Consider the last time you sat down to begin a complex activity, such as writing a scientific article or crafting a persuasive letter to a colleague. When you started did you have, in your head, an exact outline of what you wanted to say and then transferred those ideas, verbatim, to your word-processing software? Or did you have a general idea of the topics you wanted to cover and, as you began writing, saw your text emerge as you typed and interacted with the software? In other words, did your final written document go directly from your brain
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FROM THE EDITOR
MD, MCR,
PhD, and
MD, MPH
Merriam-Webster defines quality as a degree of excellence.1 What is left unstated is how degree and excellence are defined. Does this suggest that the quality of medical education research, like beauty, lies in “the eye of the beholder?” Can we measure quality objectively and consistently or is it subjective and contextual, varying with the type of research question, reviewers' judgments, or quality indices applied? Do these factors capture the aspects of quality that you, our readers, value? We pose these questions for your consideration as you read the following review papers published
From the Editor
Artino views graduate medical education through the lens of situated cognition, commenting on perception rather than memory as the primary means by which people learn and learn to apply the knowledge gained (pp. 177).
Perspectives
Three perspectives address training for careers in primary care. West discusses attributes of generalist practice that may limit the appeal of “front line” medicine (pp. 184). Lee summarizes dialogue from a Society of General Internal Medicine Education Summit on how graduate medical education can help meet primary care challenges arising from the implementation of the Affordable Care Act (pp. 187). Orientale proposes
PERSPECTIVES
MD, PhD
The United States is facing a severe shortage of physicians providing access at the front lines of care access. Specialties with provider shortages include general medicine, family medicine, and other fields providing longitudinal primary and comprehensive care.1,2 In fact, because nearly one-half of visits to subspecialists actually involve primary and general medical care services,3,4 the insufficient supply of front-line physicians to meet patient care demands may be even more extreme than current projections suggest.
Despite this impending crisis, student and resident interest in these front-line longitudinal care fields has been stagnant at
MD,
MD, MPP,
MD,
MD, MPH,
MD, MPH, and
MD, FACP
Introduction
The ground has shifted in US health care. With President Obama's reelection in November 2012, the Affordable Care Act is here to stay, and tens of millions of Americans soon will gain access to health insurance. Numerous experiments are underway to better organize and coordinate care at the levels of the individual practice, the “medical neighborhood,” and the larger health system.1–5 Underlying these activities is a fundamental switch from a reactive care system oriented toward sickness (in which individual providers were paid for discrete elements of care) to a proactive care system oriented toward wellness,
MD
Abstract
How long a resident must train to achieve competency is an ongoing debate in medicine. For family medicine, there is an Accreditation Council for Graduate Medical Education (ACGME)–approved proposal to examine the benefits of lengthening family medicine training from 3 to 4 years. The rationale for adding another year of residency in family medicine has included the following: (1) overcoming the effect of the duty hour limits in further reducing educational opportunities, (2) reversing the growing number of first-time takers of the American Board of Family Medicine primary board who fail to pass the exam, (3) enhancing the family medicine training experience by “decompressing” the ever-growing number of Residency Review Committee requirements to maintain accreditation, and (4) improving the overall quality of family medicine graduates.
SPECIAL ARTICLE
MD, FACP and
MD, FRCPC, FCCP
Abstract
Many nations are struggling with the design, implementation, and ongoing improvement of health care systems to meet the needs of their citizens. In the United Arab Emirates, a small nation with vast wealth, the lives of average citizens have evolved from a harsh, nomadic existence to enjoyment of the comforts of modern life. Substantial progress has been made in the provision of education, housing, health, employment, and other forms of social advancement. Having covered these basic needs, the government of Abu Dhabi, United Arab Emirates, is responding to the challenge of developing a comprehensive health system to serve the needs of its citizens, including restructuring the nation's graduate medical education (GME) system. We describe how Abu Dhabi is establishing GME policies and infrastructure to develop and support a comprehensive health care system, while also being responsive to population health needs. We review recent progress in developing a systematic approach for developing GME infrastructure in this small emirate, and discuss how the process of designing a GME system to meet the needs of Emirati citizens has benefited from the experience of “Western” nations. We also examine the challenges we encountered in this process and the solutions adopted, adapted, or specifically developed to meet local needs. We conclude by highlighting how our experience “at the GME drawing board” reflects the challenges encountered by scholars, administrators, and policymakers in nations around the world as they seek to coordinate health care and GME resources to ensure care for populations.
REVIEWS
MD
Given how much is spent annually on medical education, it is quite remarkable how little is invested in research to spur the generation of theories and provide evidence about what works and what does not. In the arena of graduate medical education (GME), we are all familiar with the figure of $9.5 billion, the amount the Centers for Medicare & Medicaid Services expends annually on direct and indirect medical education payments.1 However, the actual annual expenditure on residency education, including Veterans Administration funding, the contributions of the states through Medicaid, and the support that hospitals provide to fund
MD,
MD, MPH,
MD,
MD, MSPH,
MD, MPH,
MD, PhD,
MD,
MD,
MD, PhD,
MD,
MD, PhD,
MD,
MS, and
MD, MPH
Abstract
Background
Evidence-based practice in education requires high-quality evidence, and many in the medical education community have called for an improvement in the methodological quality of education research.
Objective
Our aim was to use a valid measure of medical education research quality to highlight the methodological quality of research publications and provide an overview of the recent internal medicine (IM) residency literature.
Methods
We searched MEDLINE and PreMEDLINE to identify English-language articles published in the United States and Canada between January 1, 2010, and December 31, 2011, focusing on IM residency education. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI), which has demonstrated reliability and validity. Qualitative articles were excluded. Articles were ranked by quality score, and the top 25% were examined for common themes, and 2 articles within each theme were selected for in-depth presentation.
Results
The search identified 731 abstracts of which 223 articles met our inclusion criteria. The mean (±SD) MERSQI score of the 223 studies included in the review was 11.07 (±2.48). Quality scores were highest for data analysis (2.70) and lowest for study design (1.41) and validity (1.29). The themes identified included resident well-being, duty hours and resident workload, career decisions and gender, simulation medicine, and patient-centered outcomes.
Conclusions
Our review provides an overview of the IM medical education literature for 2010–2011, highlighting 5 themes of interest to the medical education community. Study design and validity are 2 areas where improvements in methodological quality are needed, and authors should consider these when designing research protocols.
MD, MSc, FRCPC,
MD,
MD, MHPE, and
MD, MPH
Abstract
Background
A rapidly evolving body of literature in medical education can impact the practice of clinical educators in graduate medical education.
Objective
To aggregate studies published in the medical education literature in 2011 to provide teachers in general internal medicine with an overview of the current, relevant medical education literature.
Review
We systematically searched major medical education journals and the general clinical literature for medical education studies with sound design and relevance to the educational practice of graduate medical education teachers. We chose 12 studies, grouped into themes, using a consensus method, and critiqued these studies.
Results
Four themes emerged. They encompass (1) learner assessment, (2) duty hour limits and teaching in the inpatient setting, (3) innovations in teaching, and (4) learner distress. With each article we also present recommendations for how readers may use them as resources to update their clinical teaching. While we sought to identify the studies with the highest quality and greatest relevance to educators, limitation of the studies selected include their single-site and small sample nature, and the frequent lack of objective measures of outcomes. These limitations are shared with the larger body of medical education literature.
Conclusions
The themes and the recommendations for how to incorporate this information into clinical teaching have the potential to inform the educational practice of general internist educators as well as that of teachers in other specialties.
MD,
MD,
MD,
MD,
MD, and
PhD
Abstract
Background
Exploring the trends in surgical education research offers insight into concerns, developments, and questions researchers are exploring that are relevant to teaching and learning in surgical specialties.
Objective
We conducted a review of the surgical education literature published between 2002 and 2012. The purpose was 2-fold: to provide an overview of the most frequently cited articles in the field of surgical education during the last decade and to describe the study designs and themes featured in these articles.
Methods
Articles were identified through Web of Science by using “surgical education” and “English language” as search terms. Using a feature in Web of Science, we tracked the number of citations of any publication. Of the 800 articles produced by the initial search, we initially selected 23 articles with 45 or more citations, and ultimately chose the 20 articles that were most frequently cited for our analysis.
Results
Analysis of the most frequently cited articles published in US journals between the years 2002–2012 identified 7 research themes and presented them in order of frequency with which they appear: use of simulation, issues in student/resident assessment, specialty choice, patient safety, team training, clinical competence assessment, and teaching the clinical sciences, with surgical simulation being the central theme. Researchers primarily used descriptive methods.
Conclusions
Popular themes in surgical education research illuminate the information needs of surgical educators as well as topics of high interest to the surgical community.
ORIGINAL RESEARCH
BA,
MA, and
PhD
Abstract
Background
Cultural competency is an important skill that prepares physicians to care for patients from diverse backgrounds.
Objective
We reviewed Accreditation Council for Graduate Medical Education (ACGME) program requirements and relevant documents from the ACGME website to evaluate competency requirements across specialties.
Methods
The program requirements for each specialty and its subspecialties were reviewed from December 2011 through February 2012. The review focused on the 3 competency domains relevant to culturally competent care: professionalism, interpersonal and communication skills, and patient care. Specialty and subspecialty requirements were assigned a score between 0 and 3 (from least specific to most specific). Given the lack of a standardized cultural competence rating system, the scoring was based on explicit mention of specific keywords.
Results
A majority of program requirements fell into the low- or no-specificity score (1 or 0). This included 21 core specialties (leading to primary board certification) program requirements (78%) and 101 subspecialty program requirements (79%). For all specialties, cultural competency elements did not gravitate toward any particular competency domain. Four of 5 primary care program requirements (pediatrics, obstetrics-gynecology, family medicine, and psychiatry) acquired the high-specificity score of 3, in comparison to only 1 of 22 specialty care program requirements (physical medicine and rehabilitation).
Conclusions
The degree of specificity, as judged by use of keywords in 3 competency domains, in ACGME requirements regarding cultural competency is highly variable across specialties and subspecialties. Greater specificity in requirements is expected to benefit the acquisition of cultural competency in residents, but this has not been empirically tested.
BSc(Adv), MBBS(Hon),
BSc(Med)Hon, MBBS(Hon),
BArts(Eng lit/Politics), MBBS,
BAppSc(PHTY), MBBS(Hon), MMedEd, FRACP, and
BMed(Hons), GradDipEpi, PhD, FRACP, FAFRM(RACP)
Abstract
Background
Medical officers (trainees) in their first to third postgraduate years (PGY-1–3s) work in complex, busy environments, performing tasks that require concentration and application of learned skills. There are frequently competing demands, and being paged is among the most common.
Objective
We quantified and described the effect of interruptions that paging created on the clinical workflow of PGY-1–3s during ward duties.
Methods
This prospective study was conducted at 2 teaching hospitals in Sydney, Australia. Medical students were recruited as observers to log interruptions of PGY-1–3s' workflow arising from pages from other members of the hospital team.
Results
Forty-two pairs consisting of a PGY-1–3 trainee and an observer were recruited, with 24 proceeding to data collection. Nursing was the most frequent source of pages (47%); other medical staff accounted for 16% of pages, allied health for 12%, and others for 24% (with pharmacy the most common). Pages commonly involved direct patient care (46%), followed by medication issues (21%). Tasks interrupted by pages encompassed direct patient care (37%), indirect patient care (15%), and documentation (12%). Only 27% of pages were assessed as appropriate and urgent, while 58% were considered appropriate but not urgent, and 16% were not appropriate. Only 38% of pages were judged to be clinically more important than the task they interrupted.
Conclusions
Pages frequently interrupted direct patient care activities for PGY-1–3 trainees, and a significant proportion of pages were identified as either not requiring immediate attention or not appropriate, resulting in potentially avoidable interruptions to clinical workflow. Alternate means of alerting trainees to nonurgent tasks may reduce interruptions and facilitate patient care.
MD, MSc,
MPH, MIA,
MPH,
MD, and
MD, MSc
Abstract
Background
Since the legalization of abortion services in the United States, provision of abortions has remained a controversial issue of high political interest. Routine abortion training is not offered at all obstetrics and gynecology (Ob-Gyn) training programs, despite a specific training requirement by the Accreditation Council for Graduate Medical Education. Previous studies that described Ob-Gyn programs with routine abortion training either examined associations by using national surveys of program directors or described the experience of a single program.
Objective
We set out to identify enablers of and barriers to Ob-Gyn abortion training in the context of a New York City political initiative, in order to better understand how to improve abortion training at other sites.
Methods
We conducted in-depth qualitative interviews with 22 stakeholders from 7 New York City public hospitals and focus group interviews with 62 current residents at 6 sites.
Results
Enablers of abortion training included program location, high-capacity services, faculty commitment to abortion training, external programmatic support, and resident interest. Barriers to abortion training included lack of leadership continuity, leadership conflict, lack of second-trimester abortion services, difficulty obtaining mifepristone, optional rather than routine training, and antiabortion values of hospital personnel.
Conclusions
Supportive leadership, faculty commitment, and external programmatic support appear to be key elements for establishing routine abortion training at Ob-Gyn residency training programs.
MD, MSc,
MD, MSc,
MD, and
MD, MS
Abstract
Background
Prior data suggest that opportunities in family planning training may be limited during obstetrics and gynecology (Ob-Gyn) residency training, particularly at faith-based institutions with moral and ethical constraints, although this aspect of the Ob-Gyn curriculum has not been formally studied to date.
Objectives
We compared Ob-Gyn residents' self-rated competency and intentions to provide family planning procedures at faith-based versus those of residents at non-faith-based programs.
Methods
We surveyed residents at all 20 Ob-Gyn programs in Illinois, Indiana, Iowa, and Wisconsin from 2008 to 2009. Residents were queried about current skills and future plans to perform family planning procedures. We examined associations based on program and residents' personal characteristics and performed multivariable logistic regression analysis.
Results
A total of 232 of 340 residents (68%) from 17 programs (85%) returned surveys. Seven programs were faith-based. Residents from non-faith-based programs were more likely to be completely satisfied with family planning training (odds ratio [OR] = 3.4, 95% confidence limit [CI], 1.9–6.2) and to report they “understand and can perform on own” most procedures. Most residents, regardless of program type, planned to provide all surveyed family planning services.
Conclusions
Despite similar intentions to provide family planning procedures after graduation, residents at faith-based training programs were less satisfied with their family planning training and rate their ability to perform family planning services lower than residents at non-faith-based training programs.
MD,
MD, MPH, and
MD
Abstract
Background
Competence in evidence-based medicine (EBM) is an important clinical skill. Pediatrics residents are expected to acquire competence in EBM during their education, yet few validated tools exist to assess residents' EBM skills.
Objective
We sought to develop a reliable tool to evaluate residents' EBM skills in the critical appraisal of a research article, the development of a written EBM critically appraised topic (CAT) synopsis, and a presentation of the findings to colleagues.
Methods
Instrument development used a modified Delphi technique. We defined the skills to be assessed while reviewing (1) a written CAT synopsis and (2) a resident's EBM presentation. We defined skill levels for each item using the Dreyfus and Dreyfus model of skill development and created behavioral anchors using a frame-of-reference training technique to describe performance for each skill level. We evaluated the assessment instrument's psychometric properties, including internal consistency and interrater reliability.
Results
The EBM Critically Appraised Topic Presentation Evaluation Tool (EBM C-PET) is composed of 14 items that assess residents' EBM and global presentation skills. Resident presentations (N = 27) and the corresponding written CAT synopses were evaluated using the EBM C-PET. The EBM C-PET had excellent internal consistency (Cronbach α = 0.94). Intraclass correlation coefficients were used to assess interrater reliability. Intraclass correlation coefficients for individual items ranged from 0.31 to 0.74; the average intraclass correlation coefficients for the 14 items was 0.67.
Conclusions
We identified essential components of an assessment tool for an EBM CAT synopsis and presentation with excellent internal consistency and a good level of interrater reliability across 3 different institutions. The EBM C-PET is a reliable tool to document resident competence in higher-level EBM skills.
MD, MDiv,
MD, MPH, and
MD, MS
Abstract
Background
Burnout in physicians is common, and studies show a prevalence of 30% to 78%. Identifying constructive coping strategies and personal characteristics that protect residents against burnout may be helpful for reducing errors and improving physician satisfaction.
Objective
We explored the complex relationships between burnout, behaviors, emotional coping, and spirituality among internal medicine and internal medicine-pediatrics residents.
Methods
We anonymously surveyed 173 internal medicine and medicine-pediatrics residents to explore burnout, coping, and spiritual attitudes. We used 3 validated survey instruments: the Maslach Burnout Inventory, the Carver Coping Orientation to Problems Experienced (COPE) Inventory, and the Hatch Spiritual Involvement and Beliefs Scale (SIBS).
Results
A total of 108 (63%) residents participated, with 31 (28%) reporting burnout. Residents who employed strategies of acceptance, active coping, and positive reframing had lower emotional exhaustion and depersonalization (all, P < .03). Residents who reported denial or disengagement had higher emotional exhaustion and depersonalization scores. Personal accomplishment was positively correlated with the SIBS total score (r = +.28, P = .003), as well as the internal/fluid domain (r = +.32, P = .001), existential axes (r = +.32, P = .001), and humility/personal application domain (r = +.23, P = .02). The humility/personal application domain also was negatively correlated with emotional exhaustion (r = −.20, P = .04) and depersonalization (r = −.25, P = .009). No activity or demographic factor affected any burnout domain.
Conclusions
Burnout is a heterogeneous syndrome that affects many residents. We identified a range of emotional and spiritual coping strategies that may have protective benefit.
PhD,
MD,
MD,
MD,
MD,
MD,
MD,
MD, and
MD
Abstract
Background
Studies across a range of specialties have consistently yielded positive associations between performance on in-training examinations and board certification examinations, supporting the use of the in-training examination as a valuable formative feedback tool for residents and residency programs. That association to date, however, has not been tested in child and adolescent psychiatry residents.
Objective
This is the first study to explore the relationship between performance on the American College of Psychiatrists' Child Psychiatry Resident In-Training Examination (CHILD PRITE) and subsequent performance on the American Board of Psychiatry and Neurology's (ABPN) subspecialty multiple-choice examination (Part I) in child and adolescent psychiatry (CAP).
Methods
Pearson correlation coefficients were used to examine the relationship between performance on the CHILD PRITE and the CAP Part I examination for 342 fellows.
Results
Second-year CAP fellows performed significantly better on the CHILD PRITE than did the first-year fellows. The correlation between the CHILD PRITE total score and the CAP Part I examination total score was .41 (P = .01) for first-year CAP fellows; it was .52 (P = .01) for second-year CAP fellows.
Conclusions
The significant correlations between scores on the 2 tests show they assess the same achievement domain. This supports the use of the CHILD PRITE as a valid measure of medical knowledge and formative feedback tool in child and adolescent psychiatry.
MD,
MD,
MD., MBA, and
PhD
Abstract
Background
As resident attrition disrupts educational and workload balance and reduces the number of graduating physicians to care for patients, an ongoing goal of graduate medical education programs is to retain residents.
Objective
We compared annual rates of resident attrition in obstetrics and gynecology (Ob-Gyn) with other clinical specialties of similar or larger size during a recent 10-year period, and explored the reasons for resident attrition.
Methods
In this observational study, we analyzed annual data from the American Medical Association Graduate Medical Education Census between academic years 2000 and 2009 for residents who entered Ob-Gyn and other core clinical specialties. Our primary outcome was the trend in averaged annual attrition rates.
Results
The average annual attrition was 196 ± 12 (SD) residents, representing 4.2% ± 0.5% of all Ob-Gyn residents. Rates of attrition were consistently higher among men (5.3%) and international medical school graduates (7.6%). The annual rate of attrition was similar to that for other clinical specialties (mean: 4.0%; range: from 1.5% in emergency medicine to 7.9% in psychiatry). The attrition rates for Ob-Gyn residents were relatively stable for the 10-year period (range: 3.6% in 2008 to 5.1% in 2006). Common reasons for attrition were transition to another specialty (30.0%), withdrawal/dismissal (28.2%), transfer to another Ob-Gyn program (25.4%), and leave of absence (2.2%). These proportions remained fairly constant during this 10-year period.
Conclusions
The average annual attrition rate of residents in Ob-Gyn was 4.2%, comparable to most other core clinical specialties.
PhD,
MD, and
PhD
Abstract
Background
Residents' ability to interpret statistics is important for scholarly pursuits and understanding evidence-based medicine. Yet there is limited research assessing residents' statistical literacy and their training in statistics.
Methods
In 2011 we surveyed US obstetrics-gynecology residents participating in the Council for Resident Education in Obstetrics and Gynecology In-Training Examination about their statistical literacy and statistical literacy training.
Results
Our response rate was 95% (4713 of 4961). About two-thirds (2980 of 4713) of the residents rated their statistical literacy training as adequate. Female respondents were more likely to rate their statistical literacy training poorly, with 25% (897 of 3575) indicating inadequate literacy compared with 17% (141 of 806) of the male respondents (P < .001). Respondents performed poorly on 2 statistical literacy questions, with only 26% (1222 of 4713) correctly answering a positive predictive value question and 42% (1989 of 4173) correctly defining a P value. A total of 51% (2391 of 4713) of respondents reported receiving statistical literacy training through a journal club, 29% (1359 of 4713) said they had informal training, 15% (711 of 4713) said that they had statistical literacy training as part of a course, and 11% (527 of 4713) said that they had no training.
Conclusions
The findings suggest that statistical literacy training for residents could still be improved. A total of 37% (1743 of 4713) of obstetrics-gynecology residents have received no formal statistical literacy training in residency. Fewer residents answered the 2 statistical literacy questions correctly compared with previous studies.
PhD,
PhD,
PhD, and
MD
Abstract
Background
The graduate medical education community uses results from the United States Medical Licensing Examination (USMLE) to inform decisions about individuals' readiness for postgraduate training.
Objective
We sought to determine the relationship between performance on the USMLE and the American Board of Anesthesiology (ABA) Part 1 Certification Examination using a national sample of examinees, and we considered the relationship in the context of undergraduate medical education location and examination content.
Methods
Approximately 7800 individuals met inclusion criteria. The relationships between USMLE scores and ABA Part 1 pass rates were examined, and predictions for the strength of the relationship between USMLE content areas and ABA performance were compared with observed relationships.
Results
Pearson correlations between ABA Part 1 scores and USMLE Steps 1, 2 (clinical knowledge), and 3 scores for first-taker US/Canadian graduates were .59, .56, and .53, respectively. A clear relationship was demonstrated between USMLE scores and pass rates on ABA Part 1, and content experts were able to successfully predict the USMLE content categories that would least or most likely relate to ABA Part 1 scores.
Conclusions
The analysis provided evidence on a national scale that results from the USMLE and the ABA Part 1 were correlated and that success on the latter examination was associated with level of USMLE performance. Both testing programs have been successful in conceptualizing many of the knowledge areas of interest and in developing test content to reflect those areas.
EDUCATIONAL INNOVATION
MD,
EdD,
MBA,
MD, and
MD, MBA
Abstract
Background
Rising costs pose a major threat to US health care. Residency programs are being asked to teach residents how to provide cost-conscious medical care.
Methods
An educational intervention incorporating the American College of Radiology appropriateness criteria with lectures on cost-consciousness and on the actual hospital charges for abdominal imaging was implemented for residents at Scripps Mercy Hospital in San Diego, CA. We hypothesized that residents would order fewer abdominal imaging examinations for patients with complaints of abdominal pain after the intervention. We analyzed the type and number of abdominal imaging studies completed for patients admitted to the inpatient teaching service with primary abdominal complaints for 18 months before (738 patients) and 12 months following the intervention (632 patients).
Results
There was a significant reduction in mean abdominal computed tomography (CT) scans per patient (1.7–1.4 studies per patient, P < .001) and total abdominal radiology studies per patient (3.1–2.7 studies per patient, P = .02) following the intervention. The avoidance of charges solely due to the reduction in abdominal CT scans following the intervention was $129 per patient or $81,528 in total.
Conclusions
A simple educational intervention appeared to change the radiologic test-ordering behavior of internal medicine residents. Widespread adoption of similar interventions by residency programs could result in significant savings for the health care system.
MD,
MD, MHPE,
MD, and
MD, MSc
Abstract
Background
Self-directed learning (SDL) skills, such as self-reflection and goal setting, facilitate learning throughout a physician's career. Yet, residents do not often formally engage in these activities during residency.
Intervention
To develop resident SDL skills, we created a learning coach role for a junior faculty member to meet with second-year residents monthly to set learning goals and promote reflection.
Methods
The study was conducted from 2008–2010 at the Brown Family Medicine Residency in Pawtucket, Rhode Island. During individual monthly meetings with the learning coach, residents entered their learning goals and reflections into an electronic portfolio. A mixed-methods evaluation, including coach's ratings of goal setting and reflection, coach's meeting notes, portfolio entries, and resident interviews, was used to assess progress in residents' SDL abilities.
Results
Coach ratings of 25 residents' goal-setting ability increased from a mean of 1.9 to 4.6 (P < .001); ratings of reflective capacity increased from a mean of 2.0 to 4.7 (P < .001) during each year. Resident portfolio entries showed a range of domains for goal setting and reflection. Resident interviews demonstrated progressive independence in setting goals and appreciation of the value of reflection for personal development.
Conclusions
Introducing a learning coach, use of a portfolio, and providing protected time for self-reflected learning allowed residents to develop SDL skills at their own pace. The learning coach model may be applicable to other residency programs in developing resident lifelong learning skills.
MD, MBA,
MD, PhD,
MD,
MD, and
MD, PhD
Abstract
Background
The Stanford Anesthesia Teaching Scholars Program was launched in 2007 to further pedagogic training of faculty and improve residency education.
Objectives
The goals of this article are to describe the program intervention and improvements made based on participant feedback, summarize the characteristics of the faculty enrolled and projects undertaken, and report on program outcomes tracked to date.
Intervention
The Teaching Scholars Program housed within the Department of Anesthesia supports faculty in these areas: (1) attending education-related meetings; (2) engaging in a monthly seminar on core topics paired with independent study reading; and (3) undertaking a project to improve resident education. Structured interviews with all graduates (n = 19; 47% women) were conducted using a pilot-tested questionnaire.
Results
A total of 15 of 19 Scholars (79%) were instructors/assistant professors. Sixteen Scholars (84%) attended an off-site education meeting. The Scholars pursued a variety of projects, including curriculum (53%), teaching (26%), administration (11%), assessment (5%), and advising/mentoring (5%). Projects were fully completed by 13 of 19 participants (68%), and 12 of 19 projects (63%) are currently integrated into the residency. Completed projects were published/presented at conferences by 4 of 13 participants (31%), and education grants were received by 3 of 19 participants (16%).
Conclusions
This is the first description of a faculty development (education) program in an anesthesiology department. The program has been well accepted by participants and resulted in increased educational products, some of which have become a permanent part of the residency curriculum. This educational innovation can be replicated in other departments of anesthesiology provided that funding is available for faculty time and meeting expenses.
MD,
MD,
PhD, and
MD, PhD
Abstract
Background
The need for consistent academic productivity challenges junior clinician-scholars, who often lack the aptitude to ensure efficient production of manuscripts.
Intervention
To solve this problem, an academic division of a major medical center developed an off-site writing retreat. The purpose of the retreat was not to teach writing skills, but to offer senior mentor assistance with a focus on the elements of manuscript writing.
Methods
The retreat paired senior faculty members with junior staff. Senior faculty identified manuscript topics and provided real-time writing and editing supervision. Team-building exercises, midcourse corrections, and debriefing interviews were built into the retreat. The number of manuscripts and grant proposals generated during the 2008–2011 retreats was recorded, and the program was evaluated by using unstructured debriefing interviews.
Results
An average of 6 to 7 faculty members and fellows participated in each retreat. During the past 4 years, participants produced an average of 3 grant proposals and 7 manuscripts per retreat. After the writing retreat, each fellow and junior faculty member produced an average of 4 scholarly products per year, compared to fewer than 2 for prior years' retreats. Participant feedback indicated the success of the retreat resulted from protected time, direct mentorship by the scholars involved, and pairing of authors, which allows for rapid production of manuscripts and accelerated the editing process. More than 80% of mentors returned each year to participate.
Conclusions
The writing retreat is a feasible, effective strategy to increase scholarship among faculty, acceptable to mentees and mentors, and sustainable over time.
MD,
MD,
MD,
MD,
MD,
MD,
DO, and
MD, MAPP
Abstract
Background
Handoff is the process in which patient care is transitioned from one provider to another. In teaching hospitals, handoffs are frequent, and resident duty hour restrictions have increased the use of night float staff. To date, few studies have focused on long-term sustainability and effectiveness of a handoff quality improvement project.
Objective
The objective of our resident-driven quality improvement project was to evaluate the effectiveness and sustainability of a standardized template for handoff quality in a community hospital internal medicine program.
Methods
We used a multistep continuous quality improvement approach. Problems in the handoff process were identified through process mapping and anonymous needs assessment of the residents. A group of residents and faculty identified problems during biweekly discussions, created a standardized template, and adopted a new handoff process. We audited handoffs and surveyed residents at 3 and 9 months after implementation to assess effectiveness and sustainability.
Results
Before the intervention, only 40% of residents reported regular morning handoff. Using the standardized template, statistically significant, sustained improvements were seen in morning handoff frequency (59% preintervention, 90% at 3 months, 89% at 9 months), along with decreases in unreported overnight events (84% preintervention, 58% at 3 months, 50% at 9 months) and uncertainty about decisions because of poor handoffs (72% preintervention, 49% at 3 months, 37% at 9 months). Statistically significant decreases in missed content (69%–46%) and copy-and-paste behavior (78%–38%) at 3 months were not sustained.
Conclusions
We demonstrated sustained improvements in unreported events and uncertainty caused by poor handoffs. Initial improvements in missed content and copy-and-paste behavior that were not sustained suggest a need for ongoing reinforcement and monitoring of handoff quality.
MD, MA,
MD, and
MD, MPH
Abstract
Background
Delirium is a common and debilitating complication of inpatient care for many older adults, yet internal medicine residents often do not recognize delirium or its risk factors. Integrating geriatric education (eg, delirium recognition) with inpatient quality improvement (QI) is not well tested.
Methods
We developed an educational pilot program within an ongoing hospital-wide geriatric QI initiative (Global Risk Assessment and Careplan for the Elderly-Acute Care [GRACE-AC]). GRACE-AC modifies the inpatient computerized provider order entry system to meet the needs of vulnerable older adults and uses a bedside care checklist to identify patients with possible delirium and promote delirium prevention by checking on the need for “tethers” (intravenous fluids, Foley catheters, and telemetry). Residents were assessed before and after each inpatient rotation by using anonymous electronic surveys.
Results
A total of 167 eligible residents (91%) completed prerotation surveys, and 102 (56%) residents completed postrotation surveys. All but the first rotating resident group received a standardized 2-minute educational in-service orientation. In a comparison of postrotation responses before and after implementation of the in-service, the proportion of residents who reported improvement in their ability to recall which patients had tethers increased from 17% to 52% for intravenous fluids (P = .004), 28% to 75% for Foley catheters (P < .001), and 21% to 50% for telemetry (P = .02). Comparing pre- and postrotation surveys, the proportion of correct responses to questions on haloperidol dosing and the characteristics of delirium increased from 26% to 76% and 31% to 63%, respectively (both P < .001).
Conclusions
Our pilot program demonstrated that inpatient geriatric QI initiatives can be successfully merged with a brief educational curriculum.
BRIEF REPORT
DO., MBA,
MD,
MD, and
MD
Abstract
Background
The Accreditation Council for Graduate Medical Education (ACGME) standards for resident education in anesthesiology mandate required rotations including rotations inside the operating room (OR). When residents complete rotations outside the OR, other providers must be used to maintain the OR's clinical productivity.
Objective
We quantified and compared the costs of replacing residents by using two different working patterns that are compliant with the ACGME anesthesiology program requirements: (1) the minimum amount of time in the OR, and (2) working the maximum amount of time permitted in the OR.
Methods
We calculated resident replacement costs over a 36-month residency period in both a minimum and maximum OR time model. We used a range of Certified Registered Nurse Anesthetist (CRNA) pay scales determined by a local market analysis for cost comparisons.
Results
Depending on CRNA pay rates, the cost differentials to replace a resident in the OR between the minimum and maximum OR time models ranged from $236,000 to $581,876, assuming a 50-hour resident work week, and $373,400 to $931,001, assuming an 80-hour resident work week. This cost was per resident over the entire 3 years of their residency.
Conclusions
Varying the amount of time residents work in the OR (as allowed under ACGME program requirements) has significant financial implications over a 36-month anesthesiology residency. The larger the residency, the more significant will be the impact on the department and sponsoring institution.
MD,
MD,
BS,
EdD, and
MD
Abstract
Background
Duty hour restrictions and enhanced focus on patient safety have prompted the development of new instruction models for practice of surgical techniques outside the operating room, including models for teaching loop electrosurgical excisional procedure (LEEP), a common procedure that gynecology residents perform to diagnose and manage cervical disease.
Objective
We sought to develop an inexpensive and reusable training model for guided practice opportunities that will improve gynecology residents' LEEP technique.
Methods
Polyvinyl chloride, foam, and a polish sausage are used to simulate the basic anatomy of the vagina and cervix. A 2-in-diameter polyvinyl chloride pipe and high-density foam are used to create a realistic representation with the sausage simulating the cervix. An electrosurgical pad is attached to the sausage and a standard operating room electrosurgical generator is used.
Results
After a brief lecture and demonstration of the LEEP procedure, gynecology residents are positioned at individual stations. Use of 2 to 3 instructors allows for the provision of directions and feedback to residents as they perform the simulated LEEP. During the last 6 years, this model has continued to improve residents' confidence and skills with the procedure.
Conclusions
An anatomically accurate LEEP model can not only improve resident knowledge, skills, and confidence, but also improve quality and patient safety. This training model allows residents to refine their surgical skills through guided practice and instructors to monitor performance before residents to perform the procedure on patients.
MD, MSEd, MPH,
MPH,
MD, MPH, and
MD, MPH
Abstract
Background
Resident attendance and participation at didactic conferences is often limited owing to time demands. In 2010, University of Wisconsin-Madison pediatrics residency eliminated all noon conferences and implemented a new block format, PEARL (Pediatric Education and Active Resident Learning).
Objective
The purpose of this study was to assess whether changes in a conference structure improved resident attendance, distractibility, satisfaction, perception of clinical relevance, and connection.
Methods
Pediatrics residents were surveyed to compare experiences in 2 different conference structures: a traditional noon conference and an interactive case-based PEARL conference. Pediatrics residents from the 2008–2010 classes were surveyed about noon conference experiences and 2009–2011 classes were surveyed about PEARL conference experiences.
Results
Participants included 32 residents in the 2010 presurvey and 36 in the 2011 postsurvey. All measures of attendance, distractibility, and satisfaction showed positive changes. For example, the average proportion of conferences attended was 73% with noon conferences and 98% with PEARL (P = .001). However, measures of perceived clinical relevance and resident participation did not change significantly. For example, on average 47% of residents reported contributing comments in a noon conference, whereas 56% of residents reported contributing in a block conference (P = .199).
Conclusions
PEARL conference significantly improved resident attendance, lowered distractibility, and improved resident satisfaction. However, these structural changes did not lead to changes in perceived clinical relevance of information learned or resident participation. Further content changes or faculty teaching strategies should be considered.
MD,
MD, MPH,
MD, MAPP,
MD, and
MD
Abstract
Background
Most internal medicine (IM) residency programs provide ambulatory training in academic medical centers. Community-based ambulatory training has been suggested to improve ambulatory and primary care education. Free clinics offer another potential training setting, but there have been few reports about the experience of IM residents in free clinics.
Objective
We assessed the feasibility and acceptability of inclusion of an ambulatory rotation in a free clinic and IM residency curriculum and the advantages of the free clinic setting over the traditional ambulatory clinic model.
Methods
In 2010, the University of Chicago Internal Medicine Residency Program partnered with a free clinic in order to establish a community-based continuity clinic experience. To assess the feasibility of this innovation, 16 residents were surveyed 9 months after implementation of the clinic to determine satisfaction, perceived preparation to address common medical conditions, and attitudes toward the underserved care population. A subset of these responses was compared to responses from residents in the traditional clinic model.
Results
Residents in the free clinic rotation were more satisfied and perceived they were more prepared to work in low-resource settings and reported similar levels of preparation regarding common outpatient conditions than residents in a traditional continuity clinic format. They reported increased future likelihood of working in an underserved clinic.
Conclusions
Our exploratory study suggests free clinics may be an effective platform for community-based continuity clinic training.
RIP OUT
MD,
MD, MHPE, FACS,
MD,
MD, and
MD
The Challenge
The safe performance of procedures is among the most critical aspects confronting surgical resident education. Increasing public concerns about physician performance and patient safety have augmented the need to demonstrate competence in surgical skills.1 Assessment of residents' operative skills should be both formative (feedback to the resident outlining areas for performance improvement) and summative (a statement of the resident's competence and skill level). With progressive experience and competence, advanced responsibility can be assigned to residents in complex operations.
Intraoperative assessment of residents can be particularly challenging. Surgical skills are attained through practice and include a combination
MD,
MD,
MD, and
MD, MAPP
The Challenge
The Accreditation Council for Graduate Medical Education Common Program Requirements mandate that all residency programs need to monitor and ensure resident competency in patient handoffs.1 Changes in resident duty hours have increased the volume and complexity of handoffs and have increased the use of “bridge” or “float”
COMMENTARIES
PhD, MHA
Given the stresses and cognitive burden1– 5 imposed by constant interruptions, it is not surprising that one of the latest developments in mobile phone technology is a sophisticated “interruption” filter. This filter allows us to screen out all but specified priority callers while we concentrate on the job at hand. Meanwhile, our phones will let everyone else know we are busy. Once we signal we are free, our phones will remind us to deal with missed calls and messages. This is an elegant technologic solution to a common modern-day problem: A solid body of largely experimental evidence links
PhD
Health care providers are the most highly rated sources of health information.1 Thus, responsibility for helping patients understand the potential benefits and harms of medical prevention and intervention falls largely upon physicians. Can physicians fulfill this task? The news on that front is not encouraging. Eddy2 reported already three decades ago that 95 out of 100 physicians overestimated the probability of breast cancer after a positive mammography test result by an order of magnitude. More recently, Bramwell and colleagues3 found that only 1 out of 21 obstetricians were able to estimate the probability of
TO THE EDITOR
MD,
OD, MD, and
RD, MSc
Female physicians have remained proportionately poorly represented in the research academic track.1 Opportunities for female residents to have an impact on the future of academic research may be considerable if early developmental characteristics are identified in a timely way.
We offered mentoring for female residents in an academic psychiatry department at McMaster University, a 5-year postgraduate training program, where research activities are not a requirement. Consecutively enrolled third-year female residents (n = 5), who underwent their 2-month core inpatient psychiatry rotation, were assigned to the same female faculty supervisor. This pilot project was conducted during a 12-month period
MB, FRCPI, FHEA
Lebensohn et al present a fascinating account of online curriculum on integrative medicine during residency education.1 They demonstrate high rates of curriculum completion, positive course evaluations, and statistically significant improvements in medical knowledge scores. The weakness of the study lies in what the authors do not report—the paper makes no mention of the costs of the new program or of the potential returns on this investment. In the modern era of medical education, neither omission is acceptable any longer.
The costs of this new program should be reported, and we assume that the cost of a program of
MD, MPH and
MD
While we find the results of the study by Mullan et al1 in the March 2013 issue of the Journal of Graduate Medical Education alarming, the findings sadly do not come as a surprise. The authors administered an anonymous questionnaire to more than 500 interns at Partners Healthcare, Boston, MA, during 2010 and 2011. Of the nearly 400 participants, 93% had experienced “disruptive behavior” during internship, including condescending behavior, berating, exclusion from decision-making, inappropriate jokes, abusive language, and gender bias. Even more concerning is the fact that 54% of the interns reported experiencing these behaviors once
MD, FACP and
MD, MPH, FAAFP, CPE
The article on service versus education by Galvin and Buys1 in the December 2012 issue of the Journal of Graduate Medical Education highlights a fundamental dilemma in graduate medical education: the balance between service and education. The authors found that learners attribute different levels of educational value to similar activities despite a marked overlap between the characteristics of service and education. The lack of clear distinctions between service and education, combined with a negative connotation attributed to the term service, may be detrimental to any educational process in residency and should not be ignored.
ON TEACHING
MSc, MD
I am no stranger to culture shock. My father is an academic, and for his job we crossed the Atlantic Ocean 3 times by the time I was 10, landing finally in the small town of Dundas, Canada. Each time, I reluctantly adjusted to a new place, new people, a new language, and a new way of doing things. As a young adult I moved again, away from my comfortable, nurturing home and into a college dorm several hundred miles away. Then there was another move to the big city for graduate school, and yet another for medical school. I
ERRATUM
We report and correct an error in a reference in J Grad Med Educ. 2012;4(4):407–410.
Rickards G, Magee C, and Artino AR Jr. You Can't Fix by Analysis What You've Spoiled by Design: Developing Survey Instruments and Collecting Validity Evidence. J Grad Med Educ. 2012;4(4):407–410.
The title of the editorial altered an original statement, and the footnote on page 407 did not reference the original, which was “You can't fix by analysis what you bungled by design.” The original statement appeared in Light RJ, Singer JD, Willett JB. By Design: Planning Research on Higher Education
NEWS AND VIEWS
MD,
MD, JD,
MD, MBA, and
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 JGME.
Introduction
In 2009, the Accreditation Council for Graduate Medical Education (ACGME) began work on a Next Accreditation System (NAS), a more outcomes-based and improvement-focused approach to the accreditation of programs and sponsoring institutions. The transition to the NAS is scheduled for phased implementation, beginning July 2013 with 7 Phase I specialties and their subspecialties (emergency medicine, internal medicine, neurological surgery, orthopaedic surgery, pediatrics,
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
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ISSN: 1949-8349
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