I recently visited a retired physician who practiced in Roma, Texas, population 10 000. His family has lived and ranched in Roma for 6 generations, well before the border was moved and Roma became part of the United States. As the town's first and only physician for most of his 4-plus decades in practice, Dr Mario Ramirez did it all: deliveries, house calls, minor sugery, and seeing 60 people a day. After wearing himself ragged by racing to attend women in labor, far away from his office, he managed to rent a house, a historical structure, right in Roma's central square
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From the Guest Editors
MD and
ScM, MD
Editor's note: This reflection was jointly authored by Tazo and Thomas Inui. Tazo is a first-year resident in the University of California, San Diego, surgery program. Thomas (Tazo's father) was an intern and resident in the Osler Medicine Service at Johns Hopkins Hospital. One generation apart, they recall their first night on call, noting differences and similarities.
1969, Baltimore, Maryland, Medicine Intern Thomas Inui
On the afternoon of Tuesday, June 30, 1969, I picked up my “whites” and presented myself to Osler 3, one of the internal medicine house staff services at the Johns Hopkins Hospital. My internship formally began
PhD, MBA
Merriam-Webster’s dictionary defines supervision as “critical watching and directing (of activities or a course of action).”1 Though attention has focused predominantly on limits on resident hours, New York State’s regulations, the Institute of Medicine subcommittee recommendations, and the Accreditation Council for Graduate Medical Education requirements all stipulate that supervision is critical for patient safety and the education and professional development of residents. Much of this issue of JGME is devoted to work on supervision and the related topic of clinical teaching and learning.
Twin editorials reflect on clinical learning and practice. Abraham Verghese (p 1) discusses
Supervision
PhD, JD,
DO,
MS,
PhD,
MD, MS,
MD,
MD, MA,
MD, MPH,
PhD,
MD, MPH,
MD, PhD,
MD,
MD, and
BS
Abstract
Background
Graduate medical education is based on an on-the-job training model in which residents provide clinical care under supervision. The traditional method is to offer residents graduated levels of responsibility that will prepare them for independent practice. However, if progressive independence from supervision exceeds residents' progressive professional development, patient outcomes may be at risk. Leaders in graduate medical education have called for “optimal” supervision, yet few studies have conceptually defined what optimal supervision means and whether optimal care is theoretically compatible with progressive independence, nor have they developed a test for progressive independence.
Objective
This research develops theory and analytic models as part of the Resident Supervision Index to quantify the intensity of supervision.
Methods
We introduce an explicit set of assumptions for an ideal patient-centered theory of optimal supervision of resident-provided care. A critical assumption is that informed attending staff will use available resources to optimize patient outcomes first and foremost, with residents gaining clinical competencies by contributing to optimal care. Next, we derive mathematically the consequences of these assumptions as theoretical results.
Results
Under optimal supervision, (1) patient outcome is expected to be no worse than if residents were not involved, (2) supervisors will avoid undersupervising residents (when patients are at increased risk for poor outcomes) or oversupervising residents (when residents miss clinical opportunities to practice care), (3) optimal patient outcomes will be compatible with progressive independence, (4) progressive development can be inferred from progressive independence whenever residents contribute to patient care, and (5) analytic models that test for progressive independence will emphasize adjusting the association between length of graduate medical education training and supervision for case complexity and clinic workload, but not patient health outcomes.
Conclusion
An explicit theoretical framework is critical to measure scientifically progressive independence from supervision using graduate medical education data.
PhD, JD,
DO,
MD, MA,
MS,
PhD,
MD, MS,
MD,
MD, MPH,
PhD,
MD, MPH,
MD, PhD,
MD,
MD, and
BS
Abstract
Background
A Resident Supervision Index (RSI) developed by our research team quantifies the intensity of resident supervision in graduate medical education, with the goal of testing for progressive independence. The 4-part RSI method includes a survey instrument for staff and residents (RSI Inventory), a strategy to score survey responses, a theoretical framework (patient centered optimal supervision), and a statistical model that accounts for the presence or absence of supervision and the intensity of patient care.
Methods
The RSI Inventory data came from 140 outpatient encounters involving 57 residents and 37 attending physicians during a 3-month period at a Department of Veterans Affairs outpatient clinic. Responses are scored to quantitatively measure the intensity of resident supervision across 10 levels of patient services (staff is absent, is present, participated, or provided care with or without a resident), case discussion (resident-staff interaction), and oversight (staff reviewed case, reviewed medical chart, consulted with staff, or assessed patient). Scores are analyzed by level and for patient care using a 2-part model (supervision initiated [yes or no] versus intensity once supervision was initiated).
Results
All resident encounters had patient care supervision, resident oversight, or both. Consistent with the progressive independence hypothesis, residents were 1.72 (P = .019) times more likely to be fully responsible for patient care with each additional postgraduate year. Decreasing case complexity, increasing clinic workload, and advanced nonmedical degrees among attending staff were negatively associated with supervision intensity, although associations varied by supervision level.
Conclusions
These data are consistent with the progressive independence hypothesis in graduate medical education and offer empirical support for the 4-part RSI method to quantify the intensity of resident supervision for research, program evaluation, and resident assessment purposes. Before informing policy, however, more scientific research in actual teaching settings is needed to better understand the relationships among patient outcomes, clinic workload, case complexity, and graduate medical education experience in resident supervision and professional development.
MD, MPH,
MD,
MD, and
MD
Abstract
Background
As part of an ongoing evaluation of our residency program, a needs assessment was performed to assess resident and attending perspectives on current methods of surgical skills training in the operating room.
Methods
Participants included obstetrics-gynecology residents and faculty at a university program. Two surveys were developed and validated. Results were analyzed with 2-sample t tests, comparing Likert scores. Findings were significant if the difference between means was >1.
Results
Thirty of 31 residents and 40 of 60 attending physicians responded to the survey. Residents and attending physicians agreed that the surgical skills training program needs improvement (difference in mean, −0.39; confidence interval [CI]: −0.98 to 0.20). The areas of most disagreement were regarding feedback on surgical skills and instrument handling (difference in mean, 2.53; CI: 1.81–3.26, and difference in mean, 2.24; CI: 1.44–3.05).
Conclusions
A significant proportion of surgical skills training during residency occurs as on-the-job training, and operating room time provides a key learning opportunity. This report demonstrates that there is a noteworthy difference in the perception of attending physicians and residents about the quality of teaching and feedback that is currently occurring in the operating room. The difference in perspectives among residents and attending physicians reported in this survey suggests a need for improved communication and systematic feedback in order to capitalize on operating room time as a critical surgical skills training arena.
MD,
PhD, and
MD
Abstract
Background
Concerns over patient safety have made adequacy of clinical supervision an important component of care in teaching settings. Yet, few studies have examined residents' perceptions about the quality and adequacy of their supervision. We reanalyzed data from a survey conducted in 1999 to explore residents' perspectives on their supervision.
Methods
A national, multispecialty survey was distributed in 1999 to a 14.5% random sample of postgraduate year 2 (PGY-2) and PGY-3 residents. The response rate was 64.4%. Residents (n = 3604) were queried about how often they had cared for patients “without adequate supervision” during their preceding year of training.
Results
Of responding residents, 21% (n = 737) reported having seen patients without adequate supervision at least once a week, with 4.5% saying this occurred almost daily. Differences were found across specialties, with 45% of residents in ophthalmology, 46% in neurology, and 44% in neurosurgery stating that they had experienced inadequate supervision at least once a week throughout the year, compared with 1.5% of residents in pathology and 3% in dermatology. Inadequate supervision was found to be inversely correlated with residents' positive ratings of their learning, time with attendings, and overall residency experience (P < .001 for all), and positively correlated with negative features of training, including medical errors, sleep deprivation, stress, conflict with other medical personnel, falsifying patient records, and working while impaired (P < .001).
Conclusions
In residents' self-report, inadequate clinical supervision correlates with other reported negative aspects of training. Collectively, this may detrimentally affect resident learning and patient safety.
MD, MHPE,
MSPH, PhD,
MD, PhD,
PhD,
MD,
PhD, and
MD, MA
Abstract
Background
Supervision is central to resident education and patient safety, yet there is little published evidence to describe a framework for clinical supervision. The aim of this study was to describe supervision strategies for on-call internal medicine residents.
Methods
Between January and November 2006, internal medicine residents and attending physicians at a single hospital were interviewed within 1 week of their final call on the general medicine rotation. Appreciative inquiry and critical incident technique were used to elicit perspectives on ideal and suboptimal supervision practices. A representative portion of transcripts were analyzed using an inductive approach to develop a coding scheme that was then applied to the entire set of transcripts. All discrepancies were resolved via discussion until consensus was achieved.
Results
Forty-four of 50 (88%) attending physicians and 46 of 50 (92%) eligible residents completed an interview. Qualitative analysis revealed a bidirectional model of suggested supervisory strategies, the “SUPERB/SAFETY” model; an interrater reliability of 0.70 was achieved. Suggestions for attending physicians providing supervision included setting expectations, recognizing uncertainty, planning communication, having easy availability, reassuring residents, balancing supervision, and having autonomy. Suggested resident strategies for seeking supervision from attending physicians included seeking input early, contacting for active clinical decisions or feeling uncertain, end of life issues, transitions in care, or help with systems issues. Common themes suggested by trainees and attending physicians included easy availability and preservation of resident decision-making autonomy.
Discussion
Residents and attending physicians have explicit expectations for optimal supervision. The SUPERB/SAFETY model of supervision may be an effective resource to enhance the clinical supervision of residents.
MD,
MD,
MD, and
MD, DrPH
Abstract
Background
An increased emphasis on patient safety has led to calls for closer supervision of medical trainees. It is unclear what effect an increased degree of faculty presence will have on educational and clinical outcomes. The aim of this study was to evaluate resident and attending attitudes and preferences regarding overnight attending supervision.
Methods
This study was a cross-sectional electronic survey of physicians. Participants were resident and faculty physicians recently on inpatient service rotations after implementation of an overnight attending coverage system.
Results
Of 58 total respondents, most faculty (91%) and resident (92%) physicians reported they were satisfied with the overall quality of care delivered and believed the quality of care delivered overnight improved with an in-house attending system (90% and 85%, respectively). Most resident physicians (82%) believed the educational experience improved with the system of increased attending availability. Nearly all faculty (95%) and resident (97%) physicians preferred the in-house attending system to the traditional system of attendings being available by pager. The implementation of such coverage resulted in increased cost to the hospital for compensating covering hospitalist physicians.
Conclusion
In-house attending coverage was acceptable to both residents and faculty, with perceived improvements in quality and educational experience.
MD, MSc,
MD, MPH,
MD, FHM,
MD, FACP,
MD, and
MD, MSc, FHM
Abstract
Background
In 2003, the Accreditation Council for Graduate Medical Education instituted common duty hour limits, and in 2008 the Institute of Medicine recommended additional limits on continuous duty hours. Using a night-float system is an accepted approach for adhering to duty hour mandates.
Objective
To determine the effect of an on-site night-float attending physician on resident education and patient care.
Methods
Night-float residents and daytime ward residents were surveyed at the end of their rotation about the impact of an on-site night-float attending physician on education and quality of patient care. Responses were provided on a 5-point Likert scale ranging from 1, strongly agree, to 5, strongly disagree.
Results
Overall, 92 of the 140 distributed surveys were completed (66% response rate). Night-float residents found the night-float attending physician to be helpful with cross-cover issues (mean = 2.00), initial history and physical examination (mean = 1.56), choosing appropriate diagnostic tests (mean = 1.79), developing a treatment plan (mean = 1.74), and improving overall patient care (mean = 1.91). Daytime ward residents were very satisfied with the quality of the admission workups (mean = 1.78), tests and diagnostic procedures (mean = 1.76), and initial treatment plan (mean = 1.62) provided by the night-float service.
Conclusion
A night-float system that includes on-site attending physician supervision can provide a valuable opportunity for resident education and may help improve the quality of patient care.
Bedside Care and Learning
MD, MPH,
MD, MPH,
MD, PhD,
MD,
MD, MPH, and
MD
Abstract
Objective
At our institution, traditional postpartum rounds consisted of separate visits from all members of the obstetric team. This led to patient care inefficiencies and miscommunication. In an effort to improve patient care, patient-centered collaborative care (PCCC) was established, whereby physicians, residents, medical students, nurses, case managers, and social workers conduct rounds as a team. The goal of this observational study was to evaluate how PCCC rounds affected resident physicians' assessment of their work environment.
Methods
Obstetrics and gynecology residents completed a 13-question written survey designed to assess their sense of workflow, education, and workplace cohesion. Surveys were completed before and 6 months after the implementation of PCCC. Responses were compared in aggregate for preintervention and postintervention with Pearson χ2 test.
Results
Ninety-two percent of the obstetrics residents (n = 23) completed the preintervention survey, and 79% (n = 19) completed the postintervention survey. For most measures, there was no difference in resident perception between the 2 time points. After implementation of PCCC rounds, fewer residents felt that rounds were educational (preintervention = 39%, postintervention = 7%; P = .03).
Conclusion
Residents did not report negative impacts on workflow, cohesion, or general well-being after the implementation of PCCC rounds. However, there was a perception that PCCC rounds negatively impacted the educational value of postpartum rounds. This information will help identify ways to improve the resident physician experience in the obstetric service while optimizing patient care.
MD,
MD, MPH,
MD,
MD, MPH,
MD, MSPH, and
MD, PhD
Abstract
Objective
At our institution, traditional postpartum rounds were time consuming and inefficient with a low percentage (approximately 12%) of patients meeting the goal of being discharged by 11:00 am. A patient-centered collaborative care (PCCC) initiative was implemented to improve discharge efficiency, staff communication, and patient satisfaction. We investigated whether this paradigm shift to PCCC could improve clinical inefficiencies and timely discharge.
Methods
The PCCC rounding system was created by a representative group of physicians, residents, nurses, case managers, and social workers. An intervention study was conducted to examine the impact of PCCC during which physicians, residents, medical students, nurses, case managers, and social workers made rounds together. Efficiency data were collected for patients whose infants were delivered by the obstetric service for a 1-month period before and 6 months after implementing PCCC. Comparisons were made on the time of discharge and whether Foley catheter removal affected discharge time. χ2 test, Wilcoxon 2-sample test, and Pearson correlation coefficient were used where appropriate.
Results
Three hundred five patients were included in this analysis, of which 156 participated in traditional postpartum rounds and 149 in PCCC rounds. Discharge efficiency significantly improved with PCCC rounds, with 20.8% of patients being discharged by 11:00 am as compared to 11.5% for traditional postpartum rounds (P = .03). Early Foley catheter removal was significantly associated with time to discharge order (Pearson correlation coefficient, 0.22; P = .01) and discharge time (Pearson correlation coefficient, 0.28; P = .002).
Conclusions
Patient-centered collaborative care rounds improve the efficiency of postpartum care and discharge time.
MD,
MD,
DNP, MPH,
MPH,
MD,
MD, and
PhD
Abstract
Background
There are well-established deficiencies in residents' knowledge of acute-pain assessment and treatment in hospitalized children.
Methods
Among residents in 3 specialties (anesthesiology, orthopedics, and pediatrics), we investigated whether a pediatric pain management (PPM) curriculum that offered a lecture combined with a demonstration of how to use the OUCH card would yield higher performance on a subsequent PPM knowledge assessment. The OUCH card was created as a portable reference tool for trainees to provide analgesic dosing information, pain-assessment tools, and treatment of opioid-induced adverse effects. There was an initial convenience sample of 60 residents randomized to Form A or B of the pretest. From this, 39 residents (15 anesthesiology, 13 orthopedic, 11 pediatric) completed a PPM knowledge posttest approximately 4 weeks after the pretest, PPM lecture, and OUCH card instruction.
Results
Using a repeated measure design, the interaction of resident specialty and pretest to posttest scores was significant (P = .01) along with the covariate of residency year (P = .026).
Conclusions
These preliminary data based on a convenience sample of residents suggest that PPM training along with use of the OUCH card may help to reduce knowledge differences among residents. Faculty whose clinical practice includes children with acute pain should consider including learning or performance aids like the OUCH card in education and clinical care for its potential benefit in resident learning.
MD and
MD, JD
Abstract
Background
Pediatric residency programs are required to provide community and child advocacy experiences, but providing such community knowledge within the context of a busy, largely hospital-based training program can be challenging.
Objective
To assess the effectiveness of a community resource fair as a tool for increasing residents' knowledge of community-oriented care resources.
Design/Methods
We organized a community resource fair for pediatrics and family medicine residents. Exhibitors (n = 31) represented a wide range of pediatric resources. An anonymous preassessment and postassessment was administered.
Results
Thirty-two trainees participated in the resource fair. On the basis of the preassessment, 62% (8 of 13) of the pediatrics residents reported that they had little or no knowledge about community resources, while 38% (5 of 13) were neutral; none felt somewhat or very knowledgeable. After the fair, 91% (10 of 11) of residents felt somewhat knowledgeable and 9% (1 of 11) felt very knowledgeable about community resources. Of the resident participants, 92% (12 of 13) found this to be a “worthwhile experience.”
Conclusions
The community resource fair provides an interactive format that brings residents and community organizations face-to-face to discuss what services are offered and how they can work together to coordinate patient care.
MD, MPH,
MD, MPH,
MD,
MD, and
MD
Abstract
Background
The learning atmosphere of hospital morning report is frequently interrupted by nonurgent beeper pages to participating residents.
Intervention
During 176 consecutive internal medicine morning reports, 1 of the 4 chief residents at a single academic medical center collected and answered house staff pages during the 30-minute conference.
Results
A total of 884 pages were answered during this period. Of these, 743 could wait until after the end of morning report, resulting in more than 4 interruptions averted per session. Over half of the pages were from nursing personnel. There was no significant decrease in the total number of pages or nurse pages during the observation period.
Discussion
In summary, our simple system of holding intern pages resulted in a dramatic reduction in interruptions during hospital morning report.
Evaluation and Assessment
MD,
PhD,
MA,
PhD, and
MD
Abstract
Purpose
The purpose of this study was to describe the validation process for assessing an instrument to assess residents' aseptic technique skills.
Methods
The validation study entailed comparisons of the performance of aseptic technique procedures between postgraduate year–1 (PGY-1) surgical residents and PGY-2/3 surgical residents. We also compared the performance of PGY-1 surgical residents from 2 different academic years for the same procedures. Finally, we compared the performance of novices (medical students) and experts (operating room nurses) in an effort to determine validity.
Results
Our initial analysis found no significant difference between the performance of PGY-1 (mean score, 75.8) and PGY-2/3 (mean score, 75.6) surgical residents for aseptic technique (t (55) = 0.84, P = 0.404). Further investigation of validity was obtained to determine whether the no difference results reflected a lack of reliability or validity or a true equivalence between the 2 cohorts. The comparison of novices and experts produced the following findings. For reliability, the internal consistency of the checklist for each of the 2 raters was 0.87 and 0.71 (Cronbach α), interrater reliability was 0.74, with P < 0.001 (intraclass correlation coefficient) for the global scale. (Internal consistency was done within instrument, ie, between items not between raters.) For validity, operating room nurses outperformed students on the global scale (t 14 = 7.47, P < 0.0001 and t (14) = 10.66, P < 0.0001 for the 2 raters, respectively) and on several checklist items. The effect size values for raters were large (Cohen d = 3.0 and 4.4), providing validity evidence for the ability of this assessment to detect difference in performance on this task.
Conclusion
The validation study showed that the instrument exhibited reliability and evidence for validity, making it useful for the assesment of aseptic technique skills in different specialties. Programs may want to consider using a validated instrument to check competence given that appropriate use of sterile technique frequently occurs in the context of unsupervised activities. Further work is needed to enhance resident skills in the area of aspectic technique because of limited improvement despite additional clinical experience.
MD,
MD,
MD,
MD,
MD,
MD,
MD,
PhD, and
PhD
Abstract
Background
Although residency programs must prepare physicians who can analyze and improve their practice, practice improvement (PI) is new for many faculty preceptors. We describe the pilot of a PI curriculum incorporating a practice improvement module (PIM) from the American Board of Internal Medicine for residents and their faculty preceptors.
Methods
Residents attended PI didactics and completed a PIM during continuity clinic and outpatient months working in groups under committed faculty.
Results
All residents participated in PI group projects. Residents agreed or strongly agreed that the projects and the curriculum benefited their learning and patient care. A self-assessment revealed significant improvement in PI competencies, but residents were just reaching a “somewhat confident” level.
Conclusion
A PI curriculum incorporating PIMs is an effective way to teach PI to both residents and faculty preceptors. We recommend the team approach and use of the PIM tutorial approach especially for faculty.
PhD,
PhD,
MD,
MD, and
MA
Abstract
Background
Cultural competency is an important part of medical policy and practice, yet the evidence base for the effectiveness of training in this area is weak. One reason is the lack of valid, reliable, and feasible tools to quantify measures of knowledge, skill, and attitudes before and/or after cultural training. Given that cultural competency is a critical aspect of “professionalism” and “interpersonal and communication skills,” such a tool would aid in assessing the impact of such training in residency programs.
Objectives
The aim of this study is to enhance the feasibility and extend the validity of a tool to assess cultural competency in resident physicians. The work contributes to efforts to evaluate resident preparedness for working with diverse patient populations.
Method
Eighty-four residents (internal medicine, psychiatry, obstetrics-gynecology, and surgery) completed the Cross-Cultural Care Survey (CCCS) to assess their self-reported knowledge, skill, and attitudes regarding the provision of cross-cultural care. The study entailed descriptive analyses, factor analysis, internal consistency, and validity tests using bivariate correlations.
Results
Feasibility of using the CCCS was demonstrated with reduced survey completion time and ease of administration, and the survey reliably measures knowledge, skill, and attitudes for providing cross-cultural care. Resident characteristics and amount of postgraduate training relate differently to the 3 different subscales of the CCCS.
Conclusions
Our study confirmed that the CCCS is a reliable and valid tool to assess baseline attitudes of cultural competency across specialties in residency programs. Implications of the subscale scores for designing training programs are discussed.
PhD, ABPP,
PhD, ABPP, and
MD, FAAFP
Abstract
Background
The SEGUE (Set the stage, Elicit information, Give information, Understand the patient's perspective, and End the encounter) Framework is a checklist-style rating scale to facilitate the teaching and assessment of communication skills in medical learners. It has been used for over 15 years, and it is recommended in the Accreditation Council for Graduate Medical Education toolbox of assessment methods for resident training. When it was developed, its ability to provide objective scoring was a substantial improvement over global ratings.
Methods
In this article we describe the strengths and weaknesses of the SEGUE Framework. We highlight one residency program's experience with using the SEGUE Framework to evaluate residents' communication skills. Specifically, we cite previous studies and describe our own analysis of resident interviewing performance that demonstrates how the SEGUE Framework did not distinguish between different levels of interviewing skill level in our sample.
Results
Two case examples illustrate how the SEGUE Framework is not an ideal instrument to measure either the quality or the process of medical interviews.
Conclusion
Therefore, we propose a new method of contextualized assessment that builds on the SEGUE Framework. Our system evaluates discrete interviewing behaviors within the context of an ambulatory medical interview. We describe our interview structure, as well as a new instrument (the Wy-Mii, pronounced “why me”), to assess both communication and interpersonal skills. We expect that our new method of contextualized assessment will better differentiate between beginning and advanced levels of medical interviewing skills for residents.
MD and
MD
Abstract
Background
The Accreditation Council for Graduate Medical Education promotes direct observation of residents as a key assessment tool for competency in patient care, professionalism, and communication skills. Although tools exist, validity and reliability have not been demonstrated for most, and many tools may have limited feasibility because of time constraints and other reasons. We conducted a study to measure feasibility of a simplified observation tool to evaluate these competencies and provide timely feedback.
Methods
In the pediatric resident continuity clinic of a large children's hospital, we used a direct observation form with a 3-point scale for 16 items in the domains of patient care, professionalism, and communication skills. The form was divided by portion of visit, with specific items mapped to 1 or more of the competencies, and was used to provide direct oral feedback to the resident. Faculty and residents completed surveys rating the process (ease of use, satisfaction, and self-assessed usefulness) on a 5-point Likert scale.
Results
The study encompassed 89 surveys completed by attending physicians; 98% (87 of 89) of the time the form was easy to use, 99% (88) of the time its use did not interfere with patient flow, and 93% (83) of the observations provided useful information for resident feedback. Residents completed 70 surveys, with the majority (69%, 48) reporting they were comfortable about being observed by an attending physician; 87% (61) thought that direct observation did not significantly affect their efficiency. Ninety-seven percent of the time (68) residents reported that direct observation provided useful feedback.
Conclusion
The data suggest the form was well-received by both faculty and residents, and enabled attending physicians to provide useful feedback.
MD,
MD,
AB,
MD,
MD, PhD, and
MD
Abstract
Background
The Accreditation Council for Graduate Medical Education requires fellows in many specialties to demonstrate attainment of 6 core competencies, yet relatively few validated assessment tools currently exist. We present our initial experience with the design and implementation of a standardized patient (SP) exercise during gastroenterology fellowship that facilitates appraisal of all core clinical competencies.
Methods
Fellows evaluated an SP trained to portray an individual referred for evaluation of abnormal liver tests. The encounters were independently graded by the SP and a faculty preceptor for patient care, professionalism, and interpersonal and communication skills using quantitative checklist tools. Trainees' consultation notes were scored using predefined key elements (medical knowledge) and subjected to a coding audit (systems-based practice). Practice-based learning and improvement was addressed via verbal feedback from the SP and self-assessment of the videotaped encounter.
Results
Six trainees completed the exercise. Second-year fellows received significantly higher scores in medical knowledge (55.0 ± 4.2 [standard deviation], P = .05) and patient care skills (19.5 ± 0.7, P = .04) by a faculty evaluator as compared with first-year trainees (46.2 ± 2.3 and 14.7 ± 1.5, respectively). Scores correlated by Spearman rank (0.82, P = .03) with the results of the Gastroenterology Training Examination. Ratings of the fellows by the SP did not differ by level of training, nor did they correlate with faculty scores. Fellows viewed the exercise favorably, with most indicating they would alter their practice based on the experience.
Conclusions
An SP exercise is an efficient and effective tool for assessing core clinical competencies during fellowship training.
MD,
BA,
MD,
MA, and
MD
Abstract
Objective
To assess if the Thomas-Kilmann Conflict MODE Instrument predicts residents’ performance.
Study Design
Nineteen residents were assessed on the Thomas-Kilmann conflict modes of competing, collaborating, compromising, accommodating, and avoiding. Residents were classified as contributors (n = 6) if they had administrative duties or as concerning (n = 6) if they were on remediation for academic performance and/or professionalism. Data were compared to faculty evaluations on the Accreditation Council for Graduate Medical Education (ACGME) competencies. P value of < .05 was considered significant.
Results
Contributors had significantly higher competing scores (58% versus 17%; P = .01), with lower accommodating (50% versus 81%; P 5 .01) and avoiding (32% versus 84%; P = .01) scores; while concerning residents had significantly lower collaborating scores (10% versus 31%; P = .01), with higher avoiding (90% versus 57%; P = .006) and accommodating (86% versus 65%; P = .03) scores.
There were significant positive correlations between residents’ collaborating scores with faculty ACGME competency evaluations of medical knowledge, communication skills, problem-based learning, system-based practice, and professionalism. There were also positive significant correlations between compromising scores and faculty evaluations of problem-based learning and professionalism with negative significant correlations between avoiding scores and faculty evaluations of problem-based learning, communication skills and professionalism.
Conclusions
Residents who successfully execute administrative duties are likely to have a Thomas-Kilmann profile high in collaborating and competing but low in avoiding and accommodating. Residents who have problems adjusting are likely to have the opposite profile. The profile seems to predict faculty evaluation on the ACGME competencies.
Environment and Context
MD,
MD,
AS,
PhD, and
MD
Abstract
Objective
This study sought to evaluate the immediate impact of participation in the Electronic Residency Application Service (ERAS) on a single cardiology fellowship program.
Method
The study reviewed all applications (n = 1824) made to the Geisinger Medical Center cardiology fellowship program over a 4-year period (2004–2007). The aggregate data for the first 2 years (pre-ERAS, 2004 and 2005) was compared to that of the last 2 years (post-ERAS, 2006 and 2007).
Results
Compared to the pre-ERAS period, the total number of applications in the post-ERAS period increased by 49% (732 versus 1092; p<.05) and the number of complete applications increased by 70% (577 versus 983; p<.05). Other significant differences (p<.05) included a higher percentage of applications from female candidates (81 of 732 [11%] versus 186 of 1092 [17%]), and a greater geographic distance from applicants’ internal medicine residency institutions (420 ± 454 miles versus 585 ± 559 miles]. Comparison of applicants’ age, citizenship status, graduation origin, years since medical school graduation, and United States Medical Licensing Examination scores yielded no significant differences between pre-ERAS and post-ERAS periods.
Conclusion
Participation in ERAS resulted in an immediate increase in the total number of applications, higher proportion of applications with complete data, a higher number and proportion of female applicants, and a wider geographic distribution of applications. This likely reflects ease of application submission through a central electronic service. However, the administrative burden on fellowship programs and the effects of wider geographic distribution of applications on the fellowship-matching process merit further evaluation.
MD,
PhD, and
MD
Abstract
Background
Residency programs strive to accurately assess applicants' qualifications and predict future performance. However, there is little evidence-based guidance on how to do this. The aim of this study was to design an algorithm for ranking applicants to an internal medicine residency program.
Methods
Ratings of overall performance in residency were compared to application characteristics of 230 graduating residents from 2000–2005. We analyzed 5 characteristics of the application: medical school, overall medical school performance, performance in junior medicine clerkship, United States Medical Licensing Examination (USMLE) Step 1 score, and interview ratings. Using bivariate correlations and multiple regression analysis, we calculated the association of each characteristic with mean performance ratings during residency.
Results
In multiple regression analysis, the most significant application factors (r 2 = 0.22) were the quality of the medical school and the applicant's overall performance in medical school (P < .001).
Conclusion
This data has allowed the creation of a weighted algorithm to rank applicants that uses 4 application factors—school quality, overall medical school performance, medicine performance, and USMLE Step 1 score.
MD, PhD and
MD
Abstract
Objective
To develop and evaluate an academic career development curriculum.
Methods
We anonymously surveyed 25 fellows and advanced trainees in 9 obstetrics and gynecology subspecialty fellowships prior to the start of an academic career development common curriculum in 2007. Results were compared with responses from the same survey given at the completion of the 2-year program to guide and improve the curriculum. Fourteen surveys were completed for both administrations.
Results
Most fellows expressed the desire to pursue academic careers and planned to present and publish research from their fellowship in both surveys. After completing the curriculum, fellows reported overall improvement in self-appraised confidence for speaking at national meetings and preparing a research grant. The most substantial change in self-assessment was increased awareness and utilization of departmental research support personnel. Elements of training that showed improvement but were not main topics of core sessions included the frequency of constructive feedback from mentors and peers, and frequency of discussion of research ethics.
Conclusion
Instituting an academic career development curriculum for obstetrics and gynecology fellows was associated with increased self-appraised confidence in specific academic skills as assessed by anonymous survey.
MD, MPH,
PhD,
PhD,
PhD,
BA, and
MD
Abstract
Background
Beginning a graduate medical education training program is associated with a steep learning curve for incoming residents.
Objective
To compare the efficacy and efficiency of live versus webcast formats for Institutional Orientation.
Methods
This 2-year non-blinded study, with a nonrandomized cohort, compares outcomes for trainees oriented Summer 2005 in a ‘‘live-lecture’’ format with trainees oriented Summer 2006 using a webcast format. Outcomes include posttest success, the time required, presentation quality and utility, and cost.
Results
In 2005, 249 trainees attended the live orientation. Of the 211 who completed the posttest; 132 (63%) passed it within 3 attempts. Of the 241 trainees in 2006, 236 completed the posttest. Of these, 215 (91%) passed it within 3 attempts. Compared to the live-lecture cohort, the webcast cohort rated the posttest as more difficult. Despite performing better, significantly fewer trainees in the webcast cohort rated the posttest as “appropriate” (χ2 = 5 28.57, df 5 1, P , .001). There were no significant differences between the 2 groups on their perceptions of quality and utility of the presentations. While the first year cost of the webcast exceeded that of live lectures, the amortized cost was nearly identical to the live-lecture costs.
Discussion
As corroborated by resident comments, the web-based approach was more effective because it provided trainees flexibility regarding when to study, options on how to view the material, and opportunities to review it if needed for mastery. We plan to continue using the webcast strategy, revising the content as needed.
ACGME News and Views
MD
Editor's Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its review committees. The decision to publish the article is made by the ACGME.
Underlying the clamor for reform of health care insurance, financing, and delivery is a demand for accountability in medical education. Academic medicine must overcome complexity and inertia to accommodate unprecedented societal expectations for safety, quality, and reliability. To achieve this shift, the academic community must rethink and transform learner supervision, autonomy, observation, and feedback.
Deep-rooted logical fallacies impede this transformation. Several key items are discussed in
PhD, MBA
Editor's Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its review committees. The decision to publish the article is made by the ACGME.
Resident physicians are inserted into the challenging context of the inpatient unit to meet the twin aims of learning and provision of care for patients. The institution of national limits on resident hours in 2003 has focused attention on the patient handoff as a critical time when failures in information transfer may produce subsequent errors in care. Errors attributed to problems with the handoff
Rouge on the Lips of Silence
Yuki TeramotoMD, PhD
Evaluating Methodology for Increasing Diversity in US Residency Training Programs: A Scoping Review
Lauren BoeckermannMD, MPH,
Dennis MenjivarBS,
Emily E. HagnMD,
Melissa PreviteraMLIS,
Samuel H. CheshierMD, PhD,
Hilary C. McCraryMD, MPH, and
Jeremiah A. AltMD, PhD
Scoping Review of Simulation-Based Training for Social Determinants of Health Within Residency Programs
Nathan TunellMS,
Sehr KhanMD,
Ashley PavlicMD, MA, and
Taylor SonnenbergMD, MSGH
Career Outcomes Among Graduates of 2 Urban Health Primary Care Training Programs
Preetham BachinaBS,
Ariel G. VilidnitskyMD,
Katherine ShawMD,
Monica MixMD, MPH,
Talia Robledo-GilMD, and
Leonard FeldmanMD, FACP, FAAP, MHM
Trends in MedEdPORTAL Faculty Development Resources for Clinician Educators
Amna AneesMD, FACP,
Craig NoronhaMD,
Aashish DidwaniaMD, and
Karen FriedmanMD, MS
The Effect of Paging Reminders on Fellowship Conference Attendance: A Multi-Program Randomized Crossover Study
Joshua SmithMD,
Lorenzo ZaffiriMD,
Julie ClaryMD, MBA,
Tyler DavisMD, and
Gabriel T. BossletMD, MA
A Values Affirmation Intervention to Improve Female Residents' Surgical Performance
Arghavan SallesMD, PhD,
Claudia M. MuellerPhD, MD, and
Geoffrey L. CohenPhD
Improving Residents' Safe Opioid Prescribing for Chronic Pain Using an Objective Structured Clinical Examination
Daniel P. AlfordMD, MPH,
Brittany L. CarneyMS,
Belle Brett EDD,
Sharon J. ParishMD, and
Angela H. JacksonMD
Integrating a Resident-Driven Longitudinal Quality Improvement Curriculum Within an Ambulatory Block Schedule
Aleksey TentlerMD,
Mirela FeurdeanMD,
Steven KellerPhD, and
Neil KothariMD
Skills for Interviewing Adolescent Patients: Sustainability of Structured Feedback in Undergraduate Education on Performance in Residency
Nadim JoukhadarBSc,
Genna BourgetMD,
Sarah ManosMD,
Karen MannPhD,
Jill HatchettePhD, and
Kim BlakeMD
eISSN: 1949-8357
ISSN: 1949-8349
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