Consider the last time you answered a questionnaire. Did it contain questions that were vague or hard to understand? If yes, did you answer these questions anyway, unsure if your interpretation aligned with what the survey developer was thinking? By the time you finished the survey, you were probably annoyed by the unclear nature of the task you had just completed. If any of this sounds familiar, you are not alone, as these types of communication failures are commonplace in questionnaires.1–3 And if you consider how often questionnaires are used in medical education for evaluation and
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FROM THE EDITOR
MD., MPH
“I love deadlines. I love the whooshing noise they make as they go by.”
-Douglas Adams
The Salmon of Doubt: Hitchhiking the Galaxy One Last Time1
Many of us envy and even view with awe the ease with which others write. Program directors and faculty educators often find writing to be uncomfortable, slow, and readily postponed. Yet with a dearth of useful information regarding successful, feasible, and affordable strategies to teach the next generation of physicians, educators must contribute to the national and international discussion.
In addition, “publish or perish” is an often-heard term for persons involved in
From the Editors
Willis et al provide key pointers on the use of cognitive interviewing to improve surveys used in medical education research and evaluation (p. 353). Sullivan discusses why many academic physicians experience difficulties with scholarly writing, and provides practical strategies to overcome them (p. 357).
Perspectives
Using 2 case presentations, Ramani describes the dangers of a “near complete faith” in the admitting diagnosis and the resultant dearth of independent inquiry (p. 362). Snyder and colleagues discuss the advantages for individuals and teaching institutions of providing on-site child care for residents and faculty (p. 365). Drolet et al studied duty hour reporting and
PERSPECTIVES
MBBS, MMEd, MPH
In today's clinical environment, residents may begin and end patient care at the computer, seeing the patient only during a brief period between these electronic interactions. In contradiction to Oslerian teachings, clinical reasoning and faculty feedback on this important element of physician competence are conspicuous by their absence. Patients admitted from the emergency department (ED) to a specialty team at a teaching hospital come prepackaged with a diagnosis and treatment plan. Traditionally, residents interviewed and examined patients, generated their own assessment and plans, and reviewed old medical records. Today, residents “biopsy” electronic records in preparation for the many patient care
MD, MPH,
MLS,
MSPH, and
MD
Individuals in residency and fellowship training work long, often unpredictable hours, including nights and weekends, and residency training typically occurs during individuals' childbearing and child-rearing years. However, it is unclear how residents with children arrange child care that accommodates the 80-hour resident work week. Additionally, during the past 40 years, the proportion of women in medicine in the United States has increased dramatically. Historically, parental leave and child care have been considered women's issues, but they affect both men and women, especially for dual-professional and dual-physician couples. Additionally, residents often face repayment of educational debt while earning a limited salary, which
MD,
BA,
MD, PhD, and
MD
The Accreditation Council for Graduate Medical Education (ACGME) first established national standards for resident duty hours in 2003 as part of the Common Program Requirements.1 Residents were limited to 30-hour duty periods, with a maximum 80 working hours and 1 day free from clinical responsibilities each week, averaged over a 4-week period.1 In 2008, the Institute of Medicine recommended greater supervision and additional limits on residents' hours.2
In response, an ACGME Duty Hours Task Force developed new Common Program Requirements that were released in 2010.3 The objectives of these revisions were to improve the
REVIEWS
MD,
MD,
MD., MS, and
MD
Abstract
Background
Morning report is accepted as an essential component of residency education throughout different parts of the world.
Objective
To review the evidence of the educational value, purpose, methods, and outcomes of morning report.
Methods
A literature search of PubMed, Ovid, and the Cochrane Library for English-language studies published between January 1, 1966, and October 31, 2011, was performed. We searched for keywords and Medical Subject Heading terms related to medical education, methods, attitudes, and outcomes in regard to “morning report.” Title and abstract review, followed by a full-text review by 3 authors, was performed to identify all pertinent articles.
Results
We identified 71 citations; 40 articles were original studies and 31 were commentaries, editorials, or review articles; 56 studies (79%) originated from internal medicine residency programs; 6 studies (8%) focused on ambulatory morning report; and 63 (89%) originated from the United States. Identified studies varied in objectives, methods, and outcome measures, and were not suitable for meta-analysis. Main outcome measures were resident satisfaction, faculty satisfaction, preparation for professional examinations, use of evidence-based medicine, clinical effects on patient care, adverse event detection, and utilization of a curriculum in case selection.
Conclusions
Morning report has heterogeneous purposes, methods, and settings. As an educational tool, morning report is challenging to define, its outcome is difficult to measure, and this precludes firm conclusions about its contribution to resident education or patient care. Residency programs should tailor morning report to meet their own unique educational objectives and needs.
MA and
MD
Abstract
Background
Communicating with patients has long been identified as an important physician competency. More recently, there is a growing consensus regarding the components that define physician-patient communication. There continues to be emphasis on both the need to teach and to assess the communication skills of physicians.
Objective
This narrative review aims to summarize the work that has been conducted in physician-patient communication that supports the efficacy of good communications skills. This work may also help to define the physician-patient communication skills that need to be taught and assessed.
Results
A review of the literature shows it contains impressive evidence supporting positive associations between physician communication behaviors and positive patient outcomes, such as patient recall, patient understanding, and patient adherence to therapy. There is a consensus about what constitutes “best practice” for physician communication in medical encounters: (1) fostering the relationship, (2) gathering information, (3) providing information, (4) making decisions, (5) responding to emotions, and (6) enabling disease- and treatment-related behavior.
Conclusions
Evidence supports the importance of communication skills as a dimension of physician competence. Effort to enhance teaching of communication skills to medical trainees likely will require significant changes in instruction at undergraduate and graduate levels, as well as changes in assessing the developing communication skills of physicians. An added critical dimension is faculty understanding of the importance of communication skills, and their commitment to helping trainees develop those skills.
ORIGINAL RESEARCH
MD,
MD,
MEd,
PhD, and
MD
Abstract
Background
Effective communication during patient care transitions is essential for high-quality patient care.
Objective
The purpose of this study was (1) to objectively assess patient handoff skills of internal medicine residents, and (2) to evaluate correlations between clinical experience and patient handoff skill self-assessment with directly observed skill.
Methods
We studied simulated patient handoffs in postgraduate year (PGY)-1 and PGY-2 residents between July 2011 and September 2011, using a standardized scenario in an observed structured handoff exam (OSHE). Our design was a posttest-only, with nonequivalent groups. Assessment used a previously published checklist for evaluating handoff skills. Residents were asked about clinical experience with patient handoffs and about their self-confidence in performing a patient handoff independently. We evaluated between-group differences on OSHE checklist performance, patient handoff experience, and self-confidence and used multiple regression analyses to assess the association between performance, experience, and confidence.
Results
Forty-seven PGY-1 residents and 38 PGY-2 residents completed the study. Interrater reliability was substantial (intraclass correlation = 0.68). There was no significant difference in OSHE performance by PGY-1 residents (mean = 79%, SD = 4.6) and PGY-2 residents (mean = 82%; SD = 7.6; P = .07). The PGY-2 residents were significantly more experienced (P < .001) and confident (P < .001) than PGY-1 residents were, yet clinical experience and self-confidence did not significantly predict OSHE performance.
Conclusions
Clinical experience and self-assessment do not predict skills in simulated patient handoffs, and residents with substantial clinical experience still benefit from further skills development.
MD,
MD,
RN, MS, NNP-BC, CPNP,
MD,
MD, and
MD
Abstract
Background
Pediatrics residents are expected to demonstrate preparedness for neonatal resuscitation, yet research has shown gaps in residents' readiness to perform this skill.
Objective
To evaluate procedural skills and team performance of pediatrics residents during neonatal resuscitation (NR) using a high-fidelity mannequin, and to assess residents' confidence in their NR skills before and after training.
Methods
Two teams of residents (all had completed NR program training) participated in 2 separate, 90-minute sessions (2 to 3 weeks apart) in an off-site delivery room during their neonatal intensive care rotation. Residents' confidence in assisting and leading NR was surveyed before each session. Teams participated in a scenario (adapted from the NR program), which required 5 skills (positive pressure ventilation, chest compressions, endotracheal intubation, umbilical vein catheterization, and epinephrine administration). Video recording was used for debriefing and scoring. Skills were scored for technique and timeliness, and team behaviors were scored for communication, management, and leadership.
Results
Twenty-six residents (11 teams) completed 2 paired sessions. Self-confidence scores increased between the 2 sessions but were not correlated with performance. Gaps in procedural skill performance were observed, and timeliness for most skills did not meet expectations. Significant improvement in team communication was noted.
Conclusions
Important gaps in procedural skill performance, particularly timeliness, were detected by NR simulation training; residents' improvements in self-confidence did not reflect gains in actual performance. Their relative unpreparedness for NR (despite prior certification) highlights the need for deliberate practice and specific team training before and during neonatal intensive care delivery room rotations.
MD, MPH,
MD, MSCE,
MSc,
PhD, and
MD, MPH
Abstract
Background
Resident physicians are at risk for increasing weight status given their changes in environment, resources, and stress level.
Objective
To describe body mass index (BMI), blood pressure, eating habits, and physical activity during postgraduate training and to compare the findings to data for nationally matched controls.
Methods
This was a combined cross-sectional study and longitudinal cohort, with a comparison to matched controls in 2 academic hospital centers in the eastern and western United States. BMI and blood pressure were objectively measured, and an eating and exercise habits recall was obtained for 375 enrolled medical and surgical residents (93 longitudinally) at the onset of each postgraduate year (PGY) in 2006, 2007, and 2008.
Results
Nearly half (43%) of overweight residents described themselves as normal weight. Residents were more likely to be overweight (BMI ≥25) at the beginning of PGY-3 than at the beginning of PGY-1 (49% versus 30%; odds ratio 2.26; 95% confidence interval 1.19–4.28). The average BMI of residents at PGY-1 was lower than that of their matched controls, but the magnitude of this difference decreased with increasing PGY (P = .02).
Conclusions
Overweight status is underacknowledged by overweight residents and increases by PGY of training. These changes differ significantly from that of controls and may affect overweight physicians' long-term health.
MD,
MD, and
PhD
Abstract
Background
Evidence-based medicine (EBM) has become an important part of residency education, yet many EBM curricula lack a valid and standardized tool to identify learners' prior knowledge and assess progress.
Objective
We developed an EBM examination in psychiatry to measure our effectiveness in teaching comprehensive EBM to residents.
Methods
We developed a psychiatry EBM test using the validated EBM Fresno Test of Competence for family medicine. The test consists of case scenarios with open-ended questions. We also developed a scoring rubric and obtained reliability with multiple raters. Fifty-seven residents provided test data after completing 3, 6, 25, or 31 EBM sessions. The number of sessions for each resident was based on their length of training in our program.
Results
The examination had strong interrater reliability, internal reliability, and item discrimination. Many residents showed significant improvement on their examination scores when data were compared from tests taken before and after a sequence of teaching sessions. Also, a threshold for the level of expert on the examination was established using test data from 5 EBM teacher-experts.
Conclusions
We successfully developed a valid and reliable EBM examination for use with psychiatry residents to measure essential EBM skills as part of a larger project to encourage EBM practice for residents in routine patient care. The test provides information on residents' knowledge in EBM from entry level concepts through expert performance. It can be used to place incoming residents in appropriate levels of an EBM curriculum and to monitor the effectiveness of EBM instruction.
MD,
MD,
MD, FAAEM, and
RN, MS
Abstract
Background
Academic medical centers play a major role in disaster response, and residents frequently serve as key resources in these situations. Studies examining health care professionals' willingness to report for duty in mass casualty situations have varying response rates, and studies of emergency medicine (EM) residents' willingness to report for duty in disaster events and factors that affect these responses are lacking.
Objective
We sought to determine EM resident and faculty willingness to report for duty during 4 disaster scenarios (natural, explosive, nuclear, and communicable), to identify factors that affect willingness to work, and to assess opinions regarding disciplinary action for physicians unwilling to work in a disaster situation.
Methods
We surveyed residents and faculty at 7 US teaching institutions with accredited EM residency programs between April and November 2010.
Results
A total of 229 faculty and 259 residents responded (overall response rate, 75.4%). Willingness to report for duty ranged from 54.1% for faculty in a natural disaster to 94.2% for residents in a nonnuclear explosive disaster. The 3 most important factors influencing disaster response were concern for the safety of the family, belief in the physician's duty to provide care, and availability of protective equipment. Faculty and residents recommended minimal or no disciplinary action for individuals unwilling to work, except in the infectious disease scenario.
Conclusions
Most EM residents and faculty indicated they would report for duty. Residents and faculty responses were similar in all but 1 scenario. Disciplinary action for individuals unwilling to work generally was not recommended.
MD, MA,
MS,
PhD,
PhD,
MD, MPH,
MD, and
MD, MPH
Abstract
Background
Workload has traditionally been measured by using surrogates, such as number of patients admitted or census, but these may not fully represent the complex concept of workload.
Objective
We measured self-reported subjective workload of interns and explored the relationship between subjective workload and possible predictors of it.
Methods
Trained research assistants observed internal medicine interns on call on a general medicine service. Approximately once an hour, the research assistants recorded the self-reported subjective workload of the interns by using Borg's Self-Perceived Exertion Scale, a 6 to 20 scale, and also recorded their own perceptions of the intern's workload. Research assistants continuously recorded the tasks performed by the interns. Interns were surveyed before and after the observation to obtain demographic and census data.
Results
Our sample included 25 interns, with a mean age of 28.6 years (SD, 2.4 years). Mean self-reported subjective workload was 12.0 (SD, 2.4). Mean self-reported subjective workload was significantly correlated with intern age (r = 0.49, P < .05), but not with team or intern census, number of admissions, or number of patients cross-covered. Self-reported subjective workload in the period after sign-out was significantly higher than in the period before and during sign-out (P < .001).
Conclusions
Self-reported subjective workload was not associated with traditional measures of workload. However, receiving sign-out and assuming the care of cross-coverage patients may be related to higher subjective workload in interns. Given the patient safety implications of workload, it is important that the medical education community have tools to evaluate workload and identify contributors to it.
MD,
MD,
MPH,
MS,
MD,
MD,
MD,
MD, and
MD
Abstract
Background
The educational milestones were designed as a criterion-based framework for assessing resident progression on the 6 Accreditation Council for Graduate Medical Education competencies.
Objective
We obtained feedback on, and assessed the construct validity and perceived feasibility and utility of, draft Internal Medicine Milestones for Patient Care and Systems-Based Practice.
Methods
All participants in our mixed-methods study were members of competency committees in internal medicine residency programs. An initial survey assessed participant and program demographics; focus groups obtained feedback on the draft milestones and explored their perceived utility in resident assessment, and an exit survey elicited input on the value of the draft milestones in resident assessment. Surveys were tabulated using descriptive statistics. Conventional content analysis method was used to assess the focus group data.
Results
Thirty-four participants from 17 programs completed surveys and participated in 1 of 6 focus groups. Overall, the milestones were perceived as useful in formative and summative assessment of residents. Participants raised concerns about the length and complexity of some draft milestones and suggested specific changes. The focus groups also identified a need for faculty development. In the exit survey, most participants agreed that the Patient Care and Systems-Based Practice Milestones would help competency committees assess trainee progress toward independent practice.
Conclusions
Draft reporting milestones for 2 competencies demonstrated significant construct validity in both the content and response process and the perceived utility for the assessment of resident performance. To ensure success, additional feedback from the internal medicine community and faculty development will be necessary.
MD,
BA,
MD, MSPH,
MD, MPH, and
MD, MPH, MS
Abstract
Background
Since 1965, Medicare has publically financed graduate medical education (GME) in the United States. Given public financing, various advisory groups have argued that GME should be more socially accountable. Several efforts are underway to develop accountability measures for GME that could be tied to Medicare payments, but it is not clear how to measure or even define social accountability.
Objective
We explored how GME stakeholders perceive, define, and measure social accountability.
Methods
Through purposive and snowball sampling, we completed semistructured interviews with 18 GME stakeholders from GME training sites, government agencies, and health care organizations. We analyzed interview field notes and audiorecordings using a flexible, iterative, qualitative group process to identify themes.
Results
Three themes emerged in regards to defining social accountability: (1) creating a diverse physician workforce to address regional needs and primary care and specialty shortages; (2) ensuring quality in training and care to best serve patients; and (3) providing service to surrounding communities and the general public. All but 1 stakeholder believed GME institutions have a responsibility to be socially accountable. Reported barriers to achieving social accountability included training time constraints, financial limitations, and institutional resistance. Suggestions for measuring social accountability included reviewing graduates' specialties and practice locations, evaluating curricular content, and reviewing program services to surrounding communities.
Conclusions
Most stakeholders endorsed the concept of social accountability in GME, suggesting definitions and possible measures that could inform policy makers calls for increased accountability despite recognized barriers.
MD, MS and
PhD
Abstract
Background
Duty hour limitations initiated by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 could improve resident education in surgical specialties.
Objective
The purpose of this study was to evaluate national surgical board examination performance and its relationship to the ACGME duty hour standards.
Methods
In this retrospective cohort study, electronically published website content was evaluated for examination statistics for the 10 surgical boards in the American Board of Medical Specialties. To evaluate examination trends over time, we performed simple linear regression. We also performed interrupted time series analyses, using segmented logistic regression. The secondary analyses consisted of a χ2 test of passing and failing examinees before and after 2003. All statistics used α = .05.
Results
There were 8 of 10 (80%) surgical boards with examinations that met inclusion criteria and a total of 72 482 unique examination results. Of the 16 examinations evaluated (50% written, 50% oral), 13 (81%) had either significant pass rate trends on regression analyses and/or a significant pre-post pass rate surrounding the initiation of the ACGME duty hour standards in 2003 in the secondary analysis (P < .05).
Conclusions
There are both increasing examination pass rates and some downward trends in examination performance on surgical board examinations since the initiation of the ACGME duty hour standards in 2003. The etiology of these trends is unclear, but trends are important to know for individual examinees, residency training programs, and surgical boards.
MD,
MEd,
MD,
MD,
MD,
PhD, and
MD
Abstract
Background
Whether cognitive and patient care skills attained during simulation-based mastery learning (SBML) are retained is largely unknown.
Objective
We studied retention of intensive care unit (ICU) clinical skills after an SBML boot camp experience.
Methods
Forty-seven postgraduate year (PGY)-1 residents completed SBML intervention designed to increase procedural, communication, and patient care skills. The intervention included ICU skills such as ventilator and hemodynamic parameter management. Residents were required to meet or exceed a minimum passing score (MPS) on a clinical skills examination before starting actual patient care. Skill retention was assessed in 42 residents who rotated in the medical ICU. Residents received a standardized 15-minute booster teaching session reviewing key concepts during the first week of the rotation. During the fourth week of their rotation, PGY-1 residents completed a clinical skills examination at the bedside of an actual ICU patient. Group mean examination scores and the proportion of subjects who met or exceeded the MPS at each testing occasion were compared.
Results
Residents scored a mean 90% (SD = 6.5%) on the simulated skills examination immediately after training. Residents retained skills obtained through SBML as the mean score at bedside follow-up testing was 89% (SD = 8.9%, P = .36). Thirty-seven of 42 (88%) PGY-1 residents met or exceeded the MPS at follow-up.
Conclusion
SBML leads to substantial retention of critical care knowledge, and patient care skills PGY-1 boot camp is a highly efficient and effective model that can be administered at the beginning of the academic year.
EDUCATIONAL INNOVATION
MD,
DO., MPH,
MD,
PhD, and
MD
Abstract
Background
Residents deemed at risk for low performance on standardized examinations require focused attention and remediation.
Objective
To determine whether a remediation program for residents identified as at risk for failure on the Emergency Medicine (EM) Written Board Examination is associated with improved outcomes.
Intervention
All residents in 8 classes of an EM 1–3 program were assessed using the In-Training Examination. Residents enrolled in the Focused Board Intervention (FBI) remediation program based on an absolute score on the EM 3 examination of <70% or a score more than 1 SD below the national mean on the EM 1 or 2 examination. Individualized education plans (IEPs) were created for residents in the FBI program, combining self-study audio review lectures with short-answer examinations. The association between first-time pass rate for the American Board of Emergency Medicine (ABEM) Written Qualifying Examination (WQE) and completion of all IEPs was examined using the χ2 test.
Results
Of the 64 residents graduating and sitting for the ABEM examination between 2000 and 2008, 26 (41%) were eligible for the program. Of these, 10 (38%) residents were compliant and had a first-time pass rate of 100%. The control group (12 residents who matched criteria but graduated before the FBI program was in place and 4 who were enrolled but failed to complete the program) had a 44% pass rate (7 of 16), which was significantly lower (χ2 = 8.6, P = .003).
Conclusions
The probability of passing the ABEM WQE on the first attempt was improved through the completion of a structured IEP.
MD,
MD,
MSW,
MS,
BS,
BA, and
MD
Abstract
Background
Education for all physicians should include specialty-specific geriatrics-related and chronic disease-related topics.
Objective
We describe the development, implementation, and evaluation of a chronic disease/geriatric medicine curriculum designed to teach Accreditation Council for Graduate Medical Education core competencies and geriatric medicine competencies to residents by using longitudinal encounters with a standardized dementia patient and her caregiver daughter.
Intervention
Over 3 half-day sessions, the unfolding standardized patient (SP) case portrays the progressive course of dementia and simulates a 10-year longitudinal clinical experience between residents and a patient with dementia and her daughter. A total of 134 residents participated in the University of Cincinnati-based curriculum during 2007–2010, 72% of whom were from internal medicine (79) or family medicine (17) residency programs. Seventy-five percent of participants (100) said they intended to provide primary care to older adults in future practice, yet 54% (73) had little or no experience providing medical care to older adults with dementia.
Results
Significant improvements in resident proficiency were observed for all self-reported skill items. SPs' evaluations revealed that residents' use of patient-centered language and professionalism significantly improved over the 3 weekly visits. Nearly all participants agreed that the experience enhanced clinical competency in the care of older adults and rated the program as “excellent” or “above average” compared to other learning activities.
Conclusions
Residents found this SP-based curriculum using a longitudinal dementia case realistic and valuable. Residents improved in both self-perceived knowledge of dementia and the use of patient-centered language and professionalism.
MD and
PhD
Abstract
Background
Portfolios are effective instruments for assessment of teaching skills among professional teachers and have recently been adapted in medical education. However, scoring rubrics are needed to effectively guide assessors.
Intervention
Portfolio assessors reviewed and made assessment comments about the resident-as-teacher sections of 11 internal medicine residents' electronic portfolios and discussed their assessments in an assessor group discussion. We performed qualitative analyses of written and oral comments. Major themes were identified, and member checking and triangulation with the literature was performed to evaluate the trustworthiness of the qualitative analysis.
Results
Three faculty educators reviewed and commented on 241 uploaded e-portfolio documents accompanying reflections. Three major themes were identified: Application of Teaching Skills, Presentation Skills, and Insights as a Teacher. Themes and subthemes matched closely to several components of the conceptual framework of effective presentations formulated in Glassick standards for scholarly work, as well as themes found in assessments of professional teachers' portfolios.
Conclusions
Assessments of portfolios by experienced faculty educators appear to be useful for identifying many important facets of formal teaching presentations and may be useful for creation of a scoring rubric.
DO,
MD, and
IV, MD
Abstract
Background
A large volume of literature has documented racial disparities in the delivery of cardiovascular care in the United States and that decreased access to procedures and undertreatment lead to worse outcomes. A lack of diversity among physicians is considered to be a major contributor. The fellowship training program in cardiovascular medicine at The Ohio State University Medical Center had never trained a fellow from a minority group underrepresented in medicine (URM) before 2007.
Intervention
In 2005, the fellowship made it a priority to recruit and match URM candidates in an effort to address the community's lack of diversity and disparities in cardiovascular care.
Methods
Program leaders revised the recruitment process, making diversity a high priority. Faculty met with members of diverse residency programs during visits to other institutions, the focus of interview day was changed to highlight mentorship, additional targeted postinterview communications reached out to highly competitive applicants, and a regular mentoring program was constructed to allow meaningful interaction with URM faculty and fellows.
Results
Since these changes were implemented, the program has successfully matched a URM fellow for 5 consecutive years. Such candidates currently make up 4 of 16 total trainees (25%) in the fellowship in cardiovascular medicine.
Conclusions
The cardiovascular medicine fellowship training program at The Ohio State University was able to revise recruitment to attract competitive URM applicants as part of a concerted effort. Other educational programs facing similar challenges may be able to learn from the university's experiences.
PhD,
PhD,
MD, PhD,
PhD, and
MD, MACP
Abstract
Background
High rates of burnout and distress in resident physicians suggest a significant number would benefit from counseling.
Intervention
A resident wellness program (RWP) was designed to lower known barriers limiting resident access to services.
Methods
In 2011, medical residents and fellows were surveyed and logistic regression analyses were conducted to identify demographic and training program differences in perceived barriers and willingness to access the RWP.
Results
Of the 88% of trainees who knew about the RWP, 87% indicated they would be very likely or somewhat likely to seek out services. Time remained the biggest barrier for residents to getting help. Being male (odds ratio [OR] = 0.54, 95% confidence interval [CI] 0.34–0.84) or an ethnic/racial minority (OR = 0.49, 95% CI 0.28–0.85) was associated with greater unwillingness to seek counseling. Reluctance to access the RWP was associated with concerns about helpfulness, confidentiality, being unable to take a break, and stigma. Women (OR = 1.60, 95% CI 1.06–2.42) and primary care residents (OR = 1.58, 95% CI 0.98–2.54) were more likely to be concerned about taking a break. Men were more likely to question the helpfulness of counseling (OR = 0.55, 95% CI 0.36–0.85).
Conclusions
The RWP removed barriers of cost and knowledge about counseling services. More educational outreach is needed to address sex and ethnic differences about RWP utilization and attitudes in medical culture about a physician's right to address personal health care needs.
BRIEF REPORT
MD,
MD,
MD, and
MD
Abstract
Background
Point-of-care ultrasound has emerged as a powerful diagnostic tool and is also being increasingly used by clinicians to guide procedures. Many current and future internists desire training, yet no formal, multiple-application, program-wide teaching interventions have been described.
Intervention
We describe a structured 30-hour ultrasound training course in diagnostic and procedural ultrasound implemented during intern orientation. Internal medicine interns learned basic ultrasound physics and machine skills; focused cardiac, great vessel, pulmonary, and abdominal ultrasound diagnostic examinations; and procedural applications.
Results
In postcourse testing, learners demonstrated the ability to acquire images, had significantly increased knowledge scores (P < .001), and demonstrated good performance on practical scenarios designed to test abilities in image acquisition, interpretation, and incorporation into medical decision making. In the postcourse survey, learners strongly agreed (4.6 of 5.0) that ultrasound skills would be valuable during residency and in their careers.
Conclusions
A structured ultrasound course can increase knowledge and can result in learners who have skills in image acquisition, interpretation, and integration in management. Future work will focus on refining and improving these skills to allow these learners to be entrusted with the use of ultrasound independently for patient care decisions.
MD,
PhD,
MD, and
MD
Abstract
Background
Ultrasound is a valuable tool in the safe performance of an increasing number of procedures. It has additionally emerged as a powerful instrument for point-of-care assessment by offering internists an opportunity to extend their traditional physical examination.
Objective
This study explored how internal medicine (IM) educators perceive the use of ultrasound for procedures and point-of-care assessments, the extent to which curricula for teaching IM residents ultrasound skills exist, and perceived barriers to teaching its use.
Methods
In February 2012, we administered a 27-question survey to all members of the Association of Program Directors in Internal Medicine, eliciting their opinions about the use of point-of-care ultrasound.
Results
Of 2200 surveys distributed electronically, 234 were returned (a 11% response rate), including 167 by program directors or assistant program directors. Respondents highly rated the usefulness of ultrasound for central-line placement, thoracentesis, paracentesis, and diagnosis of pleural effusions. Evaluation of vena cava and heart, and placement of radial artery catheters received somewhat lower usefulness scores. Forty-five respondents (25%) reported having formal curricula to teach point-of-care ultrasound, and 46 respondents without current ultrasound programs were planning to initiate them in the next 12 months. Potential barriers to teaching and use of ultrasound included the time and cost to train faculty, the cost of ultrasound machines, and the time required to train residents.
Conclusions
Educational leaders in IM view point-of-care ultrasound as a valuable tool in diagnosis and procedures, and many residency programs are teaching these skills to their learners.
MD, FAAFP,
RN, C-TAGME,
DO, and
MD, FAAFP
Abstract
Background
Residency interviews can place significant time and financial burdens on applicants.
Objective
To determine whether the use of Skype as a screening tool during interview season in a family medicine residency is cost-effective and time-efficient for the applicant and the residency program.
Methods
We surveyed 2 groups of medical students during interviews for our family medicine program. Thirty-two students were interviewed via our face-to-face, traditional interview (TI) process, and 10 students, the second group, who did not meet the program's standard interview selection criteria for TI, underwent our Skype interview (SI) process.
Results
Using an unpaired t test, we found that the applicants' costs of an SI were significantly less than a TI, $566 (95% confidence interval [CI] $784–$349, P < .001). Direct cash savings plus indirect salary savings to the program were $5,864, with a time savings of 7 interview days. Three of the applicants who were participants in the SI limb of the study were in our final rank order list.
Conclusions
For interviewing in family medicine residencies, use of Skype may be a cost-effective and time-efficient screening tool for both the applicant and the program. Alternate uses of SI may include the time-sensitive, postmatch Supplemental Offer and Acceptance Program.
MD, MA,
MD,
MD, and
MD
Abstract
Background
Important components of fellowship training include learning teaching skills and career development. Pulmonary and critical care medicine (PCCM) fellows' opinions of the importance of developing teaching skills and interest in careers in medical education have not been previously described, and there are no tools to assess interest in acquiring teaching skills.
Objective
We describe the development and initial psychometric validation of a survey tool to assess trainees' attitudes toward and interest in acquiring teaching skills.
Methods
A survey tool to assess attitudes toward teaching and medical education skills was designed and psychometrically characterized. We then anonymously surveyed fellows in 1 PCCM program to assess their perceptions of and attitudes regarding acquiring teaching skills.
Results
The survey tool demonstrated acceptable psychometric properties. The survey showed that most fellows felt that acquiring teaching skills was “very important,” and nearly half reported being “interested” or “very interested” in pursuing careers as medical educators. However, fellows disagreed with the feedback they received from attending physicians with regard to their teaching abilities (10% disagreed with feedback at the beginning of the year, 36% disagreed at the end of the year; P = .03).
Conclusions
Our survey demonstrates acceptable psychometric properties and performance characteristics in a single-site study of PCCM fellows during 1 academic year. Fellows are interested in improving their teaching skills but do not know how to become better teachers. Added research in multiple settings should explore the generalizability of our findings.
MD, MACMD,
MD,
MS,
MS,
MBA,
PhD,
RN., AAS,
MD., MBA,
PhD, and
MD
Abstract
Background
Research suggests pediatrics practitioners lack confidence and skills in the end-of-life (EOL) care.
Objective
This pilot study explored the impact of a curriculum designed to prepare future pediatricians to manage pain and provide comfort for children and infants with life-threatening conditions and to be more confident and competent in their EOL discussions with families.
Methods
Participants included 8 postgraduate year (PGY)-2 residents in the study group and 9 PGY-3 residents in a control group. The EOL curriculum included 4, 1-hour sessions consisting of didactic lectures, videos, and small-group, interactive discussions. Topics included discussing EOL with families, withdrawal of care, and pain assessment and management. Curriculum evaluation used an objective structured clinical examination (OSCE), self-assessment confidence and competency questionnaire, and a follow-up survey 18 months after the intervention.
Results
The OSCE showed no statistically significant differences between PGY-2 versus PGY-3 residents in discussing EOL issues with family (mean = 48.3 [PGY-2] versus 41.0 [PGY-3]), managing withdrawal of care (mean = 20.9 [PGY-2] versus 18.91 [PGY-3]), and managing adolescent pain (mean = 30.97 [PGY-2] versus 29.27 [PGY-3]). The self-assessment confidence and competency scores improved significantly after the intervention for both PGY-2 residents (0.62 versus 0.86, P < .01) and PGY-3 residents (0.61 versus 0.85, P < .01).
Conclusions
An EOL curriculum for PGY-2 pediatrics residents delivered during the intensive care unit rotation is feasible and may be effective. Residents reported the curriculum was useful in their practice.
RIP OUT
MPH,
MD, MHPE,
MA, and
MD, MHPE
MD,
MD, and
PhD, MBA
The Challenge
Problems with clinical reasoning (wrong, delayed, or missed diagnosis and/or treatment) make up a sizable portion of preventable adverse outcomes.1,2 In 1 review of diagnostic errors, 75% were at least in part due to cognitive errors.3 Of 320 cognitive factors identified in 74 cases, 45 were due to faulty data gathering and 264 resulted from errors in problem representation and clinical reasoning.1 Teaching good clinical reasoning is an important component of resident education.
What Is Known
One framework for defining “Good Clinical Thinking” is presented in box 1 .
MD,
MD, and
PhD., MBA
The Rip Out on approaches to reduce diagnostic error in this issue of the Journal of Graduate Medical Education offers practical strategies for defining, teaching, and assessing critical thinking.1 Valuable by itself, this approach can be applied in greater detail to inform curricula, teaching strategies, and resident assessment, using a crosswalk between curricular Milestones2 and the Trowbridge3 12 concepts to avoid errors in clinical reasoning.
The detailed curricular Milestones developed by the internal medicine community in 2009 are not the reportable components of the Next Accreditation System currently being implemented by the
COMMENTARIES
MD, PhD, FAHA and
MSPH
Physician health is important not just for the individual practitioner and medical community as a whole, but also because patients and the general population may benefit from having health-conscious physicians. The potential role that physicians' physical and emotional health may have on their patients' health has been of interest for more than 3 decades. Strong associations have been consistently found between providers' self-reported lifestyle habits and their related preventive practices—the “Healthy Doctor–Healthy Patient” relationship.1–3
For example, physicians who do not smoke are more likely to encourage patients to quit smoking,4 and physically active doctors are
MD
The availability of clinicians to respond to an acute disaster is an integral aspect of emergency management in the medical setting. Without a supply of clinicians who are ready to care for patients, it is difficult to imagine how a health care system would prepare for, or respond to, a large influx of patients (a “surge”).
In this issue of the Journal of Graduate Medical Education, Snipes et al1 describe their survey of several emergency medicine residency programs in academic health care centers and evaluate the projected response rates of faculty and residents. The authors found
EdD and
MA
The September 2013 issue of the Journal of Graduate Medical Education includes a study by Auseon and colleagues,1 “Successful Efforts to Increase Diversity in a Cardiology Fellowship Training Program” that profiles an initiative to attract more underrepresented minority physicians into a university-based cardiovascular medicine fellowship. The piece contributes to a sparse but growing body of literature regarding promising practices for creating diverse and inclusive residency training programs.2
Much of the discourse regarding diversity in medicine has focused on ways to increase the pipeline of minority students prepared for and accepted into undergraduate medical education and,
TO THE EDITOR
MD,
MD,
EdD,
MD, and
MD
Communication among providers is a crucial aspect of patient care. Poor communication is well documented and can lead to erosion of interspecialty relationships and suboptimal patient outcomes.1,2 The Accreditation Council for Graduate Medical Education identifies interpersonal and communication skills as core competencies, setting broad expectations to teach and model ideal communication.3 However, there is currently little evidence to guide teaching about optimal modes of communication. We conducted a mixed-methods study to measure the impact of an interprofessional education program on interspecialty communication at an academic medical center.4 This report describes providers' preferences
MD, FACP and
MD, FACP, FAAP
The Next Accreditation System will focus graduate medical education on outcomes and competency rather than months and years.1 As we shift to performance-based evaluation of trainees, an equally important change in the faculty structure is needed.
Improvement is not always a steady climb to a milestone. Dating back to Bryan and Harter's series in the 1890s on telegraph operators, studies show that new skill acquisition progresses with periods of large increases in performance interrupted by short plateaus or decrements.2,3 How, then, do we view a trainee that has a plateau or decrease in performance?
ON TEACHING
MD, MSc
I stepped inside kaigishitsu ichi (conference room 1) and froze. I had just completed a teaching session and had hustled up and down numerous flights of stairs through the hospital complex. With labored breathing and dilated pupils, I stared at a whiteboard on the far wall, 30 feet away, which displayed a scientific poster titled, “Thrombotic Thrombocytopenic Purpura with Myocardial Infarction.” At that moment, the poster was slowly sliding down the board. The room had been empty in the morning when I left this poster, along with 2 others. Presently, in front of the whiteboard were 10 feet of carpet,
MD and
MD, MPH
It's Sunday and you are covering 3 hospitals as a consultant for otolaryngology. A fairly urgent consult awaits you at the children's hospital. You receive a call from a primary care team at another hospital asking you to evaluate an oral lesion in a patient who has been in the hospital for 1 week. The primary team wonders if this lesion needs surgical management before they move forward with placement of a left ventricular assist device and chronic anticoagulation, planned for the next day. The lesion has been present for more than 1 year. When asked what the lesion looks like, there
NEWS AND VIEWS
MD, JD,
MD, MBA, and
PhD, MBA
Background
On July 1, 2013, the first group of programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) transitioned into the Next Accreditation System (NAS), and 1 year later, the remaining accredited specialties, the transitional year, and the review of sponsoring institutions will move into the NAS.1 The NAS is an outcomes-based and improvement-focused approach to the accreditation of programs and sponsoring institutions. The intent is to both ensure a level of quality (through assessment of compliance with the accreditation standards) and to promote ongoing improvement in all programs and innovation in high-performing programs.1 The
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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