Introduction

The role of clinician-educators has been widely recognized as pivotal to the educational objectives and clinical functions of academic medical centers [1, 2]. This awareness has led to a steady growth of clinical-educator tracks provided to faculty and graduate trainees at medical schools in recent years. Although trainee instruction in teaching skills has become a core requirement for many residency programs, this is not so for medical students and therefore not included in most medical school required curricula [3]. Many schools do offer a range of 1–8-week elective opportunities or have the option of a medical education pathway of emphasis which can offer students opportunities to teach and complete curricular projects [4,5,6,7,8,9].

Accordingly, medical students may benefit from formal training in foundational medical educational principles and theories, effective feedback provision, utilization of evidence-based diverse teaching modalities, and opportunities to connect with medical education mentors, practice teaching skills in a supervised setting, and develop and present scholarly work through professional conferences and academic journals. Exposure to such opportunities under the guidance of influential mentors early in the development of medical trainees has been shown to increase interest in careers in academic medicine, further serving the mission of the academic medical center [10].

Yoon et al. [11] performed a qualitative analysis of narrative reflections from students who experienced a medical educator course. In their prior study, students indicated themes such as using teaching strategies for adult learning, preparing for class, modeling professionalism, incorporating clinical correlations, exceeding course requirements, giving and receiving feedback, providing mentoring, creating a positive learning climate, and growing as educators [11]. Students are clearly highly engaged parties in improving medical education and are eager to be involved. Burk-Rafel et al. [12] noted that they are “untapped educational change agents.”

At our institution, we developed a longitudinal medical education elective for fourth-year medical students, comprised of attending five seminars, leading 15 teaching sessions, formulating a curricular project, and ultimately writing a reflective essay (Fig. 1). In this study, we analyzed student survey data from this elective and a qualitative analysis of their end-of-course reflective essays. Our research questions were as follows:

  1. 1.

    To what degree did the senior elective influence self-efficacy and self-perception of abilities as a medical educator?

  2. 2.

    How did the education curricular project promote reflection on management and leadership growth of 4th-year medical students?

  3. 3.

    To what extent did 4th-year medical students use the reflective essay to help inform their future professional plans as medical educators and change agents in academic medicine?

Fig. 1
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Course blueprint that visually describes the alignment of general physician competencies with primary course goals, learning objectives, and learning activities. Green boxes represent activities conducted as part of the elective. Orange boxes represent course components specifically aligned with the student reflection essay

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Methods

Curricular Intervention

We developed and offered a medical education senior elective to approximately 10–15 fourth-year medical students per year. Students began the course by attending five seminars at the beginning of the academic year. These seminars covered the history of medical education in the United States, principles of adult learning and educational theories, small group and problem-based learning facilitation, case vignette writing, principles of team-based learning, clinical and bedside teaching, the microskills of teaching, running teaching rounds, writing learning objectives, designing exam questions, designing an Objective Structured Clinical Exam (OSCE), provision of effective feedback, the RIME evaluation model, mentoring students with difficulties, and principles of educational research.

Students were responsible for reading all assigned materials and being prepared to discuss pertinent topics at each seminar. Surveys assessing self-perceived medical education knowledge, skills, and attitudes were completed by students before and after participating in the seminars. Students were then required to lead at least 15 supervised teaching sessions over the course of the academic year. Opportunities for leading teaching sessions included, but were not limited to, problem-based learning (PBL) small groups, team-based learning (TBL) sessions, patient-oriented problem solving (POPS) sessions, skills labs (anatomy, surgical, obstetrics), clinical teaching (bedside, free clinics), lectures, bedside teaching rounds, and medical education journal club facilitation. Students also formulated a curricular medical education project, and ultimately wrote a reflective essay describing lessons learned and their potential interests in academic medicine as a career. Upon the successful completion of the elective, students received two weeks of elective credit and a certificate of completion.

Organization and Setting

The five seminar sessions required a small learning space that could accommodate up to 20 students and was equipped with audio-visual equipment to present material. Student participation in the fifteen separate teaching sessions did not require particular materials and were specific to the chosen activity. Likewise, physical space and materials required for completion of student curricular projects were specific to each chosen project. The university’s learning management system facilitated course organization and was used to post the course syllabus, readings, and other digital course materials.

The course faculty are both medical education deans and general internists (Associate Dean of Curriculum and Regional Dean for Medical Education). They provided all the seminars. The Associate Dean of Curriculum had oversight of all the projects but there are individual faculty mentors for each curricular project. The class size for this elective ranged from 6 to 15 per class. During the timeframe of this study, we collected 34 survey responses and 33 essays from the participants. Informal peer and faculty feedback was provided during teaching sessions, but no standardized rubrics were used. Additionally, medical students were not assigned teaching sessions. Rather, they had a choice of clinical bedside sessions, problem-based learning in courses, case-based or team-based learning sessions in clerkships, leading a medical education journal club, or facilitating other small group sessions. They kept logs of their teaching sessions and hours. Any growth in knowledge was self-assessed because there were no formal rubrics of teaching abilities that were assessed by faculty. Students made adjustments based on informal feedback. Education projects were monitored by the course director and by the individual faculty mentor. A summary of seminar topics is provided within Appendix 1. And examples of some educational projects that our medical students completed is located within Appendix 2.

Data Collection and Analysis

Our exploratory quasi-experiment used a concurrent mixed methods data collection approach to analyze student reflections and perceptions of their longitudinal learning experiences. Thirty-four students completed pre-/post-surveys with Likert-style prompts and then submitted final essay assignments that were coded retrospectively to help identify emergent themes and patterns. The research team repurposed an existing survey with free-response items (personal communication with Dr. Donna Jeffe at Washington University School of Medicine), which was distributed to students via a hard copy. This was completed at the beginning (pre) and end (post) of the seminars. The surveys focused on items related to medical educator growth, which included learners’ self-efficacy (eight prompts with a five-point scale) and self-perception of their abilities (ten prompts with a six-point scale). Survey data was transposed into an Excel workbook and then cleaned for quality assurance. Descriptive statistics (% of responses, medians, and modes) were then calculated to help explain the survey data.

Emergent themes and patterns were revealed through multiple coding procedures of the qualitative data [13,14,15]. During the document analysis, student essays were read thoroughly by an independent educator (who was not affiliated with the senior elective in any way). Initial themes were highlighted through an open coding process using ATLAS.ti qualitative data analysis and research software. When generating the codebook, these initial umbrella themes were renamed as categories, and then transferred to an MS Excel spreadsheet. Each reflective essay was individually coded to establish emergent sub-categories. To complete the codebook, we paraphrased the sub-categories and aligned each with an umbrella category. For each sub-category code, we calculated frequencies and percentage of students who reported. These data informed the creation of a concept map that summarized and explained the qualitative dataset (Fig. 2). To ensure credibility and trustworthiness of our qualitative data analysis, we shared the summary concept map with several former students who anonymously provided feedback via a member checking process.

Fig. 2
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The visual map summarizes and explains emergent themes from our document analysis. Themes are grouped within categories and subcategories, which demonstrate the evolutionary growth of physicians in-training throughout their entire educational journey, both before and during their medical school training. These learner reflections helped to inform their future professional plans, including their future career paths

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Results

Our document analysis (spanning four years of this elective and 33 student reflection essays) revealed five thematic categories and thirteen sub-categories (Table 1). Emergent patterns revealed that during their written reflections, students primarily highlighted learning impacts, medical educator growth, leadership growth, medical school reflections, and future professional plans. Self-efficacy and growth as an educator was a consistent sub-category that appeared in 100% of student essays. Nearly 88% of students specifically addressed how the elective helped them gain both collaboration and problem-solving skills, which they felt would help them as medical educators/leaders. Students also reflected on pre-medical school educational experiences that helped shape their identities as medical educators.

Table 1 Summary of patterns that resulted from the qualitative document analysis. Five thematic categories emerged, which are listed and formatted in bold font. For each sub-category listed, the frequency of times with which this appeared across the entire dataset is included, and the percentage of students who included this within their reflective essay is presented
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Additionally, students consistently stated their positive experiences with both the elective and with the impact of their medical education projects. Similarly, patterns revealed that students felt strongly that this elective helped increase their perceptions of self-efficacy and growth as a medical leader, respect for the process involved with being a quality medical educator, and overall interest in the medical education field for future professional plans. While some students mentioned negative items related to their prior medical school experiences (9.375%) and included specific opportunities for improvement (25%), these patterns emerged at a much lower frequency when compared with the other emergent themes.

Given the inherent complexities involved with explaining medical educator growth, the survey prompts compartmentalized key factors associated with self-efficacy (Table 2a) and with self-perception of abilities (Table 2b). Before the elective (pre-survey), medical students were most confident in their abilities to provide effective feedback (%PRE Strongly Agree and Agree = 41.31%) and that they would ultimately work in an academic environment (%PRE Strongly Agree and Agree = 43.48%). Incoming students were most unsure about their abilities to do the following: utilize the 1-min preceptor model in teaching a student (26.47% unsure), design an OSCE (8.82% unsure), assign a RIME classification to a learner (20.59% unsure), and conduct a curricular educational project (11.76% unsure).

Table 2 Pre-/post-survey data with descriptive statistics (% of responses, median, and mode are reported). (a) Medical student self-efficacy and (b) medical student self-perception of abilities
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Post-survey data revealed that student self-efficacy increased across all categories. The largest increase related to student confidence with understanding of adult learning principles (%PRE Strongly Agree and Agree = 13.04%; %POST Strongly Agree and Agree = 69.57%). Similarly, students self-reported increased confidence with their understanding of principles of educational research (%PRE Strongly Agree and Agree = 6.52%; %POST Strongly Agree and Agree = 52.17%). Medical student self-perceptions of their abilities to effectively serve as a medical educator also increased in all categories. The majority of students reported they could do most tasks independently or with minimal supervision. Conducting bedside clinical teaching, writing clinical exam vignettes questions, and designing an OSCE were the three categories for which students felt they could still use supervision.

Our mixed methods analysis found that students felt more confident in their knowledge of foundational educational principles and with their abilities to implement newly acquired teaching methods. Importantly, high interest in pursuing careers in academic medicine was maintained, though it is important to keep in mind the self-selected nature of these participants. Students enjoyed the flexibility afforded by the course’s longitudinal nature and expressed satisfaction with having the opportunity to work directly with faculty mentors during teaching sessions, while getting a “behind-the-scenes” experience of their own training. All enrolled students completed educational curricular projects in congruence with their own interests, and importantly, several of these have persisted as permanent and valuable components of the current medical curriculum. Essays completed by students reflecting on their experiences in the course mirrored survey data, indicating that students felt better equipped to engage in their future teaching roles as residents.

Integrating results from the document analysis and pre-/post-surveys helped explain how our next generation of academic medicine leaders evolved their personal leadership philosophies throughout their medical education training (Table 3). Positive pre-medical school educational experiences begin shaping their views on what quality teaching is. During medical school, being provided opportunities to apply their learning was a key characteristic of quality medical education. Students reflected positively on their experiences with the elective itself (enjoyment, challenging, interesting, and transformative) as they were able to observe effective teaching practices from mentors and then create their own learning experience for others to use. The elective appeared to help motivate students (strive to educate others, helped improve lack of confidence, make a meaningful impact) and provided them opportunities to grow as professionals (temporal evolution and growth, observing other educators to improve performance, learning from feedback, and identifying and overcoming teaching challenges). Students reflected on their self-efficacy and growth as leaders (interested in leadership roles and improved abilities to effectively lead). Students also highlighted three specific medical educator management and leadership skills: collaboration, communication, and problem-solving (adapting to unforeseen events, project management, and lifelong learning).

Table 3 Representative student quotations aligned with each of the five emergent patterns
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Discussion

Medical school faculty and leadership benefit when engaging with students in a collaborative manner during curricular renewal and enhancement processes [12, 16]. Expanding intentional opportunities empowers students and fosters collaboration [16]. Furthermore, involving students in values-based curricular enhancement initiatives builds community and stimulates interest in academic medicine as a viable career option 17. These kinds of empowerment efforts can promote mentor–mentee relationships, generate inclusive educational experiences, and increase diversity in academic medicine [18, 19].

This senior elective provided students with opportunities to reflect on their entire medical school journey. Their reflections revealed how they gained new understandings of the medical education field, increased self-efficacy, and developed critical skills. This augmented their respect for the process involved with being a quality medical educator and helped inform their future professional plans. For some students, the elective alongside their past educational experiences, served to influence their future career paths, as they transition into the next phases of their professional journeys to become medical educators and leaders.

Based on our analysis, we recommend that medical schools incorporate longitudinal paths for students where they can develop their educator and leadership skills. Not only can students be involved in evaluation processes, but they can also serve as important liaisons for faculty members. For example, during the design and development of new and technologically enhanced curricular assets, students-as-partners can provide valuable knowledge, skills, and insight. Senior electives can serve as significant capstone experiences, where students may reflect on their learning paths and begin their transitions into academic medicine leadership roles. Student reflections can also help inform data-driven decision-making processes that can drive continuous quality improvements at the institutional level [20, 21].

This exploratory study of 4th-year medical students’ reflection-on-practice was limited to a single institution with a relatively small number of participants, which may impact its generalizability to other situational contexts. A future opportunity for research is to identify whether or not our learners actually pursued a career in academic medicine. Additionally, learners’ self-assessments of their own competencies may present inaccuracies [22]. That said, learner experiences within this senior elective are consistent with previously reported results from similar reflective opportunities. For example, Yoon et al. [11] identified nine themes that described practical medical educator skills. While our study did not intentionally code for their exact themes, our learners did relay similar feedback in terms of their self-efficacy and growth as an educator (Table 4). Taken together, these studies help illustrate the importance of formally including foundational training in academic medicine within the modern medical school curriculum.

Table 4 Comparison/alignment of this study’s emergent educator-focused patterns against themes from the Yoon et al. [11] article. Two themes did not quite align across studies and are indicated with a blank space in their respective columns
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This is particularly true if we want our future leaders in academic medicine to have profound experiences with incorporating adult learning theory into practice, confidence in their abilities to lead, and capacity to contribute to the scholarship of teaching and learning [12, 23]. After all, our medical students are our agents of change for the future of academic medicine and are characterized by key attributes that we can help them nurture (Table 5). Developing effective medical educators of the future relies on sound educational experience and institutional support for curricular innovations [24,25,26,27]. A consideration that arises from our quasi-experiment is for medical schools to evaluate their responsibilities of intentionally providing experiential opportunities for medical educator and leadership skills development within our curricula (Fig. 3).

Table 5 Leadership growth outcomes from the senior elective that help define characteristics of an academic medicine change agent
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Fig. 3
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Our Senior Elective analysis revealed consistencies in the characteristics that help define an academic medicine change agent. Future leaders in academic medicine will master critical skills and abilities that complement their intrinsic interest in academic medicine leadership roles. Medical schools can facilitate their educator growth and leadership evolution by intentionally including and assessing medical education “touch-points” longitudinally throughout the modern curricula

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