What Do Medical Students Actually Want from Learning Communities? A Comprehensive Needs Assessment

This article was migrated. The article was marked as recommended. Purpose: The demanding nature of medical education has been well-described. Learning Communities (LCs) have been formed in a number of medical schools to address unmet needs such as wellness, social support, and academic/career counseling. However, there is limited information regarding the student perspective in shaping LC goals and activities. This study examined that perspective using a needs assessment survey. Methods: A formal needs assessment survey was completed by 510 medical students. The survey included 16 Likert-scale items and one open response item. Topics focused on student well-being, career planning, meaningful professional relationships, and academic success. Results: As expected, residency success and academic performance were the domains ranked as most important. Of note, the domain of wellness was ranked as less important overall. Results also varied by medical school year and gender. Conclusion: Formal assessment of student needs can serve as a guide to the development of LC programming, hopefully increasing student engagement.


Introduction
A growing number of medical schools are implementing learning communities (LC) in order to address student needs (Champaloux and Keeley, 2016;Slavin, Schindler and Chibnall, 2014;Smith et al., 2016).Although the general objective of LCs is to improve the learning environment for student success in medical school, the structure and specific goals of LCs vary widely.Some LCs are within curriculum, including clinical skills teaching and board preparation, while others are extracurricular, including activities related to professional development and social bonding (Shochet et al., 2019).Even the names used to describe LCs vary, some of which include advisory colleges, academic houses and Learning Communities.
Several articles describe the process of implementing LCs in medical schools (Fleming et al., 2013;Stewart et al., 2007;Wasson et al., 2016).Faculty typically decide what types of LC activities may be valuable to students.Yet if the purpose of implementing LCs is to enhance student experience, their active input is essential (Baños, Noah and Harada, 2019;Ferguson et al., 2009;Rosenbaum et al., 2007).Student needs assessments in the form of questionnaires or structured interviews are seen as a valuable resource for collecting student input related to programs and educational experiences.In an emergency medicine interest group curriculum, faculty and student opinions differed in a formal needs assessment (Lee, Uijtdehaage and Coates, 2011).An extensive search of the existing literature regarding needs assessments for LCs from a student perspective did not yield any further results.There is a need for research on this topic from the student perspective (Tackett et al., 2011).An important objective of this study was to assess whether student goals for LCs were consistent with those of the faculty.To our knowledge, this is the first reported student needs assessment during the formation of a LC in a medical school setting.
The purpose of this study was to conduct a formal assessment of the students' perceived needs from the LC.In other words, what do students perceive to be important needs which might be met in a learning community?

Methods
This study was a cross-sectional survey offirst (M1), second (M2), and third year (M3) class of medical students to ascertain their perceived needs that might be served in a LC program.
Setting: The College of Medicine (COM) at the University of Arkansas for Medical Sciences (UAMS) offers a four-year M.D. degree.The COM, a Liaison Committee on Medical Education (LCME) accredited public institution, is the only M. D.-granting medical school in Arkansas, a mid-sized largely rural Southern state.Our mission is to create physicians who will serve the medical needs of our state.This study was reviewed by the institutional review board and deemed exempt.
Learning Communities: The COM was facing challenges of a more competitive residency process as well as a need for better academic advising and professional mentoring.In an effort to address these issues, the COM implemented a learning communities program in 2016.Each LC consists of 100 students (25 students per class) with 6 faculty LC advisors (2 PhDs and 4 MDs), except our Northwest regional campus house which includes 60 students and two faculty (with 1 PhD and 1 MD).

Population:
The population surveyed included M1-M3 students during the spring of 2016.Male/female ratio for the class of 2019 (M1) was 55% male / 45% female, the class of 2018 (M2) was 62% male / 38% female, and the class of 2017 (M3) was 69% male / 31% female.M4 students were not surveyed because they would not be a part of the newly established LC program.

Instrument:
The 17-item needs assessment was designed with input from representative faculty and administrators who had been involved in professional development related to learning community implementation (See Appendix 1).The questions covered the following five domains: (1) residency success (guidance on preparing for residency, guidance with residency application and guidance with career choice); (2) academic performance (step preparation, better academic performance in courses, access to other faculty in research); (3) wellness (strategies to decrease burn-out, ways to manage personal stress, ways to manage school related stress, and work-life balance); (4) professional relationships (improved academic collaboration with other students, having meaningful relationships with other students, and having meaningful relationships with faculty advisors; and (5) cross-domains (time management skills, help getting organized, & access to opportunities in community service).
The students were asked to rate each item they would like to see achieved through the academic houses as "not important," "somewhat important," and "most important."It also included demographic questions on age, gender, race, and ethnicity.The survey included a space to write in any other expectations students had for the LCs.The needs assessment was distributed via paper following a class session for two of the classes (M1s and M2s) and electronically for the M3s because the students were located at various clinical sites.The survey was anonymous and voluntary.
Data Analysis: Data were analyzed using the SAS v 9.4 (Cary, NC).Proportions of students responding to specific items were calculated.Statistical significance comparing responses between gender and medical school year were estimated using Chi square test of proportions.

Results/Analysis
A total of 406 students participated in the needs assessment survey giving a response rate of 80%.Of the respondents, 36.7% were M1 students (N=149), 38.9% (N=158) were M2 students, and 24.4% (N=99) were M3 students.Of those who identified their gender, 61.6% (N=231) were males, 38.4% (N=144) were females, and 31 did not identify a gender.Of those who identified their race, 84.2% (N=304) identified themselves as Caucasian, 15.8% (N=57) identified as non-Caucasian, and 45 students did not identify their race.
Overall the domains students ranked as "most important" were residency success and academic performance.The domains that students felt were less important were wellness, professional relationships, and professional development.The sub-domains that students most often selected as being "most important" included: guidance in preparing for residency (86.6%), the residency application process (85.9%), and help in United States Medical Licensing Examinations (USMLE) Step preparation (70.3%).In addition, assistance in achieving better academic performance in courses (59.1%) and meaningful relationships with faculty advisors (54.8%) were the next two areas of importance.
The sub-domains that students selected most often as "not important" were: help getting organized (37.4%), time management skills (34.8%), ways to manage personal stress (34.0%), work-life balance (26.7%), and improved academic collaboration with other students (26.1%) (Table 1).The three major themes that emerged from the wide range of comments that students wrote about their expectations from the LCs included help with the residency process and match, relationship with faculty, and relationship with other students.
Perceived Needs by Medical School Class.Of the five sub-domains most often selected as "most important," the perceived needs varied by medical school class for guidance with the residency application process (p=.004),USMLE Step preparation (p<.0001), better academic performance in courses (p=.004), and having meaningful relationships with faculty advisors (p=.004).Fewer M3 students selected these sub-domains as "most important" compared to M1 and M2 students.The sub-domain of guidance in preparing for residency did not vary by class (Table 2).
Of the sub-domains that students selected most often as "not important," the perceived needs varied by medical school class for work-life balance (p=.01) and help getting organized (p=.03).More M1 students selected these as "not important" compared to M2 and M3 students.The sub-domains of time management skills, ways to manage personal stress, and improved academic collaboration with other students did not vary by class (Table 2).
Perceived Needs by Gender.Of the sub-domains that students most often selected as being "most important," only two varied by gender: having meaningful relationships with other students (p=.007) and meaningful relationships with faculty advisors (p<.0001).Female students more often selected these as being "most important" compared to male students.The other three sub-domains of guidance for preparing for residency, Step preparation, and better academic performance in courses did not vary by gender (Table 3).
Of the sub-domains that students most often selected as "not important," only work-life balance varied by gender, where more males reported it as being not important (p=.01).The other four sub-domains of help getting organized, time management skills, ways to manage personal stress, and improved academic collaboration with other students did not vary by gender (Table 3).

Discussion
To the best of our knowledge, this is the first published survey of medical students' expectations and needs regarding their participation in a learning community.The focus of LCs in many medical schools includes promoting wellness, developing leadership skills, improving interpersonal relationships, and creating a more positive learning environment (Fleming et al., 2013;Stewart et al., 2007).We anticipated that our students would have similar priorities.The survey results in some domains were expected, while other results were not.Although there was substantial overlap in faculty and student opinions of what students could gain from participation in LCs, there were also areas where student priorities were different from faculty priorities.
As expected, domains related to career success such as academic performance and residency success were high priority for students across years.While meaningful relationships with faculty advisors and other students were also high priority for the students across years, they were significantly higher priority for female students.The focus on career success was not surprising given the increased challenges surrounding board exams, residency selection, and the match process.In addition, interests and needs varied according to program year.For example, M1s and M2s were more interested in USMLE Step 1 preparation, whereas M3s were more interested in the residency selection process.The planning processes for establishing the LCs incorporated these expected findings.
One unexpected finding was that although the M3 students noted that residency preparation was their highest priority, the proportion who ranked that as most important was lower than the M1s and M2s.This may be the result of the fact that the M3s were already connected with specialty advisors and were receiving mentoring, albeit outside of the LC.In addition, the college holds required meetings where residency selection and National Residency Match Program (NRMP) preparation is covered throughout the year.
Another unexpected finding was in the wellness domain.Faculty felt work-life balance and stress management was an important need for students and prioritized this as one of the main objectives of the LCs.However, students reported wellness as a lower priority when compared with academics.A possible explanation for this is that students view personal wellness as something they should self-manage and distinct from their school work.Thus, they view wellness as less of a priority when competing with the demands of medical school, impending USMLE Step examinations, and residency selection process.Nevertheless, approximately one-third of the students ranked the four wellness sub-domains as "most important."Given the well-documented high rates of depression and stress among medical students in the literature (Wasson et al., 2016;Dyrbye, Thomas and Shanafelt, 2006), it is critical to educate students in the importance of wellness and proactively incorporate such activities into the LCs.
The results of this unique needs assessment survey provided valuable information that were used to inform development and modification of our LC activities.More proactive wellness programs were offered to students.The COM started an annual Academic House Olympics for the LCs, where students bring family and friends to participate in friendly, competitive, recreational activities.Longitudinal 1:1 faculty-student mentoring across all four years was established as part of the LC mentoring program.Community service was incentivized within the LC structure.In addition, the feedback also provided ideas to implement in the medical school curriculum.For example, a required longitudinal senior residency preparation course was added to the curriculum.USMLE Step 1-style question review sessions were also added to the pre-clinical curriculum.A limitation of this study is that this needs assessment was a one-time cross-sectional survey.It is possible that perceived needs may change over time.Nevertheless, the findings of this study provide valuable insight to schools who want to begin or improve their LC programs.This needs assessment model will be used to make future improvements to our LCs.

Conclusion
Several findings of the study would be helpful for other schools as they plan the development or improvement of LCs.
Activities that promote academic success and residency preparation, which students ranked as highest priorities, are likely to be well accepted.However, students may be less likely to accept LC activities designed to address wellness, time management, and help with organization because they may not perceive them as high priorities.It should nevertheless be considered a critical mission of an LC to educate students as to why these areas are important and integral to their academic and career success, and to provide students with skills to improve in those areas.

Take Home Messages
Formally assessing student needs is important in programatic and curriculum planning.
Students ranked academic success and residency preparation as highest priorities for learning community programming.
Students may be less likely to accept learning community activities designed to address wellness, time management, and help with organization because they may not perceive them as high priorities.

Notes On Contributors
Karina Renee Clemmons, EdD, is an Associate Professor at the University of Arkansas for Medical Sciences College of Medicine.
Sara Ghori Tariq, MD, is a Professor at the University of Arkansas for Medical Sciences College of Medicine.
James Graham, MD, is a Professor at the University of Arkansas for Medical Sciences College of Medicine.
Jason Scott Mizell, MD, is an Associate Professor at the University of Arkansas for Medical Sciences College of Medicine.
Annlee Taylor Glass-Hicks, BS, is a medical student at the University of Arkansas for Medical Sciences College of Medicine.
Purushottam Bhadra Thapa, MD, is a Professor at the University of Arkansas for Medical Sciences College of Medicine.

Ken Masters
Sultan Qaboos University This review has been migrated.The reviewer awarded 4 stars out of 5 An interesting paper on what medical students actually want from learning communities.This is an important topic, as my experience has frequently been that faculty direct the creation of the LC based upon perceived needs, and are guided strongly by the curriculum and teaching circumstances and their own experiences.In this case, the authors have approached the problem from the other side: identifying student needs.These may not always coincide with curriculum and professional requirements, but is a useful approach to gathering information on which to build.The study has been well conducted, has clear goals, and has mostly met those goals.I do feel, however, that given the wide disparity between the needs expressed by the students, and massive impact of burnout and other issues that is known to hit residents, that the study results would have been strengthened with follow-up focus groups, because one area that would need to be explored more detail is what to do with the information.I would venture that it would be a grave disservice to the students if the school decided to tailor their effort only at these needs.One interpretation of the results may be that the students may have no idea about what they are about to face.On the other hand, another interpretation may be that the current student support system is so well structured, and students are already receiving such high-quality support, that they feel they have the confidence to concentrate on other issues.Before the school restructures any efforts, it would be useful to round off this research by examining those aspects in more detail.Nevertheless, a useful read to gauge the students' perspectives on what is required.
Competing Interests: No conflicts of interest were disclosed.
Reviewer Report 12 February 2020 https://doi.org/10.21956/mep.19961.r30329 © 2020 Gibbs T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Trevor Gibbs AMEE
This review has been migrated.The reviewer awarded 4 stars out of 5 An interesting paper that I enjoyed reading.I believe it is an important paper during a time when student / doctor resilience is being discussed, as is the burn-out and stress levels of students.One of the main reasons for student stress is often quoted as an early need to be looking toward the future and enabling a clinical position, which I feel supports your conclusions.As you say, the paper does have its limitations but despite those I do think that the paper deserves recognition and I would recommend it to all curriculum planners Competing Interests: No conflicts of interest were disclosed.

Table 1 .
Listing of Needs Reported by Medical Students to Accomplish Through the Academic Houses (N=406)

Table 2 .
Listing of Needs Reported by Medical Students to Accomplish Through the Academic Houses (N=406) by Medical School Year

Table 3 .
Listing of Needs Reported by Medical Students to Accomplish Through the Academic Houses (N=406) by Gender*

Table 3 .
Continued Other areas you would like to gain from the Learning Community/Academic House:DeclarationsThe author has declared that there are no conflicts of interest.Statement This study was submitted to University of Arkansas for Medical Sciences Institutional Review Board (IRB) and was declared exempt because it was determined not to be "human subject" under the policy.IRB number 205850.Website for general policies: http://irb.uams.edu/irb-policies/The new and improved learning community at Johns Hopkins University School of Medicine resembles that at Hogwarts School of Witchcraft Continued Which of the following do you WANT to achieve from involvement in the Learning Community/Academic House?Rate on a scale of 1-3 from Not important to Most important.Tackett,, S., Wright,, S., Colbert-Getz,, J. and Shochet,, R. (2018) Associations between learning community engagement and burnout, quality of life, and empathy among medical students.International Journal of Medical Education.9, pp.316-322.Reference Source Wasson,, L. T., Cusmano,, M. A., Meli,, L., Louh,, I., et al. (2016) Association between learning environment interventions and medical student well-being: A systematic review.Journal of the American Medical Association.316(21), pp.2237-2252.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.