“Do I need to submit a research abstract or paper to graduate?” is an often asked question by trainees. As faculty, we look to the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements for guidance. The requirements mandate that residency training programs demonstrate resident and faculty scholarly activity, as well as an “environment of inquiry and scholarship with an active research component.”1 The features of that environment include faculty participation in clinical discussions, rounds, and journal clubs; receipt of peer-reviewed funding; publication of original articles or chapters; publication or presentation of case reports or clinical series
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FROM THE EDITOR
PhD,
MD, MCR, and
MD, MS
MD, MPH and
PhD
DOI: 10.4300/JGME-5-4-18
Likert-type scales are frequently used in medical education and medical education research. Common uses include end-of-rotation trainee feedback, faculty evaluations of trainees, and assessment of performance after an educational intervention. A sizable percentage of the educational research manuscripts submitted to the Journal of Graduate Medical Education employ a Likert scale for part or all of the outcome assessments. Thus, understanding the interpretation and analysis of data derived from Likert scales is imperative for those working in medical education and education research. The goal of this article is to provide readers who do not have extensive statistics background with
MD and
MD
In the United States, an imbalance in the production of primary care and specialist physicians, the declining production and a geographic maldistribution of primary care physicians, and an adverse practice environment for primary care have proven to be vexing and seemingly intractable problems that challenge the ability of the health system to provide appropriate and timely access to primary care.1 This also appears to be an emerging problem in other developed nations.2 Despite considerable evidence that a robust primary care infrastructure produces better outcomes at lower cost,3 designing and implementing a comprehensive health care
From the Editors
Simpson, Yarris, and Carek define scholarly activity, drawing on classic interpretations of scholarship (p. 539). Sullivan and Artino provide practical guidance for analyzing and interpreting Likert scales, assuring researchers that it is acceptable to use parametric tests with ordinal data (p. 541).
Perspectives
Alexander et al identify 4 types of “difficult residents,” and offer tips for identification and management (p. 547); Rocke and Lee discuss educating residents on how to disclose errors to patients and families (p. 550); and Fargen and Rosen speculate whether duty hour limits may teach residents that dishonesty is an acceptable response to a challenging situation (p. 553).
PERSPECTIVES
PhD,
MD, and
MD
In a 1978 article entitled “Taking Care of the Hateful Patient” James Groves1 identified 4 types of patients who induce “hateful” feelings in medical providers. The 4 types overlap considerably with personality disorders ( table ). Groves' seminal article identified a common, yet hidden fact of patient care—that certain patients evoke strongly negative feelings in their providers. This insight runs counter to the ideal that providers should “love” all of their patients. Having hateful feelings toward difficult patients is normal and can provide useful diagnostic information. Awareness and acceptance of these feelings can lead to better outcomes, both
MD, JD and
MD
During residency training, one learns about managing complications, correcting misdiagnoses, and rectifying adverse effects from the care given to patients. However, where in residency training is one taught what and how to disclose those errors to the patient and their family? This question serves as the basis of this article.
Trust is an integral component of the physician-patient relationship. During the past 60 years, this trust has eroded to the point where physicians now trail nurses, pharmacists, and veterinarians in public reports of trust in various professions.1 Although the reasons are multifactorial, a growing awareness of medical errors and
MD, MPH and
MD, PhD
Since the implementation of common duty hour standards by the Accreditation Council for Graduate Medical Education (ACGME) in 2003, and the release of added standards in 2011, there have been efforts to assess these requirements on patient safety and resident learning. A number of resident and program director surveys have sought to gauge the effects of the standards on trainee competency, fatigue, quality of life, and patient safety.1–17 While the results of these surveys differ slightly among specialties, several pervasive themes have emerged. First, the 16-hour limitation for first-year residents enacted in July 2011 is not
MD,
MD,
MD, MACP, and
MD
Introduction
The primary care physician workforce crisis has eluded solution for many years. Concerns raised 5 years ago about nadir of interest in primary care careers by medical students are now realized, as the proportion of residency graduates from our nation's teaching hospitals entering primary care careers, particularly to underserved rural areas, has hit an all-time low.1,2
There is an estimated shortage of 16 000 primary care physicians (PCPs) necessary to meet today's needs; this deficit will grow to 52 000 in the next decade.3 An aging population, with an aging population of physicians themselves, will exacerbate this
REVIEW
MD,
MD, MBA, and
MD
Introduction
In many teaching institutions, grand rounds are a weekly educational activity and a time-honored tradition.1–7 A 2006 article in the New York Times criticized grand rounds, noting “Socratic dialogue [has given way] to PowerPoint presentation” and “grand rounds are not so grand anymore.”8 The literature also suggests that the relevance of grand rounds is declining.1,5,7,9–12 With decreasing attendance and a format that is drastically different from its original design, some have proposed forgoing the term “grand rounds.”5,13,
ORIGINAL RESEARCH
PhD,
MD, MPH,
PhD,
BA, and
MD
Abstract
Background
Scholarly activity during residency is vital to resident learning and ultimately to patient care. Incorporating that activity into training is, however, a challenge for medical educators. Most research on medical student and resident attitudes toward scholarly activity to date has been quantitative and has focused on level of interest, desire to perform scholarship, and perceived importance of scholarship.
Objective
We explored attitudes, expectations, and barriers regarding participation in scholarly activity among current residents and graduates of a single family medicine residency program.
Methods
Using a phenomenologic approach, we systematically analyzed data from one-on-one, semistructured interviews with residents and graduates. Interviews included participant expectations and experiences with scholarly activity in residency.
Results
The 20 participants (residents, 15 [75%]; residency graduates, 5 [25%]) identified uncertainty in their attitudes toward, and expectations regarding, participation in scholarly activity as an overarching theme, which may present a barrier to participation. Themes included uncertainty regarding their personal identity as a clinician, time to complete scholarly activity, how to establish a mentor-mentee relationship, the social norms of scholarship, what counted toward the scholarship requirements, the protocol for completing projects, and the clinical relevance of scholarship.
Conclusions
Uncertainty about scholarly activity expectations can add to learner anxiety and make performing scholarly activity during residency seem like an insurmountable task. Programs should consider implementing a variety of strategies to foster scholarly activity during residency, including clarifying and codifying expectations and facilitating mentoring relationships with faculty.
PhD,
PhD,
MS,
MD,
MD, and
MD
Abstract
Background
Although interpersonal and communication skills are essential to physician practice, there is a dearth of effective tools to meaningfully teach and assess communication skills.
Objective
The purpose of our study was to create a standardized tool for evaluation of communication skills for residents across specialties.
Methods
We designed an Objective, Structured Communication Assessment of Residents (OSCAR) tool, consisting of 4 clinical stations, to assess intern communication skills with relationship development, their establishment of case goals, and their organization and time management skills. Interns from 11 training programs completed the stations, with senior residents trained to function as standardized patients. The 4 stations' scenarios were a disruptive patient, handling a phone call for a narcotics refill, disclosing a medical mistake, and delivering bad news.
Results
Eighty-three interns completed OSCAR during orientation. The assessment took interns about 40 minutes to complete, and participants were given immediate feedback by the standardized patients. The total possible score for each station was 50. Resident performance was highest for disclosing a medical error (94%, 47 of 50), followed by handling a disruptive patient (90%, 45 of 50), disclosing bad news (86%, 43 of 50), and handling the phone call for the narcotics refill (62%, 31 of 50). Multivariate analysis of variance results indicated differences between residents from US and international medical schools, but there were no significant differences across specialties. Interrater reliability was excellent for each station (> 0.80).
Conclusions
OSCAR is a practical tool for assessing interns' communication skills to provide timely results to program directors.
MD,
MD,
MD, and
MD, MEd
Abstract
Background
Communicating with colleagues is a key physician competency. Yet few studies have sought to uncover the complex nature of relationships between referring and consulting physicians, which may be affected by the inherent relationships between the participants.
Objective
Our study examines themes identified from discussions about communications and the role of relationships during the referral-consultation process.
Methods
From March to September 2010, 30 residents (10 emergency medicine, 10 general surgery, 10 internal medicine) were interviewed using a semistructured focus group protocol. Two investigators independently reviewed the transcripts using inductive methods and grounded theory to generate themes (using codes for ease of analysis) until saturation was reached. Disagreements were resolved by consensus, yielding an inventory of themes and subthemes. Measures for ensuring trustworthiness of the analysis included generating an audit trail and external auditing of the material by investigators not involved with the initial analysis.
Results
Two main relationship-related themes affected the referral-consultation process: familiarity and trust. Various subthemes were further delineated and studied in the context of pertinent literature.
Conclusions
Relationships between physicians have a powerful influence on the emergency department referral-consultation dynamic. The emergency department referral-consultation may be significantly altered by the familiarity and perceived trustworthiness of the referring and consulting physicians. Our proposed framework may further inform and improve instructional methods for teaching interpersonal communication. Most importantly, it may help junior learners understand inherent difficulties they may encounter during the referral process between emergency and consulting physicians.
MD,
MD, and
PhD
Abstract
Background
Medical knowledge (MK) in residents is commonly assessed by the in-training examination (ITE) and faculty evaluations of resident performance.
Objective
We assessed the reliability of clinical evaluations of residents by faculty and the relationship between faculty assessments of resident performance and ITE scores.
Methods
We conducted a cross-sectional, observational study at an academic emergency department with a postgraduate year (PGY)-1 to PGY-3 emergency medicine residency program, comparing summative, quarterly, faculty evaluation data for MK and overall clinical competency (OC) with annual ITE scores, accounting for PGY level. We also assessed the reliability of faculty evaluations using a random effects, intraclass correlation analysis.
Results
We analyzed data for 59 emergency medicine residents during a 6-year period. Faculty evaluations of MK and OC were highly reliable (κ = 0.99) and remained reliable after stratification by year of training (mean κ = 0.68–0.84). Assessments of resident performance (MK and OC) and the ITE increased with PGY level. The MK and OC results had high correlations with PGY level, and ITE scores correlated moderately with PGY. The OC and MK results had a moderate correlation with ITE score. When residents were grouped by PGY level, there was no significant correlation between MK as assessed by the faculty and the ITE score.
Conclusions
Resident clinical performance and ITE scores both increase with resident PGY level, but ITE scores do not predict resident clinical performance compared with peers at their PGY level.
DO,
MD, MA,
MD, MPH,
MD, PhD,
MD, MPH,
MD, MS,
MD,
MD,
PhD,
PhD, and
PhD, JD
Abstract
Background
In 2010, the Department of Veterans Affairs (VA) implemented a national patient-centered care initiative that organized primary care into interdisciplinary teams of health care professionals to provide patient-centered, continuous, and coordinated care.
Objective
We assessed the discriminate validity of the Learners' Perceptions Survey—Primary Care (LPS-PC), a tool designed to measure residents' perceptions about their primary and patient-centered care experiences.
Methods
Between October 2010 and June 2011, the LPS-PC was administered to Loma Linda University Medical Center internal medicine residents assigned to continuity clinics at the VA Loma Linda Healthcare System (VALLHCS), a university setting, or the county hospital. Adjusted differences in satisfaction ratings across settings and over domains (patient- and family-centered care, faculty and preceptors, learning, clinical, work and physical environments, and personal experience) were computed using a generalized linear model.
Results
Our response rate was 86% (77 of 90). Residents were more satisfied with patient- and family-centered care at the VALLHCS than at either the university or county (P < .001). However, faculty and preceptors (odds ratio [OR] = 1.53), physical (OR = 1.29), and learning (OR = 1.28) environments had more impact on overall resident satisfaction than patient- and family-centered care (OR = 1.08).
Conclusions
The LPS-PC demonstrated discriminate validity to assess residents' perceptions of their patient-centered clinical training experience across outpatient primary care settings at an internal medicine residency program. The largest difference in scores was the patient- and family-centered care domain, in which residents rated the VALLHCS much higher than the university or county sites.
MD, MSc(Med Ed), FRCPC,
MBBS, MRCP(UK), FRCPC, FAAP,
MB, ChB(Hons), MRCP, MSc, PhD, and
PhD
Abstract
Background
Family-centered bedside rounds (family-centered rounds) enable learning and clinical care to occur simultaneously and offer benefits to patients, health care providers, and multiple levels of learners.
Objective
We used a qualitative approach to understand the dimensions of successful (ie, educationally positive) family-centered rounds from the perspective of attending physicians and residents.
Methods
We studied rounds in a tertiary academic hospital affiliated with the University of Calgary. Data were collected from 7 focus groups of pediatrics residents and attendings and were analyzed using grounded theory.
Results
Attending pediatricians and residents described rounds along a spectrum from successful and highly educational to unsuccessful and of low educational value. Perceptions of residents and attendings were influenced by how well the environment, educational priorities, and competing priorities were managed. Effectiveness of the manager was the core variable for successful rounds led by persons who could develop predictable rounds and minimize learner vulnerability.
Conclusions
Success of family-centered rounds in teaching settings depended on making the education and patient care aims of rounds explicit to residents and attending faculty. The role of the manager in leading rounds also needs to be made explicit.
MD,
MD,
MD,
MS,
MD, and
MD
Abstract
Background
The current health care system requires a substantial amount of documentation by physicians, potentially limiting time spent on patient care.
Objective
We sought to explore trainees' perceptions of their clinical documentation requirements and the relationship between time spent on clinical documentation versus time available for patient care.
Methods
An anonymous, online survey was sent to trainees in all postgraduate years of training and specialties in Accreditation Council for Graduate Medical Education–accredited programs.
Results
Over a 2-month time frame, 1515 trainees in 24 specialties completed the survey. Most (92%) reported that documentation obligations are excessive, that time spent with patients has been compromised by this (90%), and that the amount of clinical documentation has had a negative effect on patient care (73%). Most residents and fellows reported feeling rushed and frustrated because of these documentation demands. They also reported that time spent on these tasks decreased their time available for teaching others and reduced the quality of their education. Respondents reported spending more time on clinical documentation than on direct patient care (P < .001).
Conclusions
Trainees' current clinical documentation workload may be a barrier to optimal patient care and to resident and fellow education. Residents and fellows report that clinical documentation duties are onerous, and there is a perceived negative effect on time spent with patients, overall quality of patient care, physician well-being, time available for teaching, and quality of resident education.
DO,
MD,
BS,
MS, ARNP-BC,
EdD,
MSN, ARNP-BC, and
MD
Abstract
Background
Residents perform invasive bedside procedures in most training programs. To date, there is no universal approach for determining competency and ensuring quality and safety of care.
Objective
We developed and implemented an assessment of central venous catheter insertion competency for internal medicine and internal medicine–pediatrics residents, using measurements for knowledge, skill, and attitude and linking them to procedural outcomes.
Methods
We conducted a cohort study of a 4-week, resident-run procedure service from July 2007 through June 2011 at a large academic medical center. Knowledge was assessed by using a written test, technical skill by using a checklist, and attitude by self- and supervisor assessments of residents' confidence and capability. Competence was defined as (1) a minimum written test score (70%); (2) a perfect checklist score; (3) a resident's self-assessed confidence and capability scores of 4 or 5 of 5; and (4) faculty rating of the resident's confidence and capability as 5 of 5. A composite success rate was based on procedural outcomes (eg, completed procedures, less than 3 forward needle passes, and complication rate) and was compared to the checklist scores.
Results
A total of 148 internal medicine and medicine–pediatrics residents inserted 639 catheters, and 53 (36%) achieved competence by the end of 4 weeks. Residents judged to be competent by checklist scores had a higher composite success rate than those deemed not competent.
Conclusions
Our multi-factorial criteria used to define central venous catheter insertion competency effectively discriminated between residents judged to be competent and those judged not competent, using data from procedural outcomes.
MD,
MD,
MD, MEd, and
MD
Abstract
Background
Pediatrics residents have few opportunities to perform cardiopulmonary resuscitation (CPR). Enhancing the quality of CPR is a key factor to improving outcomes for cardiopulmonary arrest in children and requires effective training strategies.
Objective
To evaluate the effectiveness of a simulation-based intervention to reduce first-year pediatrics residents' time for 3 critical actions in CPR: (1) call for help, (2) initiate bag-mask ventilation, and (3) initiate chest compressions.
Methods
A prospective study involving 31 first-year pediatrics residents at a children's hospital assigned to an early or late (control) intervention group. Residents underwent baseline assessment followed by repeat evaluations at 3 and 6 months. Time to critical actions was scored by video review. A 90-minute educational intervention focused on skill practice was conducted following baseline evaluation for the early-intervention group and following 3-month evaluation for the late-intervention group. Primary outcome was change in time to initiating the 3 critical actions. Change in time was analyzed by comparison of Kaplan-Meier curves, using the log-rank test. A 10% sample was timed by a second rater. Agreement was assessed using intraclass correlation (ICC).
Results
There was a statistically significant reduction in time for all 3 critical actions between baseline and 3-month evaluation in the early intervention group; this was not observed in the late (control) group. Rater agreement was excellent (ICC ≥ 0.99).
Conclusions
A simulation-based educational intervention significantly reduced time to initiation of CPR for first-year pediatrics residents. Simulation training facilitated acquisition of critical CPR skills that have the potential to impact patient outcome.
MD,
MD, MA,
PhD,
BS, and
MD
Abstract
Background
Promotion for academic faculty depends on a variety of factors, including their research, publications, national leadership, and quality of their teaching.
Objective
We sought to determine the importance of resident evaluations of faculty for promotion in obstetrics-gynecology programs.
Methods
A 28-item questionnaire was developed and distributed to 185 department chairs of US obstetrics-gynecology residency programs.
Results
Fifty percent (93 of 185) responded, with 40% (37 of 93) stating that teaching has become more important for promotion in the past 10 years. When faculty are being considered for promotion, teaching evaluations were deemed “very important” 60% of the time for clinician track faculty but were rated as mainly “not important” or “not applicable” for research faculty. Sixteen respondents (17%) stated a faculty member had failed to achieve promotion in the past 5 years because of poor teaching evaluations. Positive teaching evaluations outweighed low publication numbers for clinical faculty 24% of the time, compared with 5% for research faculty and 8% for tenured faculty being considered for promotion. The most common reason for rejection for promotion in all tracks was the number of publications. Awards for excellence in teaching improved chances of promotion.
Conclusions
Teaching quality is becoming more important in academic obstetrics-gynecology departments, especially for clinical faculty. Although in most institutions promotion is not achieved without adequate research and publications, the importance of teaching excellence is obvious, with 1 of 6 (17%) departments reporting a promotion had been denied due to poor teaching evaluations.
MD,
MD,
MD, and
MD
Abstract
Background
Birthrates during surgical residency appear to be rising. One assumption is that this is due to changes in the structure of surgical residencies.
Objective
The purpose of our study was to explore whether an increase in birthrates has occurred and the reasons for this.
Methods
We conducted an anonymous survey of current residents and alumni from 1976 to 2009 at a single university-based surgery training program.
Results
Alumni (46 of 116) and current residents (38 of 51) were surveyed, and our response rate was approximately 50% (84 of 167). Respondents were grouped into cohorts based on their residency start year. The early cohort consisted of residents starting residency between 1976 and 1999, and the late cohort consisted of residents starting residency between 2000 and 2009. The percentage of male residents with children during residency training was similar for the early and late cohorts (34% [10 of 29] versus 41% [9 of 22]). For female residents, there was a substantial increase in childbearing for the late cohort (7% [1 of 15] versus 35% [6 of 18]). Fifty-two percent (44 of 84) of the respondents who had children during residency reported that work hours and schedule had a negative effect on their decision to have children. Most respondents reported that availability or cost of child care, impact on residency, support from the program, increased length of training, or availability of family leave did not factor as concerns.
Conclusions
Childbearing during residency has increased in female residents in our study. Surgical residency programs may need to accommodate this change if they want to continue to recruit and retain talented residents.
MD, MSc,
MD, PhD,
PhD,
MD,
MD, and
MD, MPH
Abstract
Background
The Accreditation Council for Graduate Medical Education Resident-Fellow Survey measurement of compliance with duty hours uses remote retrospective resident report, the accuracy of which has not been studied. We investigated residents' remote recall of 16-hour call-shift compliance and workload characteristics at 1 institution.
Methods
We sent daily surveys to second- and third-year internal medicine residents immediately after call shifts from July 2011 to June 2012 to assess compliance with 16-hour shift length and workload characteristics. In June 2012, we sent a survey with identical items to assess residents' retrospective perceptions of their call-shift compliance and workload characteristics over the preceding year. We used linear models to compare on-call data to residents' retrospective data.
Results
We received a survey response from residents after 497 of 648 call-shifts (77% response). The end-of-year perceptions survey was completed by 87 of 95 residents (92%). Compared with on-call data, the recollections of 5 (6%) residents were accurate; however, 48 (56%) underestimated and 33 (38%) overestimated compliance with the 16-hour shift length requirement. The average magnitude of under- and overestimation was 18% (95% confidence interval = 13–23). Using a greater than 10% absolute difference to define under- and overestimation, 39 (45%) respondents were found to be accurate, 27 (31%) underestimated compliance, and 20 (23%) overestimated compliance. Residents overestimated census size, long call admissions, and admissions after 5 pm.
Conclusions
Internal medicine residents' remote retrospective reporting of compliance with the 16-hour limit on continuous duty and workload characteristics was inaccurate compared with their immediate recall and included errors of underestimation and overestimation.
PhD,
MD, FACP,
MD,
PhD,
MA, PhD (cand),
MS,
MA, PhD (cand),
MS, PhD (cand),
BS, and
MD, FAPA
Abstract
Background
Physicians in training experience fatigue from sleep loss, high workload, and working at an adverse phase of the circadian rhythm, which collectively degrades task performance and the ability to learn and remember. To minimize fatigue and sustain performance, learning, and memory, humans generally need 7 to 8 hours of sleep in every 24-hour period.
Methods
In a naturalistic, within-subjects design, we studied 17 first- and second-year internal medicine residents working in a tertiary care medical center, rotating between day shift and night float every 4 weeks. We studied each resident for 2 weeks while he/she worked the day shift and for 2 weeks while he/she worked the night float, objectively measuring sleep by wrist actigraphy, vigilance by the Psychomotor Vigilance Task test, and visual-spatial and verbal learning and memory by the Brief Visuospatial Memory Test-Revised and the Rey Auditory-Verbal Learning Test.
Results
Residents, whether working day shift or night float, slept approximately 7 hours in every 24-hour period. Residents, when working day shift, consolidated their sleep into 1 main sleep period at night. Residents working night float split their sleep, supplementing their truncated daytime sleep with nighttime on-duty naps. There was no difference in vigilance or learning and memory, whether residents worked day shift or night float.
Conclusions
Off-duty sleep supplemented with naps while on duty appears to be an effective strategy for sustaining vigilance, learning, and memory when working night float.
EDUCATIONAL INNOVATION
MD,
MD,
BMBCh,
MD,
MEd,
BS, C-TAGME,
AAS, C-TAGME, and
PhD
Abstract
Background
The traditional 1-month training blocks in pediatrics may fail to provide sufficient exposure to develop the knowledge, skills, and attitudes residents need for practice and may not be conducive to mentoring relationships with faculty and continuity with patients.
Intervention
We created a 4-month career-focused experience (CFE) for third-year residents. The CFE included block time and longitudinal experiences in different content areas related to residents' choice of urban and rural primary care, hospitalist medicine, or subspecialty care (prefellowship). Content was informed by graduate surveys, focus groups with primary care pediatricians and hospitalists, and interviews with fellowship directors. Outcomes were assessed via before and after surveys of residents' attitudes and skills, assessment of skills with an objective structured clinical examination (OSCE), and interviews with residents and mentors.
Results
Twenty-three of 49 third-year residents took part in the first 2 years of CFE. Two residents dropped out, leaving 21 who completed the 4-month experience (9 in primary care, 2 in hospitalist medicine, and 10 in a subspecialty). Residents reported improvement in their clinical skills, increased satisfaction with faculty mentoring and evaluation, and the ability to focus on what was important to their careers. OSCE performance did not differ between residents who completed the CFE and those who did not. Administrative burden was high.
Conclusions
Four-month career-focused training for pediatrics residents is feasible and may be effective in meeting part of the new requirement for 6 months of career-focused training during pediatrics residency.
DSW,
MD,
MD, MSc,
MLS, and
MD
Abstract
Background
Limited time and funding are challenges to meeting the research requirement of the orthopedic residency curriculum.
Objective
We report a reorganized research curriculum that increases research quality and productivity at our academic orthopedic medical center.
Methods
Changes made to the curriculum, which began in 2006 and were fully phased in by 2008, included research milestones for each training year, a built-in support structure, use of an accredited bio-skills laboratory, mentoring by National Institutes of Health–funded scientists, and protected time to engage in required research and prepare scholarly peer-reviewed publications.
Results
Total grant funding of resident research increased substantially, from $15,000 in 2007 (8 graduates) to $380,000 in 2010 (9 graduates), and the number of publications also increased. The 12 residents who graduated in 2005 published 16 papers from 2000 to 2006, compared to 84 papers published by the 9 residents who graduated in 2010. The approximate costs per year included $19,000 (0.3 full-time equivalent) for an academic research coordinator; $16,000 for resident travel to professional meetings; reimbursement for 213 faculty hours; and funding for resident salaries while on the research rotation, paid through the general hospital budget.
Conclusions
The number of grants and peer-reviewed publications increased considerably after our residency research curriculum was reorganized to allow dedicated research time and improved mentoring and infrastructure.
MD, MPH,
MD,
MD, MPP,
MD, and
MD, MPH
Abstract
Background
Compliance with the Accreditation Council for Graduate Medical Education duty hour standards may necessitate more frequent transitions of patient responsibility.
Intervention
We created a multidisciplinary Patient Safety and Quality Council with a Task Force on Handoffs (TFH), engaging residents at a large, university-based institution.
Methods
The TFH identified core content of effective handoffs and patterned institutional content on the SIGNOUTT mnemonic. A web-based module highlighting core content was developed for institutional orientation of all trainees beginning summer 2011 to standardize handoff education. The TFH distributed handoff material and catalogued additional program initiatives in teaching and evaluating handoffs. A standard handoff evaluation tool, assessing content, culture, and communication, was developed and “preloaded” into the institution-wide electronic evaluation system to standardize evaluation. The TFH developed questions pertaining to handoffs for an annual institutional survey in 2011 and 2012. Acceptability of efforts was measured by program participation, and feasibility was measured by estimating time and financial costs.
Results
Programs found the TFH's efforts to improve handoffs acceptable; to date, 13 program-specific teaching initiatives have been implemented, and the evaluation tool is being used by 5 programs. Time requirements for TFH participants average 2 to 3 h/mo, and financial costs are minimal. More residents reported having education on handoffs (58% [388 of 668] versus 42% [263 of 625], P < .001) and receiving adequate signouts (69% [469 of 680] versus 61% [384 of 625], P = .004) in the 2012 survey, compared with 2011.
Conclusions
Use of a multispecialty resident leadership group to address content, education, and evaluation of handoffs was feasible and acceptable to most programs at a large, university-based institution.
MD,
RN,
MD, and
MD
Abstract
Background
Despite widespread use of electronic health records (EHRs), it is unclear whether residents possess the EHR skills to perform required tasks.
Objective
We assessed first-year residents' skills on specific EHR tasks.
Methods
Incoming residents were required to participate in EHR training before starting clinical rotations. The training team developed an assessment tool for 19 EHR tasks. Senior residents used a structured template to assess interns.
Results
For ambulatory workflow skills, most participants (range, 70%–100%) demonstrated competence. The 3 skills for which interns needed the most assistance were (1) creating and routing a result note (17 of 68, 25%), (2) deleting a medication or changing a dose in reconciling medications (10 of 68, 15%), and (3) finding results for the past 90 days (10 of 68, 15%). For inpatient workflow skills, most interns (range, 63%–100%) demonstrated competence. The 3 skills in which interns needed the most assistance were (1) placing a referral order at discharge (23 of 68, 34%), (2) finding a temperature on a flow sheet and trending it over time (14 of 68, 21%), and (3) creating a discharge summary, having it reviewed, and forwarding it to the primary care physician (14 of 68, 21%).
Conclusions
Our results should help EHR training teams at other institutions to better understand the strengths and weakness of EHR training approaches and to target training on tasks with the greatest performance deficits as well as toward underperforming individuals or groups.
MD, MPH,
MD, MPH,
MD, MPH,
MD, MPH, and
MD, MPH
Abstract
Background
Simulation training may improve patient safety, decrease trainer and trainee anxiety, and reduce the number of cases needed for competency. Complications associated with dilation and evacuation (D&E) have been directly related to provider skill level, yet no low-fidelity model has been formally described or evaluated in the literature for second-trimester D&E training.
Objective
We report physicians' assessments of the realism of 3 D&E models to establish a composite training model.
Methods
We surveyed experienced providers at 2 national conferences to evaluate 3 D&E models and rate each model's components on a Likert scale.
Results
Fifty-five obstetrics-gynecology and family medicine physicians completed the survey. Most respondents rated 4 components of 1 model as somewhat realistic or very realistic. The components rated highest were the fetal parts (82% [45 of 55]) and placenta (60% [30 of 50]). This model was rated as more likely to be used in training by 80% (43 of 54) of participants than the 2 other models, as rated by 28% (15 of 54) and 9% (5 of 54) of participants.
Conclusions
A model made from a plastic bottle containing a stuffed fabric form with detachable parts has tactile similarity to a D&E procedure and should be further developed for testing and training.
MD,
MD, and
MD
Abstract
Background
Changes in graduate medical education (GME) have resulted in curricula, goals and objectives, and assessment methods becoming more formal, yet there is little financial support for the educational research required to develop better teaching approaches and assessment tools.
Objective
We sought to encourage the development of new educational tools and assessment methods to improve the overall conduct of GME at the University of Michigan.
Intervention
The University of Michigan Health System has recently established a new educational grant that is designed to foster innovative educational research in GME. We describe the experience with a new and robust internal educational grant, including the source of funding, mechanisms for reviewing and assessing the proposals, the types of proposals that have currently been funded, and the effect and results of these studies on GME at the University of Michigan Health System.
Outcomes
Projects funded by the grant have changed the curriculum in the involved programs, and many have resulted in sustained changes, including new methodologies in the simulation center, the development of an “academy” of faculty physicians with significant teaching expertise, and the creation of web-based teaching and assessment tools for “just in time” learning, and have been disseminated at national meetings and in peer-reviewed journals.
Conclusions
The GME Innovations Grant Program at the University of Michigan Health System has been successful to date, funding 11 proposals during the course of 6 years. Some of these proposals have resulted in permanent changes and additions to residency training programs.
MD, MPH,
MD,
MD,
MD,
MD,
MD, and
MD
Abstract
Background
The outpatient continuity clinic is an essential component of internal medicine residency programs, yet continuity of patient care in these clinics is suboptimal. Reasons for this discontinuity have been inadequately explored.
Objective
We sought to assess perceived factors contributing to discontinuity in trainee ambulatory clinics.
Methods
The study encompassed 112 internal medicine residents at a large academic medical center in the Midwest. We conducted 2 hours of facilitated discussion with 18 small groups of residents. Residents were asked to reflect on factors that pose barriers to continuity in their ambulatory practice and potential mechanisms to reduce these barriers. Resident comments were transcribed and inductive analysis was performed to develop themes. We used these themes to derive recommendations for improving continuity of care in a resident ambulatory clinic.
Results
Key themes included an imbalance of clinic scheduling that favors access for patients with acute symptoms over continuity, clinic triage scripts that deemphasize continuity, inadequate communication among residents and faculty regarding shared patients, residents' inefficient use of nonphysician care resources, and a lack of shared values between patients and providers regarding continuity of care.
Conclusions
The results offer important information that may be applied in iterative program changes to enhance continuity of care in resident clinics.
BRIEF REPORT
MD, MPH,
MD, MPH,
MD, MPH, and
MD
Abstract
Background
Public health training has become an important aspect of residency education. The Institute of Medicine recommends public health training for all resident physicians, and internal medicine educational milestones include general public health skills.
Objective
We sought to integrate community health into internal medicine residency training by developing a community health elective (CHE) curriculum.
Methods
We developed a 2-week CHE curriculum for internal medicine residents, featuring facilitated discussion sessions, clinical experience at health centers targeting medically underserved populations, and a culminating presentation. We evaluated our pilot curriculum using pre-elective and postelective course surveys with Likert-type questions.
Results
Of 150 eligible residents, 32 (21%) enrolled in the elective. Nearly all participants (30 of 32, 94%) strongly agreed that learning about community health was an important part of their residency training. Residents' perceived competence at discharging hospital patients with follow-up at community health sites increased 13-fold after taking the elective (P < .001). There was no increase in reported likelihood to practice in an underserved community or in primary care.
Conclusions
The CHE addresses several Accreditation Council for Graduate Medical Education competencies and internal medicine Milestones and could be a replicable model for internal medicine residency programs that seek to provide community health training.
MD,
PhD,
MS,
PhD,
DO, and
MD, MPH
Abstract
Background
The number of older adults needing primary care exceeds the capacity of trained geriatricians to accommodate them. All physicians should have basic knowledge of optimal outpatient care of older adults to enhance the capacity of the system to serve this patient group. To date, there is no knowledge-assessment tool that focuses specifically on geriatric ambulatory care.
Objective
We developed an examination to assess internal medicine residents' knowledge of ambulatory geriatrics.
Methods
A consensus panel developed a 30-question examination based on topics in the American Board of Internal Medicine (ABIM) Certification Examination Blueprint, the ABIM in-training examinations, and the American Geriatrics Society Goals and Objectives. Questions were reviewed, edited, and then administered to medical students, internal medicine residents, primary care providers, and geriatricians.
Results
Ninety-eight individuals (20 fourth-year medical students, 57 internal medicine residents, 11 primary care faculty members, and 10 geriatrics fellowship-trained physicians) took the examination. Based on psychometric analysis of the results, 5 questions were deleted because of poor discriminatory power. The Cronbach α coefficient of the remaining 25 questions was 0.48; however, assessment of interitem consistency may not be an appropriate measure, given the variety of clinical topics on which questions were based. Scores increased with higher levels of training in geriatrics (P < .001).
Conclusion
Our preliminary study suggests that the examination we developed is a reasonably valid method to assess knowledge of ambulatory geriatric care and may be useful in assessing residents.
MD and
MD
Abstract
Background
Care transitions are common and highly vulnerable times during illness. Physicians need better training to improve care transitions. Existing transitional care curricula infrequently involve settings outside of the hospital or other health care disciplines.
Intervention
We created a curriculum to teach internal medicine residents how to provide better transitional care at hospital discharge through experiential, interdisciplinary learning in different care settings outside of the acute hospital, and we engaged other health care disciplines frequently involved in care transitions.
Setting/Participants
Nineteen postgraduate year-1 internal medicine trainees at an academic medical center in an urban location completed experiences in a postacute care facility, home health care, and outpatient clinics.
Program Description
The 2-week required curriculum involved teachers from geriatric medicine; physical, occupational, and speech therapy; and home health care, with both didactic and experiential components and self-reflective exercises.
Program Evaluation
The curriculum was highly rated (6.86 on a 9-point scale) and was associated with a significant increase in the rating of the overall quality of transitional care education (from 4.09 on a 5-point scale in 2011 to 4.53 in 2012) on the annual residency program survey. Learners reported improved knowledge in key curricular areas and that they would change practice as a result of the curriculum.
Conclusions
Our transitional care curriculum for internal medicine residents provides exposure to care settings and health care disciplines that patients frequently encounter. The curriculum has shown positive, short-term effects on learners' perceived knowledge and behavior.
MD,
MD, and
MD
Abstract
Background
Patient death can be emotionally and psychologically stressful for clinicians, particularly clinicians in training.
Objective
We describe an annual memorial service as a novel approach to help internal medicine residents cope with and reflect on the experiences of patient death.
Methods
We created a memorial service in 2010 for patients who had died under the care of the internal medicine residents in our institution. Residents, medical students, and medicine faculty attended the 1-hour service. The memorial service was repeated in 2011, and a 10-question survey was sent to evaluate its impact.
Results
Twenty-two participants in either the 2010 or 2011 memorial service responded to the survey. Most of the respondents thought that reflection on patient death was important (95%) and that the memorial service was helpful in facilitating such reflection and bringing closure (95%).
Conclusions
An annual memorial service helps trainees cope with the emotional impact of patient death. It can be easily adopted by other residency programs. The long-term impact of this experience on trainees' well-being and professional development is unknown.
MD, FRCPC,
MD, FRCPC, MEd, and
MD, FRCPC
Abstract
Background
Despite a mandate to teach quality improvement (QI) to residents, many training programs lack faculty capacity to deliver a QI curriculum.
Objective
We piloted a co-learning curriculum in QI to train residents while simultaneously developing QI teachers. We evaluated the curriculum's acceptability and feasibility and its effect on faculty engagement in doing and teaching QI.
Methods
The curriculum involved 2 half-day, interactive sessions, a team-based QI project, and end-of-year project presentations. Key curriculum design principles included (1) residents and faculty co-attend all interactive sessions, (2) residents and faculty work together on team-based QI projects, and (3) QI projects align with divisional QI priorities. Using the Kirkpatrick framework for learner outcomes, we focused our program evaluation on Level 1 (satisfaction) and Level 2 (knowledge and skills acquisition) outcomes using year-end curriculum evaluations.
Results
Our study included 14 residents (70%) and 6 faculty members (30%). With respect to satisfaction (Kirkpatrick Level 1 outcome), 93% (13 of 14) of residents and 100% (6 of 6) of faculty participants rated the overall curriculum as “above average” or “outstanding.” Regarding faculty knowledge and skills acquisition (Kirkpatrick Level 2 outcomes), faculty self-rated their QI knowledge and interest in QI higher than their intent to incorporate QI into future practice and their comfort in teaching or supervising QI projects. All 5 faculty respondents (100%) rated the co-learning model for faculty development in QI as “above average” or “outstanding.”
Conclusions
Teaching QI to residents and faculty as co-learners is feasible and acceptable and offers a promising model for programs to teach QI to residents while concurrently building faculty capacity.
MD,
MD,
MD,
MD, MBA, FACC, and
MD, FACC
Abstract
Background
Teaching practice-based learning and improvement and systems-based practice are challenging. Cardiology fellows at St John Hospital & Medical Center participate in a national registry of outpatient cardiology care.
Objective
We assessed the use of the registry, hypothesizing that it could serve as an effective foundation for studying ambulatory care, identifying gaps in care, and planning interventions to advance competence in practice-based learning and improvement and systems-based practice.
Methods
Starting in 2009, trainees prospectively entered data for ambulatory cardiac patients into the PINNACLE Registry database where compliance with 28 performance measures was calculated and reported quarterly. Fellows met with the program director individually and in groups to identify performance gaps and to develop and implement plans for quality improvement. Cardiology fellows were surveyed annually to assess this process.
Results
Through March 2012, the fellows had completed 2400 patient visits. Participation was feasible because it was cost neutral, with data form completion averaging 5 minutes. It was acceptable, with most fellows describing positive effects on practice-based learning and improvement without significant detriment to work flow. Performance achievement for drug therapies ranged from 69% (77 of 111) of the patients with atrial fibrillation receiving anticoagulation to 99% (486 of 489) of patients with coronary disease receiving lipid-lowering therapy. Gaps in system performance included low levels for diabetes screening (5%; 20 of 422) and lipid monitoring (10%; 58 of 573). Initial quality improvement projects addressed practice gaps with straightforward solutions. Improving system performance was more challenging.
Conclusions
Using a registry in cardiology trainees' outpatient practice is feasible, acceptable, and valuable. It allows for planning and studying the effects of quality improvement projects.
RIP OUT
MD,
MA, and
MD, MHPE, FACP
The Challenge
Educational portfolios have been recommended for use in residency programs1,2 and are used in other fields of education.3 In its pure form, an educational portfolio is a tool for learners to review their learning, reflect on progress, and develop a learning plan.4 Reflective learning is a key tenet of portfolios in medicine,5 and it encourages residents to reflect on their learning as they progress toward Milestones in the 6 Accreditation Council for Graduate Medical Education (ACGME) competencies.6 Whether in electronic or paper form, a portfolio is
COMMENTARIES
PhD and
PhD
“In formal logic, a contradiction is the signal of defeat; but, in the evolution of real knowledge, it makes the first step in progress.”
-Alfred North Whitehead (British mathematician, 1861–1947)
Whitehead's suggestion in the quotation above, that contradiction can launch the development of real knowledge, might provide some comfort to those advocating for increased interprofessional collaboration because this field is currently faced with a fundamental contradiction. This contradiction centers on the issue of interprofessional trust. In one conversation within our literature, this trust is hailed as a laudable goal because it facilitates and expedites interprofessional communication. But in another parallel
MD, MPH and
PhD
In this issue of the Journal of Graduate Medical Education, Sandhu et al1 evaluate the differences between highly effective and low-yield family-centered bedside rounds. The “manager,” or rounds leader, must engage in a high level of planning and collaboration, and the leader's managerial skills were found to be crucial to creating a successful educational experience for the team. Where are these skills taught in a typical residency curriculum? They are not explicitly mentioned in the Accreditation Council for Graduate Medical Education core competencies, although it could be argued that practice-based learning, systems-based practice, and communication skills
TO THE EDITOR
MD,
MD,
MD,
MD,
MD,
BS, and
MD
We read with interest Edje and colleagues' article in the September 2013 issue of the Journal of Graduate Medical Education about the use of Skype (Microsoft, Redmond, WA) interviews for residency recruitment, and the suggestion to use Skype during the process of the Supplemental Offer and Acceptance Program (SOAP).1 For our pediatrics residency program, SOAP consisted of a 48-hour block of time to review approximately 600 candidates who applied for a single, unfilled slot. Similar to what Edje et al1 and Shah and colleagues2 have described, we use Skype for
MD and
MD
We read with interest the article, “An Incremental Approach to Improving Scholarly Activity,” by Penrose et al1 in the December 2012 issue of the Journal of Graduate Medical Education. In that report, the authors showed that the addition of mentoring by a postdoctoral researcher was associated with a growth in resident research activities in a small obstetrics-gynecology residency.
We would like to share our success in improving residents' scholarly activities at a small community hospital with limited resources in Queens, New York. Our pediatrics residency is accredited for 30 residents, 10 in each level of training.
INTERNATIONAL CONFERENCE ON RESIDENCY EDUCATION ABSTRACTS
,
,
,
,
, and
Editor's Note: The following abstracts are the Top 3 abstracts selected by the JGME and the International Conference on Residency Education (ICRE) for the 2013 ICRE meeting in Calgary, Canada. A full listing of submitted abstracts appears on the JGME website at www.jgme.org. Underlined author names indicate presenting author at the conference.
Background/Objectives: On internal medicine clinical teaching units (CTUs), admission case reviews play an important role in both teaching and patient care. Prior studies have explored teaching strategies for case reviews, but none have considered how attending physicians shape their supervisory role to optimize teaching and
,
, and
Background/Objectives: Acute and chronic sleep deprivation are associated with fatigue and reduced performance and have provided rationale to modify resident schedules. We evaluated sleep in trainees working in 3 Canadian intensive care units (ICUs) during trials of 3 resident overnight schedules—conventional 24-hour, 16-hour, and sequential 12-hour overnight duty.
Methods: Consenting ICU residents wore wrist Actigraphs. Data were reviewed for completeness and sleep was estimated. Days were classified as on-call, postcall, weekday, or weekend (no duty). Sleep duration (minutes), presented as median (interquartile range [IQR]), was compared using analysis of variance.
Results: The 25 trainees had a median
,
,
,
, and
Background/Objectives: Medical education researchers regularly develop excellent, evidence-based innovations. Often, these innovations are implemented, yet fail. In our program, we witnessed varying levels of success with an assessment innovation. In this study we explored the reasons for varying levels of success with an innovation that was solidly grounded in evidence and theory.
Methods: A multiple methods design was used. Using a grounded theory approach, we conducted focus groups with family medicine residents. Thirty-two first-year and second-year residents across 5 different teaching sites responded to a set of semistructured questions. An “implementation fidelity” (the degree to which the innovation
ON TEACHING
MD, MBA
The evanescent Cambridge summer was giving way to the sights and sounds of early autumn. College students made their annual return pilgrimage to the city in hordes and filled the old streets with an air of renewed youthfulness. The whisper of the Charles River's lazy current sprang to life with the hum of the precise, choreographed strokes of dozens of crew shells gliding along its length. Amidst this backdrop, a dozen newly minted second-year medical and dental students—fresh off their last foreseeable extended summer vacation—entered the hospital to embark on their yearlong quest to acquire and hone the most sacred
ACGME NEWS AND VIEWS
PhD, MBA,
MD,
MS,
MD,
MDiv, PhD, and
MD, MACP
Editor's Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its review committees. The decision to publish the article is made by the ACGME.
In their editorial on scholarship in this issue of Journal of Graduate Medical Education, Simpson et al1 discuss scholarly activities, drawing on 3 articles on this topic2–4 and exploring the foundation for scholarship laid by Glassick et al,5 as well as the expectations for resident scholarly activity and scholarship, as defined in the Accreditation Council for
MD,
RN, MA,
MD,
MD,
MD, and
MD, MACP
Editor's Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its review committees. The decision to publish the article is made by the ACGME.
Introduction
The Clinical Learning Environment Review (CLER) program was launched in late 2012 as a key component of the Accreditation Council for Graduate Medical Education's (ACGME's) Next Accreditation System. The goal of CLER is to provide formative feedback to sponsoring institutions (SIs) on the effectiveness of resident and fellow engagement in 6 focused areas ( box ), with the intent of continually improving institutional performance in
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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