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Journal of Medical Education Research

The Journal of Medical Education Research is an open access journal publishing research articles in relation to the training of healthcare professionals, in particular in undergraduate education. 

Publ. by the University of Buckingham Press

About the Journal

The  Journal of Medical Education Research  is an open access journal publishing original peer-reviewed research articles in relation to the training of healthcare professionals, in particular in undergraduate education.  While it is based at Buckingham, it draws from academic authors beyond its borders who have an established track record in their field.  The journal has a special focus on curriculum (design and implementation), evaluation, assessments, professionalism, and evidence-based medicine.  It is published annually, and the first Issue of  Journal of Medical Education Research  is focused on technology enhanced innovations in curriculum-design and delivery.

The University of Buckingham Medical School (UBMS) is one of the newer schools in the United Kingdom and the first independent not-for-profit medical school.  It offers a 4.5-year course versus the usual 5-year MBChB course and there is a resonance with innovation and fresh thinking at its core. This journal is a further manifestation of this, as we seek to showcase ideas and concepts and not simply become an organ of academic activity.  All articles published by the  Journal of Medical Education Research  will be made freely accessible online immediately upon publication without subscription charges.

Journal of Medical Education Research  accepts the following types of article:

• Research Articles

Commentaries

• Watch this space

Letters to the Editor

Please note that this journal only publishes manuscripts in English.

Preparing Your Paper

Research articles :

• Should be around 2500-5000 words, written with the following elements in this order: title page, abstract, key words, main text-introduction, methods, results, discussion, conclusion, acknowledgement, declaration of interest statement, references, tables with caption (on individual pages), figures with caption (on individual pages)
• Should contain a structured abstract of 300 words
• Should contain between 5 and 10 keywords

For further details  click  here

• Commentaries should be around 1500-2000 words and discuss findings, implications, and research on a specific topic. They are short, focused comments either on articles recently published in the journal, or trends within its field. Commentaries offer author’s original ideas or personal experience on a current hot topic or elaborate on a widely researched subject.  A current hot topic may be on a subject that is important or one that challenges the current zeitgeist.

Watch This Space

• The Journal accepts short papers, not exceeding 1,500 words with one table or figure, primarily for the purpose of publishing early important results or innovations within curriculum design and delivery, to begin the exchange of educational ideas within the Medical Education community.
• All articles should document some form of evaluation or planned evaluation of the innovation/educational research.
• The article should be written with the following elements: What We Did, How We Did It, What We have Learned, Take Home Points.
• Should contain a structured abstract of 150 words.
• Should contain between 5 and 10 keywords.
• Letters to the Editor will be a brief communication on a topic relevant to the journals should be concise pieces of no more than 800 words and not include original research, tables, or figures.
• Due to the volume of letters submitted to the editors it is not always possible to provide feedback on every submission.

Peer Review Process

Each article is peer reviewed. Initially the articles are reviewed by the editor and their assistant editors. The Journal of Medical Education Research has an editorial board, and its members cover a wide range of disciplines within the educational field. All the members of the board have an established track record in academic publication.

Once articles are accepted to peer-review they are then sent to selected peer reviewers. Each article is peer reviewed by at least two reviewers and each reviewer will submit their review including comments and a recommendation when to accept for publication, reject or to request revisions to the articles.

The process for Peer Review is as follows:

1. Submission of Paper

The corresponding or submitting author submits the paper to the journal. In virtually all cases this should be via our online platform.

2. Editorial Office Assessment

The editorial team checks the paper’s composition and arrangement against the journal’s Author Guidelines to make sure it includes the required sections and stylizations. The quality of the paper is not assessed at this point.

3. Appraisal by the Editor

The lead Editor checks that the paper is appropriate for the journal and is sufficiently original and interesting. If not, the paper may be rejected without being reviewed any further.

4. Editor Assigns an Associate Editor

Most Issues of JMER have Associate Editors who handle the peer review. If they do, they would be assigned at this stage.

5. Invitation to Reviewers

The handling editor sends invitations to individuals they believe would be appropriate reviewers. As responses are received, further invitations are issued, if necessary, until the minimum number of two reviewers per article is confirmed.

6. Response to Invitations

Potential reviewers consider the invitation against their own expertise, conflicts of interest and availability. They then accept or decline. If possible, when declining, they might also suggest alternative reviewers.

7. Review is Conducted

The reviewer sets time aside to read the paper several times. The first read is used to form an initial impression of the work. If major problems are found at this stage, the reviewer may feel comfortable rejecting the paper without further work. Otherwise they will read the paper several more times, taking notes so as to build a detailed point-by-point review. The review is then submitted to the journal, with a recommendation to accept or reject it – or else with a request for revision (usually flagged as either major or minor) before it is reconsidered.

8. Journal Evaluates the Reviews

The handling editor considers all the returned reviews before making an overall decision. If the reviews differ widely, the editor may invite an additional reviewer so as to get an extra opinion before making a decision.

9. The Decision is Communicated

The author receives a decision email including any relevant reviewer comments. As JMER operates a blind review process the author will not see the personal details of the reviewer.

10. Next Steps

If accepted, the paper is sent to production. If the article is rejected or sent back for either major or minor revision, the handling editor should include constructive comments from the reviewers to help the author improve the article. If the paper was sent back for revision, the reviewers should expect to receive a new version, unless they have opted out of further participation. However, where only minor changes were requested this follow-up review might be done by the handling editor.

Open Access Policy

This journal provides immediate gold open access under a CC-BY-NC licence to its content on the principle that making research freely available to the public supports a greater global exchange of knowledge.

Author Publication Charges

There are no charges for authors to publish their work in the journal.

Self-Archiving and Institutional Repositories

UBP offers a publishing model that enables wide access to academic research, global readership for our authors and ensures the long-term preservation of published content. As a result, we permit authors to archive their contributions to this Journal. This can be either via authors' own websites, or via their institution’s or funding body’s online repository or archive

In addition, all published articles are archived by UBP at a number of repositories including LOCKSS, CLOCKSS, PKP and The British Library.

Content is available on Open Access basis under the following license: CC Attribution-NonCommercial 4.0 (for more information visit: https://creativecommons.org/licenses/by-nc/4.0/)

Submission Preparation Checklist

As part of the submission process, authors are required to check off their submission's compliance with all of the following items, and submissions may be returned to authors that do not adhere to these guidelines..

•  The submission has not been previously published, nor is it before another journal for consideration (or an explanation has been provided in Comments to the Editor).
•  The submission file is in OpenOffice, Microsoft Word, or RTF document file format.
•  Where available, URLs for the references have been provided.
•  The text is single-spaced; uses a 12-point font; employs italics, rather than underlining (except with URL addresses); and all illustrations, figures, and tables are placed within the text at the appropriate points, rather than at the end.
•  The text adheres to the stylistic and bibliographic requirements outlined in the Author Guidelines.

Author Guidelines

We request the following information for research articles. 

Title page - The first page of the manuscript should contain the following information:

• The title of the paper
• A short title not exceeding 50 characters for use as a running head
• Names of authors
• Names of institutions at which the research was conducted
• Name, address, telephone number and email address of the corresponding author.

The abstract should not exceed 300 words.  The abstract must include the following sections:

• Introduction -  the context and purpose of the study
• Methods-  how the study was performed, and statistical tests used
• Results-  the main findings
• Conclusions-  brief summary and implications
• Keywords-  five to ten key words

Introduction

The background section should provide a background to the study, a summary of existing literature and the aims of the study

The methods section should include the aims, setting and design of the study

Characteristics of participants

Clear description of process and any interventions

This section should include the findings of the study, including appropriate results of statistical analyses, which must be included in text or as tables and figures.

This section should discuss the implications of the findings in the context of existing research and highlight any limitations of the study.

Conclusions

This section should report the main conclusions, provide an explanation of importance and relevance of the study provided.

Notes on contributors

Declarations

All manuscripts must have the following:

• Ethics and consent to participate
• Competing interest

Journal of Medical Education Research  requires all authors to declare all competing interests in relation to their work.  All submitted manuscripts must include a ‘competing interests’ section at the end of the manuscript listing all competing interests.  Where authors have no competing interests, the statement should read- ‘The authors declare that they have no competing interests.’

• Authors contributions
• Acknowledgements

Journal of Medical Education Research uses Harvard reference style for its publications.

Reference Examples

Family name, INITIAL(S). Year. Title. Edition (if not first edition). Place of publication: Publisher.

Salway, J.G. 2016.  Metabolism at a glance . 4th ed. Chichester: Wiley- Blackwell.

If you are referencing a book with an editor rather than an author, this should be indicated in the reference.

Family name, INITIAL(S) (of editor). ed(s). Year. Title. Edition (if not first edition). Place of publication: Publisher.

Herrington, C.S. ed. 2014.  Muir’s textbook of pathology . 15th ed. Boca Raton: Taylor Francis

Chapter in a book

If you are referencing a book with chapters written by different authors, you need to give details of the chapter, and the book in which you read it.

Family name, INITIAL(S). Year. Chapter title. In: Family name, INITIAL(S) (of editor). ed(s). Title of book. Edition (if not first edition). Place of publication: Publisher, page numbers.

e-book online

Family name, INITIAL(S). Year. Title. [Online]. Edition (if not first edition). Place of publication: Publisher. [Date accessed]. Available from: URL

Ng, R. (2015).  Drugs: from discovery to approval  [Online]. 3rd ed. Hoboken: Wiley-Blackwell. [Accessed 18 June 2018]. Available from:  https://www.dawsonera.com/abstract/9781118907221

Journal Article

Family name, INITIAL(S). Year. Title of article. Journal Title.  Volume  (issue number), page numbers.

Corcoran, N. 2018 Exploring International Students' Food Choices Using Photovoice Techniques.   Journal of International Students  8 (1), pp175-193.

Two authors

Family name, INITIAL(S) and Family name, INITIAL(S). Year. Title of article. Journal Title.  Volume  (issue number), page numbers.

Lindberg, C. and Oldfors, A. 2012 Prognosis and prognostic factors in sporadic inclusion body myositis Acta Neurologica Scandinavica 125, pp.353–358.

More than two authors

Family name, INITIAL(S), Family name, INITIAL(S), Family name, INITIAL(S) and Family name, INITIAL(S). Year. Title of article. Journal Title. Volume (issue number), page numbers.

Cochrane Review

Family name, INITIAL(S), Family name, INITIAL(S) and Family name, INITIAL(S). Year. Title of article. Cochrane Database of Systematic Reviews. [Online]. Issue number, article number. [Date accessed]. Available from: URL

Fisher C.A., Hetrick, S.E. and Rushford, N. (2010). Family therapy for anorexia nervosa. Cochrane Database of Systematic Reviews. [Online]. Issue 6, Art. No.: CD004780. [Accessed June 22 2018]. Available from: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD004780.pub2/full 

Family name, INITIAL(S) (or company name). Year. Title. [Online]. [Date accessed]. Available from: URL

Arthritis Foundation [no date] What is Osteoarthritis? [Online]. [Accessed 25 June 2018]. Available at:  https://www.arthritis.org/about-arthritis/types/osteoarthritis/what-is-osteoarthritis.php

Newspaper article

Family name, INITIAL(S). Year. Title of article. Newspaper title. Date, page number(s).

Bee, P. 2018. Could stinging nettles cure hay fever? The Times. 26 June, pp. 6-7.

Newspaper article (online)

Family name, INITIAL(S). Year. Title of article. Newspaper title. [Online]. Date. [Date accessed]. Available from: URL

Phillips, D. 2018. 'There are a lot of unknowns': British scientists set to work on Zika vaccine. The Guardian [Online]. 9 March [Accessed 26 June]. Available from:  https://www.theguardian.com/global-development/2018/mar/09/british-scientists-work-on-zika-vaccine-brazil-recife-birth-defects

Family name, INITIAL(S) (or company name). Year.  Title . [Leaflet]. Place of publication: Publisher.

For informal publications, such as leaflets, provide what details you can:

Cancer Research UK. 2003.  Skin cancer: how to be sunsmart and reduce your risk . [Leaflet]. London: Cancer Research UK.

For more examples of references covering different types of source see any of the books referenced in the bibliography below.

Neville, C. (2007) The Complete Guide to Referencing and Avoiding Plagiarism. London: Open University Press.

Pears, R. and Shields, G. (2016) Cite Them Right: The Essential Referencing Guide. 10th ed. London: Palgrave MacMillan.

Williams, K. and Carroll, J. (2009) Referencing and Understanding Plagiarism. London: Palgrave MacMillan.

Like all academic journals, we take plagiarism extremely seriously. We reserve the right to and routinely check articles using appropriate software. If there is a cause for concern the editor will arrange to discuss the potential problem with the contributor. We are happy to consider articles which have been submitted to other journals with the relevant permissions and attribution and the intellectual property rights of the submitted text remains with the author.

Copyright Notice

Articles are published online within Gold Open Access under a CC-BY-NC licence.

Authors retain copyright and full publishing rights for their written text.

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Information

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Editorial Team

Chief Editor:

Dr Bharathy Kumaravel

Editorial team:

Prof Joanne Harris Dr Andy McKeown Dr Andrew Thompsett Dr Emma Spikings Andrea Petrella Suhaib Abdurrezag Ghula Prof Oliver Pearce Dr Varadarajan Baskar

Privacy Statement

The names and email addresses entered in this journal site will be used exclusively for the stated purposes of this journal and will not be made available for any other purpose or to any other party.

c/o University of Buckingham Press 51 Gower Street London WC1E 6HJ

Principal Contact

Bharathy Kumaravel

[email protected]

Support Contact

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Latest Articles 16

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JMIR Medical Education

Technology, innovation, and openness in medical education in the information age..

Blake J. Lesselroth, MD MBI FACP FAMIA, University of Oklahoma | OU-Tulsa Schusterman Center; University of Victoria, British Columbia

JMIR Medical Education (JME, ISSN 2369-3762) is an open access, PubMed-indexed, peer-reviewed journal focusing on technology, innovation, and openness in medical education.This includes e-learning and virtual training, which has gained critical relevance in the (post-)COVID world. Another focus is on how to train health professionals to use digital tools. We publish original research, reviews, viewpoint, and policy papers on innovation and technology in medical education. As an open access journal, we have a special interest in open and free tools and digital learning objects for medical education and urge authors to make their tools and learning objects freely available (we may also publish them as a Multimedia Appendix). We also invite submissions of non-conventional articles (e.g., open medical education material and software resources that are not yet evaluated but free for others to use/implement). 

In our " Students' Corner ," we invite students and trainees from various health professions to submit short essays and viewpoints on all aspects of medical education, particularly suggestions on improving medical education and suggestions for new technologies, applications, and approaches. 

In 2024, JMIR Medical Education received a  Journal Impact Factor™ of 3.2  (Source: Journal Citation Reports™ from Clarivate, 2024). The journal is indexed in MEDLINE ,  PubMed , PubMed Central , Scopus , DOAJ , and the  Emerging Sources Citation Index (Clarivate) .  JMIR Medical Education received a CiteScore of 6.9, placing it in the 91st percentile (#137 of 1543) as a Q1 journal in the field of Education.

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Healthcare delivery is undergoing an accelerated period of digital transformation, spurred in-part by the COVID-19 pandemic and the use of “virtual-first” care delivery models like telemedicine. Medical education has responded to this shift with calls for improved digital health training, but there is as yet no universal understanding of needed competencies, domains, and best practices for teaching these skills. In this paper, we argue that a “digital determinants of health” (DDoH) framework for understanding intersections of health outcomes, technology, and training is critical to the development of comprehensive digital health competencies in medical education. Much like current social determinants of health models, the DDoH framework can be integrated into undergraduate, graduate, and professional education to guide training interventions as well as competency development and evaluation. We provide possible approaches to integrating this framework into training programs and explore priorities for future research in digitally-competent medical education.

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September 06, 2024 - November 01, 2024

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Explore JAMA Network Open’s Medical Education collection, including open access science about new educational approaches and technologies, work duty hours, and more.

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The Graduate Medical Education Research Journal (GMERJ) is a journal available in print and online. It provides a platform for residents and fellows to publish peer-reviewed, high quality scholarly work. GMERJ is affiliated with the Office of Graduate Medical Education at the University of Nebraska Medical Center and supports its mission to, “lead the world in transforming lives to create a healthy future for all individuals and communities through premier educational programs, innovative research, and extraordinary patient care.”

Current Issue: Volume 6, Issue 1 (2024)

Original reports.

Barriers to Education: Limited Accessibility of Study Material Used During Facial Plastic & Reconstructive Surgery Fellowship Training Kieran Boochoon, Andrew Yousef, and Deborah Watson

Trends, Predictors, and Outcomes of Hepatic Encephalopathy Treatment at a Quaternary Transplant Center From 2012-2022 Patrick Twohig, Thoetchai Peeraphatdit, Kaeli Samson, Makayla Schissel, Lynette M. Smith, Kyaw Min Tun, Ellen Tan, Kyle Scholten, Jason Barbaretta, Kevin Brittan, and Timothy McCashland

Impact of Frailty on Patient Morbidity and Outcomes Following Surgery for Urolithiasis: A NSQIP Analysis David Fu, Kaeli Samson, Bryant Van Leeuwen, Andrew J. Blazek, and Andrew Christiansen

Case Reports

Management of Variceal Hemorrhage From Extensive Portal Vein Tumor Thrombus in Hepatocellular Carcinoma and Untreated Pheochromocytoma: A Case Report Patrick Twohig, Kishan Patel, Tomoki Sempokuya, Chijoke Enweluzo, Lyudmila Muinov, and Ishfaq Bhat

Development of Takotsubo Cardiomyopathy in 46-Year-Old With Refractory Crohn's Disease Margarita Pipinos, Andrea Klooz, Maria E. Tecos, and Andrew Kamien

Breathless Laughter: Tackling Tussive Syncope in the Shadows of Obstructive Sleep Apnea Milan Terzic and Yash B. Patel

Cerebellopontine Angle Meningioma Mimicking Acute Stroke Milan Terzic and Yash B. Patel

Perspective/Commentary

Residency – A Box of Crayons Vicki Hamm

Creative Works

A Sunday Drive Grayson Huben

Zion Reflections Arthur S. Lanoux-Nguyen

Conference Proceedings

NextSTAT: A Low-Cost Lot Based Paging Solution to Request Urgent Help in the or Using Amazon AWS Cloud Nathan Goergen

A Novel, In-House, Rapid Response Solution to a Critical Supply Crisis Affecting Hyperbaric Oxygen Therapy Centers Nationwide Nathan Goergen

High-Dose Reirradiation for Recurrent High-Grade Glioma Kurtis Johnson

Jenkins: An Anesthesia Intra-Op Voice Assistant to Improve Patient Outcomes and Situational Awareness in the OR Nathan Goergen

Community Hospital Psychiatric Length of Stay Compared to Academic Center Psychiatric Length of Stay John Derr

Assessing the Accuracy of Weights With Stretcher Scales: A Novel Approach to Patient Safety Elizabeth Reiche

Iron Deficiency Anemia in Children With Short Bowel Syndrome Rasheedat Yetunde Fawole

A Case of Radiation Recall Dermatitis From Zanubrutinib Taylor Thieman

JEDI With Jasmine: Developing and Assessing a GME Curriculum on Justice, Equity, Diversity, and Inclusion Sandra Frimpong

Parasite Sufficiency Anemia – A Mysterious Cause of Iron Deficiency Anemia Garima Bhandari

A Race Against Time: The Importance of Early Surgical Intervention in Patients With Mycotic Aortic Aneurysms Chydubem Nwaiwu

Suddenly Stuck: A Classic Case of Thyrotoxicosis Periodic Paralysis Kelsey Fillman

Comparison of Injuries Sustained on Grass and Artificial Turf by USL1 Men’s Soccer Team. Part 1: Match Related Injuries Michael Osterholt

Comparison of Injuries Sustained on Grass and Artificial Turf by USL1 Men’s Soccer Team. Part 2: Total Athlete Exposure Michael Osterholt

More Than a Sore Throat; A Case of Group A Strep Meningitis Stacie Lackner

Hypertriglyceridemia Induced Acute Pancreatitis: A Case Report Michael Turco

Beware the Runny Nose – Could Be CSF Leak! Rubab Ali

Diabetes and Claudication: Reduced Pain Perception; Worse Walking Impairment and Quality of Life Ali Hakim

Length and Proximal Extent of Occlusion Dictates Severity of Disease in a Mini-Swine Model of Peripheral Artery Disease Ali Hakim

Resident Perceptions of a Residents as Teachers Curriculum: A Qualitative Assessment Kelsey Tieken

Adipose-Derived Mesenchymal Stem-Cell Therapy Improves Arteriogenesis, Hemodynamics, and Walking Performance in a Porcine Model of Peripheral Artery Disease Ali Hakim

Student, Resident, and Faculty Perceptions on Providing Excellent Surgical Education: A Qualitative Analysis Kelsey Tieken

Impact of Speed of Seizure Spread on IQ and Post-operative Seizure Freedom in Refractory Epilepsy Isha Snehal

Pregnancy and Motherhood in Neurosurgery Residency Training and Beyond Elhaum Rezaii

Quality Improvement – Optimizing Dermatology Post-discharge Care: Evaluating an EHR Intervention in Dermatology Post-discharge Follow-up Alfred Siller

Racial and Ethnic Differences in Time to Definitive Surgery for Melanoma: A Retrospective Study From the National Cancer Database Jennifer Fernandez

Impact of a Pediatric Dermatologist on Resident Education: An Evaluation of Dermatology Resident Case Logs Before and After Hiring a Pediatric Dermatologist Allison Lloyd-McLennan

Pediatric Melanoma Survival Is More Favorable in Females, a Retrospective Cohort Study of the National Childhood Cancer Registry From 1997 – 2020 Divya Sharma

The Use of Virtual Reality to Reduce Anxiety and Pain in Pediatric Dermatologic Outpatient Procedures Erica Lee

Lyme Disease and Climate Change: The Clock Is Ticking Divya Sharma

Lead Me to Lead Screening: Improving Lead Screening Rates at Urban, High-Risk Family Medicine Clinic Taylor Defreece

AI for A Eye: Implementing Point-Of-Care Artificial Intelligence Retinal Screening in a Resident Clinic Cody Masters

Effect of Advanced Patient Scheduling on Patient- And Resident-Continuity Michael Schulte

Paternity Matters: Does Paternal Involvement Have an Effect on Prenatal Care? Jacob Vasa

Risk of Coronary Artery Calcification Due to Sarcopenia: A Meta-Analysis Advait Vasavada

Vitamin D Deficiency in Patients With Symptoms of Depression Anyun Ma

Establishing the Problem: Identifying Barriers to Workflow Among Internal Medicine Resident Physicians Within the VA Medical Center Joshua Warner

Prosthetic Valve Endocarditis With Cardiobacterium Hominis: A Case Report Kaci Griffin

Report Study – A Comparison of Self-Reported Alcohol Intake Compared to Phosphatidylethanol Value as a Predictor for Return to Alcohol Use Kevin Brittan

Outcome of Organ Procurement and Transplantation Network Policy Allowing for Waiting Time Modification for Candidates Affected by Race-Inclusive eGFR Calculations Debra Wekesa

Needs Assessment of Internal Medicine Learners in Hospital Medicine Competencies Matthew Kretschmar

Between the Aorta and Superior Mesenteric Artery: A Tale of Duodenal Compression Alexandra Fiedler

A Paralyzing Consequence: Succinylcholine-Induced Hyperkalemia, a Rare but Dangerous Side Effect Hannah Kruger

Systemic Sclerosis Masquerading as Superior Mesenteric Artery Syndrome Alexandra Fiedler

Robotic Assisted Bronchoscopy: An Institutional Correlation Between Cytopathology and Surgical Resection Diagnoses Thomas Auen

Clinicopathologic and Molecular Characterization of Conjunctival Melanoma in a Multi-Institutional Study Rebecca Manzo

Effect of Biallelic TP53 Mutations in Changing the Subclassification of Myelodysplastic Neoplasm Ketav Desai

Credit or Debit? Comparison of Local Prices for Common Gastroenterology Procedures Kyle Scholten

The GIPP Never Lies: A Case of Refractory Ulcerative Colitis Kyle Scholten

Exploring the Efficacy of Pulmonary Artery Pressure Monitoring in Rural LVAD Patients: A Retrospective Cohort Study on Clinical Outcomes Landon Withrow

Looking at ANCA Vasculitis Saher Aslam

Acute Gastroparesis Following Atrial Fibrillation Ablation Mitch Sand

When Inflammatory Arthritis Gets Rash, Consider PsAPASH Morgan Newlun

Follicular Mucinosis and Cutaneous T-Cell Lymphoma Association: A Clinicopathologic and Molecular Analysis of 19 Cases Ahmad Alshomrani

Challenges and Improvements of Vitreous Fluid Processing Protocol in the Diagnosis of Intraocular Lymphomas: A 13-Year Institutional Review Jordan Burr

Extranodal Follicular Dendritic Cell Sarcoma: Clinicopathologic and Immunohistochemical Profile of a Rare Sarcoma Ahmad Alshomrani

Autoimmune Hemolytic Anemia in the Setting of Hemophagocytic Lymphohistiocytosis (HLH) Jonathan Nilles

MALDI-TOF Mass Spectrometry Used in Diagnosis of Nocardiosis in a Patient With a Renal Transplant Nathaniel Leonardi

Lenvatinib-Induced Cryoglobulinemic Glomerulonephritis: It is Never Too Late Divya Sood

When Rare Things Return: A Case of Late, Indolent, Post Transplant Recurrent Collagenofibrotic Glomerulopathy Divya Sood

Schisto-What? A Classic Case of Nephrotic Syndrome With an Unclassic Pathogen Kyle Scholten

Cost-Effectiveness Modeling of the Use of Chlorhexidine Gluconate Irrigation Solution to Prevent Postoperative Infection in Inflatable Penile Prosthesis Alan Quach

Suprachoroidal Triamcinolone for the Treatment of Refractory Macular Edema Secondary to Noninfectious Uveitis Marc Ohlhausen

Changes in Anterior Tibial Translation Are Not Associated With Degradation in Weightbearing Cartilage of the Knee Following Anterior Cruciate Ligament Reconstruction Tyler Kallman

Collaboration Between Orthopedic Surgery and Psychiatry Residency Programs to Improve Education About Orthopaedic Pain Management for Patients With Mental Illness Keagan Gertz

Obstetrics and Gynecology Subspecialty Faculty: A Workforce Analysis Morgan Steffen

Ballistic Periprosthetic Fracture: An Unusual Indication for Revision Total Knee Arthroplasty Timothy Lackner

Not All Anemias in Training Room Need Iron Replacement Spencer Cooper

Hypotension and Arrhythmia Due to Cariprazine, Olanzapine and Metoprolol Madeline Trout-Smith

Risk Factors to Consider When Working Up Shortness of Breath in the Outpatient Setting Daniel Alekyan

Cholestatic Drug Induced Liver Injury From Rad-140 Successfully Treated With Corticosteroids Bilal Niazi

A Single-Center Retrospective Study to Compare Trending of Serum Lipase With Clinical Outcomes in Hospitalized Children With Acute Pancreatitis Sandeep Puri

Livedoid Vasculopathy-Induced Peripheral Neuropathy Treated Successfully With Aspirin, Rivaroxaban, and Pentoxifylline Kevin Kwan

Widespread Primary Nodular Cutaneous Amyloidosis Due to Local Plasmacytomas Robert Borucki

The Optimized Parameters of Red Blood Cell Exchange by Apheresis in Transfusion-Dependent Thalassemia, a Small Case Series Kristina Sevcik

Quality Improvement: Reduce Trending of Serum Lipase in Pediatric Acute Pancreatitis Patients Sandeep Puri

Is Medication Management in the First 28 Days of Life Associated With Acute Kidney Injury in Extremely Low Birthweight Neonates? Shannon Haines

Right-Sided Horner's Syndrome as a Complication of Vascular Ring Repair Jaikaran Man Singh

Two True and Unrelated: Inpatient Evaluation for Severe Thrombocytopenia Audrey Lane

Neonatal Pasteurella Multocida Meningitis Lauren Glasner

Plantar Grasp Sign as a Screening Tool for Orthostatic Tremor (OT) Vekash Raja

Application of the Karnofsky Performance Scale (KPS) in Inpatient Cancer Rehabilitation Justin Comer

Paraplegia Following an Intrathecal Hydromorphone and Bupivacaine Pump Removal Joseph Fike

Focal Cerebral Arteriopathy of Childhood and Trisomy 21 Salman Assad

Rural Residency Rotations Effect on Future Emergency Physician Employment, Perspective From an Academic Emergency Medicine Residency 2007-2022 Ty Anderson

Intimate Partner Violence (IPV) Education for Medical Students and the Effect This Has on Comfort Caring for IPV Patients in Future Clinical Practice — A Medical Student Survey Morgan McKinney

Sometimes Belly Pain Isn’t as It Seems: An Unusual Presentation of SBP Kate Dusseault

Mandibular Reconstruction Using Custom TMJ Concepts Prosthesis After Resection of Conventional Ameloblastoma From Left Mandible: A Case Report Vivek Sharma

Use of Patient Specific (Custom) Plating in Complex Craniomaxillofacial Trauma Revision Surgery Chad Sloan

Bilateral Submandibular Gland Atrophy Secondary to Chronic Sialolithiasis Samuel Storey

The Role of Intraoperative Computed Tomography Scanning in Facial Reconstructive Surgery Steven Santarossa

Incompatible Batteries With Potential Hazard in MRI Environment Patrick Barone

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Back to Journals » Advances in Medical Education and Practice

Advances in Medical Education and Practice

Issn: 1179-7258.

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Editor-in-Chief: Dr Anwarul Azim Majumder

Advances in Medical Education and Practice is an international, peer reviewed, open access journal that aims to present and publish research on Medical Education.

The journal covers a broad range of fields including medical, dental, nursing, allied health care, professional education and focuses on undergraduate education, postgraduate training, and continuing medical education.

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Latest articles:

- 5 records -

Incorporating Technology Adoption in Medical Education: A Qualitative Study of Medical Students’ Perspectives [Letter]

Ali ME, Pandit M, Ali MM

Advances in Medical Education and Practice 2024 , 15:835-836

Published Date: 13 September 2024

Development, Implementation, and Assessment of an Online Modular Telehealth Curriculum for Health Professions Students [Letter]

Qureshi MH, Brewis A, Gopalamurugan S

Advances in Medical Education and Practice 2024 , 15:833-834

Published Date: 12 September 2024

Competency of Nurses on Electrocardiogram Monitoring and Interpretation in Selected Hospitals of Al-Ahsa, Saudi Arabia

Advances in Medical Education and Practice 2024 , 15:823-832

Published Date: 11 September 2024

Response to “Social Media Usage and Academic Performance Among Medical Students in Medina, Saudi Arabia” [Letter]

Belal I, Hassam S, Mirza A

Advances in Medical Education and Practice 2024 , 15:821-822

Pre-Admission Standardized Tests and the Relationship with Anesthesiologist Assistant Student Performance: A Retrospective Analysis

Monroe KS, Amerson L, Bundy W, Greene Y, Jarvis G, Stever J, Patel GP

Advances in Medical Education and Practice 2024 , 15:815-819

Published Date: 9 September 2024

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• Published: 13 September 2024

Changes in medical students’ research-related perceptions through student-engaged medical research curriculum experience

• Seong Ju Jeon   ORCID: orcid.org/0000-0002-1593-8224 1 &
• Hyo Hyun Yoo   ORCID: orcid.org/0000-0003-4226-2589 2  

BMC Medical Education volume  24 , Article number:  1002 ( 2024 ) Cite this article

Metrics details

This study investigated changes in students’ perceptions related to research following a student-engaged medical research curriculum.

Three surveys were administered to 112 medical students to examine the changes in their perceptions of the need for research competence, research interest, and research self-efficacy after each Medical Research Practice course.

The results revealed a decline in the perception of the need for research competence and research interest after Medical Research Practice 2, with a subsequent increase after Medical Research Practice 3. Conversely, research self-efficacy showed steady improvement throughout the curriculum. Additionally, students with prior research experience exhibited higher levels of perception of the need for research competence, research interest, and research self-efficacy than those without such experience.

This study provides insights into how medical students’ perceptions change in relation to student-engaged medical research course experiences, supporting expanding research-related curricula and assisting in the development and systematic implementation of similar programs in other medical schools.

Peer Review reports

In the rapidly evolving landscape of contemporary medicine, the ability to conduct, critically evaluate, and apply research has become an indispensable skill for physicians. The development of physician-scientists, who can bridge the gap between clinical practice and scientific discovery, is crucial for driving innovation in healthcare and addressing complex medical challenges [ 1 ].

However, in countries such as the USA, the declining number of doctors involved in or interested in research is a recognized issue [ 2 ]. Various efforts have been undertaken to address this issue. One initiative offers short-term programs, elective courses, and required courses to medical students to foster new physician-scientists [ 3 , 4 , 5 ].

In Korea, research competence is considered one of the virtues and roles that future doctors should pursue [ 6 ]. About 20 medical schools include research competence as a required competency for graduation [ 7 ]. To enable students to acquire research competence, many medical schools offer a research curriculum as a required course in the standard curriculum, an elective course in a non-standard curriculum, or a course offered alongside both, but only a few have fully incorporated this into their standard curriculum [ 8 ].

Through diverse research experiences in medical schools, students improve their abilities in research design, data collection and analysis, research methodology, and the reporting of results [ 9 , 10 , 11 ]. They also cultivate interest, motivation, confidence, and self-efficacy in research, as well as critical thinking, creativity, communication skills, and teamwork [ 10 , 11 , 12 , 13 , 14 , 15 ].

Offering students research experience from the beginning of their medical education is crucial. Early participation in research may promote further research in actual medical practice [ 16 , 17 , 18 , 19 , 20 ]. Research skills gained as a student influence postgraduate medical subspecialty choices, specialization choices related to research, and the research competence and performance of residents [ 20 , 21 , 22 , 23 , 24 ].

Recently, there has been a trend of emphasizing the research competence of medical students and providing them with a variety of research experiences from the beginning of their medical education [ 25 , 26 ]. However, some medical schools in Korea do not provide such experience [ 8 ]. Although medical schools recognize the importance and need for research competence and include it as a graduation competency, the actual opportunities provided for research are limited [ 7 ], and students often perceive their own research abilities as inadequate [ 27 ]. Enhancing the research competence of medical students who will become medical professionals in the future has become an important educational goal for medical schools [ 28 ].

The objective of this research was to examine changes in medical students’ perceptions of the need for research competence, research interest, and research self-efficacy in relation to a medical research curriculum. The findings are intended to present foundational data for medical schools considering the development and implementation of research curricula within their standard programs.

Study participants

Of the 141 second-year pre-medical students, 112 consistently responded to the three surveys conducted during their first year of medical school. Of them, 65 (58.0%) were male and 47 (42.0%) female. Before beginning the medical research course, 18 students (16.1%) had had prior research experience, whereas 94 (83.9%) had not.

Research instruments

Research interest was measured using a scale developed by Bieschke and Bishop [ 29 ] and subsequently used by Vaccaro [ 30 ]. This instrument consists of 16 items rated on a 6-point Likert scale. In this study, the value of Cronbach’s α, which indicates internal consistency, was 0.91 ( p  < .05). Research self-efficacy was measured using a scale developed by Park et al. [ 7 ] that comprises 18 items as follows: 6 items on presenting and reporting the results, 5 on research design, 4 on data analysis, and 3 on research ethics, all scored on a 6-point Likert scale. In this study, the reliability coefficients (Cronbach’s α value) for each factor were: presenting and reporting the result at 0.85, research design at 0.85, data analysis at 0.87, and research ethics at 0.67. Throughout the medical research curriculum, surveys were conducted to assess participants’ perception of the need for research competence for medical students. The detailed survey questions can be found in Additional File 1 .

Educational program overview

The medical research curriculum consists of five stages: research introduction, research exploration, research implementation, research result organization, and research results analysis. All these medical research courses are mandatory. The research introduction and research results analysis stages are conducted in a lecture-based format, whereas the research exploration, implementation, and organization stages adopt a student-participation format.

This study focused on subjects from the research exploration stage through the research results organization stage, during which students engaged in actual research. This curriculum aims to cultivate a perception of the need for research competence, stimulate research interest, and foster self-belief or confidence in successfully carrying out tasks such as research design and presenting and reporting results by providing students with an opportunity to experience the fundamental stages of research (Fig.  1 ). For a more detailed description of the curriculum stages, course structure, and evaluation, please refer to Additional File 2 .

• Medical research curriculum

Research design

This study sought to assess how students’ perceptions of the need for research competence, research interest, and research self-efficacy change as they engage in curricula that involve direct research participation. To this end, a one-group pretest-posttest design was utilized, with assessment conducted at three points: after the conclusion of the lecture-based Medical Research Practice 1 course, immediately after the end of the Medical Research Practice 2 course, and after the completion of the Medical Research Practice 3 course. This study was approved by the Institutional Review Board of Jeonbuk National University (IRB No. 2020-03-011-003).

Data analysis

To analyze the changes in students’ perceptions of the need for research competence, research interest, and research self-efficacy, the means and standard deviations of the three research surveys were calculated. A repeated-measures analysis of variance (ANOVA) was conducted to analyze whether there were significant differences among the three surveys, and a two-way repeated-measures ANOVA was used to analyze the differences based on prior research experience. Mauchly’s test was performed to verify the assumption of sphericity. Bonferroni post-hoc tests were conducted to identify specific differences between the survey points. PASW Statistics version 18.0 (SPSS Inc., Chicago, IL, USA) was used in this study.

Changes in the perception of the need for research competence

To determine the changes in medical students’ perceptions of the need for research competence after completing medical research courses, a repeated-measures ANOVA and Bonferroni post-hoc tests were conducted. Mauchly’s test was used to confirm the assumption of sphericity ( p  > .05). There was a significant mean score difference across the three survey points for Medical Research Practice 1, 2, and 3 ( F  = 12.91, p  < .001). For Medical Research Practice 1, the score was M  = 5.06 ( SD  = 0.98), which decreased significantly for Medical Research Practice 2 ( M  = 4.54, SD  = 1.11). However, after completing Medical Research Practice 3, the score increased significantly ( M  = 4.88, SD  = 0.96) compared to the score after Medical Research Practice 2. The scores at all three points were higher than the median, suggesting that the medical students perceived a need for research competence (Fig.  2 ; see also Additional File 3 , Supplementary Table S1 for detailed data).

Changes in research interest and research self-efficacy

To examine the changes in research interest and research self-efficacy, a repeated-measures ANOVA and Bonferroni post-hoc tests were performed on the overall scores at each survey point. The sphericity assumption was satisfied in all cases because the p -value was greater than 0.05. Detailed results can be found in Additional File 3 , Supplementary Table S2 .

In research interest, a statistically significant difference was observed in the mean scores across the surveys ( F  = 38.39, p  < .001). Specifically, the score increased significantly after Medical Research Practice 3 ( M  = 4.45, SD  = 0.70) compared to after Medical Research Practice 1 ( M  = 3.91, SD  = 0.72) and 2 ( M  = 3.73, SD  = 0.93). There were no statistically significant differences between the scores after Medical Research Practice 1 and 2.

Research self-efficacy showed a statistically significant difference in the mean scores across the surveys ( F  = 48.20, p  < .001). While no significant differences were seen in the scores after Medical Research Practice 1 (M = 3.70, SD  = 0.59) and 2 ( M  = 3.83, SD  = 0.72), a significant increase in the scores was observed after Medical Research Practice 3 ( M  = 4.33, SD  = 0.67) compared to those after Medical Research Practice 1 and 2.

Among the sub-factors of research self-efficacy, there were statistically significant differences across all three survey points for research design ( F  = 30.78, p  < .001), data analysis ( F  = 27.47, p  < .001), presenting and reporting results ( F  = 35.65, p  < .001), and research ethics ( F  = 41.83, p  < .001). For all subfactors except data analysis, there was no significant difference in scores after Medical Research Practice 1 and 2; however, a statistically significant increase was observed after Medical Research Practice 3.

Examination of the changes in mean values for research interest and research self-efficacy over the survey points in a graph (Fig.  2 ) shows that research interest decreased after Medical Research Practice 2 compared to Medical Research Practice 1 but increased after Medical Research Practice 3. However, research self-efficacy and its sub-factors showed consistent increases.

Changes in perception of the need for research competence, research interest, and research self-efficacy over time. Note * p  < .05, ** p  < .001

Changes depending on prior participation in research-related education

To ascertain whether there were differences in the perception of the need for research competence, research interest, and research self-efficacy between students who had participated in research-related education before starting the Medical Research Practice courses and those who had not, the means and standard deviations of Medical Research Practice 1, 2, and 3 surveys were compared (Additional File 3 , Supplementary Table S3 ). As illustrated in Fig.  3 , students with prior research educational participation displayed higher values for perceiving the need for research competence, research interest, and research self-efficacy than those without such experience. All sub-factors of research self-efficacy also showed higher values in the group with prior educational participation than in those without.

Changes in perception of the need for research competence, research interest, and research self-efficacy over time based on prior research-related education experience

At the Medical Research Practice 1 survey point, Levene’s test for equality of variances was conducted to check the homogeneity between the group of students who had prior experience in research-related education and the group that did not. As no statistically significant differences were observed for any of the variables ( p  > .01), we confirmed that the two groups were homogeneously distributed.

To determine whether there were significant differences in group means at the survey points after completing Medical Research Practice 1, 2, and 3, a two-way repeated-measures ANOVA was conducted on the scores for the perception of the need for research competence, research interest, research self-efficacy, and its sub-factors (Table  1 ).

To assess the within-subject effects of all the variables, we conducted Mauchly’s test of sphericity, which confirmed that the assumption of sphericity was met. In the between-subjects effects verification for the perception of the need for research competence, research interest, and research self-efficacy, a main effect of group was observed ( F  = 7.50, p  < .05; F  = 12.03, p  < .01; F  = 9.62, p  < .01), and in the within-subjects effect verification, a main effect of the time of the test was observed ( F  = 6.09, p  < .01; F  = 22.72, p  < .01; F  = 28.42, p  < .01); however, the interaction effect between the time of the test and group was not statistically significant ( p  > .05).

We analyzed whether there were statistically significant differences between the groups in terms of the sub-variables of research self-efficacy following the completion of the course. The sphericity test showed that the assumption of sphericity was satisfied. As shown in Table  2 , Statistically significant differences were observed between students with and without educational experience in terms of research design, presenting and reporting results, and research ethics ( F  = 6.20, p  < .05, F  = 18.44, p  < .01, F  = 11.27, p  < .01); however, no significant difference was observed in data analysis ( F  = 0.14, p  > .05).

The purpose of this study was to examine changes in students’ perceptions of the need for research competence, research interest, and research self-efficacy in relation to a student-engaged medical research curriculum experience.

The perception of the need for research competence and research interest decreased after completing Medical Research Practice 2 compared to Medical Research Practice 1 and then showed a tendency to increase after completing Medical Research Practice 3. This may be because Medical Research Practice 2 was conducted when the basic medical education curriculum began in earnest at the medical school, during a semester involving adaptation to the educational situation in medical school that is marked by stress from the burden of learning new subjects like anatomy, excessive study loads, pressures related to examinations, and concerns about being held back [ 31 , 32 , 33 ]. Therefore, students likely invested more time in academic adjustment, resulting in relatively low interest in the research curriculum of Medical Research Practice 2. The finding that all variables increased in the semester during which Medical Research Practice 3 was conducted supports this hypothesis.

Therefore, it is necessary to review the timing of medical research courses. It may be worth considering student participation in medical research during the clinical practice education period in the third or fourth year of medical school, when adaptation to academics and the educational environment is more stable. However, this decision should take into account several factors. In the third year, there is often a lack of time for paper-writing due to clinical practice commitments. The fourth year brings an increased psychological due to national medical licensing examinations [ 7 ]. Additionally, the school’s specific goals and the situation of the medical research courses should be considered.

Research self-efficacy, unlike their perception of the need for research competence and research interest, consistently increased as the students completed medical research courses. This coincides with previous research showing that students’ self-efficacy improved in all areas except data analysis, including research design, presenting and reporting results, and research ethics [ 7 , 34 , 35 ]. Other studies have reported that students who participated in short-term research programs experienced enhanced research self-efficacy [ 35 , 36 , 37 ]. In other words, there is a connection between research experience and self-efficacy [ 38 ]. Therefore, when developing or designing student-research-related curricula, it is essential to continuously expose students to research to foster motivation and enhance their self-efficacy.

Among the sub-factors of research self-efficacy, significant differences were observed in research design (from 3.83 to 4.45), presenting and reporting the results (from 4.09 to 4.71), and research ethics (from 4.17 to 4.84) between the initial and third assessment. The experience of participating in a student research program is likely to enhance competence in research design, methodology, and writing as well as contribute to building confidence in research [ 10 , 12 ].

However, the improvement in the data analysis factor was relatively low, with scores increasing from 2.60 in the initial survey to 3.27 in the third assessment. This may be due to the fact that the questions for the data analysis factor were composed to self-evaluate the ability to interpret statistical analysis techniques (such as variance analysis) for data analysis. There are cases in which medical researchers do not appropriately use statistical techniques when presenting research results because of a lack of understanding and difficulty in using statistics [ 39 ]. Therefore, strengthening education related to medical statistics and allowing students to directly experience their applications in actual research would likely be helpful.

Students with prior research experience before the research process in medical school had a higher perception of the need for research competence, research interest, and research self-efficacy than students without such experience. The experience of directly or indirectly participating in research constitutes a basis for the development of positive attitudes or perceptions toward research [ 20 , 22 ].

Experience in research not only increases the likelihood of participating in research after graduation [ 40 ] but also influences the research performance of residents [ 16 , 28 , 41 ]. In the long term, this allows one to maintain an interest in research throughout life. Thus, it is essential to continually foster interest in research in medical schools and provide opportunities and experiences for participation in research [ 24 ].

Students who successfully completed their research had a positive perception of it, showing increased interest and enthusiasm in research [ 22 , 26 , 42 ], but conversely, some students had negative perceptions due to negative experiences like time constraints and insufficient guidance from faculty members [ 23 , 43 , 44 ]. Therefore, research programs provided by medical schools should attempt to enhance interest in research and motivate ongoing engagement in research activities by resolving these obstacles and fostering rewarding experiences.

Significance.

This study holds significance in providing foundational data that demonstrate the association between student-engaged medical research program experience and research-related perception. It offers a rationale for expanding research-related curricula. Additionally, these data can be used for the development and systematic operation of medical research curricula in other medical schools.

Suggestions.

Because this study focused on students from a single medical school, the generalizability of the findings may be limited. To enhance generalizability, it would be necessary to expand the number of research subjects and conduct comparative studies with other schools on the development and implementation of research-related courses. Moreover, as the analysis focused only on students’ self-report, future research should include a multifaceted evaluation. This could be achieved by involving professors who participated in the operation of the courses and educational stakeholders involved in development and monitoring.

The perception changes expected from research-related courses are likely to manifest in various ways and are not limited to research interest or research self-efficacy. Further studies are thus needed to confirm the effectiveness of medical research-related education in domestic medical schools by activating related curricula or subjects in medical education. Additionally, longitudinal research should be conducted to understand the ongoing impact even after graduation.

Data availability

The datasets used and/or analyzed in the current study are available from the corresponding author upon reasonable request.

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H.H.Y. conceived and designed the study, and collected the data. S.J.J wrote the initial draft of the manuscript. H.H.Y and S.J.J analyzed the data and discussed the results. All authors contributed to the final manuscript, read, and approved the final manuscript.

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Questionnaires

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Medical Research Curriculum Overview

Additional File 3: Supplementary Table S1

. Differences in Perception of the Need for Research Competence, Supplementary Table S2 . Differences in Research Interest and Research Self-Efficacy, Supplementary Table S3 . Comparison of Perception of the Need for Research Competence, Research Interest, and Research Self-Efficacy Based on Prior Research-Related Education Experience

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Jeon, S.J., Yoo, H.H. Changes in medical students’ research-related perceptions through student-engaged medical research curriculum experience. BMC Med Educ 24 , 1002 (2024). https://doi.org/10.1186/s12909-024-06003-y

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Health, well-being and education: Building a sustainable future. The Moscow statement on Health Promoting Schools

Health Education

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Issue publication date: 4 June 2020

The purpose of this paper is to introduce the official statement of the Fifth European Conference on Health-Promoting Schools.

Design/methodology/approach

The Fifth European Conference on Health-Promoting Schools was held on 20–22 November 2019 in Moscow, Russian Federation, with over 450 participants from 40 countries. A writing group was established to prepare a draft version of the statement before the conference. On the basis of an online and offline feedback process, the opinions of the participants were collected during the conference and included in the finalisation of the statement.

The final conference statement comprises six thematic categories (values and principles; environment, climate and health; schools as part of the wider community; non-communicable diseases (NCDs); evidence base; and digital media), with a total of 23 recommendations and calls for action.

Originality/value

The recommendations and calls for action reflect current challenges for Health Promoting Schools in Europe. They are addressed to all actors in governmental, non-governmental and other organisations at international, national and regional levels involved in health promotion in schools and are to be applied for the further development of the concept.

• Health Promoting Schools
• Social change
• Child and adolescent health
• School health promotion

Dadaczynski, K. , Jensen, B.B. , Viig, N.G. , Sormunen, M. , von Seelen, J. , Kuchma, V. and Vilaça, T. (2020), "Health, well-being and education: Building a sustainable future. The Moscow statement on Health Promoting Schools", Health Education , Vol. 120 No. 1, pp. 11-19. https://doi.org/10.1108/HE-12-2019-0058

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Copyright © Kevin Dadaczynski, Bjarne Bruun Jensen, Nina Grieg Viig, Marjorita Sormunen, Jesper von Seelen, Vladislav Kuchma and Teresa Vilaça

Published in Health Education . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at: http://creativecommons.org/licences/by/4.0/legalcode

1. The Health Promoting Schools approach and its development

The Ottawa Charter, adopted in 1986, was a milestone in the development of a holistic and positive understanding of health that requires actions at different levels, from healthy public policy to the development of personal skills, using different strategies, such as enabling and advocacy approaches ( WHO, 1986 ). The charter can also be regarded as marking the birth of whole-school approaches to health that have been established in Europe and internationally under the term Health Promoting Schools ( Stewart Burgher et al. , 1999 ).

A Health Promoting Schools reflects a holistic approach that moves beyond individual behaviour change by also aiming at organisational change through strengthening the physical and social environment, including interpersonal relationships, school management, policy structures and teaching and learning conditions. This approach can be seen as the result of overcoming traditional health education at school, which aimed to influence students' knowledge, attitudes and behaviour ( Clift and Jensen, 2005 ). In accordance with a social-ecological perspective, health is considered to be the result of a complex interplay of individual, social, socio-economic and cultural factors ( Dahlgreen and Whitehead, 1991 ). Since the early 1990, actions on school health promotion have been coordinated in national networks and the European network on Health Promoting Schools as a WHO supported network. The current work on school health promotion on a European level is organised through the Schools for Health in Europe Network Foundation (SHE), with national representatives from 36 countries.

Values of the Health Promoting Schools approach

Health Promoting Schools ensure equal access for all to the full range of educational and health opportunities. This in the long term makes a significant impact in reducing inequalities in health and in improving the quality and availability of lifelong learning.

Sustainability

Health Promoting Schools acknowledge that health, education and development are closely linked. Schools act as places of academic learning. They support and develop a positive view of pupils' future role in society. Health Promoting Schools develop best when efforts and achievements are implemented in a systematic and continuous way. Desirable and sustainable health and educational outcomes occur mostly in the medium or long term.

Health Promoting Schools celebrate diversity and ensure that schools are communities of learning, where all feel trusted and respected. Good relationships among pupils, between pupils and school staff and between school, parents and the school community are important.

Empowerment

Health Promoting Schools enable children and young people, school staff and all members of the school community to be actively involved in setting health-related goals and in taking actions at school and community level to reach the goals.

Health Promoting Schools are based on democratic values and practise the exercising of rights and taking responsibility.

Pillars of the Health Promoting Schools approach

Whole-school approach to health

Taking a participatory and action-oriented approach to health education in the curriculum;

Taking into account the pupil's own concept of health and well-being;

Developing healthy school policies;

Developing the physical and social environment of the school;

Developing life competencies and health literacy;

Making effective links with home and the community; and

Making efficient use of health services.

Participation

A sense of ownership is fostered by pupils, staff and parents through participation and meaningful engagement, which is a prerequisite for the effectiveness of health-promoting activities in schools.

School quality

Health Promoting Schools support better teaching and learning processes. Healthy pupils learn better, and healthy staff work better and have greater job satisfaction. The school's main task is to maximise educational outcomes. Health Promoting Schools support schools in achieving their educational and social goals.

School health promotion in Europe is informed by existing and emerging research and evidence focused on effective approaches and practice in school health promotion, both on health topics (such as mental health, eating and substance use) and on the whole-school approach.

Schools and communities

Health Promoting Schools engage with the wider community. They endorse collaboration between the school and the community and are active agents in strengthening social capital and health literacy.

Since the establishment of the European network of Health Promoting Schools, four European conferences on Health Promoting Schools have been organised. The resolution of the first conference, held in Thessaloniki, Greece, in 1997, stated that every child and young person in Europe had the right to be educated in a Health Promoting Schools and urged governments in all European countries to adopt the Health Promoting Schools approach ( ENHPS, 1997 ). The Egmont Agenda was published in 2002 as a result of the Second European Conference on Health Promoting Schools in The Netherlands and emphasised conditions, programming and evaluation as being essential to developing and sustaining Health Promoting Schools ( ENHPS, 2002 ).

Seven years later, the Third European Conference on Health Promoting Schools was held in Vilnius, Lithuania ( SHE Network, 2009 ). The conference and its resolution marked an important milestone in the development of the Health Promoting Schools approach by highlighting that education and health have shared interests and complement each other. Based on this, joint actions beyond sectoral responsibilities were urged.

The Fourth European Conference was held in Odense, Denmark, in 2013 and resulted in The Odense Statement, which recognised the core values and pillars of school health promotion as a strong contributor to the aims and objectives of the WHO policy framework for health and well-being in Europe, Health 2020 and the EU2020 strategy for inclusive and sustainable growth ( SHE Network, 2013 ).

2. Recent societal challenges

Since the establishment of the Health Promoting School approach in the late 1980s, the world has seen constant societal change, with progressively faster dynamics during recent years. The changes have not only altered substantially the conditions in which people grow up and live, but have also affected behaviours in relation to health, social cohabitation, learning and working. Wars and violence, often rooted in cultural and religious differences or political and economic crisis, and climate change alter significantly the environmental and societal determinants of health ( Mucci et al. , 2016 ; Watts et al. , 2019 ).

Often, it is countries that already are experiencing political and socio-economic instability that feel the effects most ( Reibling et al. , 2017 ). An increase in international migration, commonly in perilous circumstances for migrants and refugees ( Silove et al. , 2017 ), is the consequence, raising social tensions and challenges in many countries, some of which are undergoing political developments characterised by protectionism and isolationism that can partly be seen as a countermovement to the idea, values and principles of Europe ( Harteveld et al. , 2018 ).

In many cases, uncertainty has replaced political, economic, social and individual stability, raising concern and anxiety about the future in young people and adults. This has led to an unprecedented social (grassroots) movement of participation, primarily driven by young people who are demanding social, political, ecological and economic change ( O'Brien, Selboe and Hayward, 2018 ).

These developments should not be seen as being separate from school health promotion, the aim of which is to support young people to develop healthy and self-determined lifestyles and enable them to co-create their social, physical and ecological environments and the determinants of health positively and sustainably ( Clift and Jensen, 2005 ; Simovska and McNamara, 2015 ). As the conditions for growing up and living together change, the question arises of how schools, as places for health-related teaching, learning and development, need to adapt.

Where does the Health Promoting School approach stand today, more than 30 years after the Ottawa Charter on health promotion? Can the Health Promoting School, with its holistic orientation, deliver on its promise of addressing health inequalities and improving children's and young people's health, well-being and academic achievement? To what extent can school health promotion be implemented systematically in schools and be linked to local communities?

These and more questions were raised and discussed during the Fifth European Conference on Health Promoting School, culminating in recommendations for the future development of the Health Promoting School approach.

3. The Fifth European Conference on Health Promoting Schools

The Fifth European Conference on Health Promoting Schools was held on 20–22 November 2019 in Moscow, Russian Federation, with over 450 participants from 40 countries.

A range of topics was addressed through more than 160 contributions and nine keynote presentations focusing on conceptual aspects of the Health Promoting School approach, implementation and dissemination and current social change processes, such as digitisation and heterogeneity.

Holistic approaches to school-based health promotion and health education (such as organizational change and environmental approaches to school health promotion and strategies to promote individual and organizational health literacy in schools);

Implementation and dissemination of school-based health promotion and health education (facilitators and barriers to implementing interventions in school-based health promotion and professional development and capacity-building of, for example, teachers, non-teaching school staff, school health services, parents and external professionals);

Networking and intersectoral collaboration in school-based health promotion and health education (schools as part of the wider community, and multisectoral partnerships at local, national and international levels);

Innovative approaches to dealing with heterogeneity, inclusion and special needs (pupils' and teachers' health in inclusive schooling, school-based health promotion and education for refugees, students with special needs and innovative approaches to school-based health services); and

Digital media and information and communications technology (ICT) in school health promotion and health education (practical approaches to ICT use in school-based health promotion and digital devices and media as a target for interventions and a means to promote health and well-being).

4. Recommendations for action

Be based on democratic processes and foster equal access, active involvement and participation;

Take into account the needs and background of all young people regardless of their gender, geographical, cultural and social background or religious beliefs: in that sense, a Health Promoting School can be seen as an inclusive school that celebrates heterogeneity and diversity as an enriching dimension for mutual learning, respect and acceptance;

Reflect a whole-school approach addressing different target groups and combining classroom activities with development of school policies, the physical, social and cultural environment of the school and the necessary capacities needed: we welcome new and established concepts and approaches within school-based health promotion, such as health literacy, salutogenesis, action competence and life skills, which should complement each other and be integrated in the holistic framework of the Health Promoting School approach; and

Be systematically linked with educational goals and school quality as part of a so-called add-in approach: based on rich evidence, a Health Promoting School can be regarded as a school that not only promotes and maintains health, but also strives for successful learning for pupils and working conditions for teaching and non-teaching staff, and involves parents and families in the school's daily life.

Urge all stakeholders in health and climate/sustainability education to work together systematically to support young people to grow up and live healthily and sustainably;

Urge all stakeholders to support and empower young people to raise their voice and make a lasting contribution to shaping a healthy and sustainable future for themselves and their fellow human beings;

Call for actions to link planetary health and the Health Promoting School approach more explicitly by, for instance, integrating the impact of human action on the environment and its health consequences into school curricula and everyday life; and

Call for realignment of health-promotion research agendas to address environmental challenges in, with and through schools.

All actors to move from a single-setting approach to an integrated multi-setting approach that systematically links actions at school level with actions in the local community: these actions should not be implemented in isolation, but in a coordinated fashion to create synergies and avoid discontinuities;

Intersectoral collaboration among different actors and professions, such as teachers, school health services and social and youth-care services: this requires professional development, and that existing local networks and their leadership capacities be strengthened to align sectoral policies and enable the development of a common vision and language; and

All actors to strengthen links with existing national and regional cooperation mechanisms, such as Health Promoting School networks and healthy city or healthy region networks, by pursuing joint objectives and actions.

A resource-oriented intervention approach (as described in the SHE values and pillars) be taken to tackle NCDs rather than a traditional top-down and disease-oriented approach, which normally dominates interventions related to risk factors;

Young people be viewed as part of the solution and not only as part of the problem of NCDs – we need to work with young people as powerful agents of healthy change and not as victims and recipients of risk factors;

A school environment that promotes healthy practices in areas like healthy eating, physical activity, social and emotional well-being and good hygiene be created; and

Commercial determinants are addressed by empowering young people to become critical and responsible citizens who are able to understand and critically reflect on media advertising and market mechanisms through, for instance, consumer education.

Call for evaluation approaches that reflect the complexity of the Health Promoting School by, for example, applying mixed-methods designs and considering graded health and educational outcomes;

Demand that the available scientific evidence be reviewed and evaluated using existing tools and be translated into recommendations for practical action;

Urge that a one-sided focus on outcomes research be augmented by focusing also on implementation to identify the conditions under which interventions can be effective, systematically linking both research perspectives; and

Call for systematic and strong partnerships between researchers and practitioners who develop and implement innovative interventions in school health promotion and those who conduct empirical surveys on child and adolescent health (such as the Health Behaviour in School-aged Children (HBSC) study) and the health of teaching and non-teaching staff. By sharing available social-epidemiological data, previously untried evaluation potential can be exploited.

Call on all actors in school health promotion to use the possibilities of digital media in the context of research, development, implementation and exchange of innovative interventions and good practice;

Urge all actors to use digital media as a supplement to, and not as a substitute for, non-digital (face-to-face) school health-promotion actions;

Call on all actors to ensure that the use of digital media does not lead to a step back to individual and behavioural prevention, but rather is used at organisational level to, for instance, build capacity, communicate with partners outside the school and promote low-threshold participation in change processes within the school; and

Call for actions to empower individuals and whole-school systems to deal effectively with health information complexity, including its critical assessment, selection and use and to take responsibility for providing suitable and reliable health information.

The Health Promoting School approach

Buijs , G.J. ( 2009 ), “ Better schools through health: networking for health promoting schools in Europe ”, European Journal of Education , Vol. 44 No. 4 , pp. 507 - 520 .

Clift , S. and Jensen , B.B. ( 2005 ), The Health Promoting School: International Advances in Theory, Evaluation and Practice , Danish University of Education Press , Copenhagen .

Dahlgren , G. and Whitehead , M. ( 1981 ), Policies and Strategies to Promote Social Equality in Health , Institute of Future Studies , Stockholm .

European Network of Health Promoting Schools (ENHPS) ( 2002 ), The Egmond Agenda. A New Tool to Help Establish and Develop Health Promotion in Schools and Related Sectors across Europe , available at: https://tinyurl.com/y2py8wzr ( accessed 19 November 2019 ).

European Network of Health Promoting Schools (ENHPS) ( 1997 ), “ Conference resolution ”, available at: https://tinyurl.com/wcunrec ( accessed 19 November 2019 ).

Harteveld , E. , Schaper , J. , De Lange , S.L. and Van Der Brug , W. ( 2018 ), “ Blaming Brussels? the impact of (news about) the refugee crisis on attitudes towards the EU and national politics ”, JCMS: Journal of Common Market Studies , Vol. 56 No. 1 , pp. 157 - 177 .

Mucci , N. , Giorgi , G. , Roncaioli , M. , Perez , J.F. and Arcangeli , G. ( 2016 ), “ The correlation between stress and economic crisis: a systematic review ”, Neuropsychiatric Disease and Treatment , Vol. 12 , pp. 983 - 993 .

O'Brien , K. , Selboe , E. and Hayward , B. ( 2018 ), “ Exploring youth activism on climate change: dutiful, disruptive, and dangerous dissent ”, Ecology and Society , Vol. 23 No. 3 , p. 42 .

Reibling , N. , Beckfield , J. , Huijts , T. , Schmidt-Catran , A. , Thomson , K.H. and Wendt , C. ( 2017 ), “ Depressed during the depression: has the economic crisis affected mental health inequalities in Europe? findings from the European social survey (2014) special module on the determinants of health ”, The European Journal of Public Health , Vol. 27 Suppl 1 , pp. 47 - 54 .

Schools for Health in Europe (SHE) Network ( 2013 ), “ The Odense Statement. Our ABC for equity, education and health ”, available at: https://tinyurl.com/rk8rh5e ( accessed 19 November 2019 ).

Schools for Health in Europe (SHE) Network ( 2009 ), “ Better schools through health: the Third European Conference on Health Promoting Schools. Vilnius resolution ”, available at: https://tinyurl.com/qskr692 ( accessed 19 November 2019 ).

Silove , D. , Ventevogel , P. and Rees , S. ( 2017 ), “ The contemporary refugee crisis: an overview of mental health challenges ”, World Psychiatry , Vol. 16 No. 2 , pp. 130 - 139 .

Simovska , V. and McNamara , P. (Eds) ( 2015 ), Schools for Health and Sustainability , Springer , Dordrecht .

Stewart Burgher , M. , Barnekow , V. and Rivett , D. ( 1999 ), The European Network of Health Promoting Schools. The Alliance of Education and Health , WHO Regional Office for Europe , Copenhagen .

Watts , N. , Amann , M. , Arnell , N. , Ayeb-Karlsson , S. , Belesova , K. , Boykoff , M. , … and Chambers , J. ( 2019 ), “ The 2019 report of the Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate ”, The Lancet , Vol. 394 No. 10211 , pp. 1836 - 1878 .

WHO ( 2016 ), Declaration: Partnerships for the Health and Well-Being of Our Young and Future Generations. Working Together for Better Health and Well-Being: Promoting Intersectoral and Interagency Action for Health and Well-Being in the WHO European Region , WHO Regional Office for Europe , Copenhagen .

WHO ( 1986 ), “ Ottawa Charter for Health Promotion ”, available at: https://tinyurl.com/mohfbn6 ( accessed 19 November 2019 ).

Acknowledgements

This publication has received funding under an operating grant from the European Union's Health Programme.

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The impact of death and dying on the personhood of medical students: a systematic scoping review

Chong yao ho.

1 Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228 Singapore

2 Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Crescent, Singapore, 169610 Singapore

Cheryl Shumin Kow

Chin howe joshua chia, jia ying low, yong hao melvin lai, sarah-kei lauw, ashley ern hui how.

3 Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Dr, Experimental Medicine Building, Singapore, 636921 Singapore

Lorraine Hui En Tan

Xin ling lisa ngiam, natalie pei xin chan, tze yin joshua kuek, nur haidah ahmad kamal, jeng long chia, ahmad bin hanifah marican abdurrahman.

4 Division of Cancer Education, National Cancer Centre Singapore, Level 4, 11 Hospital Crescent, Singapore, 169610 Singapore

Yun Ting Ong

Annelissa mien chew chin.

5 Medical Library, National University of Singapore Libraries, Blk MD6, Centre, 14 Medical Dr, #05-01 for Translational Medicine, Singapore, 117599 Singapore

Ying Pin Toh

6 Star PALS (Paediatric Advanced Life Support), HCA Hospice Care, Kwong Wai Shiu Hospital Singapore, 705 Serangoon Road, Block A #03-01, Singapore, 328127 Singapore

7 Department of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228 Singapore

Stephen Mason

8 Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA UK

Lalit Kumar Radha Krishna

9 Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore

10 Centre of Biomedical Ethics, National University of Singapore, Blk MD11, 10 Medical Drive, #02-03, Singapore, 117597 Singapore

11 PalC, The Palliative Care Centre for Excellence in Research and Education, PalC c/o Dover Park Hospice, 10 Jalan Tan Tock Seng, Singapore, 308436 Singapore

Associated Data

All data generated or analysed during this review are included in this published article [and its supplementary information files].

The re-introduction of medical students into healthcare systems struggling with the COVID-19 pandemic raises concerns as to whether they will be supported when confronted with death and dying patients in resource-limited settings and with reduced support from senior clinicians. Better understanding of how medical students respond to death and dying will inform educationalists and clinicians on how to best support them.

We adopt Krishna’s Systematic Evidence Based Approach to carry out a Systematic Scoping Review (SSR in SEBA) on the impact of death and dying on medical students. This structured search process and concurrent use of thematic and directed content analysis of data from six databases (Split Approach) enhances the transparency and reproducibility of this review.

Seven thousand six hundred nineteen were identified, 149 articles reviewed and 52 articles included. The Split Approach revealed similar themes and categories that correspond to the Innate, Individual, Relational and Societal domains in the Ring Theory of Personhood.

Facing death and dying amongst their patients affect how medical students envisage their personhood. This underlines the need for timely, holistic and longitudinal support systems to ensure that problems faced are addressed early. To do so, there must be effective training and a structured support mechanism.

With nearly 20 million reported cases worldwide and at least 730,000 deaths [ 1 – 4 ], the COVID-19 global pandemic has stressed healthcare systems and impacted medical education curricula in numerous countries [ 5 ]. It is against this backdrop that medical students in certain countries are being asked to step into clinical wards and bolster primary medical teams, in some cases with minimal supervision [ 6 – 10 ]. For many students, this uncertain environment will likely bring with it their first exposure to death and dying. Whilst many medical schools have incorporated palliative care into their formal curricula, a prevailing culture that sees death as a medical failure still remains [ 11 – 18 ]. Medical educators, too, continue to struggle with sufficiently preparing their students emotionally and mentally for the caring of their dying patients and families [ 19 – 22 ].

In light of this pandemic, this may be exacerbated as some medical students enter a system facing “death at unprecedented rates” [ 23 ]. As senior clinicians scramble to meet clinical demands, their ability to provide support and guidance to these students are likely to fall short [ 24 ]. Ill-equipped, these medical students may be forced to witness the acute distress of multiple patients dying in isolation and watch as families grapple with physical separation from their fading loved ones [ 25 ]. Better understanding of how medical students respond to death and dying will thus inform educationalists and clinicians on how to better support them during this pandemic and beyond.

The need for this paper

A systematic scoping review (SSR) is proposed to map available data to guide the design of much needed support systems for these medical students [ 18 , 26 ].

An SSR allows for a structured approach to systematic extraction, synthesis of actionable and applicable information and a summary of available literature across a wide range of settings [ 27 – 30 ]. To overcome concerns about the transparency and reproducibility of SSRs, we adopt Krishna’s Systematic Evidence Based Approach (SEBA) [ 31 – 37 ].

Krishna’s SEBA consists of five stages – the Systematic Approach, Split Approach [ 38 , 39 ], Jigsaw Perspective, Funnelling and SSR in SEBA Synthesis. This process is outlined in Fig.  1 .

The SEBA Process

Diversity of views and the presence of complex individual, academic, research, socio-cultural, professional and personal factors involved in understanding the impact of care of dying patients upon medical students served as the rationale for adopting SEBA as its constructivist and relativist lens allows for the mapping of complex concepts from multiple angles [ 40 – 43 ]. In addition, an interpretivist approach guided the research process.

In keeping with the SEBA methodology, opinions were sought at every stage from an expert team. This team comprised of medical librarians at the National University of Singapore (NUS) Yong Loo Lin School of Medicine (YLLSoM) and National Cancer Centre Singapore (NCCS), as well as local educational experts and clinicians at YLLSoM, NCCS, Palliative Care Institute Liverpool and Duke-NUS Medical School.

Stage 1 of SEBA: systematic approach

Determining review title and background.

Together, the research and expert teams identified the overarching goals of the SSR and ascertained the population, context and concept (PCC) to be evaluated [ 44 , 45 ].

Identifying the research question

Designed around the PCC elements of the inclusion criteria, there was consensus amongst the two teams that the primary research question should be “How does caring for a dying patient affect the medical student – such as in their professional and personal domains and in their perception of self?” A secondary research question, “ How do medical students react to exposure to dying patients? ”, was also proposed.

Inclusion criteria

A PICOS format [ 44 , 45 ] was adopted to guide the research process as shown in Table  1 .

Three members of the research team carried out independent searches of six bibliographic databases (PubMed, ERIC, Embase, Psycinfo, Cochrane and Web of Science) between 17th November 2019 and 24th April 2020. Only articles published or translated into English between 1st January 2000 and 31st March 2020 were included. These parameters were established in line with Pham et al. [ 46 ]‘s recommendations to ensure that the research process would be both viable and sustainable. The full PubMed Search Strategy may be found in Appendix A .

Extracting and charting

In order to narrow down the list of full-text articles for review, research team members independently reviewed the titles and abstracts identified from each database. Sambunjak and Straus [ 47 ]‘s approach to ‘negotiated consensual validation’ was then employed by the team to collectively arrive at a list for further consideration.

Review selection

Research team members then carried out independent reviews of these full-text articles and used ‘negotiated consensual validation’ once again to determine the final list of articles for analysis.

Charting the data

Two members then adopted the data charting form designed by Tan et al. [ 48 ] to organise all publications by author, year of publication, purpose of review/research question, practice setting, methodology, population characteristics and outcome evaluation.

Stage 2 of SEBA: Split approach

The research team then split into three sub-teams and simultaneously reviewed the 52 included full-text articles. The first sub-team summarised and tabulated the articles to ensure that all pertinent information was catalogued. Guidelines were drawn from Wong et al. [ 49 ]‘s RAMESES publication standards: meta-narrative reviews and Popay et al. [ 50 ]‘s “Guidance on the conduct of narrative synthesis in systematic reviews”.

The second sub-team analysed the included articles using Braun and Clarke [ 51 ]‘s approach to thematic analysis. The members independently constructed ‘codes’ from the ‘surface’ meaning of the text and located meaningful patterns [ 52 – 56 ] by immersing themselves in the data “without [referencing] any predetermined classification” [ 55 ]. A common coding framework was then established and refined at online and face-to-face meetings. Subthemes and themes were then developed upon collapsing the codes into larger concepts. This process yielded a list of carefully delineated themes.

In tandem, the third sub-team analysed the included articles using Hsieh and Shannon [ 57 ]‘s approach to directed content analysis. This involved “identifying and operationalising a priori coding categories” [ 58 , 59 ] from Baldwin et al’s [ 60 ] paper entitled “Guidelines for evaluating the educational performance of medical school faculty: priming a national conversation”. In keeping with deductive category application, any data not captured by these codes were assigned a new one. The coding categories were also consistently reviewed and revised where necessary. This process yielded a list of carefully delineated categories.

Finally, ‘negotiated consensual validation’ was used as a form of consolidation and peer debrief across all three sub-teams to further enhance the validity of the findings [ 61 ].

SEBA’s reiterative process

As part of the reiterative process, the findings were discussed with members of the expert team. With the prevailing literature suggesting that caring for dying patients affect the very self-concept of the medical student, with ramifications on their personal and professional domains [ 11 – 18 ], significant consistencies were identified with Krishna and Alsuwaigh (2015)‘s [ 62 ] concept of the Ring Theory of Personhood (RToP) [ 63 – 74 ]. As such, following discussions between the expert and research teams, the RToP was adopted to guide the research study.

Theoretical framework

Ring theory of personhood.

The concept of personhood or “what makes you, you” put forth by Krishna and Alsuwaigh’s RToP may be described in terms of four domains represented by the Innate, Individual, Relational and Societal Rings (Fig.  2 ).

The Ring Theory of Personhood

The Innate Ring has two components — a Core and the Secondary Elements. The Core of the Innate Ring is anchored on the notion that all humans are deserving of personhood, “irrespective of clinical status, culture, creed, gender, sexual orientation, religion, or appearance”, simply as a result of living and having human physical characteristics [ 62 ]. These aspects are unchanging and are retained till death. The Secondary Elements are the elements a child is born into and includes the family and community, their beliefs, values and culture. This component of the Innate Ring, unlike the Core, is alterable.

The Individual Ring is defined as the unique characteristics of a person, such as one’s values, beliefs, goals, personality and character traits, as well as higher order abilities related to consciousness and cognitive function.

The Relational Ring consists of all close, important and reciprocal relationships and may include family and close friends. These ties are determined by the person and may change over time.

The Societal Ring is the outermost ring and encompasses less significant and more impersonal relationships. These include acquaintances and colleagues. Additionally, the ring encompasses societal, religious, professional and legal expectations that guide and police conduct within one’s society.

In adopting the RToP as a theoretical framework amidst suggestions that witnessing death and dying would have significant impact upon the personhood of medical students, the expert team opted to carry out a second analysis of the data using Hsieh and Shannon’s directed content analysis. Codes and categories were drawn from Krishna and Alsuwaigh’s “Understanding the Fluid Nature of Personhood — The Ring Theory of Personhood” . In addition, the expert team suggested that this analysis should be carried out by a separate group of researchers to independently verify the idea. As a result, five new researchers were recruited and trained to use this analytical approach.

Seven thousand six hundred nineteenI abstracts were identified from six databases, 149 articles reviewed, and 52 articles (including 33 peer reviewed articles and 19 grey literature articles) were included as shown in Fig.  3 in the form of a PRISMA Flow Chart [ 75 ]. Tabulated summaries of the included articles may be found in Appendix B .

PRISMA Flowchart

Stage 3 of SEBA: jigsaw perspective

The jigsaw perspective saw similarities between the themes and categories compared and complementary elements pieced together to form a cohesive picture. It also ensured that critical aspects of the data were not lost when the Split Approach was performed.

Stage 4 of SEBA: the Funnelling process

Through ‘funnelling’, themes and categories delineated were compared with key insights from the tabulated summaries to further ensure a holistic picture of the data with minimal overlaps (Fig.  4 ).

Novel structured approach to SSR

Themes and categories identified

Scrutiny of the findings by the expert and research teams found that themes and categories from the thematic and content analysis were consistent with one another. To avoid repetition, we discuss the themes identified using both approaches in tandem. The four themes identified were the impact of death and dying on the medical students’ emotional, psychological and behavioral disposition; their attitudes; their interpersonal relationships, and their personal and professional development. These themes are consistent with the RToP framework. As a result, we present our findings through the lens of the RToP, along the four rings.

The innate ring

Caring for the dying influences one’s conception of life, death and religion.

Many medical students recognised the transitory nature of life [ 76 , 77 ] and expressed a greater appreciation of its value and the desire to make the most of it [ 78 , 79 ].

There were also personal reflections presented in the included articles on the meaning [ 80 ] and concept of death [ 79 , 81 – 84 ]. Some reported discomfort and fear when confronted with their own mortality [ 17 , 18 , 82 , 85 ] whilst others accepted death as a normal [ 13 , 81 , 86 ], natural part of life [ 13 , 17 , 18 , 76 , 79 , 82 , 87 – 89 ] and appreciated the notion of a “good” death [ 12 , 14 , 90 , 91 ]. In addition, most did not see the patient’s death as a failure on the part of the medical team [ 14 , 79 ]. While some developed a positive outlook [ 11 , 18 ], some maintained an opposing stance as they viewed the role of medicine as fundamentally life-giving and sustaining [ 14 , 16 ].

On religion

Whilst it would be prudent not to overgeneralise such findings, one study revealed that the experience of caring for dying patients reinforced the students’ religious beliefs [ 18 ] and two noted that it enabled them to find meaning in their experiences [ 18 , 92 ]. However, conflicts may arise when institutions or patients do not share their beliefs [ 80 ], as seen in Smith-Han et al. [ 13 ]‘s account of medical students realising that bodies were not always treated as sacred in clinical institutions.

The individual ring

The impact of death and dying on the Individual Ring may be perceived in how medical students think, feel and act from both a personal and professional standpoint.

Memorable, powerful, inspiring and transformative [ 16 , 78 , 81 , 85 , 86 , 93 , 94 ] were some of the descriptors used by medical students when asked to describe their first experience with a patient’s death. For some, caring for the dying was a satisfying experience [ 16 , 17 , 88 ] with some feeling moved [ 17 , 92 , 94 ], humbled and grateful for the opportunity [ 92 , 94 – 97 ]. Some students felt more comfortable discussing death and dying after these personal encounters [ 78 , 80 , 86 , 91 ]. They also reported being better able to manage their emotions and cope [ 11 – 13 , 21 , 84 , 89 , 94 , 98 , 99 ]. Indeed, two studies reported improvements in the medical students’ management of sadness, hopelessness, and helplessness [ 18 , 100 ]. Positive coping strategies such as reflective writing [ 77 , 79 , 80 , 84 , 85 , 94 , 99 , 101 , 102 ] were often used to help regulate their emotions [ 13 , 21 , 99 , 102 ]. Others sought comfort by partaking in religious rituals or prayer [ 12 , 14 , 18 , 99 ], exercise or hobbies [ 12 , 13 ] or simply by taking time off work [ 14 , 101 ].

These close interactions taught medical students important lessons on the power of listening [ 17 ] and “bearing witness to another’s suffering” [ 100 ]. One article found that it instilled humility in the students [ 103 ] and encouraged them to reflect on their values [ 85 , 87 , 92 ]. Those who cared for the dying during medical school were also found to have a more positive attitude towards these patients [ 11 , 104 ], with a greater sense of relief, peace and acceptance of their abilities and limitations [ 76 , 78 , 85 , 105 ]. This may in turn minimise rates of compassion fatigue and burnout [ 94 ]. Two studies reported that students developed a greater interest in their patients’ holistic medical, psychosocial and spiritual well-being [ 18 , 100 ].

However, some medical students found themselves breaking into tears [ 13 , 14 , 21 , 76 , 77 , 81 , 84 , 87 , 94 , 98 , 99 , 101 , 106 ] and others fighting back their own emotions [ 81 , 84 , 102 ]. Some withdrew by physically stepping away from the situation [ 87 , 94 ] or isolating themselves [ 77 ]. One student defaulted to the reciting of medical protocol while others described “freezing up” [ 16 , 22 , 79 , 87 ]. Shortly after their encounter, some medicals students described being in a complete daze [ 79 , 103 ] or preoccupied with lingering thoughts of the patient [ 21 ]. Some expressed their initial denial [ 18 , 77 , 99 ] and envisaged a different outcome [ 79 ] while others tried to rationalise their thoughts away [ 87 , 106 ]. For some, sleep eluded them [ 21 ]. For others, vivid imagery and flashbacks [ 16 , 18 , 21 , 87 , 107 ] incited feelings of distress and persisted for a significant duration after the encounter.

Often, shock [ 12 , 13 , 16 , 21 , 22 , 87 , 99 , 101 , 108 ], confusion and conflict [ 21 , 22 , 77 , 79 , 80 , 85 , 101 – 103 , 109 ] were also experienced by the medical students. Being unable to find the “right words” to verbalise their feelings left many “traumatised” [ 14 , 16 , 18 , 78 ] and emotionally overwhelmed [ 18 , 21 , 81 , 84 , 85 , 87 , 92 , 98 ]. In one article, Slim [ 79 ] narrated his struggle of reconciling his patient’s “Do-Not-Resuscitate” order with his own desire to “do no harm”. Medical students also reportedly experienced sadness and grief [ 12 , 16 , 21 , 77 , 78 , 84 , 87 , 92 , 101 , 105 , 107 , 110 ], guilt [ 11 – 14 , 16 , 18 , 21 , 77 , 78 , 87 , 98 , 101 , 105 ], anger and frustration [ 14 , 18 , 21 , 84 , 87 , 90 , 92 , 101 , 104 ], a sense of injustice [ 18 , 90 , 101 ] and helplessness at being unable to change their patient’s outcome [ 18 , 21 , 22 , 78 , 81 , 92 , 97 , 99 , 104 ]. A minority described experiencing physical reactions such as throat tightness [ 76 ] and paresthesia [ 21 ] in the wake of their patient’s death.

Professional

When armoured with experience, some medical students described feeling more comfortable [ 12 , 83 , 91 , 111 ], confident and prepared for managing their dying patients [ 12 , 16 , 17 , 80 , 85 , 86 , 89 , 92 , 97 , 110 , 112 ] and better understood the responsibilities involved in processing the formalities of death [ 13 , 87 ]. Many developed a deeper appreciation of the impact of death and dying on patients and their families [ 78 , 80 , 84 , 93 , 96 ] and the need for the former’s [ 17 , 85 , 88 , 93 , 95 , 96 , 98 , 99 , 104 ] and latter’s holistic care [ 21 , 92 , 103 ]. Students also began to more consciously view their patients as fellow persons instead of apprehending them by their disease [ 17 , 78 , 81 , 84 , 85 , 92 , 98 – 100 , 103 ].

These experiences assisted in their professional identity formation as well [ 12 , 13 , 109 ]. Students were given the opportunity to hone their communication skills [ 78 , 83 , 85 , 86 , 93 , 96 , 100 , 104 , 113 – 115 ] which led to newfound self-confidence in their clinical role [ 99 ]. Witnessing a patient’s death allowed some students to develop greater empathy and sensitivity towards the dying [ 82 , 113 ]. As opposed to their previous uncertainty and anxiety, some were more self-assured as to what empathetic practice meant [ 84 ]. Crawford and Zambrano [ 89 ] observed that junior doctors trained earlier in palliative care had enhanced levels of professionalism, communication, teamwork, self-awareness and skills in patient-centered medicine – including attunement to their psychosocial and spiritual needs. Students who cared for dying patients during medical school were also found to have higher knowledge scores on end-of-life care issues [ 81 , 104 ].

Yet, some medical students also reported suppressing their feelings and detaching themselves emotionally [ 13 , 18 , 21 , 92 , 99 , 106 ] especially in front of their superiors [ 14 ]. Over time, they began to “medicalise” their thoughts on death and became increasingly desensitised to the profound humanity of their patients [ 18 , 99 ].

The relational ring

In several medical students, caring for dying patients triggered memories of personal bereavement [ 16 , 21 , 84 , 87 , 106 ]. Strong emotions were particularly evoked when the patient belonged to a similar age group to their loved ones [ 12 , 16 , 21 , 82 , 84 , 87 , 116 ]. As a means of coping with these emotional challenges [ 12 , 16 , 21 , 86 , 89 , 98 ], a number of medical students relied on their own family members for support [ 12 – 14 , 16 , 18 , 21 , 79 , 84 , 86 , 90 , 98 , 101 ].

The societal ring

The experience of death and dying had varied effects on the relationship medical students had with members of their Societal Ring – these include their patients and loved ones as well as other healthcare professionals and the profession itself. Broadly, the effect may be classified as either weakening or strengthening.

Relationship with patients

• Weakening: Some medical students faced difficulty understanding their patients’ perspectives and feelings [ 84 , 95 ]. Others felt awkward interacting with the dying [ 22 , 80 , 85 , 117 ] and were uncertain about their role when doing so [ 107 ].
• Strengthening: Conversely, some felt that the experience allowed them to better understand the needs of their dying patients [ 77 , 78 , 84 , 95 , 96 , 103 ]. They learnt how to better listen and provide support [ 12 , 14 , 17 , 84 , 97 , 99 , 100 ], honed their soft skills in communication [ 95 , 116 ] and developed virtues such as patience [ 17 ] and compassion [ 82 ]. Many built rapport, developed attachments [ 12 , 14 , 76 , 80 , 98 ] and were inspired by their patients’ and their own experiences [ 86 , 94 , 108 ].

Relationship with patients’ loved ones

• Weakening: Some medical students found it emotionally challenging and stressful to interact with their patients’ loved ones [ 14 , 18 , 21 , 118 ], especially if it involved breaking bad news [ 18 ] as they dreaded having to deal with the emotional anguish [ 110 ]. Pessagno et al. [ 14 ] noted that some were also worried about potential litigation issues. At times, the students struggled to reconcile incongruences with their patient’s wishes, that of their loved ones and professional medical opinion their best interests [ 79 , 106 ]. Some felt pressured to accede to their family’s demands [ 106 ].
• Strengthening: While caring for their patients, medical students also learnt to communicate sensitively and build rapport with their patients’ loved ones [ 12 , 21 , 93 , 95 , 98 ]. They learnt the importance of showing empathy and supporting the family through the process [ 12 , 17 , 21 , 80 , 95 , 98 , 99 , 107 ] and some also journeyed together with them through prayer [ 98 , 99 ].

Relationship with other healthcare professionals and the profession

Individual studies attributed the varied effects on medical student-clinician relationships to different levels of emotional sensitivity and personalities of the clinicians [ 102 ], different care settings — emergency department versus inpatient service [ 21 ] — and cultural or societal norms in different countries [ 102 ].

• Weakening: Many medical students struggled with a lack of support and guidance from their seniors and faculty [ 16 , 22 , 87 , 101 , 102 , 107 ]. Some did not feel comfortable approaching their superiors for help. Diverse reasons include the fear of being burdensome [ 101 , 107 ], their feelings of awkwardness [ 79 ], the desire to appear professional [ 14 ], the medical team’s insensitivity or lack of emotion [ 16 , 21 ] and their disagreement with advice proffered by their seniors to simply desensitise themselves to death [ 77 , 102 ]. Others felt disempowered and discouraged from actively participating in the care of the patient [ 12 , 99 , 102 ]. Such experiences may have contributed to their belief that their educational needs were not adequately met [ 16 ].
• Strengthening: However, some medical students found comfort in discussing their experiences and emotions with other senior clinicians [ 12 – 14 , 16 , 90 , 99 , 102 ]. Some were impressed and regarded their seniors as good role models to emulate their behaviour on [ 12 , 17 , 21 , 82 , 84 – 96 , 99 , 102 , 113 , 118 ] and were able to built strong positive relationships with them [ 12 – 14 , 84 , 86 , 90 , 98 , 99 , 102 ].
• On palliative care and the role of doctors: Medical students became more aware of the value of palliative care and adopted positive attitudes towards it [ 11 , 101 ]. Baumrucker and Woods [ 96 ] reported that medical students felt more comfortable referring their patients with terminal illnesses to hospices. Kearsley and Lobb [ 84 ] found that prior negative impressions of palliative care were positively altered. This may be attributed to their broadened understanding of what it means to be a physician — from trying to “cheat death” and prolong life, to preserving their patient’s quality of life and helping them transition towards a more dignified death [ 13 , 17 , 92 ]. Perceptions of the doctor as a life-saving hero was altered to one centred on showing care through the effective management of illness [ 13 ] and the provision of bereavement aid [ 11 , 111 ]. Individual studies reported that through these experiences, medical students acknowledged the limitations of medical intervention [ 14 ] and recognised that non-medical acts such as providing a listening ear or a warm embrace may provide much needed healing for the dying patient [ 76 ].

Stage 5 of SEBA: synthesis of SSR in SEBA

The SSR produced was guided by the Best Evidence Medical Education (BEME) Collaboration guide [ 119 ] and the STORIES (Structured approach to the Reporting In healthcare education of Evidence Synthesis) statement [ 120 ]. In addition, two members of the research team employed the Medical Education Research Study Quality Instrument (MERSQI) [ 121 ] and the Consolidated Criteria for Reporting Qualitative Studies (COREQ) [ 122 ] to evaluate the quality of quantitative and qualitative studies included in this review respectively (Appendix B ).

In mapping how medical students are affected by their exposure to death and dying, this SSR in SEBA highlights the advantage of using RToP as a wider framework to analyse these findings.

Implications of the entwined rings of personhood

The entwined nature of the rings of the rtop.

The four rings of personhood do not stand in isolation to one another but are dynamically entwined as originally put forth by Krishna and Alsuwaigh. Whilst the Societal Ring is traditionally seen as a means of ensuring that basic standards of practice, etiquette, rights and codes of conduct are adhered to, senior clinicians have an immediate effect on how the medical student thinks, feels and behaves through the provision of timely personalised advice and feedback, role-modelling, support for their professional identity formation, active facilitation of their continuous learning, guidance in the development of their self-efficacy in caring for the dying, and by helping them develop better methods of coping in the face of their patients’ demise [ 77 , 79 , 80 , 84 , 85 , 90 , 94 , 99 , 102 ]. These may be best understood as ‘organisational influences’ which are intrinsic to the medical program’s culture and structure. Well-supported students are inclined to see these trying experiences as transformative [ 76 , 78 , 85 , 105 ] and affirmative of their career choices.

Building resilience

Such experiences underscore the impact of positive and congruent experiences on building one’s resilience. This highlights a further feature of the RToP, that experiences in one ring may strengthens the others. For example, societal and familial support and religious beliefs that positively impact the Societal, Relational and Innate Rings also bolster the Individual Ring. This helps to build resilience in medical students and boost their self-assurance.

When medical students face challenges in their line of work, significant family and friends from the Relational Ring may serve as a prominent source of encouragement, allowing for their reprieve and reinvigoration [ 12 , 21 , 84 , 87 , 116 ]. Similarly, the reevaluation and reinforcement of their religious and spiritual values within the Innate Ring may allow students to derive meaning from and make meaning of their bleak experiences [ 13 , 17 , 18 , 76 , 79 , 82 , 87 – 89 ].

‘Dyssynchrony’

Conversely, evidence of their entwined nature provides a unique opportunity to observe how caring for the dead and dying may result in conflicts or ‘dyssynchrony’ between the rings of personhood. This may arise when changes in one ring run against convictions, values or practices held in another ring (Fig.  5 ).

Caring for the dying provokes ‘dyssynchrony’ (red arrows) between the Rings of Personhood

Dissonance have been reported between the medical student’s:

• Individual and Societal Rings .
• personal beliefs, expression of feelings and expectations that a professional should remain detached and emotionally distant towards patients [ 13 , 16 , 84 , 101 , 102 , 107 ].
• personal values of honesty and the professional ideal of diplomacy and sensitivity [ 116 ].
• personal, religious and/or moral duty to save and prolong lives which are “at odds” with the patient’s wishes and professional obligations to respect “Do-Not-Resuscitate” orders [ 79 ].
• 2. Innate and Societal Rings .
• innate or cultural view that death is a failure and the patient’s subsequent death [ 16 , 79 ].
• innate view that “young deaths” are unnatural and their occurrence in reality [ 14 , 18 , 87 ].
• religious beliefs about the sanctity of the human body and the attitude adopted towards bodies in hospitals [ 13 ].

The ramifications of unresolved ‘dyssynchrony’ between two or more rings may exacerbate and prolong feelings of moral distress and confusion in medical students [ 18 , 89 ]. Risking potential compromise of their responsibilities as healthcare providers, these feelings may manifest in the form of guilt [ 18 ], anger [ 18 , 89 ], feelings of incompetence [ 16 , 18 ] and in questioning their “purpose of being a doctor” [ 18 ].

In addition, medical students may be conflicted between their obligations to the safety of their families and their duty to augment healthcare workforces in the face of the COVID-19 pandemic [ 123 – 128 ]. The personal and professional desire to always ‘do no harm’ is also compromised amidst reports of feeling overwhelmed and exhausted by the increased workload and shortage of personal protective equipment (PPE) [ 129 , 130 ].

Higher volumes of dying patients also intensify the dyssynchrony between their aspiration to save lives and their forced reality to let die. Students may find themselves entangled in “emotionally and ethically fraught resource-allocation decisions” [ 24 ] due to the utilitarian shift away from individual choice and autonomy, and towards “saving as many lives” [ 131 ].

These situations are further exacerbated by the act of being thrust into a “completely new context” with the new environment in the isolation wards bringing with them “a sense of oppression” [ 130 ]. Restrictions placed on religious congregational services, limited access to usual support systems [ 132 – 135 ], and the discontinuation of death rituals as a result of safe distancing measures may lead to disenfranchised grief, with little time and space to resolve this ‘dyssynchrony’. It could be surmised from the SARS epidemic [ 136 , 137 ] that such unresolved ‘dyssynchrony’ across the various domains of personhood may result in higher rates of psychiatric morbidity, burnout and post-traumatic stress (PTS) [ 133 – 135 ]. The dyssynchronous effects of COVID-19 across the various rings and the disruptions they bring are presented in Fig.  6 .

‘Dyssynchrony’ between the rings of personhood exacerbated by the COVID-19 pandemic

Supportive interventions in medical school curriculum

Evidence of adverse clinical, psycho-emotional, spiritual and personal repercussions underlines the need to consider organizational strategies to manage these risks. While medical students have a potential role in alleviating manpower shortages, this must be weighed against other important considerations such as their physical and emotional well-being, which institutions have a duty to ensure, as well as their potential threat and actual benefit to the system. Their manifold likelihood of carrying and transmitting the virus may “introduce unnecessary risks for patients and other clinicians” and the activation of these students may consume already strained supplies of PPE [ 104 ]. Should the organisation be unable to provide adequate support to the medical students and address these concerns, it would not be ethically justifiable to involve them in patient care during this period.

In light of these and drawing from lessons learnt in ‘peace time’, we proffer suggestions as to how to address the needs of medical students entering and/or returning to clinical care. A phased return to clinical practice is crucial. This will provide educators with the opportunity to establish an ethics team to guide difficult ethical decision-making, train senior clinicians to mentor more effectively, identify at-risk students, facilitate their professional identity formation, offer access to professional help and formally integrate debriefs, discussions and reflections into the curriculum structure (Fig.  7 ). These interventions are expanded upon in Table  2 .

Suggested interventions (in blue) and their target(s)

Suggested Interventions to Improve Medical Students’ Management of Dying Patients

Limitations

This review is not without its limitations. This SSR is limited by articles published in English or with English translations. Hence, much of the data comes from North American and European Western countries or in the English language, skewing perspectives and raising questions as to the applicability of these findings in the setting of other cultures. Whilst databases used were selected by the expert team and the team utilized independent selection processes, some critical papers may still have been omitted. Despite the use of the Split Approach and tabulated summaries which allowed for triangulation and transparency in the direction of the SSR, reviewers’ inherent biases could still have an impact on the data analysis. Furthermore, while quality assessment of included articles was conducted using MERSQI and COREQ, we were unable to quality assess all the articles due to the heterogeneity in the methodologies used. While many supportive interventions were identified in this review, this SSR was not designed to assess them. More evidence-based literature reviews are required to examine the effectiveness and extensiveness of supportive interventions. As we used a single model (RToP) to review the impact of death and dying on medical students, imperfections and presumptions from the models are transferred to this review. As such, studies employing other models of personhood can be integrated to support our findings.

The findings of this SSR in SEBA should be a rallying cry to ensure that medical students are effectively supported. It is clear that support of trained senior clinicians who are sensitive to the dilemma and conflicts that students working in a structured and nurturing environment is key in the era of the COVID-19 pandemic and beyond. The silver lining in these unprecedented times may be a chance to correct years of poor preparation. We have much to learn but the adversity posed now may be just the impetus to make the change.

Supplementary Information

Acknowledgements.

The authors would like to dedicate this paper to the late Dr. S Radha Krishna whose advice and ideas were integral to the success of this paper. The authors would like to thank the anonymous reviewers whose advice and feedback greatly improved this manuscript.

Abbreviations

Authors’ contributions

CYH, CSK, CHJC, JYL, YHML, SKL, AERH, LHET, NXLL, NCPX, KTYJ, NHAK, CJL, ABHMA, AMCC, YPT, SM, LKRK were involved in data curation, formal analysis, investigation, preparing the original draft of the manuscript as well as reviewing and editing the manuscript. MC, YTO were involved in reviewing and editing the manuscript. All authors have read and approved the manuscript for submission.

No funding was received for this review.

Availability of data and materials

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All authors declare no competing interests.

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Medical education in the United Arab Emirates: Challenges and opportunities

Affiliations.

• 1 Department of Medical Education and Examination, Department of Health, Abu Dhabi, United Arab Emirates.
• 2 Chancellor Office, Gulf Medical University, Ajman, United Arab Emirates.
• 3 Department of Health Sciences Education, University of Cape Town, Cape Town, South Africa.
• PMID: 33915071
• DOI: 10.1080/0142159X.2021.1908978

Medical education (ME) in the United Arab Emirates (UAE) has a relatively short history that begins with the inception of the UAE almost 50 years ago. The UAE has made great strides in widening access to ME through the rapid implementation of national agendas aimed at advancing healthcare and expanding higher education, in addition to the presence of a strong infrastructure for privatization and business development. While progress is being made at all levels of ME, complex challenges for both undergraduate and postgraduate ME remain. Going forward, issues of standardization, quality, sustainability of academic and healthcare workforces, and research must continue to be addressed.

Keywords: Medical education; UAE; United Arab Emirates.

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2024 NIDA International Forum Executive Summary

June 14-15, 2024                 Montreal, Canada

After three years of virtual meetings, the 2024 NIDA International Forum returned to an in-person format. The meeting, which was held on June 14 and 15 in Montreal in conjunction with the College on Problems of Drug Dependence (CPDD) Annual Scientific Meeting, was cochaired by NIDA International Program’s leadership, Dr. Tom Clarke and Dr. Lindsey Friend. It was attended by over 200 individuals from 73 countries. The meeting included several plenary sessions, four breakout sessions, and an international research poster session featuring 90 posters presented by substance use and addiction researchers from 26 countries.

The Forum began on June 14 with two sessions on advancing quality of addiction study programs and on addiction neuroscience research in Bulgaria, as well as a workshop on how to get addiction research published in peer-reviewed journals.

Day 2 started with the official welcome and updates on NIDA’s programs. This was followed by four breakout sessions on addiction treatment and criminal justice systems, professional healthcare education regarding medical cannabis, addressing opioid stigma in pharmacies, and effective interventions to increase treatment access and intake in real-world settings across the globe. The meeting concluded with two plenary sessions that discussed substance use and associated health problems in humanitarian settings and addressed two current global topics, namely, emerging synthetic drugs in Latin America and the Caribbean and the treatment of children with substance use problems. Rounding out the program were a joint workshop conducted by NIDA staff and staff from the CPDD, as well as a poster session.

Following are brief summaries of the topic sessions presented at this year’s International Forum.

Welcome and NIDA Update

Dr. Clarke provided a high-level overview of NIDA’s research priorities. In the United States, the most pressing problem continues to be the opioid overdose crisis, which is currently driven by co-use of fentanyl and stimulants and disproportionately affects American Indian/Alaska Native and Black communities. Also highly concerning are continued high rates of unintentional fentanyl-related overdose deaths in youths ages 15-19. In response, NIDA’s 2022 to 2026 strategic plan has identified five core research priorities, including (1) understanding drugs, the brain, and behavior; (2) prevention, treatment, and recovery; (3) the intersection of substance use and HIV; (4) implementation science; and (5) innovative heath applications.

Dr. Clarke also introduced several large programs that NIDA supports — partly together with other NIH Institutes — to address the opioid public health crisis. One of these efforts is the Helping to End Addiction Long-term® Initiative, or NIH HEAL Initiative® — an NIH-wide effort to speed scientific solutions to the opioid health crisis that is jointly led by NIDA and the National Institute on Neurological Disorders and Stroke. Other major NIDA-supported research efforts include the longitudinal HEALthy Brain and Child Development (HBCD) and Adolescent Brain Cognitive Development (ABCD) studies, the HEALing Communities Study, the Justice Community Opioid Innovation Network (JCOIN), the Harm Reduction Research Network, and the NIDA Clinical Trials Network. Together, these efforts address challenges, such as emerging drugs (e.g., xylazine), increasing fentanyl and polysubstance use, persistent stigma, better care for hard-to-reach and underserved populations, continuity of care for substance use disorders (SUDs), and novel harm reduction approaches.

Dr. Friend summarized the activities of the NIDA International Program and its role in international policy development, information, exchange, research, and training. In particular, NIDA supports international research through grants awarded to U.S. researchers partnering with foreign investigators. NIDA’s international training and research programs include INVEST postdoctoral fellowships and Hubert H. Humphrey Fellowships. INVEST fellowships offer a 12-month postdoctoral research training with a NIDA grantee that includes professional development activities to establish personal relationships between the fellows and NIDA grantees and NIDA officials. They are for international researchers with a doctoral degree and a minimum of 2 years postdoctoral experience. Hubert H. Humphrey Fellowships are mid-career fellowships to approximately 12 individuals per year that include a 10-month research fellowship at Virginia Commonwealth University as well as 6-week professional affiliations, allowing fellows to make connections to advance their ongoing work. Additionally, NIDA offers the Distinguished International Scientist Collaboration Awards (DISCA) that fund innovative collaborations between international and NIDA-funded senior researchers. Dr. Friend also highlighted NIH’s Research Portfolio Online Reporting Tool, NIH RePORTER ( https://reporter.nih.gov ), as an excellent tool for learning about NIDA-funded projects or investigators funded in other countries.

Addiction Treatment and Criminal Justice Systems: Drug Policy Reforms and Implications

This breakout session was chaired by Dr. Gregory Bunt from the International Society of Addiction Medicine (ISAM), who introduced the International Consortium for Alternatives to Incarceration (ICATI). ICATI works with countries, organizations, professionals, and program sites to support the global development of treatment, care, and accountability as alternatives to incarceration for individuals who use drugs and become involved with the justice system. At various stages in the judicial process, the justice system can divert people to treatment and services in the community instead of incarcerating them. This has been shown to reduce recidivism. To help adopt and implement such measures, ICATI promotes and supports all phases of national and regional planning, training, technical assistance, evaluation, and implementation; identifies, develops, and provides resources; and helps establish international networks.

In lieu of Dr. Carl Erik Fisher from Columbia University in New York, who was not able to attend the meeting, Dr. Bunt also gave Dr. Fisher’s presentation on the “Portuguese model” of decriminalization as an alternative harm reduction approach for treating SUDs in minoritized communities. Decriminalization means elimination of criminal penalties for drug possession for personal use; it differs from depenalization, which generally means that criminal penalties are reduced or not enforced but are not legally eliminated, and from legalization of drug use. This approach was first implemented in Portugal, where drug possession was decriminalized in 2001 but people carrying a personal drug supply had to get mandatory treatment. This was accompanied by several other socio-medical and harm-reduction interventions for a holistic approach with wrap-around services. However, because existing laws against personal drug use had already been only loosely enforced, decriminalization may ultimately have formalized existing practices rather than drive new norms and attitudes. In the United States, a similar approach has been implemented in Oregon but has been less successful because people were not diverted to effective treatment. This suggests that even the best reform programs do not guarantee success because drug-related problems are shaped by additional factors, such as cultural attitudes, social support networks, or mental health resources.

Dr. David Martell from the Canadian Society of Addiction Medicine reported on Canada’s drug decriminalization efforts. Canada has a history of targeted exemptions from penalizing drug use, from prescription maintenance programs and wide availability of opioid agonist therapy to supervised consumption sites and drug checking programs. Dr. Martell also listed various legislative approaches to drug decriminalization, such as the 2017 “Good Samaritan Drug Overdose Act” or cannabis legalization in 2018, which legalized personal use but maintained criminal penalties for certain offenses. This legalization resulted in increased cannabis use for most age groups and a temporary increase in the cannabis industry, but more Canadians now get cannabis legally. A newer decriminalization pilot program started in 2023 decriminalizes use of small amounts of opioids, crack, cocaine, methamphetamine, or MDMA at certain sites (e.g., private residences, but also overdose prevention, drug checking, or supervised consumption sites). The aim is to eliminate the harms associated with drug seizure, help connect people who use drugs to services and support, and enhance public awareness and understanding. However, over the first 12 months, the project has not yielded benefits, and many issues are also still unaddressed. Dr. Martell concluded that Canada’s national drug policy landscape is still fragmented and the search for the best approach continues.

Dr. Hamed Ekhtiari from the University of Minnesota and ISAM Regional Council chair, discussed how the ISAM Global Expert Network (ISAM GEN) can contribute to global drug policy reforms. ISAM’s organizational hierarchy allows for representation and policy involvement across the globe through regional representatives, national ambassadors, addiction medicine societies, and 10 country experts for each country who represent the ISAM GEN. By eliciting information from these experts and conducting a range of global surveys, ISAM GEN can help map and reshape global policies. ISAM GEN has established a well-honed road map for conducting their surveys, from idea development and steering committee formation all the way to manuscript submission. ISAM GEN’s first global survey assessed treatment service provision for opioid use disorder by querying national addiction societies and organizations in 39 countries from six continents. It gathered valuable information on availability of different types of opioids and availability of different types of treatment services for opioid use disorder, harm reduction facilities, and 12-step programs. Researchers interested in establishing their own international working groups or developing surveys can contact ISAM for further information.

Medical Cannabis in Professional Healthcare Education: Multinational Policies, Perspectives, and Competencies

In this breakout session, which was moderated by Dr. Richard Isralowitz from the Ben-Gurion University of the Negev—RADAR Center in Israel, Dr. Richard Rawson, professor emeritus from the University of California, Los Angeles, first provided a historical overview of substance use training in professional curricula. He noted that information on substance use and its impact has only recently been integrated into professional healthcare training rather than being covered only in ad-hoc separate training events. Since 2000, training in substance use and its treatment has become more formalized, with exams and certification processes offered by national and international certification organizations. International training activities are coordinated by the International Consortium of Universities for Drug Demand Reduction (ICUDDR), which facilitates networking among universities to promote high-quality education and training for prevention, treatment, and public health intervention purposes. As a result, many universities now integrate alcohol, tobacco, and other drug content into their curricula, often within many specialty areas; however, cannabis and medical marijuana remain a new curriculum topic.

Dr. Yuval Zolotov from the Albert Einstein College of Medicine in the Bronx, New York, summarized the results of an international survey among healthcare professions’ students in Israel, Malta, Greece, Cyprus, Russia, Belarus, Thailand, and the United States regarding their attitudes, beliefs, and knowledge about medical cannabis. Participants were 4,427 students (70% female) of medicine, nursing, social work, and psychology; 74% came from countries where medical cannabis was legal. Dr. Zolotov reported that, overall, respondents expressed relatively high levels of support for medical cannabis, but also concerns about potential risks and harms. Almost all respondents believed that medical cannabis should be included in their education and practical experiences, but almost 87% reported receiving no formal education in this area. As a result, about 70% of respondents felt unprepared to answer patient questions about medical cannabis. Dr. Zolotov concluded that a great need for formal education in medical cannabis exists and that standardized curricula can help bridge the existing gaps.

Dr. Mazen Sakka from the Substance Abuse Research Center, Palestine, summarized a similar survey among medical staff at two hospitals and students at four universities in the Palestinian territories (West Bank, Gaza Strip) about their knowledge, beliefs, and attitudes regarding medical cannabis. The survey also explored the roles of gender, religiosity, and legal status of medical cannabis on these domains. In the Palestinian territories, cannabis is considered a schedule I substance, together with other addictive drugs. The survey found that while most medical staff and many students believed that medical cannabis can help certain patients, they also saw a high risk of mental and physical health problems. However, many respondents had only limited knowledge on the subject. Additionally, attitudes and beliefs differed somewhat between males and females and were affected by religious views and the fact that cannabis is considered an illegal drug. Nevertheless, Dr. Sakka noted that most respondents seemed open to more information or training on medical marijuana, supporting efforts to enhance such activities.

Given the apparent need for and interest in professional healthcare education on medical cannabis, Dr. Mikhail Kogan from George Washington University and Dr. Leslie Mendoza Temple from the University of Chicago described a Delphi process to identify teaching standards and essential medical cannabis education competencies. The Drug Enforcement Agency in the United States is set to reschedule cannabis to a lower status, which would require all pharmacies in the United States to carry cannabis products. After a 2021 scoping review found that healthcare trainees lack proper education and knowledge about medical cannabis, implementation of expanded competencies-based curricula is essential. Drs. Kogan and Temple described the Delphi process methodology, which relies on synthesizing opinions among a group of experts via repeated rounds of discussion until a consensus is reached. In this case, the process involved 23 experts with different areas of expertise, who identified six core competencies to guide development of medical school curricula in the United States and Canada. These included (1) understanding the basics of the endocannabinoid system, (2) describing the main components of the cannabis plant and their effects, (3) reviewing the legal and regulatory landscape on cannabis in the United States, (4) describing the evidence base for health conditions that are commonly managed with cannabis, (5) understanding the potential risks of medical cannabis use, and (6) understanding basic clinical management with medical cannabis.

Addressing Opioid Stigma in Pharmacies — Developing Strategies for Pharmacy Professionals

This breakout session with Dr. Beth Sproule and Dr. Braiden Cutmore from the Canadian Centre for Addiction and Mental Health and Dr. Sarah Bhatti from the Public Health Agency of Canada (PHAC) centered on the stigma that people who use drugs and people with chronic pain frequently face. The session focused specifically on stigma from pharmacy professionals. As Dr. Bhatti noted, experiences of stigma may decrease use of treatment and social services as well as quality of care. A 2019 report by the Canadian Chief Public Health Officer concluded that responding to stigma in the health system requires a comprehensive approach through education, training, practice, and policy. PHAC conducted a literature review to clarify the nature and manifestations of stigma; assess stigma related to treatment with naloxone, opioid agonist therapy, harm reduction approaches, and opioid treatment for pain in pharmacy professionals; as well as anti-stigma approaches. The review identified several key ingredients for anti-stigma programs, such as repeated social contact, demonstration of recovery, myth busting, and enthusiastic facilitation. Dr. Bhatti also indicated that targeted education is more successful than general education.

Dr. Cutmore described several stakeholder roundtables organized by PHAC that discussed definitions of stigma, experiences of stigma, positive experiences with pharmacies, and potential messages for pharmacy professionals. The roundtables included people with opioid use disorder, people with chronic pain, and pharmacy professionals, respectively. Based on the feedback from the three stakeholder groups, six messages for pharmacists were drafted that addressed the main themes raised — for example, that pharmacy professionals need to see patients as a whole person and treat them with dignity and respect, that they need to understand the patient’s opioid medication experience and act as allies to support patients, or that they need to proactively engage and empower patients through education. Agreement with these messages was then assessed in an anonymous survey among roundtable participants. According to Dr. Cutmore, the roundtables and resulting messages highlighted that it is crucial for pharmacy professionals to challenge negative attitudes and beliefs by reflecting on their assumptions toward people taking opioids and recognize their impact. Additionally, they need to help empower through communication their patients who are prescribed opioids.

Dr. Sproule then presented a newly developed tool kit delineating strategies for pharmacy professionals to address opioid stigma in pharmacies. It highlights eight key strategies to support people who use opioids, such as respecting all customers equally, getting to know customers, offering support through education, explaining and reviewing pharmacy process, providing harm reduction services, delivering compassionate healthcare, respecting the right to privacy, and raising public awareness. The toolkit also provides tips on how to put those strategies into practice. One concept Dr. Sproule highlighted is the idea that “words matter” — that how one talks to or about people who use substances can either reinforce or, in contrast, counter stigmatizing attitudes, views, and actions. The toolkit also includes social media assets and posters to raise awareness of and address opioid stigma in pharmacies. Infographics, videos, courses, and other resources are also available. The toolkit was launched in February 2024 with a webinar attended by more than 250 pharmacy professionals and other stakeholders.

Successful Real-World Evidence-Based Interventions That Have Increased Treatment Access and Intake in Different Countries

This breakout session was chaired by Dr. Adrian Abagiu from the Romanian National Institute for Infectious Diseases and Dr. Matei Bals from the ARENA OST Center in Romania. Dr. Abagiu reported on a program in Romania to increase adherence to antiretroviral therapy (ART) among people living with HIV (PLWH) who were incarcerated. He described that some of these individuals refused ART due to restrictions according to detention regulations. To improve ART adherence, they developed an information program involving a 20-minute PowerPoint presentation, a 10-minute Q&A session, and information leaflets for small groups of PLWH at one of the prisons. The intervention improved adherence, but the effect declined after 4 months. As a result, the program was refined further and assessed in a study comparing 100 PLWH who received the intervention with 50 PLWH who did not in one jail. Before the intervention, ART refusal rates were the same in both groups. After the intervention, refusal rates declined in the intervention group, but remained relatively stable in the control group; again, the effect was lost at 4 months after the intervention. Based on these findings, the intervention was delivered every 2 months to all new PLWH arriving at the prison, and while it had to be halted during the COVID-19 pandemic, it was resumed after the end of the pandemic.

Next, Dr. Dace Svikis from Virginia Commonwealth University described the Expanding Medical Prevention and Outreach While Enhancing Recovery and Retention (EMPOWER) project that seeks to increase engagement and retention in SUD and HIV treatment for underserved Black people in Baltimore, Maryland. Dr. Svikis explained that Baltimore has one of the highest rates of new HIV cases and also has the highest fatal overdose rates among large cities in the United States, but is also a leader in SUD treatment and harm reduction approaches. EMPOWER was assessed within the Recovery Enhanced by Access to Comprehensive Healthcare (REACH) Health Services Program that offers comprehensive outpatient SUD treatment as well as mental health counseling. However, Black individuals in the program were less likely to engage in SUD treatment, more likely to drop out of care, and thus less access to HIV-related testing and care. The EMPOWER program seeks to address these disparities using tailored, patient-focused, evidence-based interventions to engage and retain Black individuals in treatment. Importantly, the EMPOWER team includes people who have lived experience and represent the population of focus, such as peer recovery specialists and nurse care managers. EMPOWER uses evidence-based interventions, such as motivational interviewing, continency management, safer sex skill building, and Seeking Safety, a cognitive behavioral therapy for post-traumatic stress disorder and SUD. The EMPOWER program started recruitment in February 2024 and will last 6 months, after which regular REACH services will continue. Preliminary findings indicate that EMPOWER can increase treatment retention at 3 months compared with the normal REACH program; additional data will be gathered in the coming months.

The third presenter was current Hubert H. Humphrey Fellow Thinzar Tun from Myanmar, director of the Asian Harm Reduction Network (AHRN) and Best Shelter Myanmar, who reported on a program she is spearheading to increase treatment access and intake for people who use drugs (PWUD) or inject drugs (PWID). She explained that Myanmar has about 93,000 PWID, about 35% of whom have HIV. AHRN provides facility-based harm reduction, treatment, and care, whereas Best Shelter offers community-based harm reduction, prevention, referral, and care. Specific services include outreach, health education, self-help groups, job creation efforts, peer education, counseling, and treatment. Some services are specifically aimed at women as a particularly vulnerable population, such as services to improve sexual and reproductive health, as well as pre- and postnatal care, and services to curb gender-based violence. Ms. Tun specifically described their needle and syringe programs, including efforts to return and safely dispose of used needles and syringes, as well as HIV testing and treatment. These are implemented either during outreach with mobile units or at fixed locations in clinics or in the community. Ms. Thun reported that for 2022, about 18 million needles and syringes were distributed, with a return rate of 86%. For HIV testing, the program brought testing closer to the PWID and their families, allowed for effective linkage to care and rapid ART initiation, as well as testing and treatment in hard-to-reach locations. The program reduced the proportion of PWID who were HIV positive and achieved high linkage to treatment and ART initiation for both PWUD and PWID and their sexual partners. Ms. Tun concluded that to address drug use and HIV in countries such as Myanmar, understanding the context and needs of clients is essential, and that community inclusion and harm reduction approaches work.

Substance Use and Associated Health Problems in Humanitarian Settings — Responding to the Needs of Affected Populations

This plenary session was started by Dr. Anja Busse from the United Nations Office on Drugs and Crime (UNODC), who provided an update on addressing substance use in humanitarian emergencies. Dr. Busse explained that humanitarian emergencies (e.g., disasters, armed conflicts, epidemics) threaten the lives and well-being of very large numbers of people or a very large percentage of a population, often result in displacement, and require assistance from multiple sectors. There is only limited evidence on substance use among displaced persons; however, there seem to be regional differences regarding the most commonly used substances. Displaced populations or people in humanitarian emergencies may face particular challenges related to drug use, such as sudden interruptions of patterns of drug use, disruption of treatment services, and resumption of drug use with increased risk of overdose; these compound social and mental health problems associated with humanitarian crises. Dr. Busse noted that substance use is included in humanitarian health guidance as part of mental health interventions. A Desk Review by the United Nations High Commissioner for Refugees (UNHCR) found that community-based, peer-led programs and training of healthcare workers in SUD treatment are feasible in low-resource and refugee settings and that brief interventions have significant potential. Opioid agonist therapy may also be possible in humanitarian settings with support from international donors and organizations. Several international policy documents have provided policy direction for addressing SUDs in humanitarian emergencies. UNODC and the World Health Organization (WHO) have a joint program for such situations, and the UNODC/WHO International Standards for Treatment of Drug Use Disorders can be adapted for humanitarian emergencies. A handbook by UNODC, UNHCR, and WHO will soon be published, disseminated, and field-tested. It creates an implementation framework for both the acute phase and the protracted phase of the emergency. It has identified two main principles — saving lives first (i.e., addressing life-threatening concerns such as overdose and withdrawal first), and full inclusion of people with SUD in other support available.

Dr. Dzmitry Krupchanka from the WHO described the organization’s approach to addressing substance use during humanitarian emergency responses. He noted that people in humanitarian settings have much higher rates of mental health problems than other populations; moreover, mental and physical health conditions are often comorbid with SUDs. Dr. Krupchanka mentioned a 2024 WHO draft resolution on strengthening mental health and psychosocial support (MHPSS) before, during, and after humanitarian emergencies. The resolution includes MHPSS as an integral component of preparedness, response, and recovery activities in all emergencies. He then reviewed the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings, which delineate key actions to minimize harm related to alcohol and other substance use. These measures aim to conduct rapid assessments, prevent harmful alcohol and other substance use and dependence, facilitate harm reduction interventions in the community, and manage withdrawal and other acute problems. An open, free course is available to learn about this, as well as some cultural adaptations. Additionally, several WHO resources to address substance use and its consequences in humanitarian settings will be forthcoming.

Dr. Karen Paul from the IASC Reference Group for Mental Health and Psychosocial Support in Emergencies talked about interagency collaboration regarding substance use and SUD in humanitarian emergencies. She emphasized that a multi-sector response is needed in such situations, and some of these sectors are also addressed in the IASC Guidelines mentioned by Dr. Krupchanka. Dr. Paul also described the IASC MHPSS Reference Group, which is cochaired by WHO, UNODC, and UNHCR and involves over 11 member agencies as well as five observers. Their current priority is developing materials for training and orienting various groups of humanitarian workers on substance use, from materials for basic communication to materials on advanced interventions. For example, orientation materials are being developed on SUDs as health conditions, how to provide support, life-threatening conditions related to substance use, and similar topics. These materials are currently being field tested, with an eye to adapting them to various cultures and contexts. A substance use module for integrating MHPSS into disaster risk management and preparedness training is also being developed, including a framework for assessment and action.

Finally, Dr. Mustafa al’Absi from the Duluth Global Health Research Institute and the University of Minnesota discussed the implications of traumatic stress and substance use in the context of humanitarian emergencies. He noted that trauma exposure, particularly in children and adolescents, is associated with an increased risk for SUD; moreover, substance use can impact the course and severity of traumatic stress symptoms. Increases in political conflicts as well as natural disasters have led to rising mental health and substance use problems. Consequently, it is important to integrate mental health and substance use services in emergency responses and increase capacity for trauma-informed care among humanitarian workers. Dr. al’Absi presented case studies from recent conflicts and natural disasters, such as the conflicts in Syria, Yemen, and Afghanistan, or the an earthquake in Turkey. Each of these has unique features regarding substance use that need to be considered. The crisis in Afghanistan also provided an example of partnerships between WHO, UNODC, and others for treatment of SUDs to improve the health and well-being of vulnerable populations. Dr. al’Absi concluded that guidelines informed by epidemiological, intervention, and implementation knowledge are needed to address the challenge of SUD in humanitarian settings. He also issued a call to action for improving substance use services capacity and integration in humanitarian emergencies in order to help prioritize the well-being of affected populations in emergency response efforts. These efforts also must address the issue of stigma in order to be effective.

Current Global Topics: Synthetic Drugs in Latin America and the Caribbean and Treating Children for Substance Use Problems

In this session moderated by Dr. Andrew Thompson from the Bureau of International Narcotics and Law Enforcement Affairs (INL), Dr. Marya Hynes from the Inter-American Observatory on Drugs reported on emerging synthetics and new psychoactive substances (NPS) in Latin America and the Caribbean. She noted that synthetic drugs have proliferated in those drug markets, particularly since 2013, and that NPS also have become more common. Of concern are amphetamine-type stimulants (ATS), such as amphetamines and prescription stimulants, methamphetamine, synthetic hallucinogens, and synthetic opioids. Information on NPS is coming from drug seizures and early warning data that are reported to the Early Warning System for the Americas. These notifications have highlighted several trends, such as appearance of “pink cocaine” (a mixture of various synthetic compounds); increasing prevalence of benzodiazepines in females in every population studied; greater presence of stimulants, particularly among females; synthetic cannabinoids; and a variety of synthetics sold as other drugs. As Dr. Hynes emphasized, even at low prevalences, these trends are concerning because they indicate that people are using more and more mixed and adulterated substances that have unknown composition, unknown effects, often high potency, and often rapid onset and long duration of effects. The most severe implications are for countries with fragile health care systems. These developments affect particularly teenagers and young adults, including health risks and mental health issues that drive drug use and are themselves driven by drug use. These developments need to inform efforts for detection, treatment, and prevention.

Dr. Antonio Pascale from the University of Montevideo further described the health impacts of NPS and increasing availability of adulterated drugs among younger users. For example, adulterants may potentiate the toxicity of the original drugs or induce unintended toxic effects. ATS are associated with harmful effects, such as hyperthermia, which can be exacerbated by the settings where these drugs are often consumed (e.g., clubs with high temperatures, poor ventilation, and intense physical activity); serotonergic syndrome; and hyponatremia. Synthetic cannabinoids, which are increasingly used by young people as well as other vulnerable populations, can be associated with acute toxicity as well as greater morbidity and mortality in the context of polydrug use. Synthetic opioids (e.g., fentanyl and its analogues, nitazenes) are an increasing problem in Latin America with the associated acute toxicity and risk of fatal overdoses. An emerging concern is illicit use of benzodiazepines (often as adulterants of other drugs), which is associated with acute intoxication and altered consciousness that increases vulnerability to sexual crimes and other harms. Dr. Pascale concluded that to address this public health problem effectively, it is essential to strengthen networks involving government agencies, clinical and forensic laboratories, universities, toxicology centers, and nongovernment agencies with access to PWUD.

Dr. Hendrée Jones from the University of North Carolina at Chapel Hill provided an overview of the Child Intervention for Living Drug-free (CHILD) program to treat children under age 12 for substance use problems. Dr. Jones explained that children are increasingly victims of drug trafficking and drug use within their families and communities, leading to children as young as 5-12 years having an SUD. The CHILD intervention was developed to respond to this growing threat. It is a global, evidence-based program with an integrated health approach, full spectrum of services, and family involvement. It includes professional development and a tailored program for each country that uses techniques (e.g., motivational interviewing, mindfulness, dialectic behavior therapy, art therapy) that can be translated into language and activities appealing to children. The program has been disseminated to numerous countries through “training of trainers,” webinars, and “Echo” training. Dr. Jones also shared information on a randomized clinical trial of the CHILD intervention in children ages 7-12 in India. Preliminary results indicate that it reduces substance use in these children at 12 months after treatment better than usual care.

Advancing Quality in Addiction Studies Programs

In this session chaired by Dr. Carly Searcy from ICUDDR, Mr. Jordan Turner, also from ICUDDR, provided an overview of the current state of quality assurance in specialty addiction studies programs. He shared results from a survey of 322 ICUDDR members that assessed program quality along six dimensions of care in members’ curricula. Among the 88 respondents, 63% addressed quality improvement through their curriculum plans. However, qualitative data indicated a minimal focus on quality of care among institutions; barriers within member institutions that prevented quality of care to be addressed, and a need for ICUDDR’s assistance in curriculum building. Mr. Turner concluded that the study positioned ICUDDR to work with members to create frameworks for addressing quality and quality improvement.

Dr. Amelie Lososová from the Charles University in Prague presented previous research on establishing quality assurance at the university level. Several organizations, such as the Substance Abuse and Mental Health Services Administration, American Society of Addiction Medicine, and American Psychiatric Association in the United States, as well as the WHO have addressed quality standards in education programs. Similarly, two projects (WAVE project and FENIQS-EU project) have been conducted in Europe, and for the WAVE project, several project papers will be published soon. Dr. Lososová noted the importance of making education a research focus and highlighted several future research questions and challenges—for example, whether international standards are really needed, what areas of addiction research should be included; which educational programs should apply the standards; and how regional, cultural, and communication differences can be accommodated.

Dr. Dennis McCarty from the Oregon Health & Science University discussed what kind of research is needed. Examples included integration of research into educational standard development, integration of outcome measures into training processes and systems of care, assessments of the impact of standards on care delivery and outcomes, and cross-national comparisons of training and training standards. Dr. McCarty pointed out that each country is unique, and it is therefore important to determine which facets of addiction studies programs are replicable and generalizable. The relatively new areas of dissemination and implementation research are also crucial to determine how research findings can be translated into standards of practice on an international scale.

In the final presentation, Dr. Victor Capoccia from the Technical Assistance Collaborative discussed the development a certification framework for addiction studies programs as a documentation of program quality. He also highlighted questions that would need to be addressed in this process. For example, what should be included in a certification according to international standards (e.g., minimum content for the curriculum, minimum hours of exposure to content, number and qualifications of faculty). Equally important is an understanding of factors that drive differences in standards across the globe. Levels of education and credentialing desired (e.g., nondegree certification, associate, baccalaureate, master’s), cultural and historical contexts of drug use, governmental/legal context, health system infrastructure, and medical traditions all need to be considered. In fact, one set of standards may not be appropriate for all international scenarios. Thus, development of any certification or accreditation process must first determine what components are nonnegotiable and must be uniform and what country or regional characteristics might be accommodated in variations from the standards.

Twenty Years of Addiction Neuroscience Research in Bulgaria: Lessons Learned and Future Directions

This session presented the results of three sets of studies conducted by a large multinational team of researchers in Bulgaria over the past 20 years. As the first presenter, Dr. Jasmin Vassileva from Virginia Commonwealth University, explained, Bulgaria is well suited for their studies of people who use opiates and stimulants because it is located on one of the main heroin trafficking routes into Europe and is a major center for amphetamine production. Dr. Vassileva is investigating which dimensions of impulsivity are associated with addiction in general or specific drug classes. Her team used computational approaches to address this question, including data-driven, machine learning processes for classification and prediction, as well as theory-driven cognitive modeling to increase precision of neurocognitive phenotyping. Dr. Vassileva presented results of several of their studies that have been published in recent years. The findings indicated that some dimensions of impulsivity are common across addictions, whereas others are unique to specific drug classes. The studies also demonstrated that computational approaches have significant potential as phenotyping tools, for identifying markers for addictions, for increasing precision of neurocognitive assessments, and for prognosis and diagnosis. They may also help refine neurocognitive phenotypes and identify different biotypes of addictions with different underlying mechanisms, which may have implications for prevention and intervention.

Dr. Elena Psederska from the New Bulgarian University presented on studies assessing the interplay of personality and neurocognitive function in stimulant and opioid use disorders. Specifically, the team studied the effects of psychopathy on neurocognitive domains of impulsivity in people who previously had used heroin and amphetamine. They assessed the effects of the interpersonal/affective domain and the impulsive/antisocial domain of psychopathy on impulsive choice and impulsive action in both groups. The analyses identified an interaction between the two dimensions of psychopathy and dependence on specific classes of drugs. Some profiles were common across SUDs, whereas others were unique for specific drugs. Another investigation assessed neurocognitive impulsivity in people who used heroin at different times of abstinence. These analyses demonstrated that while some deficits in impulsive choice and impulsive action may only occur in early abstinence, others may persist even with sustained periods of abstinence. Overall, Dr. Psederska concluded that personality influences both common and unique profiles of impairments in neurocognitive impulsivity in people who use opioids or stimulants, and that these impairments may persist even with sustained abstinence. Thus, extended treatment and rehabilitation approaches that are tailored to individual personality profiles are needed.

The final presentation by Dr. James Bjork from Virginia Commonwealth University addressed similarities and differences in brain recruitment by reward, inhibition, and memory in people with different SUDs. The study included individuals with opioid, stimulant, or polysubstance use disorder as well as controls and compared individual differences in brain activation as measured by MRI while participants were conducting three different tasks. The study is still ongoing, but there is preliminary evidence that brain areas activated by specific tasks can be correlated with characteristics determined in addictions neuroclinical assessments, such as emotion-related impulsivity, cognitive difficulties in daily life, or inattention.

Publishing Workshop: How to Get Your Addiction Research Published in Peer-Reviewed Journals

In this workshop, Adam Gordon and Casy Calver from the International Society of Addiction Journal Editors (ISAJE) highlighted three essential aspects to publishing addiction research: choosing a journal, submission and peer review, and authorship. They noted that there are over 100 peer-reviewed addiction journals, and journals from other disciplines also publish addiction articles. They listed 15 factors to consider when choosing a journal as well as questions to ask of a journal (e.g., whether it reaches the specific audience authors want to target, the journal’s mission and content area). Practical aspects, such as editorial support provided or cost of publication/open access, are also important, as are various metrics associated with the journal. These include journal metrics (e.g., impact factor), public impact metrics (e.g., Altmetric attention score), editorial efficiency metrics (e.g., time to first decision, acceptance rate), and author metrics.

For submitting manuscripts, authors first need to check author guidelines, select an appropriate article type, and obtain approval from all authors to submit. Once a manuscript is submitted, a multistep peer-review process follows that may include one or more author revision steps. Peer review is essential to advise the editorial decision-making process, justify rejections, improve the quality of acceptable manuscripts, and identify instances of ethical or scientific misconduct. While the reviewers make recommendations, the editors make the final decision and may even disagree with reviewer recommendations. If the decision is to revise and resubmit the paper, authors should decide if they want to resubmit the paper and, if so, respond to each criticism by either modifying the manuscript or debating/refuting the criticism.

The issue of authorship is increasingly important. The authors on a manuscript certify a public responsibility for the truth of the publication. Authorship also is an indicator of productivity, promotion, and prestige, and credit should be assigned equitably. Especially in addiction research, inclusion of people with lived experience (e.g., patient coauthors in case studies) is important but authors also need to be aware of and sensitive to ethical considerations. Several measures can be taken to avoid authorship problems (e.g., early agreement on the precise roles of all contributors; periodic review of authorship credit status, and adherence to authorship guidelines). Overall, authors must avoid the “seven deadly sins” of carelessness, redundant publication, unfair authorship, undeclared conflict of interest, human subjects’ violations, plagiarism, and other fraud. To avoid plagiarism, all sources must be appropriately acknowledged and permission for use of large amounts of others’ written or illustrative materials obtained. This also applies to self-plagiarism, as authors are not allowed to reuse previously published materials when rights have been assigned to the publisher. The ISAJE provides author resources on their website ( https://www.isaje.net/ ); additional information is available in the JAMA Users’ Guide to Medical Literature and from the Committee on Publication Ethics (COPE) ( https://publicationethics.org ).