As an optimistic person, I understand the desire on the part of others to view the world through rose-colored glasses, see the cup as half filled, and generally look on the bright side of things. The world of medical education is replete with those who honestly view events more positively than skeptically. One might even say that optimism is an essential trait for those who toil in the medical education fields today. In the public arena, spin is associated with reframing the current story into one that is favorable to the speaker with the goal of manipulating public opinion. In
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Editorial
An editorial by Sullivan points out our flaws and omissions in reporting medical education research that can distort or misrepresent results (p. 405).
Perspectives
Yunyongying suggests uses of gaming concepts in curricular design (p. 410); Benzinger offers a humorous take on hidden meaning in dean's letters and advocates for transparency (p. 413); Yang et al suggest “instinctive teaching” for seamless integration of teaching and clinical care (p. 415); and Klink et al discuss changes in grant-supported faculty development under the Affordable Care Act (p. 419). Two perspectives present the consensus of participants in a workshop on quality in medical education research: the first redefines
MD, FACP
The search for an answer to the question of how to teach inexperienced physicians while protecting patient safety has led medical educators to become creative and innovative in designing curricula. One place where educators are looking for answers is video gaming.
In 2009, video games earned $10 billion with an estimated 1 out of 3 households nationally playing video games. More than half of all gamers are adults 18 to 49 years old.1 Kevin Kruse, author of We: How to Increase Performance and Profits through Full Engagement writes, “Game design indeed has broad utility for learning and
MD, PhD
Galen Eminence, MD
Dean of Students
The Medical School
Dear Dr Eminence:
The leaves are starting to turn outside, and my computer is filling rapidly with applications from your graduates who want to become anesthesiologists. Of course, I'm grateful for their interest. Like any program director, I stand before 2 sets of decisions. Which of these applicants will I invite to visit our program, and once those interviews are over, how do I fit these multifaceted, talented young physicians into the 1-dimensional hierarchy of our National Residency Matching Program match list?
Although the evidence supporting my belief is thin,1
MD,
MD,
DO,
MD, and
MD
Abstract
Effective clinical teaching is essential in physician education, yet faculty members rarely receive formal training in clinical teaching. Formal models for training clinical educators are often tedious and require significant time and effort. Instinctive clinical teaching allows clinicians to seamlessly integrate and promote effective teaching into their clinical practice. The approach is guided by similarities between the components of Kolb's experiential learning cycle—concrete experience, reflective observation, abstract conceptualization, and active experimentation—and the elements of the patient care process—history and physical, initial assessment, differential, hypothesis, final diagnosis, management, and follow-up. Externalization of these clinical thought processes allows for inclusion of learners and promotes effective clinical teaching.
MD, FAAFP,
DrPH, MPH., MSSS, and
MD, MPH
Abstract
Health reform requires well-trained primary care physicians with new skills. Teaching faculty need to develop proficiency to deliver care in new models and systems, to lead change, and to teach these skills to the next generation of clinicians. Title VII Section 747 of the Public Health Service Act, modified and reauthorized under the Patient Protection and Affordable Care Act (ACA), is the only federal program that specifically supports the professional development of primary care faculty. We analyzed the effect of the modifications under the ACA on a funding opportunity announcement addressing faculty development needs and attributes of funded applications, including geographic regions. The data offer useful insights to programs interested in tapping sources of support for primary care faculty development. The data also show that targeted federal funding can bring about changes that contribute to an up-to-date, responsive primary care workforce. Title VII programs, as amended by the ACA, focus on curriculum development, teaching in community-based settings, and integrating patient-centered medical home concepts and interprofessional education and practice into the training of the next generation of physicians. These strategies drive change and improve the quality of care and patient outcomes.
MD, MPH,
PhD,
MD, MHPE,
MD,
MD, MPH,
MD,
PhD, MBA, and
MD, MCR
Abstract
Background
Despite an explosion of medical education research and publications, it is not known how medical educator consumers decide what to read or apply in their practice.
Objective
To determine how consumers of medical education research define quality and value.
Methods
Journal of Graduate Medical Education editors performed a literature search to identify articles on medical education research quality published between 2000 and 2013, surveyed medical educators for their criteria for judging quality, and led a consensus-building workshop at a 2013 Association of American Medical Colleges meeting to further explore how users defined quality in education research. The workshop used standard consensus-building techniques to reach concept saturation. Attendees then voted for the 3 concepts they valued most in medical education research.
Results
The 110 survey responses generated a list of 37 overlapping features in 10 categories considered important aspects of quality. The literature search yielded 27 articles, including quality indexes, systematic and narrative reviews, and commentaries. Thirty-two participants, 12 facilitators, and 1 expert observer attended the workshop. Participants endorsed the following features of education research as being most valuable: (1) provocative, novel, or challenged established thinking; (2) adhered to sound research principles; (3) relevant to practice, role, or needs; (4) feasible, practical application in real-world settings; and (5) connection to a conceptual framework.
Conclusions
Medical educators placed high value on rigorous methods and conceptual frameworks, consistent with published quality indexes. They also valued innovative or provocative work, feasibility, and applicability to their setting. End-user opinions of quality may illuminate how educators translate knowledge into practice.
MD, MCR,
EdD, MEd,
PhD,
MD, MPH,
MD,
PhD, and
PhD
Abstract
Background
To further evolve in an evidence-based fashion, medical education needs to develop and evaluate new practices for teaching, learning, and assessment. However, educators face barriers in designing, conducting, and publishing education research.
Objective
To explore the barriers medical educators face in formulating, conducting, and publishing high-quality medical education research, and to identify strategies for overcoming them.
Methods
A consensus workshop was held November 5, 2013, at the Association of American Medical Colleges annual meeting. A working group of education research experts and educators completed a preconference literature review focusing on barriers to education research. During the workshop, consensus-based and small group techniques were used to refine the broad themes into content categories. Attendees then ranked the most important barriers and strategies for overcoming them with the highest potential impact.
Results
Barriers participants faced in conducting quality education research included lack of (1) expertise, (2) time, (3) funding, (4) mentorship, and (5) reward. The strategy considered most effective in overcoming these barriers involved building communities of education researchers for collaboration and networking, and advocating for education researchers' interests. Other suggestions included trying to secure increased funding opportunities, developing mentoring programs, and encouraging mechanisms to ensure protected time.
Conclusions
Barriers to education research productivity clearly exist. Many appear to result from feelings of isolation that may be overcome with systemic efforts to develop and enable communities of practice across institutions. Finally, the theme of “reward” is novel and complex and may have implications for education research productivity.
MA
Kenneth Ludmerer's Let Me Heal: The Opportunity to Preserve Excellence in American Medicine is an absorbing book that transports the reader through the evolution of physician education over 2 centuries. The discourse on the topic is much needed. Writing in spare and elegant prose, Ludmerer traces the concept of American graduate medical education from its antecedents in the unpaid apprenticeships of the 18th century to the institutionalized, heavily taxpayer-supported residencies of today. For nonphysicians, the book shines a light on a mysterious world and answers questions many did not even know needed to be asked.
Several leitmotifs define
MD
In the final decades of the 19th century, the American general hospital served as a social welfare institution for the poor as often as it served as a medical institution for the sick: It provided food, warmth, and cleanliness to the impoverished, along with splints and dressing changes to the injured.1 To the extent that hospitals did offer medical treatment, they catered to the “worthy poor,” composed of the urban working class, many of them recent immigrants, a group whose illness was attributed to misfortune rather than to immoral behavior.2 Anyone with even modest resources preferred
MD, FACEP
It's 1895 and you are a house officer at the storied Johns Hopkins Hospital. You share cramped and dilapidated living quarters with 3 other interns. The food is awful and the paint is peeling. It is your third night on call this week, and you have not left the hospital in nearly a month. You remind yourself that, as rough as these conditions are, you feel blessed by the excellent teaching you are receiving from the staff physicians, and know that your counterparts at the hospital across town have it a lot worse. You grab a short nap after taking
SPECIAL BOOK REVIEW
MD
As a resident, I am always being encouraged to read more. Read this chapter. Read that journal article. Read the new practice bulletin. Rarely is there time to read for fun. Like potential space, the time for nonwork reading isn't there until you create it. When asked to review Kenneth Ludmerer's Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, part of me rebelled: Why would I want to read more about medicine—isn't that what I eat, sleep, and breathe? However, the history major in me triumphed: Wouldn't it be interesting to learn about my roots,
MD
Let Me Heal: The Opportunity to Preserve Excellence in American Medicine is the third (but, one hopes, not the final) volume in a history of medical education in America by Kenneth Ludmerer, the unchallenged doyen of this essential area of scholarship.
His two previous volumes are titled Learning to Heal (1996), which examined the structure, content, evolution, and purpose of medical education in America from its beginnings to the 1920s, and Time to Heal (1999), which described the years from the 1920s to 1994, the span he considers to cover both the rise
MD, PhD
In 1979, I became hematology/oncology fellow in the Department of Developmental Therapeutics at the world-famous MD Anderson Cancer Center in Houston, Texas. I had almost finished my residency in internal medicine at the Academic Hospital Maastricht in the Netherlands, and with curiosity and anxiety I looked forward to my new working and training environment. It turned out to be a once-in-a-lifetime experience. There were 6 patients per fellow (rather than 12 as a resident in Holland), daily rounds by the attending physician (rather than once a week), rounds on Saturday and Sunday (rather than having the weekend off), and patients
MD
As a trainee on the brink of the fellow-to-faculty transition, perhaps I am particularly reflective about the issues raised by Kenneth Ludmerer's newest book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. This exhaustive history of graduate medical education inspired me to feel nostalgic—partly for a past I never experienced, but mostly for the transformative 8-year educational period of my own career that is quickly drawing to a close. Reading the book also helped me place my training in perspective. It left me feeling reassured that my experience as a resident and fellow has truly
MD,
MD,
PhD,
MD, and
MD., PhD
Abstract
Background
The impact of global health experiences on practice location is not clear.
Objective
We studied whether participants in global health tracks (GHTs) and global health electives (GHEs) were more likely to practice in underserved areas.
Methods
Our study used the 2010 American Medical Association Masterfile to evaluate the practice location of 999 graduates (1980–2009) from 5 family medicine programs. The variable of interest was participation in a GHT or GHE. Outcome measures were percentage of graduates practicing in (1) health professional shortage areas, (2) medically underserved areas or populations, (3) rural areas, (4) areas of dense poverty, and (5) any rural or underserved area. We also examined whether availability of a GHT or GHE in the program affected nonparticipants' practice location.
Results
Sixty-four percent (112 of 174) of participants practiced in areas of dense poverty compared with 56% (463 of 825) of nonparticipants (P = .04). Those graduating after GHT implementation were more likely to practice in a rural or underserved area compared with those graduating before implementation. After controlling for potential confounders, GHT participants were not more likely to work in an underserved area.
Conclusions
Graduates of programs with global health experiences were more likely to practice in an underserved or rural area. Making these experiences available may affect participants and nonparticipants.
PhD and
BS
Abstract
Background
Obstetrics and gynecology residents face difficult clinical situations and decisions that challenge their moral concepts.
Objective
We examined how moral and nonmoral judgments about patients are formulated, confirmed, or modified and how moral distress may be alleviated among obstetrics-gynecology residents.
Methods
Three focus groups, guided by open-ended interview questions, were conducted with 31 obstetrics-gynecology residents from 3 academic medical institutions in northeast Ohio. Each focus group contained 7 to 14 participants and was recorded. Two investigators independently coded and thematically analyzed the transcribed data.
Results
Our participants struggled with 3 types of patients perceived as difficult: (1) patients with chronic pain, including patients who abuse narcotics; (2) demanding and entitled patients; and (3) irresponsible patients. Difficult clinical encounters with such patients contribute to unalleviated moral distress for residents and negative, and often inaccurate, judgment made about patients. The residents reported that they were able to prevent stigmatizing judgments about patients by keeping an open mind or recognizing the particular needs of patients, but they still felt unresolved moral distress.
Conclusions
Moral distress that is not addressed in residency education may contribute to career dissatisfaction and ineffective patient care. We recommend education and research on pedagogical approaches in residency education in a model that emphasizes ethics and professional identity development as well as the recognition and alleviation of moral distress.
MD,
MD,
DO,
MD,
DO,
RN,
DO, and
PhD
Abstract
Background
Cardiopulmonary arrests are rare, high-stakes events that benefit from using crisis resource management (CRM). Simulation-based education with deliberate practice can promote skill acquisition.
Objective
We assessed whether using simulation-based education to teach CRM would lead to improved performance, compared to a lecture format.
Methods
We tested third-year internal medicine residents in simulated code scenarios. Participants were randomly assigned to simulation-based education with deliberate practice (SIM) group or lecture (LEC) group. We created a checklist of CRM critical actions (which includes announcing the diagnosis, asking for help/suggestions, and assigning tasks), and reviewed videotaped performances, using a checklist of skills and communications patterns to identify CRM skills and communication efforts. Subjects were tested in simulated code scenarios 6 months after the initial assessment.
Results
At baseline, all 52 subjects recognized distress, and 92% (48 of 52) called for help. Seventy-eight percent (41 of 52) did not succeed in resuscitating the simulated patient or demonstrate the CRM skills. After intervention, both groups (n = 26 per group) improved. All SIM subjects announced the diagnosis compared to 65% LEC subjects (17 of 26, P = .01); 77% (20 of 26) SIM and 19% (5 of 26) LEC subjects asked for suggestions (P < .001); and 100% (26 of 26) SIM and 27% (7 of 26) LEC subjects assigned tasks (P < .001).
Conclusions
The SIM intervention resulted in significantly improved team communication and cardiopulmonary arrest management. During debriefing, participants acknowledged the benefit of the SIM sessions.
MD, FACP,
MD, FACP,
MD,
MD, FACP,
MD,
MD, FACP,
MD,
MD, FACP,
MD,
MD, MPH, FACP,
MS,
MD, FACP,
MD, and
MD, MS
Abstract
Background
Many internal medicine programs have reorganized their resident continuity clinics to improve the ambulatory care experience for residents. The effect of this redesign on patient satisfaction is largely unknown.
Methods
Our multi-institutional, cross-sectional study included 569 internal medicine residents from 11 programs participating in the Educational Innovations Project Ambulatory Collaborative. An 11-item patient satisfaction survey from the Consumer Assessment of Healthcare Providers and Systems was used to assess patient satisfaction, comparing patient satisfaction in traditional models of weekly continuity clinic with 2 new clinic models. We then examined the relationship between patient satisfaction and other practice variables.
Results
Patient satisfaction responses related to resident listening and communication skills, knowledge of medical history, perception of adequate visit time, overall rating, and willingness to refer to family and friends were significantly better in the traditional and block continuity models than the combination model. Higher ambulatory workload was associated with reduced patient perception of respect shown by the physician. The percentage of diabetic patients with glycated hemoglobin < 8% was positively correlated with number of visits, knowledge of medical history, perception of respect, and higher scores for recommending the physician to others. The percentage of diabetic patients with low density lipoprotein < 100 mg/dL was positively correlated with the physician showing respect.
Conclusions
Patient satisfaction was similar in programs using block design and traditional models for continuity clinic, and both outperformed the combination model programs. There was a delicate balance between workload and patient perception of the physician showing respect. Care outcome measures for diabetic patients were associated with aspects of patient satisfaction.
MD and
MD, FACP
Abstract
Background
Studies show postinterview communication from applicants may affect their placement on the program's National Resident Matching Program (NRMP) rank order list.
Objective
To determine whether postinterview correspondence from applicants to a residency program is associated with the applicant's subsequent position on the program's rank list.
Methods
During 2 recruitment seasons, we collected postinterview correspondence from applicants to 1 residency program. Applicant characteristics and the content and timing of correspondence were compared with the applicant's position on the program's rank list. Data were analyzed using the Pearson χ2 test.
Results
Of 470 applicants interviewed, 290 (61.7%) sent unsolicited correspondence to the program after interviewing. Ten percent (29 of 290) stated they planned to rank the program first, 11.7% (34 of 290) that they planned to rank it highly, and 78.3% (227 of 290) gave no indication of ranking intentions. Applicants who corresponded were no more likely to be ranked in the top 2 quartiles on the rank list than those who did not (P = .32) nor were applicants who communicated plans to rank the program “first” or “highly” ranked higher than other corresponding applicants (P = .34). Of the 16 applicants who planned to rank the program “first” and who were ranked in the program's match range, 5 did not match with the program, suggesting they may have misled the program.
Conclusions
Postinterview correspondence by applicants was not associated with position on the rank order list. Correspondence does not benefit the applicant and can lead to misleading statements, which may violate the NRMP participation agreement.
MD,
PhD,
MD,
MD, and
MD, MPH
Abstract
Background
Several national initiatives aim to teach high-value care to residents. While there is a growing body of literature on cost impact of physicians' therapeutic decisions, few studies have assessed factors that influence residents' prescribing practices.
Objective
We studied factors associated with intensive health care utilization among internal medicine residents, using brand name statin prescribing as a proxy for higher-cost care.
Methods
We conducted a retrospective, cross-sectional analysis of statin prescriptions by residents at an urban academic internal medicine program, using electronic health record data between July 1, 2010, and June 30, 2011.
Results
For 319 encounters by 90 residents, patients were given a brand name statin in 50% of cases. When categorized into quintiles, the bottom quintile of residents prescribed brand name statins in 2% of encounters, while the top quintile prescribed brand name statins in 98% of encounters. After adjusting for potential confounders, including patient characteristics and supervising attending, being in the primary care track was associated with lower odds (odds ratio [OR], 0.38; P = .02; 95% confidence interval [CI], 0.16–0.86), and graduating from a medical school with an above-average hospital care intensity index was associated with higher odds of prescribing brand name statins (OR, 1.70; P = .049; 95% CI, 1.003–2.88).
Conclusions
We found considerable variation in brand name statin prescribing by residents. Medical school attended and residency program type were associated with resident prescribing behavior. Future interventions should raise awareness of these patterns in an effort to teach high-value, cost-conscious care to all residents.
MD,
MD, and
PhD
Abstract
Background
It is not known if construct-related validity (progression of scores with different levels of training) and generalizability of Objective Structured Clinical Examination (OSCE) scenarios previously used with non-US graduating anesthesiology residents translate to a US training program.
Objective
We assessed for progression of scores with training for a validated high-stakes simulation-based anesthesiology examination.
Methods
Fifty US anesthesiology residents in postgraduate years (PGYs) 2 to 4 were evaluated in operating room, trauma, and resuscitation scenarios developed for and used in a high-stakes Israeli Anesthesiology Board examination, requiring a score of 70% on the checklist for passing (including all critical items).
Results
The OSCE error rate was lower for PGY-4 than PGY-2 residents in each field, and for most scenarios within each field. The critical item error rate was significantly lower for PGY-4 than PGY-3 residents in operating room scenarios, and for PGY-4 than PGY-2 residents in resuscitation scenarios. The final pass rate was significantly higher for PGY-3 and PGY-4 than PGY-2 residents in operating room scenarios, and also was significantly higher for PGY-4 than PGY-2 residents overall. PGY-4 residents had a better error rate, total scenarios score, general evaluation score, critical items error rate, and final pass rate than PGY-2 residents.
Conclusions
The comparable error rates, performance grades, and pass rates for US PGY-4 and non-US (Israeli) graduating (PGY-4 equivalent) residents, and the progression of scores among US residents with training level, demonstrate the construct-related validity and generalizability of these high-stakes OSCE scenarios.
PhD
Abstract
Background
The Communication Assessment Tool (CAT), a paper-based patient survey, is 1 method to assess residents' interpersonal and communication skills. To further enhance the interpretation of the CAT, benchmark data are needed.
Objective
We sought to expand upon initial benchmarking data for the use of the CAT as an evaluation tool in family medicine residency programs.
Methods
Data were collected on 120 residents from 7 family medicine residency programs. Following an appointment with a resident, 1703 patients completed the CAT.
Results
The overall mean percentage of items rated as excellent was 73%. Significant differences were found in the overall percentage of items rated as “excellent” based on location of training (78% US graduate versus 71% international medical graduate) and native language of the resident (76% English speaking versus 69% non-English speaking). There were no significant differences found in the overall percentage of items rated as excellent based on the year of training or sex of the residents.
Conclusions
These benchmarking data allow family medicine residency programs to compare the performance of their residents with other programs. The CAT can be used as an evaluation and a learning tool in family medicine and may be applicable to other specialties.
Evaluating Simulation-Based ACLS Education on Patient Outcomes: A Randomized, Controlled Pilot Study
MD,
MD,
MD,
MD,
MD, MSc,
MD,
PharmD, BCPS,
MD,
MA,
MD, MSc, and
MD, MPH
Abstract
Background
Simulation training is widely accepted as an effective teaching tool, especially for dealing with high-risk situations.
Objective
We assessed whether standardized, simulation-based advanced cardiac life support (ACLS) training improved performance in managing simulated and actual cardiac arrests.
Methods
A total of 103 second- and third-year internal medicine residents were randomized to 2 groups. The first group underwent conventional ACLS training. The second group underwent two 2 1/2-hour sessions of standardized simulation ACLS teaching. The groups were assessed by evaluators blinded to their assignment during in-hospital monthly mock codes and actual inpatient code sheets at 3 large academic hospitals. Primary outcomes were time to initiation of cardiopulmonary resuscitation, time to administration of first epinephrine/vasopressin, time to delivery of first defibrillation, and adherence to American Heart Association guidelines.
Results
There were no differences in primary outcomes among the study arms and hospital sites. During 21 mock codes, the most common error was misidentification of the initial rhythm (67% [6 of 9] and 58% [7 of 12] control and simulation arms, respectively, P = .70). There were no differences in primary outcome among groups in 147 actual inpatient codes.
Conclusions
This blinded, randomized study found no effect on primary outcomes. A notable finding was the percentage of internal medicine residents who misidentified cardiac arrest rhythms.
MD, FAANS,
MD,
MD, and
MD
Abstract
Background
Continuity of care in neurological surgery includes preoperative planning, technical and cognitive operative experience, and postoperative follow-up. Determining the extent of continuity of care with duty hour limits is problematic.
Objective
We used electronic health record data to track continuity of care in a neurological surgery program and to assess changes in rotation requirements.
Methods
The electronic health record was surveyed for all dictated resident–neurological surgery patient encounters (excluding progress notes), discharge summaries, and bedside procedures (July 2009–November 2011). Encounters were designated as preoperative, operative, or postoperative and were grouped by postgraduate year (PGY)–1 through PGY-6.
Results
A total of 6382 dictations were reviewed, with 5231 (82.0%) pertinent to neurological surgery. Of the 1469 operative notes, 303 (20.6%) had a record of an encounter with the operating resident in either a postoperative or preoperative setting. Preoperative encounters totaled 10.1% (148 of 1469); postoperative, 5.1% (75 of 1469); and encounters with both were 5.4% (80 of 1469). Continuity of care was as follows: PGY-1, 13.8% (4 of 29); PGY-2, 17.4% (26 of 149); PGY-3, 29.0% (36 of 124); PGY-4, 24.8% (73 of 294); PGY-5, 28.8% (109 of 379); and PGY-6, 11.1% (55 of 494). One of the highest continuity rates was observed in a rotation specifically constructed to enhance continuity of care.
Conclusions
The electronic health record can be used to track resident continuity of care in neurological surgery. The primary operating resident saw the patient in nonoperative settings, such as general admission, clinic visitation, or consultation in 20.6% (303 of 1469) of cases.
MBBS,
MHMS,
BA, and
MD, JD
Abstract
Background
Anesthesiology residents acquire clinical skills and acumen primarily from experience providing anesthesia for procedural cases, with prior preparation maximizing learning. Ambulatory surgery and associated management styles create fluid anesthesiology staffing—reducing predictability for learners and disrupting continuity of care.
Objective
This prospective, observational study aimed to quantify anesthesia personnel changes in the operating rooms of a single teaching hospital.
Methods
For a 5-week period, Monday through Friday, we recorded the surgical schedule on the prior evening. After the day of surgery, tracking software provided a list of cases performed. We completed electronic health record review for each case, recorded the actual anesthesiology personnel involved, and compared that to the personnel originally scheduled. We also recorded the occurrence of any permanent transitions of care within a case, the type of operation, and the anesthesia start and end times.
Results
Anesthesia providers included 47 residents and 32 attending physicians. The study period included 1285 scheduled cases, 55% (n = 711) of which were started and finished by the originally scheduled resident and attending physician. Including canceled cases (126 of 1285, 10%) and added cases (207 of 1366, 15%), residents started anesthetics on patients and with attending physicians assigned to them from the day before 54% of the time. Transitions of care occurred in 19% (260 of 1366) of the cases.
Conclusions
Anesthesiology residents prepare for many procedures that do not eventuate and frequently start other cases without prior opportunity for preparation and study. Transitions of care further reduce continuity of care and fragment supervision.
MD, MEHP,
MD, MEHP,
PhD, and
PhD
Abstract
Background
Educators agree on the importance of assessing the quality of graduate medical education. In the United States, the Accreditation Council for Graduate Medical Education (ACGME) resident survey is an important part of the accreditation process, yet some studies have questioned its validity.
Objective
We assessed the reliability and acceptance of the ACGME-International (ACGME-I) resident survey in the culturally distinct, nonnative English-speaking resident population of Abu Dhabi in the United Arab Emirates.
Methods
A total of 158 residents in ACGME-I accredited institutions in Abu Dhabi received an online link to the ACGME-I survey. Reliability analysis was conducted using the Cronbach α. A focus group was then held with a convenience sample of 25 residents from different institutions and specialties to understand potential challenges encountered by survey participants.
Results
Completed surveys were received from 116 residents (73.4%). The 39 items in the survey demonstrated high reliability, with a Cronbach α of 0.918. Of the 5 subscales, 4 demonstrated acceptable to very good reliability, ranging from 0.72 to 0.888. The subscale “resources” had lower reliability at 0.584. Removal of a single item increased the Cronbach α to a near-acceptable score of 0.670. Focus group results indicated that the survey met standards for readability, length, and time for completion.
Conclusions
The ACGME-I resident survey demonstrates acceptable reliability and validity for measuring the perceptions of residents in an international residency program. The data derived from the survey can offer an important set of metrics for educational quality improvement in the United Arab Emirates.
MD,
MEd,
MD,
MD,
MD,
MD, and
MD
Abstract
Background
Residents need to acquire an understanding of the biopsychosocial aspects of caring for older adults with chronic illness, along with effective use of interdisciplinary services inside and outside of the hospital.
Objective
We expanded the geriatric medicine experience for second-year internal medicine residents and present the results of the first year's experience.
Methods
We paired a mandatory rotation for postgraduate year–2 internal medicine residents (2 weeks of day and 1 week of night inpatient experience in the Acute Care for Elders Unit), and a 1-week outpatient systems-based practice experience with online modules and readings. Evaluation included a case presentation, an oral examination, a written questionnaire for all residents, and a global assessment of the residents' performance on the geriatrics portion of the 2012 In-Training Examination (ITE).
Results
All residents passed their oral examination; there was little difference between classes in systems-based practice knowledge. More than 90% (21 of 23) of the residents who took the rotation reported that it left a lasting impression on how they would care for their patients. Mean ITE scores in geriatrics for all residents increased from 53% (versus 61% overall) in 2010 to 87% (versus 81%) in 2012, although they dropped to 69% (versus 82%) in 2013.
Conclusions
A rotation in geriatrics that is highly rated and covers both acute care and systems-based practice concepts is feasible for internal medicine residents. Residents did not learn detailed knowledge about specific programs for older adults, but clinical geriatrics knowledge improved.
PharmD, MMedEd,
BS,
MD,
MD, and
MD
Abstract
Background
Development of cognitive skills for competent medical practice is a goal of residency education. Cognitive skills must be developed for many different clinical situations.
Innovation
We developed the Resident Cognitive Skills Documentation (CogDoc) as a method for capturing faculty members' real-time assessment of residents' cognitive performance while they precepted them in a family medicine office. The tool captures 3 dimensions of cognitive skills: medical knowledge, understanding, and its application. This article describes CogDoc development, our experience with its use, and its reliability and feasibility.
Methods
After development and pilot-testing, we introduced the CogDoc at a single training site, collecting all completed forms for 14 months to determine completion rate, competence development over time, consistency among preceptors, and resident use of the data.
Results
Thirty-eight faculty members completed 5021 CogDoc forms, documenting 29% of all patient visits by 33 residents. Competency was documented in all entrustable professional activities. Competence was statistically different among residents of different years of training for all 3 dimensions and progressively increased within all residency classes over time. Reliability scores were high: 0.9204 for the medical knowledge domain, 0.9405 for understanding, and 0.9414 for application. Almost every resident reported accessing the individual forms or summaries documenting their performance.
Conclusions
The CogDoc approach allows for ongoing assessment and documentation of resident competence, and, when compiled over time, depicts a comprehensive assessment of residents' cognitive development and ability to make decisions in ambulatory medicine. This approach meets criteria for an acceptable tool for assessing cognitive skills.
MD, PhD,
PhD,
MD,
MD,
MD,
MD, PhD, and
MD, MHPE
Abstract
Background
Making an accurate diagnosis is a core skill residents must develop. Assessments of this skill and decisions to grant residents clinical independence often are based on global impressions. A workplace-based assessment of diagnostic accuracy could be a useful part of a competency-based assessment program and could inform decisions about granting residents independence.
Innovation
We developed a method for measuring diagnostic accuracy that was integrated into the workflow of internal medicine residents and attending physicians.
Methods
Four senior medical residents and 6 attending physicians working in the internal medicine clinical teaching unit of a tertiary hospital participated in this study. To determine their diagnostic accuracy, residents documented a leading diagnosis for each patient they evaluated in the emergency department. After reviewing each case with the resident and after examining the patient, the resident's attending physician documented the diagnosis. Discharge diagnosis was determined by retrospective chart review to allow determination of resident and attending physician diagnostic accuracy. Data were collected for 240 consecutive patients referred for a medicine consultation.
Results
Resident diagnostic accuracy was 66% (95% CI 60–72), whereas attending physician accuracy was significantly higher at 79% (95% CI 74–84, P < .001). By logistic regression, the accuracy of the attending physician was found to be influenced by the accuracy of the resident. Participants felt this process motivated them to improve their clinical reasoning.
Conclusions
Measuring resident diagnostic accuracy provides information that could be used in a competency-based assessment program to provide feedback and motivation to stimulate performance improvement.
MD,
MD,
MD, and
MD
Abstract
Background
Many patients in internal medicine resident continuity clinics experience difficulty accessing care, making posthospitalization ambulatory follow-up challenging. Experiential learning in care transitions is also lacking for residents.
Objective
We sought to assess the feasibility and impact of a weekly Resident Discharge Clinic (RDC) in increasing access to early posthospitalization follow-up and providing learning opportunities for residents.
Methods
We staffed the RDC with an ambulatory block resident, an internal medicine preceptor, and a clinical pharmacist. We assessed time to posthospitalization follow-up, readmission rates, and resident perceptions of postdischarge care for resident-clinic patients, comparing data before and after RDC implementation.
Results
There were 636 discharges in the baseline group, 662 during the intervention period, and 56 in the RDC group. Six months after RDC implementation, the percentage of discharged resident-clinic patients with follow-up within 7 days improved from 6.6% at baseline to 9.7% (P = .04). The mean interval to the posthospitalization follow-up appointment in the RDC group was 7.4 days compared with 33.9 days in the baseline group (P < .001). The percentage of surveyed residents (n = 72) who agreed that early follow-up was easy to arrange increased from 21% to 77% (P < .001). There was no significant decrease in the 30-day readmission rate for patients in the RDC group (18.1% versus 12.5%, P = .29).
Conclusions
The RDC was easily implemented, increased access to timely posthospitalization follow-up, and provided a platform for resident learning about care transitions.
MD, MPH,
MD, MBA,
MD, MBA,
MBA,
MA,
MB,
MD, MHS, and
MD
Abstract
Background
Systematically engaging residents in large programs in quality improvement (QI) is challenging.
Objective
To coordinate a shared QI project in a large residency program using an online tool.
Methods
A web-based QI tool guided residents through a 2-phase evaluation of performance of foot examinations in patients with diabetes. In phase 1, residents completed reviews of health records with online data entry. Residents were then presented with personal performance data relative to peers and were prompted to develop improvement plans. In phase 2, residents again reviewed personal performance. Rates of performance were compared at the program and clinic levels for each phase, with data presented for residents. Acceptability was measured by the number of residents completing each phase. Feasibility was measured by estimated faculty, programmer, and administrator time and costs.
Results
Seventy-nine of 86 eligible residents (92%) completed improvement plans and reviewed 1471 patients in phase 1, whereas 68 residents (79%) reviewed 1054 patient charts in phase 2. Rates of performance of examination increased significantly between phases (from 52% to 73% for complete examination, P < .001). Development of the tool required 130 hours of programmer time. Project analysis and management required 6 hours of administrator and faculty time monthly.
Conclusions
An online tool developed and implemented for program-wide QI initiatives successfully engaged residents to participate in QI activities. Residents using this tool demonstrated improvement in a selected quality target. This tool could be adapted by other graduate medical education programs or for faculty development.
MD,
MD, MPH,
MD, MPP,
MD,
PhD, and
MD, MPH
Abstract
Background
Education in health policy and advocacy is recognized as an important component of health professional training. To date, curricula have only been assessed at the medical school level.
Objective
We sought to address the gap in these curricula for residents and other health professionals in primary care.
Innovation
We created a health policy and advocacy curriculum for the VA Connecticut Healthcare System, Center of Excellence in Primary Care Education, an interprofessional, ambulatory-based, training program that includes internal medicine residents, nurse practitioner fellows, health psychology fellows, and pharmacy residents. The policy module focuses on health care finance and delivery, and the advocacy module emphasizes negotiation skills and opinion-based writing. Trainee attitudes were surveyed before and after the course, and using the Wilcoxon signed rank test, relative change was determined. Knowledge acquisition was evaluated with precourse and postcourse examinations using a paired sample t test.
Results
From July 2011 through June 2013, 16 trainees completed the course. In the postcourse survey, trainees demonstrated improved comfort with understanding health law and the American health care system (Likert mean increased from 2.1 to 3.0, P = .01), as well as with associated advocacy skills (Likert mean increased from 2.0 to 2.9, P = .04). Knowledge-based test scores also showed significant improvement (increasing from 55% to 78% correct, P ≤ .001).
Conclusions
Our curriculum integrating core health policy knowledge with advocacy skills represents a novel approach in postgraduate health professional education and resulted in sustained improvement in knowledge and comfort with health policy and advocacy.
MD, FACP,
MD, FACP,
MD, and
MD, FACP
Abstract
Background
Comprehensive evaluations of clinical competency consume a large amount of time and resources. An oral examination is a unique evaluation tool that can augment a global performance assessment by the Clinical Competency Committee (CCC).
Objective
We developed an oral examination to aid our CCC in evaluating resident performance.
Methods
We reviewed tools used in our internal medicine residency program and other training programs in our institution. A literature search failed to identify reports of a similar evaluation tool used in internal medicine programs. We developed and administered an internal medicine oral examination (IMOE) to our postgraduate year–1 and postgraduate year–2 internal medicine residents annually over a 3-year period. The results were used to enhance our CCC's discussion of overall resident performance. We estimated the costs in terms of faculty time away from patient care activities.
Results
Of the 54 residents, 46 (86%) passed the IMOE on their first attempt. Of the 8 (14%) residents who failed, all but 1 successfully passed after a mentored study period and retest. Less than 0.1 annual full-time equivalent per faculty member was committed by most faculty involved, and the time spent on the IMOE replaced regular resident daily conference activities.
Conclusions
The results of the IMOE were added to other assessment tools and used by the CCC for a global assessment of resident performance. An oral examination is feasible in terms of cost and can be easily modified to fit the needs of various competency committees.
MD, MCR,
MD,
MD, and
MD, MCR
Abstract
Background
In July 2013, emergency medicine residency programs implemented the Milestone assessment as part of the Next Accreditation System.
Objective
We hypothesized that applying the Milestone framework to real-time feedback in the emergency department (ED) could affect current feedback processes and culture. We describe the development and implementation of a Milestone-based, learner-centered intervention designed to prompt real-time feedback in the ED.
Methods
We developed and implemented the Milestones Passport, a feedback intervention incorporating subcompetencies, in our residency program in July 2013. Our primary outcomes were feasibility, including faculty and staff time and costs, number of documented feedback encounters in the first 2 months of implementation, and user-reported time required to complete the intervention. We also assessed learner and faculty acceptability.
Results
Development and implementation of the Milestones Passport required 10 hours of program coordinator time, 120 hours of software developer time, and 20 hours of faculty time. Twenty-eight residents and 34 faculty members generated 257 Milestones Passport feedback encounters. Most residents and faculty reported that the encounters required fewer than 5 minutes to complete, and 48% (12 of 25) of the residents and 68% (19 of 28) of faculty reported satisfaction with the Milestones Passport intervention. Faculty satisfaction with overall feedback in the ED improved after the intervention (93% versus 54%, P = .003), whereas resident satisfaction with feedback did not change significantly.
Conclusions
The Milestones Passport feedback intervention was feasible and acceptable to users; however, learner satisfaction with the Milestone assessment in the ED was modest.
MD, MPH,
MD, MPH,
MD, MPH, and
MD
Abstract
Background
The Accreditation Council for Graduate Medical Education duty hour standards restrict continuous duty for postgraduate year (PGY)–1 residents to 16 hours.
Objective
We aimed to assess the relationship between a duty hour–compliant schedule and resident sleep.
Methods
To comply with 2011 duty hour limits, Beth Israel Deaconess Medical Center restructured its intensive care unit call model for internal medicine PGY-1 residents from a traditional shift model to an overlapping shorter-duration shift model with preserved educational periods. Before and after schedule changes, we used daily surveys of PGY-1 residents to collect self-reported data on quantity and quality of sleep and quality of education.
Results
A total of 1162 surveys were sent to 43 interns before scheduling changes, and 1305 were sent to 41 interns after the changes. Response rate was 31.2% (362 of 1161) before and 22.2% (290 of 1305) after. Before changes, 57.7% (209 of 362) reported receiving 6 hours or more of sleep in a 24-hour period compared to 72.4% (210 of 290) after the changes (adjusted relative risk, 1.33; 95% CI, 1.15–1.53), with an adjusted difference of 0.83 hours of sleep per 24 hours (95% CI, 0.28–1.38). After the intervention, on a 5-point Likert scale, residents reported higher quality of sleep (odds ratio [OR], 1.62; 95% CI, 1.01–2.60) and greater satisfaction with their education (OR, 2.59; 95% CI, 1.40–4.81).
Conclusions
Following conversion to a duty hour–compliant model with preserved didactic time, PGY-1 residents reported minor increases in quantity and quality of sleep per 24-hour period, and increased satisfaction with the educational experience.
MD,
MD, and
MD
Abstract
Background
Medicare funding for graduate medical education may be cut in the next federal budget.
Objective
We quantified the value of work that 1 orthopedic surgery resident performs on call and compare it to Medicare educational funding received by the hospital for each resident.
Methods
A single orthopedic resident's on-call emergency department and inpatient consults were collected during a 2-year call period at a large, tertiary, level-1 trauma center. Patient charts were reviewed; ICD-9 codes, evaluation and management, and procedural treatment were recorded. Codes were converted into work relative value units. The number of work relative value units was multiplied by the 2012 Medicare rate of $34.03 per relative value units to calculate the monetary value of resident work.
Results
Of 120 resident call shifts, 115 call sheets (95.8%) were available for review, and 1160 patients were seen (average = 10.09 consults/call). A total of 4688 work relative value units were generated (average = 40.76 per night), and the total dollar value generated was $159,561 ($1,387 per call) during the 2 years of call (average = $79,780 annually). Evaluation and management codes generated 2340 work relative value units, with a calculated dollar amount of $79,648, and procedural codes generated 2348 work relative value units, with a calculated dollar amount of $79,913.
Conclusions
Our institution estimated Medicare direct medical education support per resident at $40,000/y, and total funding was $130,000/resident. At our tertiary care institution, the unbilled work of 1 orthopedic resident on call amounts to more than 60% of Medicare direct medical education and indirect medical education funding annually.
MD,
MD, and
MD
Abstract
Background
Development of professionalism is a critical component of a military transitional year residency. Little published research exists to guide programs in meeting this challenge.
Objective and Methods
After significant concerns regarding resident professionalism were raised by Tripler Army Medical Center faculty, a novel transitional residency professionalism curriculum was conceived and implemented. Universal expectations of physician professionalism, as perceived by various stakeholders (patients, parents, faculty, and nurses), were explored using a small group, discussion-based curriculum. This was combined with a small group, discussion-based, lessons-learned project and a military-unique curriculum.
Results
Since implementation, the curriculum has had 100% satisfaction on the part of the faculty and 80% to 100% on the part of the residents, as measured by annual review surveys. Although resident professionalism scores on evaluations did not change significantly, the number of adverse actions because of professionalism lapses has decreased steadily in the 4 years since inception, and the program has been without any such actions for the past 18 months.
Conclusions
Our novel transitional residency professionalism curriculum has been successful in a military residency program.
MD,
MD,
MD, and
MD
Abstract
Background
Limits on resident duty hours instituted in 2003 and 2011 have compressed medical resident daily workload. Despite this compression, residents must gain competence to practice medicine without supervision.
Objective
We sought to determine whether moving the time our educational conference is scheduled affects the time when patient discharges are completed on an internal medicine teaching service.
Methods
The study was conducted at a county hospital within a large internal medicine residency program. During the 4-month study period, the morning report conference for internal medicine residents was shifted from 8:30 am to 2 pm. Patient discharge times, defined as the time the discharge order set was signed, were obtained for the service via the electronic health record. The outcomes measured were patient discharge time variation and internal medicine resident preference for conference time.
Results
Survey response rate was 82% (42 of 51). Of the residents who responded, 64% (27 of 42) preferred the 8:30 am report time, and 74% (31 of 42) felt the 8:30 am time was also better for education and timing of teaching rounds. There was no difference in discharge times for 2999 patients on the medicine teaching service, whether educational case conference morning report occurred at 8:30 am or at 2 pm.
Conclusions
Medical patient average discharge time was not influenced by time of educational conference. Factors other than the timing of educational conference appear to influence hospital discharge times on an inpatient internal medicine service.
MD, DM,
MD,
MD, MPH,
MD, and
MD
Abstract
Background
The electronic health record (EHR) includes a rich data set that may offer opportunities for data mining and natural language processing to answer questions about quality of care, key aspects of resident education, or attributes of the residents' learning environment.
Objective
We used data obtained from the EHR to report on inpatient documentation practices of residents and attending physicians at a large academic medical center.
Methods
We conducted a retrospective observational study of deidentified patient notes entered over 7 consecutive months by a multispecialty university physician group at an urban hospital. A novel automated data mining technology was used to extract patient note–related variables.
Results
A sample of 26 802 consecutive patient notes was analyzed using the data mining and modeling tool Healthcare Smartgrid. Residents entered most of the notes (33%, 8178 of 24 787) between noon and 4 pm and 31% (7718 of 24 787) of notes between 8 am and noon. Attending physicians placed notes about teaching attestations within 24 hours in only 73% (17 843 of 24 443) of the records. Surgical residents were more likely to place notes before noon (P < .001). Nonsurgical faculty were more likely to provide attestation of resident notes within 24 hours (P < .001).
Conclusions
Data related to patient note entry was successfully used to objectively measure current work flow of resident physicians and their supervising faculty, and the findings have implications for physician oversight of residents' clinical work. We were able to demonstrate the utility of a data mining model as an assessment tool in graduate medical education.
MD (@LMelvinMD) and
HBSc, BEd, MD, FRCPC (@TChanMD)
The Challenge
Faculty and residents are faced with many competing demands on their time, including the need to stay current with the literature and new clinical developments in the specialty. Using technologies available at one's fingertips allows us to stay current in our fields of interest as clinicians and educators but may seem overwhelming and intimidating at first. To address this challenge, we outline how Twitter can be used as a professional tool to efficiently stay up-to-date in medicine and education.
What Is Known
Twitter is a social media site created in 2006 that uses 140-character messages to share information
PhD
Medical educators1–5 are turning their attention to a concept from nursing ethics: moral distress, defined as distress that results when health care providers are unable, because of institutional constraints, to do what they believe to be the right thing.1 The original definition, and much of the research tradition, pertains to analyses of nurses as disempowered.2 The concept also assumes a patient-centered lens: Patients do not cause moral distress; rather, insufficient resources, inflexible institutions, or family wishes that are discordant with patients' needs cause distress for nurses who want to deliver
MD, MSHS and
MD, MPH
To improve residents' ambulatory care clinic experience and attract more of them to a primary care career, as well as to fulfill Residency Review Committee requirements, internal medicine programs have adopted a variety of scheduling strategies for resident continuity clinics. In 2009, the Residency Review Committee required internal medicine residents to have 130 ambulatory, half-day sessions over 3 years, an increase from the 108 sessions required in 2004, and a scheduling approach that reduces conflict between ambulatory and inpatient responsibilities.1 In response, residency programs have developed block models to better separate inpatient from ambulatory care.
Whether such changes in
MD,
MD, MPH, and
MD, MPH
The imperative to reduce health care costs in the United States has led to a growing movement to better educate medical students, residents, and practicing physicians about providing high-value, cost-conscious care.1 It has even been suggested that the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties establish resource stewardship as the seventh general competency.2 The use of equally effective but less expensive generic alternatives in place of brand name drugs represents 1 way of practicing high-value, cost-conscious care and has been highlighted as a top priority by the American Board of
MD, MA,
MD, FACP, and
PhD, MBA
In a recent Perspective entitled “Competency-Based Education: Milestones or Millstones?” Norman et al1 listed conceptual, psychometric, and logistic problems with competency-based medical education (CBME). Their conclusion—that learning and assessment based on the Milestones offer real benefit—may be lost on readers of this provocative piece. We take this opportunity to expand their description of 4 benefits of CBME over a traditional approach. We also suggest 2 additional benefits: (1) Milestones are critical to assessment based on direct observation in the context of real clinical practice; and (2) by targeting essential attributes of a high-performing physician, Milestones will advance the
MD, FACS,
MD, FACS,
MD, MPH, FACS,
MD,
MD, FACS,
MD, FACS, and
MD, PhD, FACS
We read with great interest the recent editorial by Simpson et al.1 Merriam-Webster defines scholarly as “of, characteristic of, or suitable to learned persons.”2 Because this is certainly a trait that we would expect for all physicians, it is imperative that residency programs teach their trainees to become scholarly. As such, our answer to the first question posed, “Are we seeking to ensure that ALL of our graduates are ‘scholarly physicians’?” is clearly a resounding “Yes.”
The importance of developing scholarly residents is explicitly stated in the Accreditation Council for Graduate Medical Education program
MD,
MD, and
PhD
In a recent issue, Norman et al1 and Carter2 use evocative metaphors to describe the status of the Milestone project. Norman et al1 summarize the promise of competency-based education/Milestones and categorically state, “Regrettably, these declarations appear to be more a matter of faith than of evidence.”1 Although, at this point, there is insufficient evidence that this major overhaul will be meaningful, its transformational potential remains promising.
In support of the Milestones, Carter2 states that “the Next Accreditation System (NAS) and Milestones are akin to designing a plane in flight. .
Lt Col, MD, USAF, MC
What does it mean to be proficient? The Association of American Medical Colleges (AAMC)1,2 and the Accreditation Council for Graduate Medical Education (ACGME)3 identify a “proficient” teaching faculty as the cornerstone of resident education in quality improvement and patient safety (QI/PS). The AAMC states that “all clinical faculty need to be proficient . . .”1 Likewise, the ACGME states that its focus is on “the proportion of faculty members who report to be proficient in the application of principles and practices of patient safety.”3 Clinical
MD, MPH and
RN, MHSA
In his letter to the editor,1 Dr Nagy raises important issues about faculty skills in advancing quality improvement (QI) within their clinical learning environments, and faculty skills and experience in supervising and guiding residents and fellows in the conduct of QI activities during their graduate medical education experience. Dr Nagy presents these issues as the challenge of trying to define and assess faculty proficiency. While achieving proficiency would seem like a reasonable goal for such an important set of clinical skills, at this point in time the Accreditation Council for Graduate Medical Education's (ACGME's) Clinical Learning Environment Review
MD and
MD
In another moment down went Alice after [the rabbit], never once considering how in the world she was to get out of [the rabbit hole] again.
—Alice's Adventures in Wonderland by Lewis Carroll
A third of the way through my intern year, my program director approached me about serving on the Residency Review Committee for Internal Medicine.
Rule No. 1, which applies not only in the military where I trained but also in residency: A suggestion from a superior is always answered with an enthusiastic “yes.” I soon found myself submitting a curriculum vitae and personal statement to a committee
MD,
PhD,
PhD,
MHA,
MD, MPH,
MD,
MD,
MD,
MD,
MD,
MD, and
MD, MPH
Abstract
Background
The Internal Medicine Educational Innovations Project (EIP) is a 10-year pilot project for innovating in accreditation, which involves annual reporting of information and less-restrictive requirements for a group of high-performing programs. The EIP program directors' experiences offer insight into the benefits and challenges of innovative approaches to accreditation as the Accreditation Council for Graduate Medical Education transitions to the Next Accreditation System.
Objective
We assessed participating program directors' perceptions of the EIP at the midpoint of the project's 10-year life span.
Methods
We conducted telephone interviews with 15 of 18 current EIP programs (83% response rate) using a 19-item, open-ended, structured survey. Emerging themes were identified with content analysis.
Results
Respondents identified a number of the benefits from the EIP, most prominent among them, collaboration between programs (87%, 13 of 15) and culture change around quality improvement (47%, 7 of 15). The greatest benefit for residents was training in quality improvement methods (53%, 8 of 15), enhancing those residents' ability to become change agents in their future careers. Although the requirement for annual data reporting was identified by 60% (9 of 15) of program directors as the biggest challenge, respondents also considered it an important element for achieving progress on innovations. Program directors unanimously reported their ability to sustain innovation projects beyond the 10-year participation in EIP.
Conclusions
The work of EIP was not viewed as “more work,” but as “different work,” which created a new mindset of continuous quality improvement in residency training. Lessons learned offer insight into the value of collaboration and opportunities to use accreditation to foster innovation.
PhD
Abstract
Background
Patient safety is an important concept in resident education. To date, few studies have assessed resident perceptions of patient safety across different specialties.
Objective
The study explored residents' views on patient safety across the specialties of internal medicine, general surgery, and diagnostic radiology, focusing on common themes and differences.
Methods
In fall 2012, interviews of small groups of senior residents in internal medicine, general surgery, and diagnostic radiology were conducted at 3 academic medical centers and 3 community teaching hospitals in 3 major US metropolitan areas. In total, 33 residents were interviewed. Interviews used interactive discussion to explore multiple facets of patient safety.
Results
Residents identified lack of information, common errors, volume and acuity of patients, and inadequate supervision as major risks to patient safety. Specific threats to patient safety included communication problems, transitions of care, information technology interface issues, time constraints, and work flow. Residents disclosed that reporting safety issues was viewed as burdensome and carrying some degree of risk. There was variability as to whether residents would report safety threats they encountered.
Conclusions
Residents are aware of threats to patient safety and have a unique perspective compared with other health care professionals. Transitions of care and communication problems were the most common safety threats identified by the residents interviewed.
MD, MPH,
MD,
RN, MHSA, 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 January 2014, the Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review (CLER) program released “CLER Pathways to Excellence: expectations for an optimal clinical learning environment to achieve safe and high-quality patient care” as guidance for the GME community, hospitals, medical centers, clinics, and other organizations that serve as sites for physician residency and fellowship programs.1,2 To launch this
MD, MPH,
MD, and
RN, MHSA
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 Accreditation Council for Graduate Medical Education (ACGME) recognizes the public's need for a physician workforce capable of meeting the challenges of a rapidly evolving health care environment. The ACGME has responded to this need by implementing the Clinical Learning Environment Review (CLER) program as a part of its Next Accreditation System. The CLER program is designed to provide US teaching hospitals, medical centers, health systems,
PhD, MBA and
MD
Editor's Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its review committees. The decision to publish the article is made by the ACGME.
On July 1, 2014, the second group of programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) entered the Next Accreditation System (NAS), and all programs are now functioning under the principles of NAS, which include continuous accreditation via annual reviews of data, lengthening the interval between scheduled accreditation visits, and a focus on educational outcomes. The aims are to reduce the burden of
ERRATUM
This corrects the authorship listing for the Preventive Medicine Milestones published in the 2014 Journal of Graduate Medical Education Supplement: Delgado SG. The Preventive Medicine Milestone Project. J Grad Med Educ. 2014:6(1 suppl 1):243–245.
Eric M. Wood, MD, MPH, of the University of Utah was a member of the Working Group that developed the Preventive Medicine Milestones.
The online version of the article has been corrected.
Rouge on the Lips of Silence
Yuki TeramotoMD, PhD
Evaluating Methodology for Increasing Diversity in US Residency Training Programs: A Scoping Review
Lauren BoeckermannMD, MPH,
Dennis MenjivarBS,
Emily E. HagnMD,
Melissa PreviteraMLIS,
Samuel H. CheshierMD, PhD,
Hilary C. McCraryMD, MPH, and
Jeremiah A. AltMD, PhD
Scoping Review of Simulation-Based Training for Social Determinants of Health Within Residency Programs
Nathan TunellMS,
Sehr KhanMD,
Ashley PavlicMD, MA, and
Taylor SonnenbergMD, MSGH
Career Outcomes Among Graduates of 2 Urban Health Primary Care Training Programs
Preetham BachinaBS,
Ariel G. VilidnitskyMD,
Katherine ShawMD,
Monica MixMD, MPH,
Talia Robledo-GilMD, and
Leonard FeldmanMD, FACP, FAAP, MHM
Trends in MedEdPORTAL Faculty Development Resources for Clinician Educators
Amna AneesMD, FACP,
Craig NoronhaMD,
Aashish DidwaniaMD, and
Karen FriedmanMD, MS
The Effect of Paging Reminders on Fellowship Conference Attendance: A Multi-Program Randomized Crossover Study
Joshua SmithMD,
Lorenzo ZaffiriMD,
Julie ClaryMD, MBA,
Tyler DavisMD, and
Gabriel T. BossletMD, MA
A Values Affirmation Intervention to Improve Female Residents' Surgical Performance
Arghavan SallesMD, PhD,
Claudia M. MuellerPhD, MD, and
Geoffrey L. CohenPhD
Improving Residents' Safe Opioid Prescribing for Chronic Pain Using an Objective Structured Clinical Examination
Daniel P. AlfordMD, MPH,
Brittany L. CarneyMS,
Belle Brett EDD,
Sharon J. ParishMD, and
Angela H. JacksonMD
Integrating a Resident-Driven Longitudinal Quality Improvement Curriculum Within an Ambulatory Block Schedule
Aleksey TentlerMD,
Mirela FeurdeanMD,
Steven KellerPhD, and
Neil KothariMD
Skills for Interviewing Adolescent Patients: Sustainability of Structured Feedback in Undergraduate Education on Performance in Residency
Nadim JoukhadarBSc,
Genna BourgetMD,
Sarah ManosMD,
Karen MannPhD,
Jill HatchettePhD, and
Kim BlakeMD
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