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course director and medical students developed and
assessed the impact of a short verbal CR tool,
adapted from prior CR research, during the first
day in the anatomy laboratory. The tool raises the
possibility that emotions may arise during the ses-
sion and provides several explicit suggestions for
how students can regulate their emotions, including
viewing the dissection laboratory as an opportunity
to acquire skills and knowledge, recognising one’s
own control over the situation, and acknowledging
the naturalness of death. We developed a control
reading, which did not provide students with expli-
cit instructions regarding how to regulate their emo-
tions. One hundred and twenty-first-year medical
students from the class of 2018 at the Johns Hop-
kins School of Medicine were randomised to either
a control or CR group. The introductory anatomy
laboratory session was conducted by facilitators who
had undergone a standardised training and who
used facilitator guides that were identical aside from
the differing passages that were read aloud by fac-
ulty members. Surveys administered prior to and
after the introductory laboratory session assessed
the emotional responses of students.
What lessons were learned? Total negative emotion
and seven of 10 individual measures of emotional dis-
tress were decreased in the CR group as compared
with the control group (total, p = 0.003; uneasy,
p = 0.012; overwhelmed, p = 0.032; fearful,
p = 0.002; incompetent, p = 0.028; disgusted,
p = 0.009; nauseous, p = 0.025; depressed, p =
0.045). Moreover, comparison of pre- and post-ses-
sion responses demonstrated either a significantly
larger decrease or a significantly smaller increase in
many negative emotions with CR. We believe that
these data provide support for CR as an effective way
to reduce negative emotions in medical students dur-
ing their first anatomy laboratory session. In addi-
tion, these findings raise the possibility that CR could
be employed during other emotionally challenging
learning situations and transitions during medical
school, thereby complementing current emphases on
self-care and stress management. Several limitations,
however, prevent us from making firmer conclusions.
Our survey only included measures of negative emo-
tion, which may have had an influence on student
responses. Moreover, we realised upon reflection that
our control reading passage might have inadvertently
augmented anxiety in the control group. As a result,
we plan to modify our control reading and to
broaden our survey to include measures of positive
emotions. In addition, we plan to incorporate survey
measures that address student learning, professional-
ism and well-being, as we are ultimately interested in
assessing the impact of CR on these domains.
566 ª 2016 John Wiley & Sons Ltd. MEDICAL EDUCATION 2016; 50: 564–591
REFERENCE
1 John OP, Gross JJ. Healthy and unhealthy emotion
regulation: personality processes, individual
differences, and life span development. J Pers 2004;72
(6):1301–1334.
Correspondence: Arun Venkatesan, The Johns Hopkins University
School of Medicine, Meyer 6-113, 600 N. Wolfe Street, Baltimore,
Maryland 21287, USA. Tel: 410 955 3730;
E-mail: avenkat2@jhmi.edu
doi: 10.1111/medu.13026
A code blue debriefing session to foster resiliency
Stephen Gauthier & Lisa Richardson
What problems were addressed? Cardiac arrest
resuscitations (code blues) are run by an interdisci-
plinary team. At our hospital, the internal medicine
on-call senior resident leads the team. Junior resi-
dents and medical students also attend. Code blues
can be stressful and emotionally intense situations
for trainees. A survey of our trainees (residents and
medical students) revealed a range of emotions
associated with attending code blues, including sad-
ness, shock and uncertainty. Currently, there is no
formal process for debriefing within the medical
team after a code blue. Of the 17 instances over a
1-month period in which trainees were involved in
code blues, debriefings occurred in only 59% of
cases.
What was tried? We developed a 1-hour interactive
debriefing session for all trainees on the internal
medicine clinical teaching units. The objective was
to create a supportive and non-judgemental space
in which they could discuss all aspects of the resusci-
tations, including both the medical expert content
and, of equal importance, their emotional responses
to the events. We hoped to normalise both the
expression and the discussion of these emotional
responses to foster trainee resiliency. Furthermore,
we wanted to share with trainees a framework for
reflective practice to help them debrief after future
code blues.
Sixteen trainees attended the session. Levels of
training varied from Year 3 of medical school to
fourth year of residency. The session was co-facili-
tated by the chief medical resident, residency site
director and a member from spiritual care. We dis-
cussed each of the code blues that had occurred in
the preceding month. In a non-judgemental way,
the group reflected on the medical aspects of the
code blue, including what went well and what could

have gone better. We then focused on the emo-
tional responses before (when the code blue was
announced overhead), during and after the event.
The facilitator from spiritual care used the focused
conversation method1 as a model for reflection
upon which trainees could subsequently draw to
provide a framework for conversations immediately
after future code blues.
What lessons were learned? A survey conducted
2 weeks after the session revealed that 81% of
respondents felt more comfortable discussing their
emotions following a code blue, 88% felt better pre-
pared to deal with the stress and emotions associ-
ated with code blues, and 94% felt that they were
more likely to debrief immediately following a code
blue in the future. In the supportive environment
of our debriefing session, trainees were comfortable
in sharing a range of emotions related to code
blues. Although many trainees were saddened or
upset by them, some described feelings of detach-
ment or indifference following a cardiac arrest. This
was associated with guilt or a feeling that something
may be wrong with them. In the follow-up survey,
one trainee stated that it was helpful to know that
he was not alone in feeling this way.
Whereas the expression of emotions by practition-
ers is often undermined by medical education’s
hidden curriculum, we learned that our trainees are
engaged and fulfilled by these reflective activities
when they are legitimised in the formal curriculum.
REFERENCE
1 Hogan C. Practical facilitation: a toolkit of techniques.
London: Kogan Page Publishers 2005.
Correspondence: Lisa Richardson, Department of Medicine,
Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario
M5T 2S8, Canada. Tel: 00 1 416 603 5800;
E-mail: lisa.richardson@uhn.ca
doi: 10.1111/medu.13014
The importance of quality improvement
education for medical students
Burton Shen, Luba Dumenco, Richard Dollase
& Paul George
What problems were addressed? Quality improve-
ment (QI) is an integral part of understanding
health care systems and health care delivery, and is
important in reducing patient morbidity and mortal-
ity. However, it is often overlooked in the traditional
preclinical curriculum. To quantify this area of need
ª 2016 John Wiley & Sons Ltd. MEDICAL EDUCATION 2016; 50: 564–591
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in medical education, we developed a survey to
assess rising third-year medical students’ prior expo-
sure to and understanding of QI, as well as an inter-
active task intended to highlight the importance of
collaboration and teamwork in using QI in practice.
Prior to this curricular initiative, we surveyed our
rising third-year students (n = 120, response rate =
76.7%). A majority of rising third-year medical stu-
dents had no exposure to QI or Plan, Do, Study,
Act (PDSA) cycles (57.1% and 82.6%, respectively).
However, a majority of students felt that QI was at
least as important as the basic science and clinical
curriculum in medical school (60.2% and 63.5%,
respectively).
What was tried? The Clinical Skills Clerkship is a
3-week required course that prepares rising third-
year medical students for their clinical rotations. As
part of this clerkship, an interprofessional education
workshop is held, where nursing, pharmacy, physical
therapy, social work and third-year medical students
work together. As part of this workshop, we modi-
fied a previously described curriculum innovation
using Mr Potato Head1 to teach QI to interprofes-
sional teams.
In this curricular initiative, teams of interprofes-
sional students were asked to predict how many Mr
Potato Heads they would be able to assemble in a
certain amount of time according to provided dia-
grams and then performed the task of doing so.
Students typically struggled to completely assemble
all of the Mr Potato Head patterns they were given
the first time they performed the task in their
groups. The students then repeated the task a sec-
ond and third time after briefly discussing modifica-
tions they would make to their approach. Each
time, students were asked to debrief about what
worked well, what did not, and what they would
change in future iterations. Students were also
asked how lessons learned from this could be
applied to working in interprofessional health care
teams and how they personally will apply the lessons
learned in clinical settings.
What lessons were learned? Most medical students
have not had any exposure to QI or PDSA cycles;
however, a majority of students believed that QI
should be a part of the medical school curriculum.
This deficit of QI education in undergraduate medi-
cal education can be addressed through fun, brief
exercises, such as Mr Potato Head, that teach rising
third-year medical students basic principles of both
QI and working in interprofessional teams. This
type of task is also developmentally appropriate
right at the beginning of the third year, as most stu-
dents will not have had sufficient exposure to clini-
cal settings to appreciate the role of QI principles
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