In the past decade, there has been increasing interest in competency-based education (CBE), the notion that an expert physician is defined by a broad set of identified competencies. The idea has been advanced, nearly simultaneously, in several countries—Canada (CanMEDS roles),1 the United States (Accreditation Council for Graduate Medical Education [ACGME] competencies),2 the United Kingdom (Tomorrow's Doctor),3 and Scotland (the Scottish Doctor)4—and adopted by others. CanMEDS competencies have been adopted and adapted by 16 countries, including the Netherlands, Denmark, and Mexico.5 Moreover, the Carnegie Foundation's influential Flexner centenary strongly recommended adopting
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FROM THE EDITOR
PhD,
PhD, and
MD, PhD
PhD
The simple question in the title of this piece reflects the fundamental function of undergraduate medical education (UME). In the past century, the purpose of medical training has moved from readiness for independent medical practice to readiness for postgraduate training. This requires a new benchmark for the transition from UME.
The recent emphasis on competency-based postgraduate medical training, with its competency frameworks and Milestones initiative, shows a shift from what abilities physicians in general should possess to what medical specialists should possess. An increasing number of postgraduate programs have now started to link competencies to so-called entrustable professional activities (EPAs),
Editorials
A guest editorial by Norman, Norcini, and Bordage discusses some well-known problems with competency-based education, yet also highlights the benefits of the educational Milestones (p. 1). An editorial by Olle ten Cate discusses draft core entrustable professional activities for graduating medical students and the implications of competency-based expectations at the entry to graduate medical education (p. 7).
Perspectives
Tackett describes his experience as a medical correspondent for a news organization and the challenge of making medical research germane to a lay audience (p. 13); Prayson et al examine similarities between learning plans and business plans and how they can be used to
PERSPECTIVES
MD
I was in the December doldrums during my second year of residency in internal medicine, when an e-mail came to me. “Subject: “VERY cool opportunity w ABC news—need quick response”
The e-mail text revealed that ABC News in New York City was looking for resident physicians to rotate for 1 month in their medical unit. Residents chosen for this role would review newly released medical studies and could work on pieces for internet, radio, and television. I had elective time available, and the thought of spending another summer in New York (my first had occurred 9 years earlier, when I met my
MD,
PhD, and
PhD
In 2010, Palo Alto Software performed a survey of 2877 people and found that those who completed business plans were nearly twice as likely to successfully grow their businesses or obtain capital as those who did not write a plan.1 Thus, a business plan increases individuals' likelihood of success.2 3 Along the same vein, why would you embark on developing a skill or competency or better some aspect of your learning without developing a learning plan?
The self-regulated learner would argue that you would not, and although a learning plan does not guarantee success, it can
MD
In 1999 the Accreditation Council for Graduate Medical Education (ACGME) introduced 6 clinical competencies.1 The longitudinal integration of these competencies into educational curricula and assessment of residents and fellows was intended to also generate outcomes assessments–based information on the educational effectiveness of training programs. In 2008, to further this process, ACGME Chief Executive Officer Thomas J. Nasca, MD, announced his vision for “The Next Step in the Outcomes-Based Accreditation Project,”2 which became the Next Accreditation System (NAS). This vision was notable for 2 elements: development of specialty-specific, competency-based Milestones, along with design and implementation of Milestone
REVIEW
PhD and
MD, MS
Abstract
Objective
This review evaluates the current understanding of emotional intelligence (EI) and physician leadership, exploring key themes and areas for future research.
Literature Search
We searched the literature using PubMed, Google Scholar, and Business Source Complete for articles published between 1990 and 2012. Search terms included physician and leadership, emotional intelligence, organizational behavior, and organizational development. All abstracts were reviewed. Full articles were evaluated if they addressed the connection between EI and physician leadership. Articles were included if they focused on physicians or physicians-in-training and discussed interventions or recommendations.
Appraisal and Synthesis
We assessed articles for conceptual rigor, study design, and measurement quality. A thematic analysis categorized the main themes and findings of the articles.
Results
The search produced 3713 abstracts, of which 437 full articles were read and 144 were included in this review. Three themes were identified: (1) EI is broadly endorsed as a leadership development strategy across providers and settings; (2) models of EI and leadership development practices vary widely; and (3) EI is considered relevant throughout medical education and practice. Limitations of the literature were that most reports were expert opinion or observational and studies used several different tools for measuring EI.
Conclusions
EI is widely endorsed as a component of curricula for developing physician leaders. Research comparing practice models and measurement tools will critically advance understanding about how to develop and nurture EI to enhance leadership skills in physicians throughout their careers.
ORIGINAL RESEARCH
MD,
PhD,
MD,
BS, and
MD
Abstract
Background
The lecture remains the most common approach for didactic offerings in residency programs despite conflicting evidence about the effectiveness of this format.
Objective
The purpose of this study was to explore the perspectives of internal medicine residents toward conferences held in the lecture format.
Methods
The investigators invited internal medicine residents (N = 144) to participate in focus groups discussing their perspectives about noon conference lectures. The investigators used a semistructured guide to ask about motivations for attendance and effectiveness of noon conferences, transcribed the recordings, coded the discussions, and analyzed the results.
Results
Seven focus groups with a total of 41 residents were held. This identified 4 major domains: (1) motivations for attendance; (2) appropriate content; (3) effective teaching methods; and (4) perspectives on active participation. Residents' motivations were categorized into external factors, including desire for a break and balance to their workload, and intrinsic attributes, including the learning opportunity, topic, and speaker. Appropriate content was described as clinically relevant, practical, and presenting a balance of evidence. Identified effective teaching methods included shorter teaching sessions focused on high-yield learning points structured around cases and questions. While active participation increases residents' perceived level of stress, the benefits of this format include increased attention and learning.
Conclusions
This study furthers our knowledge of the learning preferences of internal medicine residents within the changing environment of residency education and can be used in conjunction with principles of adult learning to reform how we deliver core medical knowledge.
MD and
PhD
Abstract
Background
Chronic pelvic pain (CPP) accounts for 10% of gynecologic visits and is a common complaint in university-based and community resident clinics. Resident education about CPP has been inconsistent, and review of the limited literature shows predominantly negative perceptions of patients with CPP. Current literature lacks information regarding obstetrics-gynecology residents' attitudes and acquired knowledge regarding CPP.
Objective
This targeted needs assessment aims to identify regional obstetrics-gynecology resident attitudes and self-perceived knowledge regarding chronic pelvic pain in order to better address potential educational barriers and look toward placing a greater emphasis on this area in resident training.
Methods
We conducted a focus group of obstetrics-gynecology residents to identify major themes regarding attitudes about CPP. This informed the development of a survey administered to university-based and community-based obstetrics-gynecology residents (N = 57) in the Colorado part of the Western Mountain Region. Cronbach α was calculated to determine reliability for each theme, and descriptive statistics were calculated for each theme. Independent samples t tests assessed differences between training levels and between university and community training sites.
Results
Survey response rate was 72% (41 of 57). Residents consistently reported feeling overwhelmed by CPP patients, perceived a lack of time to see these patients, and indicated a desire to learn more in this area, but they varied in chosen learning methods. No significant differences were found between levels of training or training sites.
Conclusions
Most obstetrics-gynecology residents surveyed believe they are inadequately prepared to address the needs of women presenting with CPP.
MD, MSHS,
MD,
MD,
MD, MSHS, MCR,
MD,
MD,
MD,
MD, MSCR, and
MD, MPH
Abstract
Background
Intensive care unit (ICU) use at the end of life is rising. Little research has focused on associations among critical care fellows' training, institutional support, and bedside tools with ICU use at the end of life.
Objective
We evaluated whether hospital and critical care medicine program interventions were associated with ICU use in the last 6 months of life for patients with chronic illness.
Methods
Our observational, retrospective study explored associations between results from a survey of critical care program directors and hospital-level Medicare data on ICU use in the last 6 months of life. Program directors evaluated quality of palliative care education in their critical care fellowships and reported on the number of bedside tools and the presence or absence of an inpatient palliative care consultation service.
Results
For the 89 hospitals and 71 affiliated training programs analyzed, there were statistically significant relationships between 2 of the explanatory variables—the quality of palliative care education and the number of bedside tools—in ICU use. Each level of increased educational quality (1–5 Likert scale) was associated with a 0.57-day decrease in ICU days, whereas, for each additional, evidence-based bedside tool, there was a 0.31-day decrease. The presence of an inpatient palliative care program was not a significant predictor of ICU use.
Conclusions
We found that the quality of palliative care training in critical care medicine programs and the use of bedside tools were independently associated with reduced ICU use at the end of life.
MD, MS,
PharmD,
MHS,
MD,
MD, MPH,
MD, MHSA, CMD,
PhD, and
MD
Abstract
Background
Quality improvement (QI) is an integral aspect of graduate medical education and an important competence for physicians.
Objective
We examined the QI activities of recent family medicine residency graduates and whether a standardized curriculum in QI during residency resulted in greater self-reported participation in QI activities in practice after graduation.
Methods
The family medicine residency programs affiliated with the South Carolina Area Health Education Consortium (N = 7) were invited to participate in this study. Following completion of introductory educational activities, each site implemented regularly occurring (at least monthly) educational and patient care activities using QI principles and tools. Semiannually, representatives from each participating site met to review project aims and to provide updates regarding the QI activities in their program. To examine the impact of this project on QI activities, we surveyed graduates from participating programs from the year prior to and 2 years after the implementation of the curriculum.
Results
Graduates in the preimplementation and postimplementation cohorts reported participating in periodic patient care data review, patient care registries, QI projects, and disease-specific activities (57%–71% and 54%–63%, respectively). There were no significant differences in QI activities between the 2 groups except in activities associated with status of their practice as a patient-centered medical home.
Conclusions
Most but not all family medicine graduates reported they were actively involved in QI activities within their practices, independent of their exposure to a QI curriculum during training.
MD,
PhD, and
MDCM
Abstract
Background
In Canada, there has been discussion about restructuring the accreditation process for residency education programs with the possibility of exempting selected programs from regular, on-site, external reviews.
Objective
We assessed the feasibility and acceptability of a structured and rigorous internal review that identified program strengths and weaknesses, with the aim of allowing well-performing programs to be exempt from external reviews or to facilitate a significant lengthening of the review cycle.
Methods
We simulated all aspects of a regular, on-site, external review. All participants (program directors, program coordinators, faculty surveyors, and resident surveyors) were trained and performed all components of a formal external review. Participants completed an online survey to assess perceptions of the process and outcome.
Results
The overall response rate was 73% (109 of 149). Most respondents perceived the process to be either extremely or very rigorous (84%), fair (82%), and unbiased (75%). Those with previous review experience (77%) reported that the internal review process simulated a regular, on-site, external review either well or very well (mean rating 4.87, SD 0.90). Most program directors reported the cited list of program strengths to be either extremely or very appropriate (74%, 26 of 35). Perceptions of fairness, bias, and the appropriateness of cited program strengths and weaknesses depended on review outcome.
Conclusions
A structured and rigorous internal review process that simulates a regular, on-site, external review is feasible and could yield a list of program strengths and weaknesses for use in ongoing assessment and improvement.
MD, MPH., FACP,
MD,
MD,
MD,
MD, and
MD
Abstract
Background
Rapid response teams have been adopted across hospitals to reduce the rate of inpatient cardiopulmonary arrest. Yet, data are not uniform on their effectiveness across university and community settings.
Objective
The objective of our study was to determine the impact of rapid response teams on patient outcomes in a community teaching hospital with 24/7 resident coverage.
Methods
Our retrospective chart review of preintervention-postintervention data included all patients admitted between January 2004 and April 2006. Rapid response teams were initiated in March 2005. The outcomes of interest were inpatient mortality, unexpected transfer to the intensive care unit, code blue (cardiac or pulmonary arrest) per 1000 discharges, and length of stay in the intensive care unit.
Results
Rapid response teams were activated 213 times during the intervention period. There was no statistically significant difference in inpatient mortality (3.13% preintervention versus 2.91% postintervention), code blue calls (3.09 versus 2.89 per 1000 discharges), or unexpected transfers of patients to the intensive care unit (15.8% versus 15.5%).
Conclusions
The implementation of a rapid response team did not appear to affect overall mortality and code blue calls in a community-based hospital with 24/7 resident coverage.
MD and
MD, MS
Abstract
Background
High teaching team workload has been associated with poor supervision and worse patient outcomes, yet it is unclear whether this association is more pronounced during the early months of the academic year when the residents are less experienced.
Objective
We examined the associations between teaching team workload, timing of admission, and the 30-day readmission rate.
Methods
In this retrospective observational study, all admissions to an urban internal medicine teaching service over a 16-month period were divided into 2 groups based on admission date: early in the academic year (July–September) or late (October–June) and further defined as being admitted to “busy” versus “less busy” teams based on number of monthly admissions. The primary outcome was 30-day readmission rate. Multivariate logistic regression was used to determine the independent association between teaching team workload and readmission rates, stratified by time of year of admission after adjustment for demographic and clinical characteristics.
Results
Of 12 118 admissions examined, 2352 (19.4%) were admitted early in the year, and 9766 (80.6%) were admitted later. After multivariate adjustment, we found that patients admitted to busy versus less busy teams in the first quarter had similar 30-day readmission rate (odds ratio [OR]adj = 1.03 [0.82–1.30]). Later year admission to a busy team was associated with increased risk of readmission after adjustment (ORadj = 1.16 [1.03–1.30]).
Conclusions
Admission to busy teams early in the year was not associated with increased odds of 30-day readmission, whereas admission later in the year to busy teams was associated with 16% increased odds of readmission.
MD, MSHPR,
MD,
PhD,
PhD, and
MD
Abstract
Background
Residents receive little information about how they interact with patients.
Objective
This pilot study assessed the feasibility and validity of a new 16-item tool developed to assess patients' perspectives of interns' communication skills and professionalism and the team's communication.
Methods
Feasibility was determined by the percentage of surveys completed, the average time for survey completion, the percentage of target interns evaluated, and the mean number of evaluations per intern. Generalizability was analyzed using an (evaluator:evaluatee) × item model. Simulated D studies estimated optimal numbers of items and evaluators. Factor analysis with varimax rotation was used to examine the structure of the items. Scores were correlated with other measures of communication and professionalism for validation.
Results
Most patients (225 of 305 [74%]) completed the evaluation. Each survey took approximately 6.3 minutes to complete. In 43 days over 18 weeks, 45 of 50 interns (90%) were evaluated an average of 4.6 times. Fifty evaluations would be required to reach a minimally acceptable coefficient (0.57). Two factor structures were identified. The evaluation did not correlate with faculty evaluations of resident communication but did correlate weakly (r = 0.140, P = .04) with standardized patient evaluations.
Conclusions
A large number of patient evaluations are needed to reliably assess intern and team communication skills. Evaluations by patients add a perspective in assessing these skills that is different from those of faculty evaluations. Future work will focus on whether this new information adds to existing evaluation systems and warrants the added effort.
MD, MHPE,
BA,
PhD, and
MD
Abstract
Background
Resident well-being impacts competence, professionalism, career satisfaction, and the quality of care delivered to patients.
Objective
We established normative scores and reported evidence of relationship between the Physician Well-Being Index (PWBI) score to other variables and consequence validity for the PWBI in a national sample of residents, and evaluated the performance of the index after substituting the original fatigue item with an item not associated with driving a car.
Methods
We conducted a cross-sectional survey study of a national sample of 20 475 residents. The survey included the PWBI, instruments assessing mental quality of life (QOL) and fatigue, and items on recent suicidal ideation and medical error. Fisher exact test or Wilcoxon/2-sample t test procedures were used with a 5% type I error rate and a 2-sided alternative.
Results
Of 7560 residents who opened the e-mail to participate in the study, 1701 (22.5%) completed the survey. Residents with low mental QOL, high fatigue, or recent suicidal ideation were more likely to endorse each of the PWBI items and a greater number of total items (all P < .001). At a threshold score of ≥ 5, the PWBI's specificity for identifying residents with low mental QOL, high fatigue, or recent suicidal ideation was 83.6%. PWBI score also stratified residents' self-reported medical errors. The PWBI performed similarly using either fatigue item.
Conclusions
The 7-item PWBI appears to be a useful screening index to identify residents whose degree of distress may negatively impact the quality of care they deliver.
Simulation-Based Assessment to Evaluate Cognitive Performance in an Anesthesiology Residency Program
MD,
PhD,
MD, and
PhD
Abstract
Background
Problem solving in a clinical context requires knowledge and experience, and most traditional examinations for learners do not capture skills that are required in some situations where there is uncertainty about the proper course of action.
Objective
We sought to evaluate anesthesiology residents for deficiencies in cognitive performance within and across 3 clinical domains (operating room, trauma, and cardiac resuscitation) using simulation-based assessment.
Methods
Individual basic knowledge and cognitive performance in each simulation-based scenario were assessed in 47 residents using a 15- to 29-item scenario-specific checklist. For every scenario and item we calculated group error scenario rate (frequency) and individual (resident) item success. For all analyses, alpha was designated as 0.05.
Results
Postgraduate year (PGY)-3 and PGY-4 residents' cognitive items error rates were higher and success rates lower compared to basic and technical performance in each domain tested (P < .05). In the trauma and resuscitation scenarios, the cognitive error rate by PGY-4 residents was fairly high (0.29–0.5) and their cognitive success rate was low (0.5–0.68). The most common cognitive errors were anchoring, availability bias, premature closure, and confirmation bias.
Conclusions
Simulation-based assessment can differentiate between higher-order (cognitive) and lower-order (basic and technical) skills expected of relatively experienced (PGY-3 and PGY-4) anesthesiology residents. Simulation-based assessments can also highlight areas of relative strength and weakness in a resident group, and this information can be used to guide curricular modifications to address deficiencies in tasks requiring higher-order processing and cognition.
MD,
MD,
MD,
PhD,
MS,
MS,
MD, and
MD
Abstract
Background
The academic half-day (AHD) curriculum is an alternative to the traditional noon conference in graduate medical education, yet little is known regarding its effect on knowledge acquisition and resident satisfaction.
Objective
We investigated the association between the 2 approaches for delivering the curriculum and knowledge acquisition, as reflected by the Internal Medicine In-Training Examination (IM-ITE) scores and assessed resident learning satisfaction under both curricula.
Methods
The Cleveland Clinic Internal Medicine Residency Program transitioned from the noon conference to the AHD curriculum in 2011. Covariates for residents enrolled from 2004 to 2011 were age; sex; type of medical degree; United States Medical Licensing Examination Step 1, 2 Clinical Knowledge; and IM-ITE-1 scores. We performed univariable and multivariable linear regressions to investigate the association between covariates and IM-ITE-2 and IM-ITE-3 scores. Residents also were surveyed about their learning satisfaction in both curricula.
Results
Of 364 residents, 112 (31%) and 252 (69%) were exposed to the AHD and the noon conference curriculum, respectively. In multivariable analyses, the AHD curriculum was associated with higher IM-ITE-3 (regression coefficient, 4.8; 95% confidence interval 2.9–6.6) scores, and residents in the AHD curriculum had greater learning satisfaction compared with the noon conference cohort (Likert, 3.4 versus 3.0; P = .003).
Conclusions
The AHD curriculum was associated with improvement in resident medical knowledge acquisition and increased learner satisfaction.
MD, MEd,
MD, MPH,
DO, MPH,
MD, and
MD
Abstract
Background
Innovative online technology can enhance the practice of medicine, yet it also may be a forum for unprofessional behavior.
Objective
We surveyed program directors regarding their perceptions and experiences with residents' use of social networking sites (SNS).
Methods
In September 2011, we sent an online survey to program directors and associate program directors of pediatrics residency programs within the United States who are members of the Association of Pediatric Program Directors.
Results
A total of 162 program directors or associate program directors (representing 50% of residency programs) responded to the survey. One-third of respondents are “very familiar” with SNS and 23% use them “daily or often.” Most respondents (70%) rated “friending” peers as “completely appropriate,” whereas only 1% of respondents rated “friending” current or past patients as “completely appropriate.” More than one half of respondents believe inappropriate behavior on SNS is “somewhat” or “very” prevalent, and 91% are “somewhat” or “very” concerned that the prevalence of inappropriate behavior on SNS may increase. The most commonly reported problematic online activity was posting inappropriate comments about the workplace. Posting of inappropriate comments about self, patients, and staff also was observed. Residency programs commonly educate trainees about SNS during intern orientation (45%), or using written guidelines (29%) and ad hoc remediation (16%).
Conclusions
As educators teach trainees principles of online professionalism, appropriate use of SNS needs to be included in the training process. Curricular efforts may be hindered by some program directors' lack of familiarity with SNS.
MD,
PhD,
MS, MPH, MPA, and
MD, MPH, MEd
Abstract
Background
Faculty in graduate medical education programs may not have uniform approaches to differentiating the quality of residents, and reviews of evaluations suggest that faculty use different standards when assessing residents. Standards for assessing residents also do not consistently map to items on evaluation forms. One way to improve assessment is to reach consensus on the traits and behaviors that are (or should be) present in the best residents.
Methods
A trained interviewer conducted semistructured interviews with faculty affiliated with 2 pediatrics residency programs until content saturation was achieved. Interviewees were asked to describe specific traits present in residents they identify as the best. Interviews were recorded and transcribed. We used an iterative, inductive approach to generate a coding scheme and identify common themes.
Results
From 23 interviews, we identified 7 thematic categories of traits and behaviors: personality, energy, professionalism, team behaviors, self-improvement behaviors, patient-interaction behaviors, and medical knowledge and clinical skills (including a subcategory, knowledge integration). Most faculty interviewees focused on traits like passion, enthusiasm, maturity, and reliability. Examination score or intelligence was mentioned less frequently than traits and behaviors categorized under personality and professionalism.
Conclusions
Faculty identified many traits and behaviors in the residents they define as the best. The thematic categories had incomplete overlap with Accreditation Council for Graduate Medical Education (ACGME) and CanMEDS competencies. This research highlights the ongoing need to review our assessment strategies, and may have implications for the ACGME Milestone Project.
MD,
MD, and
PhD, MPH, PStat
Abstract
Background
Graduating residents transition their continuity clinic patients to junior colleagues every year, creating a vulnerable transition period for about 1 million patients nationally.
Objective
We examined a standardized, electronic template for handing off high-risk ambulatory patients by outgoing residents from 7 residencies within a large health care system, and compared handoff quantity and provider satisfaction for handoffs with and without that template.
Methods
Residents graduating in 2011 from 5 internal medicine, 1 family medicine, and 1 internal medicine-pediatrics residency programs in 1 health care system were randomized to a new electronic handoff process with a standardized intervention template or a free-text handoff. Expert reviewers independently evaluated all handoff notes, and providers were surveyed after follow-up appointments regarding use, helpfulness, and overall satisfaction with the handoffs.
Results
Fifty-two of 79 residents (66%) participated, performing 278 handoffs. Eighty-four patients (30%, 17 of 57) failed to follow up within the study period. For patients who followed up, providers read 61% (101 of 165) of the handoffs at the time of the visit. No significant difference existed between groups in the satisfaction of the follow up provider or the quality measure of the handoffs in our process. Expert agreement on which features make the handoff “helpful” was fair (κ = 0.34).
Conclusions
A standardized template did not improve handoff quantity or satisfaction compared with a free-text handoff. Practical handoff programs can be instituted into diverse residencies within a short time frame, with most residents taking part in creating the handoff formats.
MD,
PhD,
MA,
MD,
MD, and
MD, EdM
Abstract
Background
Assessment of obstetrics-gynecology residents' ability to integrate clinical judgment, interpersonal skills, and technical ability in a uniform fashion is required to document achievement of benchmarks of competency. An observed structured clinical examination that incorporates simulation and bench models uses direct observation of performance to generate formative feedback and standardized evaluation.
Methods
The Test of Integrated Professional Skills (TIPS) is a 5-station performance-based assessment that uses standardized patients and complex scenarios involving ultrasonography, procedural skills, and evidence-based medicine. Standardized patients and faculty rated residents by using behaviorally anchored checklists. Mean scores reflecting performance in TIPS were compared across competency domains and by developmental level (using analysis of variance) and then compared to standard faculty clinical evaluations (using Spearman ρ). Participating faculty and residents were also asked to evaluate the usefulness of the TIPS.
Results
Twenty-four residents participated in the TIPS. Checklist items used to assess competency were sufficiently reliable, with Cronbach α estimates from 0.69 to 0.82. Performance improved with level of training, with wide variation in performance. Standard faculty evaluations did not correlate with TIPS performance. Several residents who were rated as average or above average by faculty performed poorly on the TIPS (> 1 SD below the mean). Both faculty and residents found the TIPS format useful, providing meaningful evaluation and opportunity for feedback.
Conclusions
A simulation-based observed structured clinical examination facilitates observation of a range of skills, including competencies that are difficult to observe and measure in a standardized way. Debriefing with faculty provides an important interface for identification of performance gaps and individualization of learning plans.
MBBS, MSc, DM, MWACP, FMCP, Cert Epid & Glob Health (Dundee),
MBBS, FWACS, and
MBBS, FWACS, FMCOG, FAS
Abstract
Background
Little is known about the competences of residents as clinical teachers in African health care institutions.
Objective
We evaluated the clinical teaching skills of internal medicine residents from the perspective of medical students in a tertiary teaching institution in Africa.
Methods
We used the augmented Stanford Faculty Development Program Questionnaire, which has evidence of validity and reliability. To avoid a Hawthorne effect, students completed the questionnaire anonymously and confidentially after clinical teaching sessions by residents. A minimum score of 4 on a scale of 1 to 5 was defined a priori as possession of good clinical teaching skills.
Results
Sixty-four medical students assessed all 20 internal medicine residents in the Department of Medicine, University of Ibadan. Mean performance scores for the domains ranged from 3.07 to 3.66. Residents performed best in creating a good learning climate and worst in the promotion of understanding and retention. Sex of the resident, duration of residency, and rank had no significant impact (.09 < P < .94) on their teaching skills.
Conclusions
Consistent with other observations in the literature, residents' clinical teaching skills were suboptimal, particularly in their ability to promote understanding and retention. To enhance these skills, we recommend the integration of appropriately tailored programs to teach pedagogic skills programs in residency training.
EDUCATIONAL INNOVATION
MD, MEd,
PhD,
PhD, MPH,
MD,
MD,
MPH, BSN., RN,
BSN, RN,
PhD, and
MD, MPPM, MEd
Abstract
Background
Simulation is an effective method for teaching clinical skills but has not been widely adopted to educate trainees about how to teach.
Objective
We evaluated a curriculum for pediatrics fellows by using high-fidelity simulation (mannequin with vital signs) to improve pedagogical skills.
Intervention
The intervention included a lecture on adult learning and active-learning techniques, development of a case from the fellows' subspecialties, and teaching the case to residents and medical students. Teaching was observed by an educator using a standardized checklist. Learners evaluated fellows' teaching by using a structured evaluation tool; learner evaluations and the observer checklist formed the basis for written feedback. Changes in fellows' pedagogic knowledge, attitudes, and self-reported skills were analyzed by using Friedman and Wilcoxon rank-sum test at baseline, immediate postintervention, and 6-month follow-up.
Results
Forty fellows participated. Fellows' self-ratings significantly improved from baseline to 6-month follow-up for development of learning objectives, effectively reinforcing performance, using teaching techniques to promote critical thinking, providing constructive feedback, and using case studies to teach general rules. Fellows significantly increased agreement with the statement “providing background and context is important” (4.12 to 4.44, P = .02).
Conclusions
Simulation was an effective means of educating fellows about teaching, with fellows' attitudes and self-rated confidence improving after participation but returning to baseline at the 6-month assessment. The simulation identified common weaknesses of fellows as teachers, including failure to provide objectives to learners, failure to provide a summary of key learning points, and lack of inclusion of all learners.
MD, MPH,
EdD, MEd,
MD,
MAT, PhD,
MD, and
MD
Abstract
Background
Program evaluation is important for assessing the effectiveness of the residency curriculum. Limited resources are available, however, and curriculum evaluation processes must be sustainable and well integrated into program improvement efforts.
Intervention
We describe the pediatric Clinical Skills Fair, an innovative method for evaluating the effectiveness of residency curriculum through assessment of trainees in 2 domains: medical knowledge/patient care and procedure. Each year from 2008 to 2011, interns completed the Clinical Skills Fair as rising interns in postgraduate year (PGY)-1 (R1s) and again at the end of the year, as rising residents in PGY-2 (R2s). Trainees completed the Clinical Skills Fair at the beginning and end of the intern year for each cohort to assess how well the curriculum prepared them to meet the intern goals and objectives.
Results
Participants were 48 R1s and 47 R2s. In the medical knowledge/patient care domain, intern scores improved from 48% to 65% correct (P < .001). Significant improvement was demonstrated in the following subdomains: jaundice (41% to 65% correct; P < .001), fever (67% to 94% correct; P < .001), and asthma (43% to 62% correct; P = .002). No significant change was noted within the arrhythmia subdomain. There was significant improvement in the procedure domain for all interns (χ2 = 32.82, P < .001).
Conclusions
The Clinical Skills Fair is a readily implemented and sustainable method for our residency program curriculum assessment. Its feasibility may allow other programs to assess their curriculum and track the impact of programmatic changes; it may be particularly useful for program evaluation committees.
MD, MSc,
MD,
MD, and
MD, MPH
Abstract
Background
Morbidity and mortality (M&M) conferences provide a forum for discussing adverse events and systems-based practice (SBP) issues; however, few models for implementing multidisciplinary, systems-focused M&M conferences exist.
Objective
To implement a new systems-focused M&M conference and evaluate success in focusing on adverse events and systems issues in a nonpunitive, multidisciplinary manner.
Methods
We implemented a new M&M conference into our large university-based internal medicine residency program. Using content analysis, we qualitatively analyzed audio recordings of M&M conferences from the first year of implementation (2010–2011) to determine the frequency of adverse events (injury resulting from medical care), SBP discussion, and allocation of blame. Multidisciplinary attendance was evaluated by attendance logs. Surveys assessed change in interns' perceptions of M&M conferences before and after the conference series (measured by median Likert-scale response) and trainee/faculty attitudes regarding the goal of M&M conferences.
Results
There were 226 attendees (66 faculty, 160 residents/fellows) at 9 M&M conferences. Average attendance per conference was 71, with representation from 16 disciplines. All M&M conferences (100%) included adverse events, SBP discussion, and lacked explicit individual blame. Interns' perceptions improved, including their belief that the M&M conference's purpose is systems improvement (4.35 versus 4.71, P = .02) and complications are discussed without blame (3.81 versus 4.34, P = .01). After experiencing M&M conferences, trainees/faculty reported favorable ratings, including beliefs that the M&M conference is important for education (97%) and the purpose is systems improvement (95%).
Conclusions
The implementation of a new systems-focused M&M conference resulted in a conference series focusing on adverse events and associated system issues in a nonpunitive, multidisciplinary context.
BRIEF REPORT
MBBS, MS,
BS,
MPH,
MD,
MD, MHS, and
MD, MHS, MEd, CMD
Abstract
Background
Understanding quality improvement (QI) is an important skill for physicians, yet educational interventions focused on teaching QI to residents are relatively rare. Web-based training may be an effective teaching tool in time-limited and expertise-limited settings.
Intervention
We developed a web-based curriculum in QI and evaluated its effectiveness.
Methods
During the 2011–2012 academic year, we enrolled 53 first-year internal medicine residents to complete the online training. Residents were provided an average of 6 hours of protected time during a 1-month geriatrics rotation to sequentially complete 8 online modules on QI. A pre-post design was used to measure changes in knowledge of the QI principles and self-assessed competence in the objectives of the course.
Results
Of the residents, 72% percent (37 of 51) completed all of the modules and pretests and posttests. Immediate pre-post knowledge improved from 6 to 8.5 for a total score of 15 (P < .001) and pre-post self-assessed competence in QI principles on paired t test analysis improved from 1.7 to 2.7 on a scale of 5 for residents who completed all of the components of the course.
Conclusions
Web-based training of QI in this study was comparable to other existing non–web-based curricula in improving learner confidence and knowledge in QI principles. Web-based training can be an efficient and effective mode of content delivery.
MD,
MD,
MD,
MPH,
MD, and
MD
Abstract
Background
The Accreditation Council for Graduate Medical Education expects resident duty hours to be monitored, yet no previous studies have examined the effect of after-hours electronic health record (EHR) use on resident hours or burnout.
Objective
We assessed internal medicine residents' perceived and actual time spent on after-hours outpatient EHR use and calculated increased duty hours if after-hours EHR use were included; we also assessed its effect on resident burnout.
Methods
We retrospectively aggregated time spent logged on to the outpatient EHR for residents in a general internal medicine clinic for 13 weeks in 2011. Residents completed a survey on EHR use, which was correlated with objectively recorded data on EHR usage. We compared actual and self-reported EHR time and identified violations that would be generated if these hours were included in reported duty hours. We also correlated resident after-hours EHR use with responses to an internally developed burnout survey.
Results
The 44 residents in this study overestimated time spent on the ambulatory EHR (they spent 3.03 hours/week on after-hours use compared with a recorded 1.20 hours/week). In total, 190 duty hour violations (mean duration of violation = 37 minutes) would have been generated if after-hours EHR usage were included in residents' reported duty hours.
Conclusions
Resident estimates of EHR use by residents were not accurate; including after-hours EHR use would increase the number of reported duty hour violations. There was no association between after-hours EHR use and resident burnout.
MD,
MD,
BA,
MBBS,
MD, and
MD, MPA
Abstract
Background
There is an increasing use of electronic health records in hospitals across the United States. The speed and accuracy of residents in documenting electronic health records has been insufficiently addressed.
Methods
We studied resident typing skills at New York Methodist Hospital. Participating residents typed a standard 100-word alphanumerical paragraph of a patient's medical history. Typing skills were assessed by calculating the net words per minute (WPM). Typing skills were categorized as follows: (1) fewer than 26 net WPM as very slow; (2) 26 to 35 net WPM as slow; (3) 35 to 45 net WPM as intermediate; and (4) greater than 45 net WPM as fast. Residents were further categorized into (1) American medical graduates; (2) American international medical graduates; and (3) non-American international medical graduates.
Results
A total of 104 of 280 residents (37%) participated in the study. There was equal representation from various specialties, backgrounds, and all postgraduate levels of training. The median typing speed was 30.4 net WPM. Typing skills were very slow (34 of 104, 33%), slow (28 of 104, 27%), intermediate (29 of 104, 28%), and fast (13 of 104, 12%) among the residents. Typing skills of non-American international medical graduates (mean net WPM of 25.9) were significantly slower than those of American medical graduates (mean net WPM of 35.9) and American international medical graduates (mean net WPM of 33.5).
Conclusions
Most residents (60%, 62 of 104) who participated in the study at our institute lacked typing skills. As the use of electronic health records increases, a lack of typing skills may impact residents' time for learning and patient care.
MD, MS,
MD,
,
PhD, and
MD, MPH
Abstract
Background
One challenge facing the health care workforce is a paucity of pediatrics subspecialists. No prior studies have investigated fellowship noncompletion as an influence of the subspecialty workforce.
Objective
We sought to determine the noncompletion rate for pediatric rheumatology fellowships and to identify demographic characteristics associated with noncompletion.
Methods
A retrospective cohort study of all trainees entering US pediatric rheumatology fellowship programs between 1997 and 2007 was performed. American Board of Pediatrics tracking data were used to determine completion status (completer or noncompleter) for each trainee. Completers were compared with noncompleters, using the independent variables sex, medical school location, and age. The noncompletion rate was calculated overall and individually. Program size was examined as a predictor of nonompletion rate. Data analysis used χ2 tests, Kruskal-Wallis tests, and Spearman correlation.
Results
The cohort included 182 trainees from 28 pediatric rheumatology fellowship programs. Program size ranged from 1 to 18 trainees. The overall noncompletion rate was 16%. Male fellows, especially male international medical graduates, were more likely to be noncompleters. Noncompletion rates varied among programs: 15 programs had noncompletion rates of 0% and 4 programs had noncompletion rates of 50% or higher. Program size was not associated with noncompletion rate.
Conclusions
During the study period, 1 of 6 pediatric rheumatology fellows did not complete training. Noncompletion was concentrated in a small number of programs. Further research should investigate noncompletion across specialties, identifying the causes of noncompletion at the individual, program, and specialty levels to inform future interventions to improve fellowship completion.
RIP OUT
MD, MBA and
MD
The Challenge
In the Next Accreditation System, the Accreditation Council for Graduate Medical Education requires training programs to develop a clinical competency committee (CCC) to monitor and record the progress of their residents on predefined Milestones. In many programs, the current practice is for the program director to weigh the evaluation data from multiple sources and make decisions about each trainee's progress with or without discussion with program faculty. Some programs, however, already use a committee for promotion decisions. The committee monitors resident growth and makes recommendations, such as specific educational or remediation plans. A few specialties such as anesthesiology
COMMENTARIES
MD, PhD
Real-time patient evaluation of physicians' communication and professional skills is a wonderful idea. Wasn't it Aristotle who said that the guests will be a better judge of the feast than the cook? But if such evaluations are so logical, why aren't patient evaluations an integral part of all assessment programs?
While reading the article by Dine et al1 in the current issue of the Journal of Graduate Medical Education, I was reminded of a silly question I asked during my younger years in medical education: “Why do we insist on structuring and standardizing our assessments, and
MD and
MD, MPH
Underlying palliative care is a philosophy that aligns patients' health care with what they deem most important. For patients in the final stages of life, this often includes the desire to avoid burdensome and high-intensity care. In the intensive care unit (ICU), where we see the highest acuity of illness, often there are many competing priorities. The principles of palliative care are vital in refocusing our attention on what matters most to the patient and his or her family. Because of the value of these principles, there is increasing interest in finding ways to improve education in palliative care and
MD, MPH
In this issue of the Journal of Graduate Medical Education, Kesselheim and colleagues1 report on a survey of pediatrics residency program leadership. The study found that approximately one-third of this group is very familiar with social networking sites (SNS), and approximately one-fifth of the respondents use it daily or often, which agrees with findings from other studies of educational leaders.1–3 Their survey reveals that three-fourths of program directors think that inappropriate behavior by residents on SNS is somewhat or very prevalent and are concerned that the prevalence may increase. In an effort
MD, MEd
In this issue of the Journal of Graduate Medical Education, Rosenbluth and colleagues1 interviewed faculty and asked them to describe the “best” residents. They identified components of physicians that can be developed over time as well as personality traits. In describing the need for their work, they argue that defining these areas is important because “there are many stakeholders [including patients, fellowship directors, and employers] who value greater differentiation among residents” than competency-based medical education may offer.1 A competency-based approach seeks to ensure that minimum levels of development are attained to be entrusted with
TO THE EDITOR
MD
Dr Snipes and colleagues1 recently explored factors influencing faculty and resident physicians' willingness and ability to report for duty during disaster events. Training program directors and hospital emergency planners using these data should consider an additional problem: several different hospitals and programs may lay claim to physicians, particularly physicians in training, who may “belong” to the medical school, to the host department and hospital, and to the department and hospital to which they are assigned on rotation. As each of these institutions does their own planning, 2 or more may be counting on the same physician and neglecting
ON TEACHING
MD, MS
The only thing worse than making a medical error is making one when you are in charge of a resident team.
He was often homeless, always emaciated, and usually dehydrated. His short-gut syndrome didn't help, and his blood pressure was rarely above 95/50 mm Hg. The social workers knew everything about him without opening his chart. He was never the patient anyone gave to medical students—not because a student wouldn't have learned from him, but because everyone knew he wouldn't talk to one. He refused medical care on a regular yet seemingly haphazard basis. Most of the time he lay on his
ACGME NEWS AND VIEWS
PhD, MBA,
MDiv, PhD,
EdD, CAE, and
PhD
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.
The Supplement to the March 2014 issue of the Journal of Graduate Medical Education features the educational Milestones for 19 Accreditation Council for Graduate Medical Education (ACGME)–accredited specialties and the Transitional Year. These specialties will enter the Next Accreditation System (NAS) on July 1, 2014. Included with each set of Milestones is a description of their development, which also discusses the architecture
PhD,
MS,
PhD, MBA, and
MD, MACP
Abstract
Background
Proposed reductions in federal funding for physician education may affect the United States' ability to produce the number of physicians needed to provide care.
Objective
Using a survey similar to that used by the ACGME in 2011, we assessed designated institutional officials' (DIOs) perceptions of the impact of potential GME funding reductions.
Method
In August 2013, we sent a survey link to all DIOs of ACGME-accredited institutions (N = 678). A 9-item survey asked how future federal funding would affect the number of residency programs in their institutions under 4 different funding scenarios: stable funding, and reductions of 10%, 33%, and 50%. We also asked about changes in the number of residency positions during the last 2 years.
Results
The response rate was 47.9% (325 of 678 DIOs); respondents represent 58.9% of accredited institutions with more than 1 program. Most respondents reported no change or an increase under the stable funding scenario. Under a 33% funding reduction, an estimated 17 379 (14.8% of all current) positions would be lost, and a 50% reduction would result in a loss of 33 562 positions (28.6%). Primary care specialties (eg, family medicine, internal medicine) would be most affected under the greatest funding reductions.
Conclusions
The findings of the 2013 survey are consistent with 2011 data, with DIOs projecting significant reductions in programs and positions under more severe budget cuts. DIO comments highlighted reduced optimism (compared to data obtained in 2011) about the effect of funding cuts and concerns about the impact of reductions on patient care and health care personnel at teaching institutions.
The Journal of Graduate Medical Education is deeply grateful to the individuals who served as reviewers and provided critiques and helpful suggestions to authors for the 4 issues published in 2013. Reviewers shown bolded reviewed a significant number of articles, and the Journal greatly appreciates the contribution of their time, energy, and expertise.
Eva Aagaard, MD
D. Clay Ackerly II, MD
Meenakshy Aiyer, MD
Ralitsa Akins, MD, PhD
Amer Aldeen, MD
Robert Allen, MD
Ronald Amedee, MD
Douglas Ander, MD
Kathryn Andolsek, MD, MPH
Felix Ankel, MD
Paul Aronowitz, MD
Carol Aschenbrener, MD
Stewart Babbott, MD
This corrects the acknowledgements for the following article published in the December 2013 issue of the Journal of Graduate Medical Education:
Cooper DD, Wilson AB, Huffman GN, Humbert AJ. Medical students' perception of residents as teachers: comparing effectiveness of residents and faculty during simulation debriefings. J Grad Med Educ. 2012;4(4):486–489.
The authors would like to acknowledge Anthony J Perkins, MS, for his work in the primary data analysis.
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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