilot had comparable numbers (not= 28 to 45), and again concerns about group size were a major theme [15]. This highlights the first paradox of SR, which is that it exists in part to reduce participants’ stress, but to do so it relies on public speaking which is in itself a stressor. common. Participants acknowledged that SRs tried to provide a safe space, but despite this, they still feared being judged by their peers. There were more concerns in the second round, specifically commenting on the discomfort of sharing with strangers. It should be noted that these concerns are expressed for rounds with a relatively small total number of participants (not=33, 32). The Point of Care Foundation recommends a minimum audience of ten people, but no upper limit [6]. This is the second paradox of SR: by being open to all, the audience has the potential to skyrocket, which can then negatively impact the success of the tour. The online platform likely exacerbated the issues here, since Microsoft Teams only showed videos of the panelists, moderator, and speaker, but in physical SRs speakers are likely to recognize their colleagues in the crowd. There is no easy answer here, as showing all participants on Teams will likely exacerbate concerns about group size, and would also be difficult on a small screen with variable WIFI.

Qualitative vs. quantitative results

The results are contrasted between quantitative and qualitative results. Focus groups showed clear advocacy for PCT integration, but feedback forms showed a negative correlation when PCT was present. The quantitative data in this study have low statistical power and conclusions are drawn with much less certainty than the qualitative results. It should also be noted that the feedback scores show overall advocacy for SRs, unrelated to the presence of PCT. Interestingly, the focus groups advocated strongly for the early integration of MDT and for more SR, but only one student spoke specifically about the benefits of MDT in the cycle he had experienced. It is therefore possible that different reflective formats are better placed to introduce the MDT.

Focus groups were able to examine reflective attitudes and SRs as concepts, whereas quantitative data is more dependent on the content of the rounds – panel stories, audience comments, round themes. Without similar studies for comparison, it is difficult to say with certainty whether the quantitative results were due to the content or the format of the cycles.

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