The goal of family-centered care (FCC) is to engage families in three key tasks of a health care visit: (1) building relationships with care providers, (2) exchanging information, and (3) deliberating about decisions.1,2 The benefits of FCC include improved resource utilization as well as increased patient and staff satisfaction.3–5 The American Academy of Pediatrics (AAP), the Accreditation Council for Graduate Medical Education (ACGME), and the Joint Commission each endorse training in FCC for all learners.6–8 To facilitate FCC, the AAP recommends conducting rounds at the bedside with the family present6 (i.e., family-centered rounds). During these rounds, students may acquire FCC skills through observing and practicing communication skills and through observing professionalism and bedside manner in their role models.6,9–12 However, learner experiences with family-centered rounds are not always positive,13–17 and as yet no formal curricula for teaching this rounding technique exist. To facilitate the learning process during family-centered rounds so that students eventually implement an FCC approach, it is imperative to understand the factors that may influence medical students’ adoption of FCC during rounds.
Social cognitive theory (SCT)18 provides a useful framework for understanding mechanisms that may influence students’ behaviors during clinical experiences, including family-centered rounds. SCT posits that knowledge and skills alone are not always good predictors of behavior because the beliefs that individuals possess about their capabilities significantly affect their behavior. Thus, self-efficacy, defined as an individual’s beliefs about her or his capabilities to organize and execute a behavior, is an important prerequisite to that behavior.19 Bandura20 proposes three specific experiences that can support self-efficacy: (1) observing role models performing the behavior, (2) having opportunities to practice the behavior (mastery experiences), and (3) receiving feedback on one’s performance. Further, self-efficacy is context specific; thus, self-efficacy with FCC during rounds must be measured in that context. Third-year clerkships often represent medical students’ first clinical experiences, and these clerkships often entail numerous stressors.9,21,22 Many students experience difficulty with prioritizing competing demands, managing time, and coping with the emotional intensity of caring for patients.23,24 Students may also encounter personal problems (e.g., a change in their own health status or that of a loved one),24 medical errors, and tension among care team members.25 These stressors may disrupt students’ abilities to implement a family-centered approach.26
Identifying the factors that support students’ self-efficacy with FCC during family-centered rounds and the mechanisms through which these supporting factors act may help inform the development of FCC curricula. Guided by SCT, we hypothesized that supportive experiences including observing role models, practicing for mastery, and receiving feedback would foster medical students’ self-efficacy with FCC during rounds. We also anticipated that the effects of these supportive experiences during rounds would be mediated by medical students’ self-efficacy with key FCC tasks (relationship building, information exchange, and decision making); that is, we hypothesized that students’ self-efficacy with key FCC tasks would serve as an intermediary step between supportive experiences and students’ beliefs about their abilities to perform FCC in the clinical setting.
Study context, participants, and procedures
Over the course of 17 pediatric clerkship rotations during the 2008–2009, 2009–2010, and 2010–2011 academic years, 184 students experienced three-week blocks of inpatient care at the 88-bed, freestanding children’s hospital affiliated with a large, midwestern academic health center. At this medical center, faculty members (primarily hospitalists) round with a multidisciplinary care team at the bedside with the family in attendance unless precluded by family preference. The care team typically includes an attending, a senior resident, two interns, up to four medical students, the patient’s nurse, and other care team members as appropriate (e.g., social worker or respiratory therapist). Family-centered rounds are conducted similarly across the pediatric clerkships. Students present up to four patients under their care each day, and they never round alone. The rounds contain a presentation of the patient’s diagnosis, progress, and care plan as well as bedside teaching and the opportunity for any member of the team or family to raise questions or concerns. The institution has routinely conducted family-centered rounds since 2007. Some attending physicians, residents, nurses, and medical students have received limited formal training in FCC. The pediatric clerkship represents the only consistent opportunity for students to participate in family-centered rounds during their medical school training.
To develop measures and respond to our study’s research questions, we administered pre- and postclerkship surveys assessing the following: (1) self-efficacy with FCC during rounds in the clinical setting, (2) self-efficacy with particular FCC tasks, and (3) the supportive experiences that students participating in these rounds encountered. The paper-based questionnaires were anonymous, voluntary, and independent of evaluation. We did not offer incentives for participation, nor did we send reminders to nonresponders. Completion of the survey implied consent. The study received approval from the University of Wisconsin–Madison’s health sciences institutional review board.
To generate items for each measure, we gathered potential items from the literature, pilot tested them with third-year medical students and faculty, and iteratively revised them as appropriate. The outcome of interest was self-efficacy with FCC during rounds—that is, the student’s belief that she or he can successfully provide FCC during rounds on the pediatric inpatient service.
Recognizing that medical students in the clinical setting face many stressors that can impede self-efficacy with FCC, we developed 11 items assessing self-efficacy with FCC during rounds while under various stressors of the clinical environment. Relevant literature and interviews with medical students informed identification of these stressors.9,21–26 Examples include fatigue, morning rounds lasting until (or even through) lunch, and, as mentioned, personal problems and tensions among care team members. Students reported self-efficacy on these items using a seven-point, Likert-type scale (1 = strongly disagree; 7 = strongly agree). See Table 1 for items assessing students’ self-efficacy with FCC during rounds.
To assess students’ exposure to supportive experiences (observing role models, practicing for mastery, and receiving feedback), we either adapted items from the Cook County Inpatient Attending Evaluation27 or created items based on SCT.20 We measured all 19 items on a frequency-based, five-point scale (1 = never; 5 = always). See Table 2 for items assessing students’ exposure to supportive experiences.
To develop items to assess self-efficacy with specific FCC tasks, we began with the definition of FCC. Specifically, as mentioned, FCC is care that supports relationship building between providers and families, optimizes information sharing, and includes families in decision making so that decisions reflect their values and preferences.1,2 Thus, self-efficacy items focused on the following three specific FCC tasks during rounds: (1) building a relationship with families (four items), (2) exchanging information with families (three items), and (3) engaging families in decision making (four items). We adapted items representing these domains from either the Health Care Climate Questionnaire (HCCQ)28 or the Medical Interview Satisfaction Scale.29 See Table 3 for items assessing self-efficacy with specific FCC tasks.
In addition, all students provided information about their age (<30 versus ≥30 years), their gender and ethnicity (white, Hispanic/Latino, African American/black, American Indian/Alaskan Native, Asian/Pacific Islander, or other), and their previously completed core clerkships (psychiatry, medicine, surgery, primary care, obstetrics–gynecology).
For the descriptive analysis of participating students, we determined means with standard errors and proportions. Preclerkship survey data (see Results) informed our development and evaluation of the three scales measuring (1) self-efficacy with FCC during rounds, (2) supportive experiences, and (3) self-efficacy with FCC key tasks.
We used exploratory factor analysis to examine the underlying constructs of both self-efficacy with FCC during rounds and supportive experiences. We used confirmatory factor analysis to verify the three-factor conceptual model of self-efficacy with three key FCC tasks. We assessed factor solutions with eigenvalues followed by model fit indices using standard criteria for χ2 ratio, standardized root mean square residual (SRMR), comparative fit index (CFI), and Tucker-Lewis index (TLI).30
To ensure that measurement models derived from preclerkship responses were appropriate post clerkship, we established tau equivalence of all models from pre to post clerkship. The condition of tau equivalence requires that the measurement models determined from the preclerkship data measure the same underlying latent dimensions with the same units of measurement in the postclerkship data.31
To evaluate both (1) the relationships between supportive experiences and self-efficacy with FCC during rounds and (2) whether the association between supportive experiences and self-efficacy during rounds is mediated through self-efficacy with key FCC tasks, we used composite indicator structural equation (CISE) models (Figure 1). CISE modeling, in which the measurement error for the composite indicator is fixed based on reliability estimates, provides a valid method of addressing measurement error that arises in multiple regression.32 We present the results as path coefficients with P values where significant. Path coefficients represent the direction and magnitude of the relationships between variables. We regarded a two-tailed P < .05 as significant. We used Mplus (Version 6.1, Los Angeles, California) and STATA (SE 9, College Station, Texas) for the analyses.
Of 184 pediatric clerkship students, 172 (93%) provided preclerkship data, and 162 (88%) provided postclerkship data. Of the 172 who provided data, 91 (53%) were female, 42 (24%) were from racial/ethnic minorities, and 19 (11%) were at least 30 years of age. As would be expected of students at different points in their third year of medical school, the students’ prior clerkship experiences varied considerably: Of the 162 students who responded to the postclerkship survey, 21 (13%) had no prior clerkship experience, 26 (16%) had rotated through one clerkship, 31 (19%) had rotated through two clerkships, 26 (16%) had rotated through three, 35 (21%) had rotated through four, 10 (6%) had rotated through five, and 13 (8%) did not respond to this question. (One student reported rotating through two different numbers of clerkships.)
Validation of measures
For medical students’ self-efficacy with FCC during rounds, exploratory factor analysis of preclerkship survey items yielded a two-factor solution (eigenvalues of 6.15 and 1.00), with good model fit (χ2 ratio = 5.62, CFI = 0.96, TLI = 0.93, SRMR = 0.06). Three items loaded on Factor 1 (Cronbach α = 0.90), and eight items loaded on Factor 2 (Cronbach α = 0.86). Table 1 presents these items and factor loadings for students’ self-efficacy with FCC during rounds while under various stressors. Factor loadings indicated the extent to which the domain covaries with the indicator items; in this case, Factor 1’s indicators reflected everyday stressors that students encounter during clinical clerkships (e.g., time constraints, fatigue), whereas Factor 2’s indicators reflected situational stressors that arise either from specific events or at specific times (e.g., personal problems, detection of medical errors).
With regard to the supportive experiences, exploratory factor analysis of preclerkship survey items identified a three-factor model (eigenvalues of 10.32, 1.87, and 1.15) using 18 of the 19 indicators with good model fit (χ2 ratio = 3.23, CFI = 0.98, TLI = 0.97, SRMR = 0.05). Factor 1’s items reflected observing role models (Cronbach α = 0.92), Factor 2’s reflected practicing for mastery (Cronbach α = 0.85), and Factor 3’s reflected receiving feedback (Cronbach α = 0.92). One item (“Attending physicians gave me the opportunity to answer patient and family questions during family-centered bedside rounds”) did not load on any of the three factors, so we dropped it from all models. Table 2 presents the items and factor loadings for supportive experiences.
Indicators for self-efficacy with key FCC tasks were based on a three-factor conceptual model of FCC, so we performed confirmatory factor analysis, again using standard model fit criteria. Confirmatory factor analysis of the preclerkship survey data supported the three-factor conceptual model of key tasks self-efficacy: building a relationship with families (Cronbach α = 0.88), exchanging information with families (Cronbach α = 0.76), and engaging families in decision making (Cronbach α = 0.90). Specifically, χ2 ratio = 3.6, CFI = 0.923, TLI = 0.896, SRMR = 0.05. Table 3 presents the items and factor loadings for self-efficacy with specific FCC tasks.
Hypothesis 1: Supportive experiences foster self-efficacy with FCC during rounds
Two of the three supportive experiences (observing role models and practicing for mastery) predicted students’ self-efficacy with FCC during rounds under both everyday and situational stresses, whereas feedback had no significant influence. Specifically, the total effects revealed that observing role models (path coefficient = 0.67, P < .01) and practicing for mastery (path coefficient = 0.72, P < .01) supported self-efficacy with FCC during rounds under everyday stress. Similarly, observing role models (path coefficient = 0.55, P < .01) and practicing for mastery (path coefficient = 0.64, P < .01) supported self-efficacy with FCC during rounds under situational stress.
Hypothesis 2: Key FCC tasks mediate supportive experiences’ impact on self-efficacy with FCC during rounds
When we examined the effects of the supportive experiences to see whether they directly affected self-efficacy with FCC during rounds or operated through self-efficacy with key FCC tasks, we found that none of the supportive experiences directly influenced self-efficacy with FCC during rounds, but all operated through their effect on self-efficacy with key FCC tasks. The effects of observing role models on self-efficacy with FCC during rounds under everyday stressors were mediated by self-efficacy with two specific FCC tasks: building a relationship with families (indirect path coefficient = 0.24, P < .05) and engaging families in decision making (indirect path coefficient = 0.47, P < .01). The effects of practicing for mastery were also mediated by self-efficacy with building a relationship with families (indirect path coefficient = 0.27, P < .05) and by self-efficacy with engaging families in decision making (indirect path coefficient = 0.47, P < .01). Indirect path coefficients were products of the direct effects of (1) supportive experiences on self-efficacy with key FCC tasks and (2) self-efficacy with key FCC tasks on self-efficacy (with FCC) during rounds (Figure 1A).
With regard to self-efficacy with FCC during rounds under situational stressors, self-efficacy with relationship building mediated the positive effects of the same two supportive experiences: observing role models (indirect path regression coefficient = 0.49, P < .01) and practicing for mastery (indirect path regression coefficient = 0.55, P < .01; Figure 1B). Feedback had no significant direct or indirect effects on self-efficacy with FCC during rounds under everyday or situational stressors (Figure 1).
To facilitate the adoption of a family-centered approach to care, it is important not only to educate learners about FCC but also to bolster their self-efficacy to deliver FCC as it occurs—in the clinical setting. Our findings shed light on factors that support learner self-efficacy with FCC during rounds, highlighting the contributions of both observing role models and practicing for mastery. Our findings did not show, however, that students’ self-efficacy was related to receiving attending/resident feedback regarding their performance. Further, the effects of the supportive experiences’ on self-efficacy with FCC during rounds in the clinical setting were mediated by self-efficacy with key FCC tasks.
Students have often identified exposure to role models as critical to the development of their communication skills and their professional bedside manner, even during the preclinical curriculum.33–36 Harrell and colleagues37 have also found a strong positive relationship between the mastery opportunities afforded in hands-on clinical opportunities and students’ confidence in caring for patients. Their observation supports much of today’s movement toward simulation-based education. For example, students who had more opportunities to observe and take part in discussions with patients who received difficult news and expressed their wishes and values had a greater sense of preparedness to provide end-of-life care than did other students.38 Thus, allowing students opportunities to observe and practice FCC skills is critical to their self-efficacy with FCC, and faculty may operationalize such opportunities for students through simulation of care as it occurs in the clinical setting, which has been done for other communication skills.39–42 In addition, these supportive experiences are congruent with both the ACGME’s and the American Board of Medical Specialties’ moves toward competency-based medical education in that they are learner-centered, formative experiences that faculty do with the learners rather than to the learners.43–45
Contrary to our hypothesis that feedback has a positive influence on self-efficacy, feedback given to students about their performance during rounds did not affect their self-efficacy with FCC during rounds. Moreover, this finding is inconsistent with recent literature concerning both the role of feedback in shaping medical students’ confidence in their abilities to care for patients46,47 and the value that students place on feedback in developing their communication skills, especially at the bedside.48 At least three plausible explanations for our finding arise from the literature. First, the manner in which faculty give feedback could hinder self-efficacy.49 According to Bandura,20 feedback that is framed in terms of shortfalls is apt to weaken students’ self-efficacy by highlighting their deficiencies. Using a competency-based approach—that is, advising learners of the next steps needed to advance in their development toward competency, rather than focusing on the gap between current ability and achievement of mastery—could be a way to more positively reframe feedback on performance during family-centered rounds.
Second, the timing of the feedback may have undermined self-efficacy. One of the common concerns of trainees about family-centered rounds is being corrected in front of families.13–17 Thus, negative feedback delivered by residents or faculty during rounds may have weakened students’ self-efficacy. Third, students report that faculty members’ and residents’ expectations of them during family-centered rounds are unclear.13 In recent interviews about family-centered rounds experiences (unpublished), students noted that unclear or inconsistent expectations across attendings and residents can lead to unexpected negative feedback. One student noted, for example, how a supervisor had asked her to eliminate medical jargon while presenting during family-centered rounds, only to later receive negative feedback suggesting that she “need[s] to learn and apply the language of medicine.” Faculty (and resident) development regarding family-centered rounds might focus on helping team leaders, first, to develop and articulate a clear, uniform progression of competencies for rounds and, then, to provide private, constructive feedback based on this progression.50
The impact of supportive experiences on self-efficacy with FCC during rounds was mediated by self-efficacy with key FCC tasks. Although the supportive experiences increase students’ self-efficacy with FCC during rounds, alone they were insufficient to improve students’ self-efficacy with FCC in real-life clinical conditions (i.e., no direct influence). Strengthening self-efficacy with key FCC tasks is an important middle step. The Dreyfus model of skill acquisition suggests that learners advance through the developmental stages as they gain a sense of competence and experience, which ultimately enable them to perform tasks under varying conditions including everyday or situational stressors.51 We found that learners’ self-efficacy with FCC in the clinical setting operated through their self-efficacy with specific FCC tasks, highlighting the importance of developing basic FCC skills in students before expecting them to succeed during family-centered rounds. Students in the first and second years of medical school who are learning basic techniques for interacting with patients might benefit from an introduction to key FCC tasks, whereas students in the clinical years may benefit from opportunities to apply these skills. Such an approach would also foster the acceptance of family-centered rounds as a model for inpatient care across all physician specialties.
This study has limitations that should be considered. First, students’ reports of their experiences with family-centered rounds may be subject to recall bias and may not be reflective of actual occurrences. Data from other sources (e.g., recordings of rounding sessions or even the perceptions of families or other health care team members) could begin to validate students’ self-reports. Second, family-centered rounding is a relatively new model at our institution. Our attendings and residents have been providing family-centered rounds consistently for nearly four years, and some have received limited formal training about teaching during bedside rounds; nonetheless, students’ experiences may reflect the challenges of this new process. Still, this model is new to many institutions,52 suggesting many students may have experiences similar to those of our students. Lastly, our results may not be generalizable to other student populations, although our findings do parallel those of prior studies,33–38 and our students are similar to those of medical schools nationally.
In summary, we find that observing role models and practicing for mastery, both of which operate through self-efficacy with key FCC tasks, foster medical students’ self-efficacy with FCC during rounds. Feedback, which often supports self-efficacy and which is highly valued by learners for developing bedside techniques and for developing communication skills,48 did not foster FCC self-efficacy for these students. Educators might consider providing exposure to FCC early in medical student education and implementing faculty development sessions centered on FCC during rounds.
Acknowledgments: This work would not have been possible without the gracious participation of medical students and the support of our clerkship staff.
Funding/Support: The authors gratefully acknowledge funding from the University of Wisconsin School of Medicine and Public Health Department of Pediatrics Research and Development Fund. Dr. Cox also gratefully acknowledges the support of the Arthur Vining Davis Foundation.
Other disclosures: None.
Ethical approval: Ethical approval has been granted from the University of Wisconsin– Madison’s health sciences institutional review board for studies involving human subjects (protocol number: M-2008-1232).
1. Bird J, Cohen-Cole SA. The three-function model of the medical interview. An educational device. Adv Psychosom Med.. 1990;20:65–88
2. . Committee on Quality of Health Care in America. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century.. Washington, DC National Academy Press
3. Solberg B. Wisconsin prenatal care coordination proves its worth. Case management becomes Medicaid benefit. Inside Prev Care.. 1996;2(1):5–6
4. Ammentorp J, Mainz J, Sabroe S. Parents’ priorities and satisfaction with acute pediatric care. Arch Pediatr Adolesc Med.. 2005;159:127–131
5. O’Keefe M, Sawyer M, Roberton D. Medical student interviewing skills and mother-reported satisfaction and recall. Med Educ.. 2001;35:637–644
6. . Committee on Hospital Care, American Academy of Pediatrics. Family-centered care and the pediatrician’s role. Pediatrics.. 2003;112:691–697
7. . Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Pediatrics.. http://www.acgme.org/acWebsite/downloads/RRC_progReq/320_pediatrics_07012007.pdf
. Accessed February 15, 2012.
8. . The Joint Commission. The Joint Commission 2009 Requirements Related to the Provision of Culturally Competent Patient-Centered Care Hospital Accreditation Program (HAP).. http://www.jointcommission.org/assets/1/6/2009_CLASRelatedStandardsHAP.pdf
. Accessed February 15, 2012.
9. Rogers HD, Carline JD, Paauw DS. Examination room presentations in general internal medicine clinic: Patients’ and students’ perceptions. Acad Med.. 2003;78:945–949
10. Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus-group study of clinical teachers. Acad Med.. 2003;78:384–390
11. Janicik RW, Fletcher KE. Teaching at the bedside: A new model. Med Teach.. 2003;25:127–130
12. Janicik R, Kalet AL, Schwartz MD, Zabar S, Lipkin M. Using bedside rounds to teach communication skills in the internal medicine clerkship. Med Educ Online [serial online].. 2007;12:1–8 http://med-ed-online.net/index.php/meo/article/viewFile/4458/4638
. Accessed February 15, 2012.
13. Cox ED, Schumacher JB, Young HN, Evans MD, Moreno MA, Sigrest TD. Medical student outcomes after family-centered bedside rounds. Acad Pediatr.. 2011;11:403–408
14. Landry MA, Lafrenaye S, Roy MC, Cyr C. A randomized, controlled trial of bedside versus conference-room case presentation in a pediatric intensive care unit. Pediatrics.. 2007;120:275–280
15. Gonzalo JD, Masters PA, Simons RJ, Chuang CH. Attending rounds and bedside case presentations: Medical student and medicine resident experiences and attitudes. Teach Learn Med.. 2009;21:105–110
16. Cameron MA, Schleien CL, Morris MC. Parental presence on pediatric intensive care unit rounds. J Pediatr.. 2009;155:522–528
17. Williams KN, Ramani S, Fraser B, Orlander JD. Improving bedside teaching: Findings from a focus group study of learners. Acad Med.. 2008;83:257–264
18. Bandura A Social Foundations of Thought and Action: A Social Cognitive Theory.. Englewood Cliffs, NJ Prentice Hall
19. Bandura A. Self-efficacy mechanism in human agency. Am Psychol.. 1982;37:122–147 http://www.des.emory.edu/mfp/Bandura1982AP.pdf
. Accessed February 15, 2012.
20. Bandura A Self-Efficacy: The Exercise of Control.. New York, NY W.H. Freeman
21. Moss F, McManus IC. The anxieties of new clinical students. Med Educ.. 1992;26:17–20
22. Mosley TH Jr, Perrin SG, Neral SM, Dubbert PM, Grothues CA, Pinto BM. Stress, coping, and well-being among third-year medical students. Acad Med.. 1994;69:765–767
23. O’Brien B, Cooke M, Irby DM. Perceptions and attributions of third-year student struggles in clerkships: Do students and clerkship directors agree? Acad Med.. 2007;82:970–978
24. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med.. 2006;81:354–373
25. Wiggleton C, Petrusa E, Loomis K, et al. Medical students’ experiences of moral distress: Development of a Web-based survey. Acad Med.. 2010;85:111–117
26. Bombeke K, Symons L, Debaene L, De Winter B, Schol S, Van Royen P. Help, I’m losing patient-centredness! Experiences of medical students and their teachers. Med Educ.. 2010;44:662–673
27. Smith CA, Varkey AB, Evans AT, Reilly BM. Evaluating the performance of inpatient attending physicians: A new instrument for today’s teaching hospitals. J Gen Intern Med.. 2004;19:766–771
28. Williams GC, Grow VM, Freedman ZR, Ryan RM, Deci EL. Motivational predictors of weight loss and weight-loss maintenance. J Pers Soc Psychol.. 1996;70:115–126
29. Wolf MH, Putnam SM, James SA, Stiles WB. The Medical Interview Satisfaction Scale: Development of a scale to measure patient perceptions of physician behavior. J Behav Med.. 1978;1:391–401
30. Hu L, Bentler PM. Fit indices in covariance structure modeling: Sensitivity to underparameterized model misspecification. Psychol Methods.. 1998;3:424–453
31. Raykov T. Behavioral scale reliability and measurement invariance evaluation using latent variable modeling. Behav Ther.. 2004;35:299–331
32. McDonald RA, Behson SJ, Seifert CF. Strategies for dealing with measurement error in multiple regression. J Acad Bus Econ.. 2005;5:80–97
33. Weissmann PF, Branch WT, Gracey CF, Haidet P, Frankel RM. Role modeling humanistic behavior: Learning bedside manner from the experts. Acad Med.. 2006;81:661–667
34. Baernstein A, Oelschlager AM, Chang TA, Wenrich MD. Learning professionalism: Perspectives of preclinical medical students. Acad Med.. 2009;84:574–581
35. White CB, Kumagai AK, Ross PT, Fantone JC. A qualitative exploration of how the conflict between the formal and informal curriculum influences student values and behaviors. Acad Med.. 2009;84:597–603
36. Murinson BB, Klick B, Haythornthwaite JA, Shochet R, Levine RB, Wright SM. Formative experiences of emerging physicians: Gauging the impact of events that occur during medical school. Acad Med.. 2010;85:1331–1337
37. Harrell PL, Kearl GW, Reed EL, Grigsby DG, Caudill TS. Medical students’ confidence and the characteristics of their clinical experiences in a primary care clerkship. Acad Med.. 1993;68:577–579
38. Billings ME, Engelberg R, Curtis JR, Block S, Sullivan AM. Determinants of medical students’ perceived preparation to perform end-of-life care, quality of end-of-life care education, and attitudes toward end-of-life care. J Palliat Med.. 2010;13:319–326
39. Losh DP, Mauksch LB, Arnold RW, et al. Teaching inpatient communication skills to medical students: An innovative strategy. Acad Med.. 2005;80:118–124
40. Bokken L, Rethans JJ, Jöbsis Q, Duvivier R, Scherpbier A, van der Vleuten C. Instructiveness of real patients and simulated patients in undergraduate medical education: A randomized experiment. Acad Med.. 2010;85:148–154
41. Bokken L, Rethans JJ, van Heurn L, Duvivier R, Scherpbier A, van der Vleuten C. Students’ views on the use of real patients and simulated patients in undergraduate medical education. Acad Med.. 2009;84:958–963
42. Kneebone R, Nestel D, Wetzel C, et al. The human face of simulation: Patient-focused simulation training. Acad Med.. 2006;81:919–924
43. Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: From Flexner to competencies. Acad Med.. 2002;77:361–367
44. Hicks PJ, England R, Schumacher DJ, et al. Pediatrics milestone project: Next steps toward meaningful outcomes assessment. J Grad Med Educ.. 2010;2:577–584
45. Carraccio C, Burke AE. Beyond competencies and milestones: Adding meaning through context. J Grad Med Educ.. 2010;2:419–422
46. Hobgood CD, Tamayo-Sarver JH, Hollar DW Jr, Sawning S. Griev_Ing: Death notification skills and applications for fourth-year medical students. Teach Learn Med.. 2009;21:207–219
47. Chen W, Liao SC, Tsai CH, Huang CC, Lin CC, Tsai CH. Clinical skills in final-year medical students: The relationship between self-reported confidence and direct observation by faculty or residents. Ann Acad Med Singapore.. 2008;37:3–8
48. Torre DM, Simpson D, Sebastian JL, Elnicki DM. Learning/feedback activities and high-quality teaching: Perceptions of third-year medical students during an inpatient rotation. Acad Med.. 2005;80:950–954
49. Teunissen PW, Stapel DA, van der Vleuten C, Scherpbier A, Boor K, Scheele F. Who wants feedback? An investigation of the variables influencing residents’ feedback-seeking behavior in relation to night shifts. Acad Med.. 2009;84:910–917
50. Gigante J, Dell M, Sharkey A. Getting beyond “Good job”: How to give effective feedback. Pediatrics.. 2011;127:205–207
51. Dreyfus HL, Dreyfus SE Mind Over Machine: The Power of Human Intuition and Expertise in the Era of the Computer.. New York, NY Free Press
52. Muething SE, Kotagal UR, Schoettker PJ, Gonzalez del Rey J, DeWitt TG. Family-centered bedside rounds: A new approach to patient care and teaching. Pediatrics.. 2007;119:829–832
53. Association of American Medical Colleges.. Table 6: Age of applicants to U.S. medical schools at anticipated matriculation by sex and race and ethnicity. https://www.aamc.org/download/159350/data/table6.pdf
. Accessed February 15, 2012.
54. Association of American Medical Colleges.. Table 29: Total U.S. medical school graduates by race and ethnicity within sex, 2002–2011. https://www.aamc.org/download/147312/data/table29-gradsraceeth0211.pdf
. Accessed April 25, 2012.