Early in my career I was lucky to work with terrific mentors and mentees. I am not always sure they were fortunate to work with me. With no formal training in education—other than as a learn-as-you-go piano and ballet teacher and teaching assistant in my youth—I might have benefited greatly from a crash course in educational theory and basic teaching skills. Forty years ago, medical teachers did not receive additional training in education. Back then, the PhDs listed on medical school and residency rosters represented basic scientists, not educators or social scientists. Now there are increasing numbers of medical school
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FROM THE EDITOR
IN THIS ISSUE
From the Editors
Editor-in-Chief Gail Sullivan presents a short list of key articles and other resources for clinicians with roles as clinician-educators (p. 153).
Perspectives
A perspective from the Institute for Healthcare Improvement offers recommendations for physician education in quality and safety and suggests that quality has outpaced patient safety in the course of residents’ active engagement in improvement efforts (Mate and Johnson, p. 158).
A perspective, which includes a clinical vignette, notes that handheld point-of-service ultrasound devices are useful in augmenting other diagnostic tools at the bedside (Phillips, p. 160).
Colbert and colleagues discuss challenges and opportunities for clinical
PERSPECTIVES
MD and
MPH
Teaching hospitals in the United States are under unprecedented pressure to demonstrate value. 1,2 Coupled with national policy trends and demand from consumers, there has been an increased focus on systems-based quality improvement and patient safety. Alongside this increased scrutiny, in 2012 the Accreditation Council for Graduate Medical Education (ACGME) outlined its new accreditation system, urging enhanced competence in systems-based practice for the next generation of physicians. 3 One component of the new system is the Clinical Learning Environment Review (CLER) program, which includes institutional site visits to assess resident participation in 6 focus areas: patient
MD
The events recounted here are true; the name Mrs. Michaels is fictional to protect the privacy of the patient.
It didn't add up. She was in shock but denied any symptoms that might suggest the cause. No fever, no chest pain, no dyspnea, no belly pain … nothing.
Three hours earlier, Mrs. Michaels had abruptly lost consciousness while seated at her breakfast table. She was tachycardic when the emergency medical technicians pushed her through the emergency room doors. Her daughter reiterated to the nurses that the day had been no different from any other in the life of her 80-year-old
PhD,
PhD, and
PhD
The Accreditation Council for Graduate Medical Education's (ACGME) new accreditation system has introduced a significantly different world of assessment with its language of milestones and centralized oversight of trainee performance by Clinical Competency Committees (CCCs). Just as the shift to competency-based education and assessment required a culture shift for graduate medical education programs across the United States, 1 so, too, does the shift to using CCCs to determine trainee progression on milestones. In this article, we offer our perspectives on the role of the CCC and discuss challenges and opportunities for graduate medical education programs as they enter this
MD, MPH and
MD
The emergence of global health as a core component of medical education is a relatively recent phenomenon. 1 Over the last 20 years, graduate medical education (GME) has documented the growth, curriculum development, and trainee benefits of global health electives (GHEs). 2 Scholarship, predominantly focused on evidence-based benefits and clinical outcomes of GHEs at the community level, has not occurred at the same pace. Efforts to standardize and understand benefits of a GHE curriculum should occur in parallel with the need to monitor and evaluate the effects of GHEs on clinical and public health outcomes.
Viewed within the
MD,
MD,
PhD,
PhD,
PhD, and
MD, FACS
The emergency medicine chief resident sits at her desk, at first just staring at an empty grid. She then determinedly starts assigning shifts to the 15 residents rotating next month. Hours later, she isn't much further along than when she started, due to the different rules for each type of resident. Difficulty accounting for various scheduling conflicts, such as medicine continuity clinics on Thursday mornings and surgical grand rounds on Tuesday mornings, has caused her to start over several times. Elsewhere in the hospital, the cardiothoracic fellows have struggled to perform an adequate number of transplant cases within their standard
BEd, MD, FRCPC,
MD,
MD, and
MBBS, MS
Your residency program has been regularly hosting a journal club for residents. The trainees rotate at multiple sites and find it difficult to attend the sessions. In addition, you would like to have experts, and ideally authors and journal editors, participate in the journal club. How can you do this?
Solution: Google Hangouts on Air
Google Hangouts is an instant messaging and video chat platform that launched in 2011. This cloud-based application allows participants in different locations to videoconference, share individual screens, text chat, and collaboratively edit documents in real time. This free software is increasingly used for study groups
REVIEWS
BA,
PhD, RN,
BS,
MD,
BS,
BS, and
MLIS
Abstract
Background
Multiple organizations have recognized that handoffs are prone to errors, and there has been an increase in the use of electronic health records and computerized tools in health care.
Objective
This systematic review evaluates the current evidence on the effectiveness of electronic solutions used to support shift-to-shift handoffs.
Methods
We searched the English-language literature for research studies published between January 1, 2008, and September 19, 2014, using National Library of Medicine PubMed, EBSCO CINAHL, OvidSP All Journals, and ProQuest PsycINFO. Included studies focused on the evaluation of physician shift-to-shift handoffs and an electronic solution designed to support handoffs. We assessed articles using a quality scoring system, conducted a review of barriers and strategies, and categorized study outcomes into self-report, process, and outcome measures.
Results
Thirty-seven articles met inclusion criteria, including 20 single group pre- and posttest studies; 8 posttest only or cross-sectional studies; 4 nonrandomized controlled trials; 1 cohort study; 1 randomized crossover study; and 3 qualitative studies. Quality scores ranged from 3.5 to 14 of a possible 16. Most articles documented some positive outcomes, with 2 of the 3 studies evaluating patient outcomes yielding statistically significant improvements. The only other study that analyzed patient outcomes showed that interventions other than the electronic tool were responsible for most of the significant improvements.
Conclusions
The majority of studies supported using an electronic tool, yet few measured patient outcomes, and numerous studies suffered from methodology issues. Future studies should evaluate patient outcomes, improve study design, assess the role of faculty oversight, and broaden the focus to recognize the role of human factors.
ORIGINAL RESEARCH
MD,
MD,
BSN,
MD,
MD, and
PhD
Abstract
Background
Management of status epilepticus (SE) in the pediatric population is highly time-sensitive. Failure to follow a standard management algorithm may be due to ineffective provider education, and can lead to unfavorable outcomes.
Objective
To design a learning module using high-fidelity simulation technology to teach mastery achievement of a hospital algorithm for managing SE.
Methods
Thirty pediatrics interns were enrolled. Using the Angoff method, an expert panel developed the minimal passing score, which defined mastery. Scoring of simulated performance was done by 2 observers. Sessions were digitally recorded. After the pretest, participants were debriefed on the algorithm and required to repeat the simulation. If mastery (minimal passing score) was not achieved, debriefing and the simulation were repeated until mastery was met. Once mastery was met, participants graded their comfort level in managing SE.
Results
No participants achieved mastery at pretest. After debriefing and deliberate simulator training, all (n = 30) achieved mastery of the algorithm: 30% achieved mastery after 1 posttest, 63% after a second, and 6.7% after a third. The Krippendorff α was 0.94, indicating strong interrater agreement. Participants reported more self-efficacy in managing SE, a preference for simulation-based education for learning practice-based algorithms of critical conditions, and highly rated the educational intervention.
Conclusions
A simulation-based mastery learning program using deliberate practice dramatically improves pediatrics residents' execution of a SE management protocol. Participants enjoyed and benefited from simulation education. Future applications include improving adherence to other hospital protocols.
MD,
MD,
MD,
MD, MPH,
BA,
MD,
MSA, and
PhD
Abstract
Background
New skills are needed to properly prepare the next generation of physicians and health professionals to practice in medical homes. Transforming residency training to address these new skills requires strong leadership.
Objective
We sought to increase the understanding of leadership skills useful in residency programs that plan to undertake meaningful change.
Methods
The Preparing the Personal Physician for Practice (P4) project (2007–2014) was a comparative case study of 14 family medicine residencies that engaged in innovative training redesign, including altering the scope, content, sequence, length, and location of training to align resident education with requirements of the patient-centered medical home. In 2012, each P4 residency team submitted a final summary report of innovations implemented, overall insights, and dissemination activities during the study. Six investigators conducted independent narrative analyses of these reports. A consensus meeting held in September 2012 was used to identify key leadership actions associated with successful educational redesign.
Results
Five leadership actions were associated with successful implementation of innovations and residency transformation: (1) manage change; (2) develop financial acumen; (3) adapt best evidence educational strategies to the local environment; (4) create and sustain a vision that engages stakeholders; and (5) demonstrate courage and resilience.
Conclusions
Residency programs are expected to change to better prepare their graduates for a changing delivery system. Insights about effective leadership skills can provide guidance for faculty to develop the skills needed to face practical realities while guiding transformation.
PhD,
MD,
MD,
MD, and
MD
Abstract
Background
The emergency medicine milestones were developed to provide more objective resident assessment than current methods. However, little is known about the best practices for applying the milestones in resident assessment.
Objective
We examined the utility of end-of-shift evaluations (ESEs) constructed using the milestones in resident assessment.
Methods
We developed 14 daily ESEs, each of which included 9 or 10 emergency medicine milestones. Postgraduate year (PGY)-1 and PGY-2 residents were assessed on milestone levels 1 through 3; PGY-3 and PGY-4 residents were assessed on levels 3 through 5. Each milestone was rated on a nominal scale (yes, no, or not applicable). The Clinical Competency Committee combined the ESE data with data from other assessments to determine each resident's proficiency level for the emergency medicine subcompetencies. We used descriptive statistics to summarize resident ESEs and milestone levels. We analyzed differences in ESE score across PGY levels using t tests and analyses of variance.
Results
Faculty completed 763 ESEs on 33 residents with a range of 2 to 54 (median = 22) ESEs per resident. Faculty rarely (8%, 372 of 4633) rated a resident as not achieving a milestone on the ESEs. Analyses of variance revealed that ESE scores on level 3 milestones did not differ significantly by PGY level. There was poor agreement between ESE scores and Clinical Competency Committee ratings.
Conclusions
The ESEs constructed using the milestones resulted in grade or milestone inflation. Our results do not support using milestones as a stand-alone assessment tool.
MD, MSc, FRCSC,
MD, FRCSC,
MD,
MD,
MD, MMEd, and
MD, PhD, FAC
Abstract
Background
Evidence suggests that simulation leads to improved operative skill, shorter operating room time, and better patient outcomes. Currently, no standardized laparoscopy curriculum exists for gynecology residents.
Objective
To design a structured laparoscopy curriculum for gynecology residents using Delphi consensus methodology.
Methods
This study began with Delphi methodology to determine expert consensus on the components of a gynecology laparoscopic skills curriculum. We generated a list of cognitive content, technical skills, and nontechnical skills for training in laparoscopic surgery, and asked 39 experts in gynecologic education to rate the items on a Likert scale (1–5) for inclusion in the curriculum. Consensus was predefined as Cronbach α of ≥ 0.80. We then conducted another Delphi survey with 9 experienced users of laparoscopic virtual reality simulators to delineate relevant curricular tasks. Finally, a cross-sectional design defined benchmark scores for all identified tasks, with 10 experienced gynecologic surgeons performing the identified tasks at basic, intermediate, and advanced levels.
Results
Consensus (Cronbach α = 0.85) was achieved in the first round of the curriculum Delphi, and after 2 rounds (Cronbach α = 0.80) in the virtual reality curriculum Delphi. Consensus was reached for cognitive, technical, and nontechnical skills as well as for 6 virtual reality tasks. Median time and economy of movement scores defined benchmarks for all tasks.
Conclusions
This study used Delphi consensus to develop a comprehensive curriculum for teaching gynecologic laparoscopy. The curriculum conforms to current educational standards of proficiency-based training, and is suggested as a standard in residency programs.
PhD
Abstract
Background
Many departments have multiple chief residents. How these coleaders relate to each other could affect their performance, the residency program, and the department.
Objective
This article reports on how co-chiefs work together during the chief year, and what may allow them to be more effective coleaders.
Methods
A phenomenological research design was used to investigate experiences of outgoing chief residents from 13 specialties at the University of Iowa Hospitals and Clinics over a 2-year period from 2012 through 2013. Thematic analysis of semistructured interviews was conducted to investigate commonalities and recommendations.
Results
Face-to-face interviews with 19 chief residents from 13 different specialties identified experiences that helped co-chiefs work effectively with each other in orienting new co-chiefs, setting goals and expectations, making decisions, managing interpersonal conflict, leadership styles, communicating, working with program directors, and providing evaluations and feedback. Although the interviewed chief residents received guidance on how to be an effective chief resident, none had been given advice on how to effectively work with a co-chief, and 26% (5 of 19) of the respondents reported having an ineffective working relationship with their co-chief.
Conclusions
Chief residents often colead in carrying out their multiple functions. To successfully function in a multichief environment, chief residents may benefit from a formal co-orientation in which they discuss goals and expectations, agree on a decision-making process, understand each other's leadership style, and receive feedback on their efficacy as leaders.
MD,
MD, and
PhD
Abstract
Background
Peer feedback is increasingly being used by residency programs to provide an added dimension to the assessment process. Studies show that peer feedback is useful, uniquely informative, and reliable compared to other types of assessments. Potential barriers to implementation include insufficient training/preparation, negative consequences for working relationships, and a perceived lack of benefit.
Objective
We explored the perceptions of residents involved in peer-to-peer feedback, focusing on factors that influence accuracy, usefulness, and application of the information.
Methods
Family medicine residents at the University of Michigan who were piloting an online peer assessment tool completed a brief survey to offer researchers insight into the peer feedback process. Focus groups were conducted to explore residents' perceptions that are most likely to affect giving and receiving peer feedback.
Results
Survey responses were provided by 28 of 30 residents (93%). Responses showed that peer feedback provided useful (89%, 25 of 28) and unique (89%, 24 of 27) information, yet only 59% (16 of 27) reported that it benefited their training. Focus group participants included 21 of 29 eligible residents (72%). Approaches to improve residents' ability to give and accept feedback included preparatory training, clearly defined goals, standardization, fewer and more qualitatively oriented encounters, 1-on-1 delivery, immediacy of timing, and cultivation of a feedback culture.
Conclusions
Residents perceived feedback as important and offered actionable suggestions to enhance accuracy, usefulness, and application of the information shared. The findings can be used to inform residency programs that are interested in creating a meaningful peer feedback process.
MD,
MD,
MD, MHPE,
MD,
MD, and
PhD
Abstract
Background
Despite the importance of feedback, the literature suggests that there is inadequate feedback in graduate medical education.
Objective
We explored barriers and facilitators that residents in anesthesiology, emergency medicine, obstetrics and gynecology, and surgery experience with giving and receiving feedback during their clinical training.
Methods
Residents from 3 geographically diverse teaching institutions were recruited to participate in focus groups in 2012. Open-ended questions prompted residents to describe their experiences with giving and receiving feedback, and discuss facilitators and barriers. Data were transcribed and analyzed using the constant comparative method associated with a grounded theory approach.
Results
A total of 19 residents participated in 1 of 3 focus groups. Five major themes related to feedback were identified: teacher factors, learner factors, feedback process, feedback content, and educational context. Unapproachable attendings, time pressures due to clinical work, and discomfort with giving negative feedback were cited as major barriers in the feedback process. Learner engagement in the process was a major facilitator in the feedback process.
Conclusions
Residents provided insights for improving the feedback process based on their dual roles as teachers and learners. Time pressures in the learning environment may be mitigated by efforts to improve the quality of teacher-learner relationships. Forms for collecting written feedback should be augmented by faculty development to ensure meaningful use. Efforts to improve residents' comfort with giving feedback and encouraging learners to engage in the feedback process may foster an environment conducive to increasing feedback.
MD, FACP,
MD, FACP,
MD, FACP,
MS, and
MD, FACP
Abstract
Background
In contrast to historical feedback, which was vague or provided residents' numerical scores without clear meaning, milestone-based feedback is focused on specific knowledge, skills, and behaviors that define developmental trajectory. It was anticipated that residents would welcome the more specific and actionable feedback provided by the milestone framework, but this has not been studied.
Objective
We assessed internal medicine (IM) residents' perceptions of receiving feedback in the milestone framework, particularly assessing perception of the utility of milestone-based feedback compared to non–milestone-based feedback.
Methods
We surveyed a total of 510 IM residents from 7 institutions. Survey questions assessed resident perception of milestone feedback in identifying strengths, weaknesses, and trajectory of professional development. Postgraduate years 2 and 3 (PGY-2 and PGY-3) residents were asked to compare milestones with prior methods of feedback.
Results
Of 510 residents, 356 (69.8%) responded. Slightly less than half of the residents found milestone-based feedback “extremely useful” or “very useful” in identifying strengths (44%), weaknesses (43%), specific areas for improvement (45%), and appropriate education progress (48%). Few residents found such feedback “not very useful” or “not at all useful” in these domains. A total of 51% of PGY-2 and PGY-3 residents agreed that receiving milestone-based feedback was more helpful than previous forms of feedback.
Conclusions
IM residents are aware of the concepts of milestones, and half of the residents surveyed found milestone feedback more helpful than previous forms of feedback. More work needs to be done to understand how milestone-based feedback could be delivered more effectively to enhance resident development.
MD,
PhD,
MD,
PhD, and
MD, MHPE
Abstract
Background
Availability of reliable, valid, and feasible workplace-based assessment (WBA) tools is important to allow faculty to make important and complex judgments about resident competence. The Minicard is a WBA direct observation tool designed to provide formative feedback while supporting critical competency decisions.
Objective
The purpose of this study was to collect validity and feasibility evidence for use of the Minicard for formative assessment of internal medicine residents.
Methods
We conducted a retrospective cohort analysis of Minicard observations from 2005–2011 in 1 institution to obtain validity evidence, including content (settings, observation rates, independent raters); response process (rating distributions across the scale and ratings by month in the program); consequences (qualitative assessment of action plans); and feasibility (time to collect observations).
Results
Eighty faculty observers recorded 3715 observations of 73 residents in the inpatient ward (43%), clinic (39%), intensive care (15%), and emergency department (3%) settings. Internal medicine residents averaged 28 (SD = 8.4) observations per year from 9 (SD = 4.1) independent observers. Minicards had an average of 5 (SD = 5.1) discrete recorded observations per card. Rating distributions covered the entire rating scale, and increased significantly over the time in training. Half of the observations included action plans with action-oriented feedback, 11% had observational feedback, 9% had minimal feedback, and 30% had no recorded plan. Observations averaged 15.6 (SD = 9.5) minutes.
Conclusions
Validity evidence for the Minicard direct observation tool demonstrates its ability to facilitate identification of “struggling” residents and provide feedback, supporting its use for the formative assessment of internal medicine residents.
EDUCATIONAL INNOVATION
MD,
MPH, and
MD
Abstract
Background
Physician-patient communication is vital to patient care, and physician-nurse interactions are equally critical. Conflict between nurses and physicians can greatly impair communication, increasing the risk of treatment errors, yet physicians receive little education during training on recognizing and resolving professional conflicts.
Innovation
We created and implemented the Standardized Professional (S-Pro) Encounter to improve training and provide opportunities to evaluate resident professionalism and communication with health care team colleagues.
Methods
The standardized patient model is well established for teaching and assessing clinical and communication skills. Using the standardized patient concept, we created a nurse-resident encounter with 2 professionally trained medical portrayers (1 “nurse,” 1 “patient”), in which the nurse disagrees with the resident's treatment plan. Residents were surveyed for prior experience with nurse-physician conflict management, and we assessed postencounter for collaborative skills and conflict resolution.
Results
All residents (n = 18) observed at least 1 physician-nurse conflict in front of patients. Eleven (61%) reported being involved in at least 1 conflict. Twelve residents (67%) had 2 or fewer prior education experiences in interprofessional conflict management. Faculty assessment and S-Pro scores demonstrated high agreement, while resident self-assessment scores demonstrated low agreement with faculty and S-Pro scores.
Conclusions
Participants and evaluators found the encounter to be reasonably authentic. There was strong agreement between the faculty and S-Pro assessment of resident performance when using the Boggs scale. The S-Pro Encounter is easily adapted for other clinical situations or training programs, and facilitates the assessment of professionalism and communication skills between residents and other health care professionals.
MD, MS,
MD,
MD, and
MD
Abstract
Background
Manual dexterity and visual spatial ability are not routinely used to evaluate candidates for surgical residency training as part of the application interview.
Objective
This study assessed the acceptability and feasibility of evaluating the manual dexterity and visual spatial ability of applicants for general surgery and otolaryngology residency, and evaluated the relationship between this information and routinely considered application factors.
Methods
During the 2012 interview season, medical students applying to our institution's general surgery and otolaryngology residency programs underwent a battery of tests relevant to surgical dexterity. Five tests shown to be related to the surgeons' dexterity or visual spatial skills were administered during the course of their in-person interview day. The results from these tests were compared with data collected as part of the current application process.
Results
A total of 64 students were enrolled, and 58 had data that could be analyzed. Regression analysis using the enter method was performed for each of the tests, and for the composite scores. None of the values were significant as defined by P ≤ .05. Neither the scatterplots of the data nor Pearson r showed a correlation between the highest performers on the surgical dexterity composite score and individuals' highest scores on the dimensions used in the current process to assess applicants.
Conclusions
The addition of 1 or more evaluations of visual spatial skills and psychomotor aptitude can be done during a standard interview day, is acceptable to applicants, and may provide information that is different from the usual components of the application.
MD, MS,
MD, MHPE,
MD, and
MD, MAPP
Abstract
Background
Written communication skills are integral to patient care handoffs. Residency programs require feasible assessment tools that provide timely formative and summative feedback, ideally linked to the Accreditation Council for Graduate Medical Education Milestones.
Objective
We describe the use of 1 such tool—UPDATED—to assess written handoff communication skills in internal medicine interns.
Methods
During 2012–2013, the authors piloted a structured practice audit at 1 academic institution to audit written sign-outs completed by 45 interns, using the UPDATED tool, which scores 7 aspects of sign-out communication linked to milestones. Intern sign-outs were audited by trained faculty members throughout the year. Results were incorporated into intern performance reviews and Clinical Competency Committees.
Results
A total of 136 sign-outs were audited (averaging 3.1 audits per intern). In the first trimester, 14 interns (31%) had satisfactory audit results. Five interns (11%) had critical deficiencies and received immediate feedback, and the remaining 26 (58%) were assigned future audits due to missing audits or unsatisfactory scores. In the second trimester, 21 interns (68%) had satisfactory results, 1 had critical deficiencies, and 9 (29%) required future audits. Nine of the 10 remaining interns in the final trimester had satisfactory audits. Faculty time was estimated at 10 to 15 minutes per sign-out audited.
Conclusions
The UPDATED audit is a milestone-based tool that can be used to assess written sign-out communication skills in internal medicine residency programs. Future work is planned to adapt the tool for use by senior supervisory residents to appraise sign-outs in real time.
MD, MPH,
EdD, MEd,
MD,
BS, and
MD
Abstract
Background
Learner benefits of tablet computer use have been demonstrated, yet there is little evidence regarding faculty tablet use for teaching.
Objective
Our study sought to determine if supplying faculty with tablet computers and peer mentoring provided benefits to learners and faculty beyond that of non–tablet-based teaching modalities.
Methods
We provided faculty with tablet computers and three 2-hour peer-mentoring workshops on tablet-based teaching. Faculty used tablets to teach, in addition to their current, non–tablet-based methods. Presurveys, postsurveys, and monthly faculty surveys assessed feasibility, utilization, and comparisons to current modalities. Learner surveys assessed perceived effectiveness and comparisons to current modalities. All feedback received from open-ended questions was reviewed by the authors and organized into categories.
Results
Of 15 eligible faculty, 14 participated. Each participant attended at least 2 of the 3 workshops, with 10 to 12 participants at each workshop. All participants found the workshops useful, and reported that the new tablet-based teaching modality added value beyond that of current teaching methods. Respondents developed the following tablet-based outputs: presentations, photo galleries, evaluation tools, and online modules. Of the outputs, 60% were used in the ambulatory clinics, 33% in intensive care unit bedside teaching rounds, and 7% in inpatient medical unit bedside teaching rounds. Learners reported that common benefits of tablet computers were: improved access/convenience (41%), improved interactive learning (38%), and improved bedside teaching and patient care (13%). A common barrier faculty identified was inconsistent wireless access (14%), while no barriers were identified by the majority of learners.
Conclusions
Providing faculty with tablet computers and having peer-mentoring workshops to discuss their use was feasible and added value.
MD,
MSW,
MPH,
BS,
MS,
PA-C, MBA, MA,
RN, MPA, and
MD, FACP
Abstract
Background
Training in patient-centered medical home (PCMH) settings may prepare new physicians to measure quality of care, manage the health of populations, work in teams, and include cost information in decision making. Transforming resident clinics to PCMHs requires funding for additional staff, electronic health records, training, and other resources not typically available to residency programs.
Objective
Describe how a 1115 Medicaid waiver was used to transform the majority of primary care training sites in New York State to the PCMH model and improve the quality of care provided.
Methods
The 2013–2014 Hospital Medical Home Program provided awards to 60 hospitals and 118 affiliated residency programs (training more than 5000 residents) to transform outpatient sites into PCMHs and provide high-quality, coordinated care. Site visits, coaching calls, resident surveys, data reporting, and feedback were used to promote and monitor change in resident continuity and quality of care. Descriptive analyses measured improvements in these areas.
Results
A total of 156 participating outpatient sites (100%) received PCMH recognition. All sites enhanced resident education using PCMH principles through patient empanelment, development of quality dashboards, and transforming resident scheduling and training. Clinical quality outcomes showed improvement across the demonstration, including better performance on colorectal and breast cancer screening rates (rate increases of 13%, P ≤ .001, and 11%, P = .011, respectively).
Conclusions
A 1115 Medicaid waiver is a viable mechanism for states to transform residency clinics to reflect new primary care models. The PCMH transformation of 156 sites led to improvements in resident continuity and clinical outcomes.
BRIEF REPORT
MD,
MD, MPH,
BA, and
MD
Abstract
Background
Direct clinical observation is an essential component of medical trainee assessment, particularly in the era of milestone-based competencies. However, the adolescent patient's perspective on this practice is missing from the literature. Quality health care is patient centered, yet we did not know if our educational practices align with this clinical goal.
Objective
We sought to better understand our adolescent/young adult patients' perspectives of the direct observation of our medical trainees in the outpatient clinical setting.
Methods
As a quality improvement initiative, we surveyed adolescent/young adult patients, medical trainees, and physician observers in our outpatient clinical practice regarding their experience following a direct observation encounter. We performed descriptive analyses of the data.
Results
During a 1-year period, responses were received from 23 adolescent/young adult patients, 8 family members, 14 trainees, and 6 faculty observers. Nearly all adolescent/young adult patients (n = 22) and all surveyed family members (n = 8) expressed comfort with direct observation, and all respondents felt the care they received was the same or better. All patient/family respondents preferred direct observation to the idea of remote observation, and most, but not all, trainees and faculty observers expressed similar opinions.
Conclusions
Adolescent/young adult patients and their family members found direct observation of their trainee providers to be comfortable and beneficial. Despite adolescent and young adults' facility and comfort with modern technologies, there was an expressed preference for direct versus remote observation.
RIP OUT
MD, FAAP/FACP,
MD, and
PhD
“If you look for perfection, you'll never be content.”
—Leo Tolstoy, Anna Karenina
The Challenge
Resident skill acquisition and competency assessment is especially challenging in today's current environment of complex patients and decreased training hours. Alternative teaching and assessment methods are critical to optimize patient
COMMENTARIES
MD
With the launch of the Outcomes Project in 2001, the graduate medical education (GME) community began the transition to competency-based medical education (CBME). While this launch promises revolutionary change to the status quo of GME, it is safe to say that the work of transitioning to a competency-based paradigm has been a slow evolutionary process that remains a work in progress. Given the enormous task of implementing true competency-based training, most educators realize that for the foreseeable future, GME will exist as a hybrid model of traditional and CBME components. 1 The release of the Accreditation Council for Graduate
MD,
MD, MCR, and
PhD
Feedback has long been recognized as the “cornerstone of effective clinical teaching.” 1 Recently, we have seen emphasis shift from an instructor-centric paradigm to a learner-centric model that aims to understand how learners seek, receive, and incorporate feedback. These are crucial first steps in improving feedback effectiveness. Rather than continuing to focus on feedback delivery methods, recent publications highlight the importance of the learner's perspective in the feedback conversation through nurturing the skill of “reflection-in-action” and promoting a culture of “informed self-assessment.” 2,3 This paradigm shift represents a welcome change, as a focus on learner-dependent variables
PhD
Over the past decades, competency-based education has become the norm in the medical education continuum. The rise of competency- or outcome-based models of education has been paralleled by an increasing interest in workplace-based assessment (WBA) to provide direct evidence of proficiencies of interest (ie, what the trainee will ultimately do in professional practice). WBA has become a cornerstone in the summative assessment of learning and professional competence. Competency-based education, however, also calls for a greater emphasis on formative assessment, or assessment for learning. Frequent feedback on performance should effectively steer and foster the acquisition
NEW IDEAS
MD, MPH,
MD, MSEd,
MD,
MD,
MD, and
MD
Editor's Note: In this section, we are pleased to present the 2015 New Ideas articles showcasing novel and implemented innovative initiatives in graduate medical education (GME). This year almost 100 submissions were reviewed in collaboration with the Society of Directors of Research in Medical Education. This process yielded 15 innovative approaches with the potential to advance the GME community's deliberations about innovation and improvement.
Setting and Problem
Anesthesiologists work in a fast-paced environment that is not always conducive to timely feedback and reflection on actions and minute-to-minute decision making. We pride ourselves on situational awareness, responding astutely to a decompensating
MD,
MEd, EdD,
MD, and
MD
Setting and Problem
Graduate medical education programs are struggling to evolve toward a competency-based educational model utilizing milestone assessments and modern innovations like e-learning and flipped classrooms. At the same time, programs have limited financial and other resources to create new educational materials. One solution is to share resources between programs. Although resource sharing exists, it does not historically provide for the extensive cooperation outlined in this report.
The Department of Anesthesiology and Perioperative Medicine at Oregon Health & Science University (OHSU) created the Anesthesia Education Toolbox to provide a business model and infrastructure to facilitate educational collaboration
MD,
MD,
MD,
MD,
MD, and
MSA
Setting and Problem
The Accreditation Council for Graduate Medical Education requires residents and fellows to be engaged in quality improvement and patient safety (QI/PS) activities. Sponsoring institutions are expected to monitor and document trainee involvement in formal QI/PS education, patient safety reporting, multidisciplinary QI/PS teams and committees, and process improvement projects. While specific details of QI/PS implementation are left to individual training programs, the “blueprint” for integrating trainees into hospital QI/PS processes and tracking their activities must come from the sponsoring institution itself. This represents a significant expansion of institutional oversight responsibilities. The challenge is developing foundational guidelines for QI/PS
MD,
MD, and
MD
Setting and Problem
The Accreditation Council for Graduate Medical Education sets expectations for institutions to provide oversight of residency and fellowship programs in quality improvement (QI) and patient safety (PS) through the Clinical Learning Environment Review program. This can prove challenging for graduate medical education leaders as they strive to build momentum in curricular change across large institutions.
Beth Israel Deaconess Medical Center is a Boston, Massachusetts, academic center with more than 40 accredited programs. Our QI/PS programs vary: Many programs are high performers, others are strong in 1 area, and a few lack curricula. We wanted high performers to
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Setting and Problem
Care transitions—which occur when a patient moves from the intensive care unit to the medical floor, from the hospital to a skilled nursing facility or home, or from one team to another—represent high-risk periods for adverse events. These transitions are more complex in older patients. Notably, almost half of patients 85 years and older, and 30% of patients 75 to 84 years old, are discharged to a skilled nursing facility. Potential adverse events in this setting include medication errors, poor communication with the patient and receiving providers, and loss of follow-up of pending tests. Improving these transitions
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Setting and Problem
With a 3-year rolling average American Board of Internal Medicine Certifying Examination (ABIM-CE) pass rate of 80%, the University of Kansas Internal Medicine Residency Training Program set out to improve its board pass rate. The intervention involved targeting residents deemed at risk for ABIM-CE failure based on performance on the Internal Medicine In-Training Examination (IM-ITE). The IM-ITE is a test administered annually by the American College of Physicians. More than 20000 internal medicine residents in more than 10 countries take the IM-ITE. Postgraduate year (PGY)–based comparative data on test performance are provided to residency program directors to
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Setting and Problem
The subspecialty consultation represents a unique opportunity for resident learning. Centered on a patient care question, residents bring a “need to know” to the interaction. Fellows have important insights into residents' learning needs, having themselves recently completed training. This learning opportunity may be particularly salient for internal medicine training programs, in which internal medicine residents on inpatient rotations frequently ask subspecialty fellows for consultative assistance with diagnosis and management of patients.
Teaching in the consultation setting can be challenging due to lack of a longitudinal relationship between the resident and fellow, time constraints, and different work incentives.
Exploring Drivers of Medical Overuse Through Transformation of Grand Rounds Into “Right Care Rounds”
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Setting and Problem
Medical overuse is a significant problem, and existing curricula for teaching residents about high-value care are inadequate to meet learner needs. It has been shown that the location where a resident trains is correlated with the ability to provide appropriately conservative care and, thus, presents an opportunity to shape a physician's behavior early in the educational process.1
Intervention
This challenge of medical overuse has been recognized by the Lown Institute in Brookline, Massachusetts, as well as by educators at the Cambridge Health Alliance in Cambridge, Massachusetts, and has given rise to a new educational conference format
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Setting and Problem
Physicians must work effectively in teams, and the Accreditation Council for Graduate Medical Education requires that residency programs teach trainees team skills. To successfully participate in well-functioning teams, physicians first need to understand the roles of other team members. We developed a highly engaging “Guess My Role” game to teach our internal medicine residents about the roles of nonphysician health care professionals with whom they work, and we conducted a preliminary study of the game's impact on residents' knowledge about these professional roles.
Intervention
Study team members used a modified Delphi method to identify the 15 nonphysician
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Setting and Problem
The Accreditation Council for Graduate Medical Education requires residents to have opportunities to teach other learners. In the past, our academic half day (AHD) was a series of small group, problem-based learning sessions that placed all levels of learners in the same classroom at the same time. We initially designed AHD so that senior residents would act as teachers to junior residents within the small groups. However, we found it difficult to satisfy the needs of students, interns, and seniors at the same time. We thus grouped the students and interns into one teaching session and the
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Setting and Problem
In 2011, the internal medicine (IM) training program at the Hospital of the University of Pennsylvania (HUP) implemented night float rotations on most of its inpatient teaching services. There were no formal educational offerings for night float rotations because all teaching conferences were held during daytime hours. Residents identified this lack of formal education on night float as an area for improvement. A group of IM residents developed a resident-led night float curriculum. The curriculum had 2 objectives: (1) to provide regular overnight conferences for interns, and (2) to provide junior and senior residents with formal opportunities
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Setting and Problem
Continuity of care is associated with improved patient and physician satisfaction, increased use of preventive care, and decreased hospitalizations and emergency department visits. However, resident continuity clinics are renowned for having poor continuity, and the finite duration of residency inherently limits longitudinal relationships.
Resident factors that contribute to poor continuity include limited clinic hours, canceled clinic sessions during night duties, competing demands from in-hospital rotations, and duty hour restrictions. System-level factors also hinder continuity, including patient insurance cards that only recognize the attending physician and suboptimal appointment and triage systems. Predominantly underserved and minority, the patient populations
MD, MPH
Setting and Problem
Residency programs often face a knowledge gap in how to teach communication and teamwork skills. These skills are needed in multiple areas and are emphasized in the Clinical Learning Environment Review pathways document. Examples include residents engaging in quality improvement activities, ideally in team settings, and transitions of care, when clear communication is critical.
Intervention
To build an effective team, multiple different personality styles or “temperaments” are needed. These personality types, coupled with understanding how people prefer to work, take in information, and interact with others, are instrumental in ensuring team effectiveness. Taking a personality test can
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Setting and Problem
The Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education (ACGME) recognize the potential impact residents may have on medical students who are on clinical clerkship rotations. An increasing number of residency applicants identify teaching as a career goal. Although academies of educational excellence have been developed for the faculty level, none currently exist at the resident/fellow level. The benefits of such academies include mentorship, collaboration among educators, recognition for teaching, and personal career development. To extend these benefits to residents, the Department of Pediatrics at Baylor College of Medicine created the first
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Setting and Problem
Diagnostic radiology is a 4-year residency (following a 1-year general internship). Recently, the American Board of Radiology (ABR) modified its testing schedule and requirements, and the Accreditation Council for Graduate Medical Education (ACGME) followed suit, to allow more flexibility in how fourth-year radiology residents spend their time. The Vanderbilt Department of Radiology, with its long history of producing leaders in radiology, took this change as an opportunity to develop a leadership development curriculum that allows for practical training under a broad definition of leadership.
Leadership at academic centers is often viewed in the research paradigm (eg, residents
TO THE EDITOR
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There are calls for a large overhaul of the nation's graduate medical education (GME) system, to be achieved through a change in the financing of resident education. The recommendations for this change come from the Institute of Medicine (IOM) and include a proposal for how, and to what entities, funds for physician training should be allocated. This change will affect residency programs across the country, and many stakeholder associations have warned about the potential outcomes. The Association of American Medical Colleges (AAMC) stated this would “destabilize a system that has produced high-quality doctors and other health professionals for more than
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The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements for scholarship and scholarly activity 1 require that “Some members of the faculty should also demonstrate scholarship by 1 or more of the following”: (1) peer-reviewed funding; (2) publications of original research or review articles in peer-reviewed journals, or chapters in textbooks; (3) publications or presentations of case reports or clinical series at local, regional, or national professional and scientific meetings; and (4) participation in national committees or educational organizations. That sounds reasonable, but, the problem is in the details.
First, the word some does not
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In their letter, Balon and Stromberg comment that clinical productivity demands are a barrier to scholarly activities for faculty who devote significant time to bedside and clinic teaching. 1 We concur with the observation of mounting clinical pressures on faculty, but we are deeply troubled by the assertion that the Accreditation Council for Graduate Medical Education (ACGME) annual review of scholarly activities may promote dishonesty among program directors, and that the appropriate response to such a lack of professionalism is a reexamination of the scholarly activity requirements. We also question whether individuals who teach “numerous hours,” yet lack time
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Every institution struggles with how to convey required educational topics to new trainees during resident orientation. The array of educational topics is staggering, with material from the Accreditation Council for Graduate Medical Education, the Joint Commission, the Centers for Medicare & Medicaid Services (CMS), local health agencies, and the given institution administering the education.
The traditional reliance on didactic lectures often fails to engage the audience, and offers no real-life context for new residents' role in the institution's patient safety, quality, and care initiatives. To address this deficiency, we created a series of clinical cases to teach new trainees this
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Due to the dynamic nature of patient care on hospital wards and in the intensive care unit (ICU), critical events can occur in different patients simultaneously, and inappropriate triage and management of such patients can lead to adverse outcomes. There is a paucity of literature to guide the training of physicians on the triage and stabilization of multiple critically ill patients simultaneously. 1 We present a simulation curriculum in which several cases are run simultaneously to train residents in the triage and management of multiple simultaneous critical events.
In our pilot study, 10 postgraduate year (PGY)-2 internal medicine residents
ON TEACHING
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As I sit at grand rounds, I wonder if these sessions can truly be described as grand. Every week, I look forward to the 1-hour grand rounds lecture and anticipate learning something new to share with my colleagues and residents. Halfway into the lecture, a pager goes off. A few minutes later, a phone rings, the sound resembling marimbas playing in the distance. It belongs to the resident sitting a few chairs away from me. As he fumbles to shut off his phone, I notice the crumbs of his morning breakfast clinging to his tie. I realize that I am
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Her plea came through tears. Four white coats hovered around her bed, watching uncomfortably as the words overwhelmed her desire to be a “good patient”—one who does as she is told and never complains.
“You need to understand,” she said. “I only see you at the crack of dawn, then sometimes very late at night. And while I wait for you, I watch the clock. Do you know how slowly the hands move when you lie in bed all day? It's agonizing.”
“Amelia” was a chronically ill, yet medically stable, patient. She had been very sick early during her admission
ACGME NEWS AND VIEWS
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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.
There are leaders and there are those who lead … Great leaders are able to inspire people to act. Those who are able to inspire give people a sense of purpose of belonging that has little to do with any external incentive … Those who are able to inspire will create a following of people who act for the good of the whole not
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Editor's Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its review committees. The decision to publish the article is made by the ACGME.
Introduction
When the leadership of the Accreditation Council for Graduate Medical Education (ACGME) conceptualized what came to be known as the Next Accreditation System, a key component was a comprehensive self-study for programs and sponsoring institutions. The intent for the self-study, and for the overall approach to accreditation, was to promote improvement and recognize that most programs already comply with the vast majority of standards. This
ERRATUM
This corrects a spelling error and omission of an author name in the References for Wynn B. Opening the “black box” of GME costs and benefits: a conceptual model and a call for systematic studies. J Grad Med Educ. 2015;7(1):125–127. On page 127, line 2, “Iannuzzi” is the proper spelling of this name. On page 127 under References, the fourth entry omitted an author. The correct citation is as follows: Iannuzzi MC, Iannuzzi JC, Holtsbery A, Wright SM, Knohl SJ. Comparing hospitalist-resident to hospitalist-midlevel practitioner team performance on length of stay and direct patient care cost. J
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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