From the Editor

Simpson and colleagues discuss job roles for medical educators, highlighting new roles as diagnostic assessors, content curators, technology adopters, learner-centered navigators, professional coaches, and clinician role models (p. 243).

Perspectives

Perspectives discuss branding in graduate medical education, including brand identity, brand image, and brand positioning, and its effective use by program leaders (Shappell et al, p. 249); legal considerations in remediation, probation, and dismissal of trainees (Lefebvre et al, p. 253); and suggestions for how to transform transient international rotations into a career in global surgery (Ranganathan et al, p. 258).

Original Research

Saudek and colleagues try

ABSTRACT

Background

Letters of recommendation (LORs) are an important part of applications for residency and fellowship programs. Despite anecdotal use of a “code” in LORs, research on program director (PD) perceptions of the value of these documents is sparse.

Objective

We analyzed PD interpretations of LOR components and discriminated between perceived levels of applicant recommendations.

Methods

We conducted a cross-sectional, descriptive study of pediatrics residency and fellowship PDs. We developed a survey asking PDs to rate 3 aspects of LORs: 13 letter features, 10 applicant abilities, and 11 commonly used phrases, using a 5-point Likert scale. The 11 phrases were grouped using principal component analysis. Mean scores of components were analyzed with repeated-measures analysis of variance. Median Likert score differences between groups were analyzed with Mann-Whitney U tests.

Results

Our survey had a 43% response rate (468 of 1079). “I give my highest recommendation” was rated the most positive phrase, while “showed improvement” was rated the most negative. Principal component analysis generated 3 groups of phrases with moderate to strong correlation with each other. The mean Likert score for each group from the PD rating was calculated. Positive phrases had a mean (SD) of 4.4 (0.4), neutral phrases 3.4 (0.5), and negative phrases 2.6 (0.6). There was a significant difference among all 3 pairs of mean scores (all P < .001).

Conclusions

Commonly used phrases in LORs were interpreted consistently by PDs and influenced their impressions of candidates. Key elements of LORs include distinct phrases depicting different degrees of endorsement.

ABSTRACT

Background

Minimally anchored Standard Rating Scales (SRSs), which are widely used in medical education, are hampered by suboptimal interrater reliability. Expert-derived frameworks, such as the Accreditation Council for Graduate Medical Education (ACGME) Milestones, may be helpful in defining level-specific anchors to use on rating scales.

Objective

We examined validity evidence for a Milestones-Based Rating Scale (MBRS) for scoring chart-stimulated recall (CSR).

Methods

Two 11-item scoring forms with either an MBRS or SRS were developed. Items and anchors for the MBRS were adapted from the ACGME Internal Medicine Milestones. Six CSR standardized videos were developed. Clinical faculty scored videos using either the MBRS or SRS and following a randomized crossover design. Reliability of the MBRS versus the SRS was compared using intraclass correlation.

Results

Twenty-two faculty were recruited for instrument testing. Some participants did not complete scoring, leaving a response rate of 15 faculty (7 in the MBRS group and 8 in the SRS group). A total of 529 ratings (number of items × number of scores) using SRSs and 540 using MBRSs were available. Percent agreement was higher for MBRSs for only 2 of 11 items—use of consultants (92 versus 75, P = .019) and unique characteristics of patients (96 versus 79, P = .011)—and the overall score (89 versus 82, P < .001). Interrater agreement was 0.61 for MBRSs and 0.51 for SRSs.

Conclusions

Adding milestones to our rating form resulted in significant, but not substantial, improvement in intraclass correlation coefficient. Improvement was inconsistent across items.

ABSTRACT

Background

Despite their placement in Veterans Health Administration centers nationwide, residents' training and assessment in veteran-centered care is variable and often insufficient.

Objective

We assessed residents' ability to recognize and address mental health issues that affect US military veterans.

Methods

Two unannounced standardized patient (SP) cases were used to assess internal medicine residents' veteran-centered care skills from September 2014 to March 2016. Residents were assessed on 7 domains: military history taking, communication skills, assessment skills, mental health screening, triage, and professionalism, using a 36-item checklist. After each encounter, residents completed a questionnaire to assess their ability to recognize knowledge deficits. Residents' mean scores were compared across training levels, between the 2 cases, and by SP gender. We conducted analysis of variance (ANOVA) tests to analyze mean performance differences across training levels and descriptive statistics to analyze self-assessment questionnaire results.

Results

Ninety-eight residents from 2 internal medicine programs completed the encounter and 53 completed the self-assessment questionnaire. Residents performed best on professionalism (0.92 ± 0.20, percentage of the maximal score) and triage (0.87 ± 0.17), and they scored lowest on posttraumatic stress disorder (0.52 ± 0.30) and military sexual trauma (0.33 ± 0.39). Few residents reported that they sought out training to enhance their knowledge and skills in the provision of services and support to military and veteran groups beyond their core curriculum.

Conclusions

This study suggests that additional education and assessment in veteran-centered care may be needed, particularly in the areas of posttraumatic stress disorder and military sexual trauma.

What I would give to you

Is the knowledge that

Whatever you can give,

Whoever you can be,

However you can make it work

And live as you, really you . . .

It will be enough.

You will fall down,

You will fail.

You will feel hot tears fill your eyes

And urge them not to spill,

But you will feel them

Wet your cheeks,

Reminding you.

You will wish you could do

More. That you could be more

Than you have been.

But you will be enough.

You will feel the beat of your own heart

Drum in