The Journal of Graduate Medical Education often receives submissions from trainees and educators highlighting work they do in quality improvement (QI). This is remarkably encouraging given the emphasis that the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System has placed on integrating QI into the clinical learning environment. 1 A major challenge for editors reviewing these manuscripts is the inconsistency with which authors report QI initiatives. After reviewing a large number of these submissions, we have noted common problems that arise and have prepared the following guide to help prospective authors prepare QI reports for
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FROM THE EDITOR
MD, FRCPC and
MD, MPH
MD
The first national report of findings from the Clinical Learning Environment Review (CLER) Program, published as a supplement to this issue of the Journal of Graduate Medical Education, is a very important initiative recently undertaken by the Accreditation Council for Graduate Medical Education (ACGME). 1 Prior discussions about interventions to improve the quality of graduate medical education (GME) have included important issues, such as standard setting, the balance of service and education, assessment, sites of training, and the content of training. The focus has been primarily on individual program review. More recently, the general quality of the
IN THIS ISSUE
From the Editor
Based on a review of quality improvement (QI) submissions in their role as editors, Wong and Sullivan highlight common problems and offer guidance to help prospective authors prepare QI reports for publication (p. 128); and a guest editorial by Thibault introduces the Clinical Learning Environment Review Program's supplement of initial findings and discusses developing closer links between education and health care delivery (p. 134).
Perspectives
Siegler et al discuss approaches to enhance resident decisions around opioid prescribing in the ambulatory setting by focusing on short-term and long-term benefits and risks (p. 138).
MacLeod discusses ethnographic research as
PERSPECTIVES
MD,
PhD, and
MD
Pain represents the chief complaint for nearly half of all emergency department (ED) 1 and outpatient clinic 2 visits in the United States, and as much as it pains the first author to admit it (being a resident physician himself), residents are the frontline clinicians who encounter these patients. Despite available resources, 3 residents often are ill-prepared to manage these patients, particularly in regard to the use of opioid analgesics. 4–6 Compared to other providers, residents are more likely to overtreat abusers of opioid analgesics 7 and refill opioid prescriptions more quickly. 8
PhD
Imagine that you are a program director with limited instructional time, and you have developed supplementary e-learning modules, but your residents do not seem to use them. You have put significant effort into their design, as the modules contain important information that residents should want to learn.
Concerned, you want to understand why this happened, so you decide to conduct a survey to explore the issue. However, despite an acceptable response rate, the results do not answer your questions. The survey data indicate that residents enjoy the modules and recognize that they cover important materials, yet the modules continue to
MBChB, MPhil HE, PhD and
PhD, MHPE
“Wasn't that a great set of workshops on teaching residents in the fall? I had no idea there was so much to giving feedback to residents. There were so many ideas.”
“Yeah, that's true. I've been so busy, though, I haven't had time to try any yet.”
“And when I mentioned trying 1 or 2 new things at our meeting last month, everybody got annoyed and said things are fine the way they are. And then we started talking about our recent revenues.”
A key challenge for faculty development is ensuring that learning is transferred to the workplace. An
MD,
MD,
MD, and
MD
Continuity of care between a patient and a physician is a core aspiration. However, we rarely achieve it in residency training, 1–4 even though benefits of care continuity accrue in several realms, including preventive services, 5,6 clinical outcomes in chronic disease, 7 patient trust 8 and satisfaction, 9 and economic efficiencies. 10 For trainees, benefits include participatory learning about the clinical courses of diseases and their patients' experience of illness, understanding the value of a continuous relationships with patients, and developing professional responsibility. 11,12
In the 1990s, threats
MD,
MD, and
MD, MHSc
Residency is a unique time in one's medical career. It is a time of intense learning and mentorship, as well as work and service. The aspects of service and education in residency have often been regarded as being on the opposite ends of a spectrum.
As an example, consider the scenario of a resident who has decided, midresidency, to move into another specialty. In order to provide the best preparation for this new career choice, one might assume that freeing up time to participate in research projects and prepare for application into the newly chosen specialty would be the best
REVIEWS
MD, PhD,
PhD,
PhD,
MD,
MD,
PhD,
MD, and
EdD
ABSTRACT
The expectation for graduate medical education programs to ensure that trainees are progressing toward competence for unsupervised practice prompted requirements for a committee to make decisions regarding residents' progress, termed a clinical competency committee (CCC). The literature on the composition of these committees and how they share information and render decisions can inform the work of CCCs by highlighting vulnerabilities and best practices.Background
We conducted a narrative review of the literature on group decision making that can help characterize the work of CCCs, including how they are populated and how they use information.Objective
English language studies of group decision making in medical education, psychology, and organizational behavior were used.Methods
The results highlighted 2 major themes. Group member composition showcased the value placed on the complementarity of members' experience and lessons they had learned about performance review through their teaching and committee work. Group processes revealed strengths and limitations in groups' understanding of their work, leader role, and information-sharing procedures. Time pressure was a threat to the quality of group work.Results
Implications of the findings include the risks for committees that arise with homogeneous membership, limitations to available resident performance information, and processes that arise through experience rather than deriving from a well-articulated purpose of their work. Recommendations are presented to maximize the effectiveness of CCC processes, including their membership and access to, and interpretation of, information to yield evidence-based, well-reasoned judgments.Conclusions
ORIGINAL RESEARCH
Creating a Framework for Medical Professionalism: An Initial Consensus Statement From an Arab Nation
MD, MEHP, FACP,
MD, MEHP, FACP,
MD, FRCPc, FCCP,
MBChB, MCh, FRCS, FACS, PhD (Edu),
MD, FRCSc,
,
MBBch, LRCP, FRCPI, FRCPC, FAAP, MSc,
MB, BCh, BAO, CCFP, MSc,
BSc, MBBS, FRCOG FWACS, FMCOG,
,
MD, MPH, FRCPCFACEP, FAAEM,
,
,
,
, and
ABSTRACT
Medical professionalism has received increased worldwide attention, yet there is limited information on the applicability and utility of established Western professionalism frameworks in non-Western nations.Background
We developed a locally derived consensus definition of medical professionalism for the United Arab Emirates (UAE), which reflects the cultural and social constructs of the UAE and the Middle East.Objective
We used a purposive sample of 14 physicians working in the UAE as clinical and education leaders. This expert panel used qualitative methods, including the world café, nominal group technique, the Delphi method, and an interpretive thematic analysis to develop the consensus statement.Methods
The expert panel defined 9 attributes of medical professionalism. There was considerable overlap with accepted Western definitions, along with important differences in 3 aspects: (1) the primacy of social justice and societal rights; (2) the role of the physician's personal faith and spirituality in guiding professional practices; and (3) societal expectations for professional attributes of physicians that extend beyond the practice of medicine.Results
Professionalism is a social construct influenced by cultural and religious contexts. It is imperative that definitions of professionalism used in the education of physicians in training and in the assessment of practicing physicians be formulated locally and encompass specific competencies relevant to the local, social, and cultural context for medical practice. Our goal was to develop a secular consensus statement that encompasses culture and values relevant to professionalism for the UAE and the Arab region.Conclusions
MD,
MD, and
MD
ABSTRACT
Variability in case exposures has been identified for orthopaedic surgery residents. It is not known if this variability exists for peripheral nerve procedures.Background
The objective of this study was to assess ACGME case log data for graduating orthopaedic surgery, plastic surgery, general surgery, and neurological surgery residents for peripheral nerve surgical procedures and to evaluate intraspecialty and interspecialty variability in case volume.Objective
Surgical case logs from 2009 to 2014 for the 4 specialties were compared for peripheral nerve surgery experience. Peripheral nerve case volume between specialties was performed utilizing a paired t test, 95% confidence intervals were calculated, and linear regression was calculated to assess the trends.Methods
The average number of peripheral nerve procedures performed per graduating resident was 54.2 for orthopaedic surgery residents, 62.8 for independent plastic surgery residents, 84.6 for integrated plastic surgery residents, 22.4 for neurological surgery residents, and 0.4 for surgery residents. Intraspecialty comparison of the 10th and 90th percentile peripheral nerve case volume in 2012 revealed remarkable variability in training. There was a 3.9-fold difference within orthopaedic surgery, a 5.0-fold difference within independent plastic surgery residents, an 8.8-fold difference for residents from integrated plastic surgery programs, and a 7.0-fold difference within the neurological surgery group.Results
There is interspecialty and intraspecialty variability in peripheral nerve surgery volume for orthopaedic, plastic, neurological, and general surgery residents. Caseload is not the sole determinant of training quality as mentorship, didactics, case breadth, and complexity play an important role in training.Conclusions
MD,
MD,
MD, MS, and
MD
ABSTRACT
Published clinical problem solving exercises have emerged as a common tool to illustrate aspects of the clinical reasoning process. The specific clinical reasoning terms mentioned in such exercises is unknown.Background
We identified which clinical reasoning terms are mentioned in published clinical problem solving exercises and compared them to clinical reasoning terms given high priority by clinician educators.Objective
A convenience sample of clinician educators prioritized a list of clinical reasoning terms (whether to include, weight percentage of top 20 terms). The authors then electronically searched the terms in the text of published reports of 4 internal medicine journals between January 2010 and May 2013.Methods
The top 5 clinical reasoning terms ranked by educators were dual-process thinking (weight percentage = 24%), problem representation (12%), illness scripts (9%), hypothesis generation (7%), and problem categorization (7%). The top clinical reasoning terms mentioned in the text of 79 published reports were context specificity (n = 20, 25%), bias (n = 13, 17%), dual-process thinking (n = 11, 14%), illness scripts (n = 11, 14%), and problem representation (n = 10, 13%). Context specificity and bias were not ranked highly by educators.Results
Some core concepts of modern clinical reasoning theory ranked highly by educators are mentioned explicitly in published clinical problem solving exercises. However, some highly ranked terms were not used, and some terms used were not ranked by the clinician educators. Effort to teach clinical reasoning to trainees may benefit from a common nomenclature of clinical reasoning terms.Conclusions
MD,
MD,
MD, MPH, and
MD
ABSTRACT
Increasing demands on residents' time have made it critically important to maximize the effectiveness of didactic activities and motivate independent study.Background
Our aim was to correlate characteristics of noon conferences with internal medicine (IM) residents' ratings of perceived effectiveness and intent to pursue independent reading.Objective
We assessed characteristics of each noon conference by direct observation using predetermined metrics. We surveyed IM residents to assess their perception of the conference's effectiveness and their intention to pursue additional reading. A variety of modeling techniques were used to discern meaningful correlations of effectiveness and motivation.Methods
A total of 649 evaluations of 29 conferences were submitted by 153 of 185 (83%) residents in the program. Median effectiveness score was 6 (on a scale of 1 to 7). Clinicopathological conferences had 0.55-point higher effectiveness scores than traditional conferences (P = .011). In multivariable analyses focusing on traditional conferences, summary statement inclusion was significantly associated with 0.43-point higher effectiveness scores (P = .016), and having resident speakers was associated with 0.50-point higher effectiveness scores than unfamiliar faculty (P = .045). Conferences with higher effectiveness scores had significantly higher proportions of respondents indicating intention to read.Results
This is the first study to quantitatively assess correlations of high effectiveness ratings of noon conferences in a residency program. Intention to read improved with increasing effectiveness scores of conferences, suggesting residents are more inclined to pursue self-directed learning when topics are well presented. Considering these attributes in designs of didactic sessions may enhance their educational value.Conclusions
MD,
MD,
MD, MPH, and
MD, PhD
ABSTRACT
From 2010 to 2011, more than 70% of the clinical rotation competency evaluations for nephrology fellows in our program were rated “superior” using a 9-point Likert scale, suggesting some degree of “grade inflation.”Background
We sought to assess the efficacy of a 5-point centered rotation evaluation in reducing grade inflation.Objective
This retrospective cohort study of the impact of faculty education and a 5-point rotation evaluation on grade inflation was measured by superior item rating frequency and proportion of evaluations without superior ratings. The 5-point evaluation centered performance at the level expected for stage of training. Faculty education began in 2011–2012. The 5-point centered evaluation was introduced in 2012–2013 and used exclusively thereafter. A total of 68 evaluations, using the 9-point Likert scale, and 63 evaluations, using the 5-point centered scale, were performed after first-year fellow clinical rotations. Nine to 12 faculty members participated yearly.Methods
Faculty education alone was associated with fewer superior ratings from 2010–2011 to 2011–2012 (70.5% versus 48.3%, P = .001), declining further with 5-point centered scale introduction (2012–2013; 48.3% versus 35.6%; P = .012). Superior ratings declined with 5-point centered versus 9-point Likert scales (37.3% versus 59.3%, P = .001), specifically for medical knowledge, patient care, practice-based learning and improvement, and professionalism. On logistic regression, evaluations without superior scores were more likely for 5-point centered versus 9-point Likert scales (adjusted odds ratio [aOR] = 8.26; 95% CI 1.53–44.64; P = .014) and associated with faculty identifier (aOR= 1.18; 95% CI 1.03–1.35; P = .013), but not fellow identifier or training year quarter.Results
Conclusions
Grade inflation was reduced with faculty education and the 5-point centered evaluation scale.
MD,
BS,
MD,
BS,
MD, MPH,
MD,
MS,
MD, MPH, and
MD
ABSTRACT
Patient-physician communication is an integral part of high-quality patient care and an expectation of the Clinical Learning Environment Review program.Background
This quality improvement initiative evaluated the impact of an educational audit and feedback intervention on the frequency of use of 2 tools—business cards and white boards—to improve provider identification.Objective
This before-after study utilized patient surveys to determine the ability of those patients to name and recognize their physicians. The before phase began in July 2013. From September 2013 to May 2014, physicians received education on business card and white board use.Methods
We surveyed 378 patients. Our intervention improved white board utilization (72.2% postintervention versus 54.5% preintervention, P < .01) and slightly improved business card use (44.4% versus 33.7%, P = .07), but did not improve physician recognition. Only 20.3% (14 of 69) of patients could name their physician without use of the business card or white board. Data from all study phases showed the use of both tools improved patients' ability to name physicians (OR = 1.72 and OR = 2.12, respectively; OR = 3.68 for both; P < .05 for all), but had no effect on photograph recognition.Results
Our educational intervention improved white board use, but did not result in improved patient ability to recognize physicians. Pooled data of business cards and white boards, alone or combined, improved name recognition, suggesting better use of these tools may increase identification. Future initiatives should target other barriers to usage of these types of tools.Conclusions
MD,
MD,
MD,
MD,
NRP, NCEE, CCEMTP,
PhD, and
MD
ABSTRACT
Ultrasound-guided peripheral intravenous line (USGPIV) placement is becoming an important tool in current clinical practice. Many residency programs utilize unstructured clinical observation to evaluate residents in this and other procedural skills. Simulation-based assessment permits educators to make objective, standardized observations, and may be ideal for assessment of important procedural competencies.Background
We created a simulation-based assessment tool for the skill of USGPIV placement.Objective
A checklist tool was developed by a review of relevant literature and an expert review in accordance with established guidelines. Emergency medicine residents were recruited and surveyed on previous experience with USGPIV placement. Blinded, independent reviewers then utilized the checklist to assess residents as they made up to 3 attempts at USGPIV placement on a simulated pediatric arm.Methods
Of the 26 residents enrolled in our study, 26 participated (100%). A best attempt checklist score greater than or equal to 9 out of 10 correlated with expert performance (P < .001). Agreement between independent raters on first-attempt USGPIV placement score was determined by weighted kappa statistics to be 0.93 (95% CI 086–1.00).Results
The checklist assessment tool has acceptable interrater reliability and ability to distinguish performance at differing levels of competence. We propose this tool as a valuable component in the assessment of USGPIV access, and we hope this article serves as a roadmap for other educators to create similar assessment tools.Conclusions
MD and
PhD
ABSTRACT
There is limited information about how residents in surgical specialties view program strengths and opportunities for improvement (OFIs).Background
This study aggregated surgical residents' perspectives on program strengths and OFIs to determine whether there was agreement in perspectives among residents in 5 surgical specialties.Objective
Resident consensus lists of program strengths and areas for improvement were aggregated from site visits reports during 2012 and 2013 for obstetrics and gynecology, orthopaedic surgery, otolaryngology, plastic surgery, and surgery programs. Four trained individuals coded each strength or OFI in 1 of 3 categories: (1) factors common to all specialties; (2) program or institutional resources; and (3) factors unique to surgical specialties. Themes were classified as most frequent when listed by residents in more than 20% of the programs and less frequent when listed by residents in less than 20% of the programs.Methods
This study included a total of 359 programs, representing 27% to 49% of the Accreditation Council for Graduate Medical Education accredited programs in the 5 specialties. The most frequent strengths were progressive autonomy, collegiality, program leadership, and operative volume. Improving research and didactics, increasing faculty teaching and attendance at educational sessions, and increasing the number of nurse practitioners and physician assistants were common OFIs.Results
Factors identified as important by surgical residents related to their learning environment, their educational program, and program and institutional support. Across programs in the study, similar attributes were listed as both program strengths and OFIs.Conclusions
EDUCATIONAL INNOVATION
MD,
MD, PhD,
MSN, RN, RN-BC,
MPH,
MD, and
MD, MBA
ABSTRACT
In 2014, the Detroit Medical Center launched a new program to engage residents and fellows in a strategy to deliver optimal care within 1 year, focusing on quality at an earlier stage of their careers and preparing them for working posttraining.Background
Residents from clinically relevant residency and fellowships programs were selected to be Resident Quality Directors. The project involved development of an interactive electronic health record (EHR) checklist to visually depict real time gaps in 40 process measures, while focusing on 14 areas related to stroke and venous thromboembolism (VTE) prophylaxis. We also implemented an incentive approach, using a pay-for-performance (P4P) model.Methods
The project included 800 residents led by 14 resident quality directors. We were able to achieve 100% resident participation. Prior compliance with VTE quality measures 6 months was 88.5%, with performance increasing to 94.2% (P < .006) at 6 months and 100% at 12 months (P < .005) after the intervention. The VTE prophylaxis score improved from the 89.7% to 92.9% range at inception to 100% by 12 months. A similar steady improvement of stroke process measures was observed, with a 100% compliance within 12 months. The institution made 4 incentive payments to trainees (ranging from $300 to $4,000 per year). The remaining 26 process measures remained at goal with above 95% compliance.Results
This quality improvement initiative was associated with system-wide quality performance on VTE prevention and stroke care process measures, which was facilitated by a interactive EHR-based checklist and linkage to P4P incentive payments.Conclusions
MD,
MD,
MD,
MD, MPH,
MD, MS,
MD,
MD,
MD, and
MD, MCR
ABSTRACT
Emergency medicine (EM) residency programs can provide up to 20% of their planned didactic experiences asynchronously through the Individualized Interactive Instruction (III) initiative. Although blogs and podcasts provide potential material for III content, programs often struggle with identifying quality online content.Background
To develop and implement a process to curate quality EM content on blogs and podcasts for resident education and III credit.Objective
We developed the Approved Instructional Resources (AIR) Series on the Academic Life in Emergency Medicine website. Monthly, an editorial board identifies, peer reviews, and writes assessment questions for high-quality blog/podcast content. Eight educators rate each post using a standardized scoring instrument. Posts scoring ≥ 30 of 35 points are awarded an AIR badge and featured in the series. Enrolled residents can complete an assessment quiz for III credit. After 12 months of implementation, we report on program feasibility, enrollment rate, web analytics, and resident satisfaction scores.Methods
As of June 2015, 65 EM residency programs are enrolled in the AIR Series, and 2140 AIR quizzes have been completed. A total of 96% (2064 of 2140) of participants agree or strongly agree that the activity would improve their clinical competency, 98% (2098 of 2140) plan to use the AIR Series for III credit, and 97% (2077 of 2140) plan to use it again in the future.Results
The AIR Series is a national asynchronous EM curriculum featuring quality blogs and podcasts. It uses a national expert panel and novel scoring instrument to peer review web-based educational resources.Conclusions
MD, MHSc,
RN, MNEd,
MS, and
MD, MPH
ABSTRACT
The patient-centered medical home (PCMH) provides a setting to enhance resident training in systems-based practice. Few studies have addressed the impact of PCMHs on resident knowledge and confidence.Background
The goal of this study was to evaluate resident knowledge, confidence, behavior, and patient outcomes in a PCMH.Objective
Our curriculum emphasized patient panel report card interpretation, a telephone medicine curriculum, and interdisciplinary team-based care of chronic medical conditions. We measured resident satisfaction, knowledge, and confidence. Patient outcomes included hemoglobin A1c (HbA1c) and blood pressures. Prescores and postscores were compared using paired t tests for continuous measures and McNemar's test for binary measures.Methods
A total of 154 residents were eligible for the curriculum. All residents participated in the curriculum, though not all residents completed the evaluation. Completion rates for paired pre-post knowledge and confidence surveys were 38% and 37%, respectively. Nearly 80% (69 of 87) of residents indicated that the curriculum was above average or outstanding. Our evaluation revealed very small immediate improvements in knowledge and confidence. No significant improvement in patients' HbA1cs or blood pressures occurred after the curriculum.Results
Explicit training to work in a PCMH was feasible and resulted in high levels of resident satisfaction and immediate small improvements in knowledge and confidence.Conclusions
MD,
MD,
MD,
MD,
MS, PA,
RN, MSN,
MD, and
MD
ABSTRACT
Many institutions are seeking ways to enhance their surgical trainees' quality improvement (QI) skills.Background
To educate trainees about the importance of lifelong performance improvement, chief residents at New York Presbyterian Hospital–Weill Cornell Medicine are members of a multidisciplinary QI team tasked with improving surgical outcomes. We describe the process and the results of this effort.Objective
Our analysis used 2 data sources to assess complication rates: the National Surgical Quality Improvement Program (NSQIP) and ECOMP, our own internal complication database. Chief residents met with a multidisciplinary QI team to review complication rates from both data sources. Chief residents performed a case-by-case analysis of complications and a literature search in areas requiring improvement. Based on this information, chief residents met with the multidisciplinary team to select interventions for implementation, and delivered QI-focused grand rounds summarizing the QI process and new interventions.Methods
Since 2009, chief residents have presented 16 QI-focused grand rounds. Urinary tract infections (UTIs) and surgical site infections (SSIs) were the most frequently discussed. Interventions to improve UTIs and SSIs were introduced to the department of surgery through these reports in 2011 and 2012. During this time we saw improvement in outcomes as measured by NSQIP odds ratio.Results
Departmental grand rounds are a suitable forum to review NSQIP data and our internal, resident-collected data as a means to engage chief residents in QI improvement, and can serve as a model for other institutions to engage surgery residents in QI projects.Conclusions
BRIEF REPORT
MD,
BS,
MD,
MD,
MD,
MD, and
MD
ABSTRACT
With the widespread adoption of electronic health records (EHRs), there is a growing awareness of problems in EHR training for new users and subsequent problems with the quality of information present in EHR-generated progress notes. By standardizing the case, simulation allows for the discovery of EHR patterns of use as well as a modality to aid in EHR training.Background
To develop a high-fidelity EHR training exercise for internal medicine interns to understand patterns of EHR utilization in the generation of daily progress notes.Objective
Three months after beginning their internship, 32 interns participated in an EHR simulation designed to assess patterns in note writing and generation. Each intern was given a simulated chart and instructed to create a daily progress note. Notes were graded for use of copy-paste, macros, and accuracy of presented data.Methods
A total of 31 out of 32 interns (97%) completed the exercise. There was wide variance in use of macros to populate data, with multiple macro types used for the same data category. Three-quarters of notes contained either copy-paste elements or the elimination of active medical problems from the prior days' notes. This was associated with a significant number of quality issues, including failure to recognize a lack of deep vein thrombosis prophylaxis, medications stopped on admission, and issues in prior discharge summary.Results
Interns displayed wide variation in the process of creating progress notes. Additional studies are being conducted to determine the impact EHR-based simulation has on standardization of note content.Conclusions
MD, FACOG,
MD, MSHP,
MS,
BA, and
MD, FAAFP
ABSTRACT
The Teaching Health Center Graduate Medical Education (THCGME) program is an Affordable Care Act funding initiative designed to expand primary care residency training in community-based ambulatory settings. Statute suggests, but does not require, training in underserved settings. Residents who train in underserved settings are more likely to go on to practice in similar settings, and graduates more often than not practice near where they have trained.Background
The objective of this study was to describe and quantify federally designated clinical continuity training sites of the THCGME program.Objective
Geographic locations of the training sites were collected and characterized as Health Professional Shortage Area, Medically Underserved Area, Population, or rural areas, and were compared with the distribution of Centers for Medicare and Medicaid Services (CMS)–funded training positions.Methods
More than half of the teaching health centers (57%) are located in states that are in the 4 quintiles with the lowest CMS-funded resident-to-population ratio. Of the 109 training sites identified, more than 70% are located in federally designated high-need areas.Results
The THCGME program is a model that funds residency training in community-based ambulatory settings. Statute suggests, but does not explicitly require, that training take place in underserved settings. Because the majority of the 109 clinical training sites of the 60 funded programs in 2014–2015 are located in federally designated underserved locations, the THCGME program deserves further study as a model to improve primary care distribution into high-need communities.Conclusions
MD,
MD, MMM,
MD,
BS, and
MD
ABSTRACT
Some research has found increased incidence of medical errors in teaching hospitals at the beginning of the academic year and have termed this the “July Phenomenon.”Background
Our primary hypothesis was that the “July Phenomenon” for anesthesiology and surgical residents might manifest itself as operational inefficiency, measured by monthly total operating room (OR) minutes. Secondary measures were monthly elective overutilized minutes (OR workload minus OR allocated time, after 5:30 pm at our institution), 80th percentile number of ORs running at 7:00 pm, and mean last room end time.Objective
Data were collected retrospectively from a 525-bed academic tertiary care hospital from January 2010 to September 2014 and were deconstructed to assess for a seasonal component using local regression (Loess). Variable month length was addressed by transforming the monthly totals to average daily minutes and overutilized minutes. Linear regression quantified significance for all primary and secondary analyses.Methods
In the regressions, monthly average minutes showed no significant difference in July (P = .65) compared to the baseline month of April. There were no significant differences for any month for overutilized minutes or 80th percentile number ORs working at 7:00 pm. Only August was significant (P = .005) for mean last room end time.Results
Data from a single institution study did not show a “July Phenomenon” in the number of operating minutes, overutilized minutes, or the number of ORs working late in July.Conclusions
MD, MHS,
MD, MHS,
MD,
MD, and
MD, MPH
ABSTRACT
Cost awareness, to ensure physician stewardship of limited resources, is increasingly recognized as an important skill for physicians. The Accreditation Council for Graduate Medical Education has made cost awareness part of systems-based practice, a core competency of resident education. However, little is known about resident cost awareness.Background
We sought to assess senior resident self-perceived cost awareness and cost knowledge.Objective
In March 2014, we conducted a cross-sectional survey of all emergency medicine, internal medicine, obstetrics and gynecology, orthopaedic surgery pediatrics, and medicine-pediatrics residents in their final year at Yale–New Haven Hospital. The survey examined attitudes toward health care costs and residents' estimates of order prices. We considered resident price estimates to be accurate if they were between 50% and 200% of the Connecticut-specific Medicare price.Methods
We sent the survey to 84 residents and received 47 completed surveys (56% response rate). Although more than 95% (45 of 47) felt that containing costs is the responsibility of every clinician, and 49% (23 of 47) agreed that cost influenced their decision when ordering, only 4% (2 of 47) agreed that they knew the cost of tests being ordered. No residents accurately estimated the price of a complete blood count with differential, and only 2.1% (1 of 47) were accurate for a basic metabolic panel. The overall accuracy of all resident responses was 25%.Results
In our study, many trainees exit residency with self-identified deficiencies in knowledge about costs. The findings show the need for educational approaches to improve cost awareness among trainees.Conclusions
DO, MHPE, FACEP,
PhD, CCRP,
PhD,
MD, MPA,
MD, MHPE, and
PhD, MHPE
ABSTRACT
In the past few years, there has been rapid growth in the number of simulation fellowships for physicians in the United States and Canada, with the objective of producing faculty with expertise and leadership training in medical simulation. Relatively little is known about the collective content and structure of these new fellowship opportunities.Background
We sought to identify a common set of core curricular elements among existing simulation fellowships and to obtain demographic background information on participants and leadership.Objective
We designed a web-based survey and circulated it to simulation fellowship directors in the United States and Canada. The questions explored aspects of the fellowship curriculum. A grounded theory approach was used to qualitatively analyze fellowship goals and objectives.Methods
Of the 29 program directors surveyed, 23 responded (79%). The most commonly listed goals and objectives were to increase skills in simulation curriculum development, simulation operations and training environment setup, research, educational theory, administration, and debriefing. The majority of the responding fellowship directors (17 of 22, 77%) indicated that a set of consensus national guidelines would benefit their fellowship program.Results
Simulation fellowships are experiencing a period of rapid growth. Development of a common set of program guidelines is a widely shared objective among fellowship directors.Conclusions
MD, MPH,
PhD, and
MD
ABSTRACT
Burnout is common in internal medicine (IM) trainees and is associated with depression and suboptimal patient care. Facilitated group discussion reduces burnout among practicing clinicians.Background
We hypothesized that this type of intervention would reduce incident burnout among first-year IM residents.Objective
Between June 2013 and May 2014, participants from a convenience sample of 51 incoming IM residents were randomly assigned (in groups of 3) to the intervention or a control. Twice-monthly theme-based discussion sessions (18 total) led by expert facilitators were held for intervention groups. Surveys were administered at study onset and completion. Demographic and personal characteristics were collected. Burnout and burnout domains were the primary outcomes. Following convention, we defined burnout as a high emotional exhaustion or depersonalization score on the Maslach Burnout Inventory.Methods
All 51 eligible residents participated; 39 (76%) completed both surveys. Initial burnout prevalence (10 of 21 [48%] versus 7 of 17 [41%], P = .69), incidence of burnout at year end (9 of 11 [82%] versus 5 of 10 [50%], P = .18), and secondary outcomes were similar in intervention and control arms. More residents in the intervention group had high year-end depersonalization scores (18 of 21 [86%] versus 9 of 17 [53%], P = .04). Many intervention residents revealed that sessions did not truly free them from clinical or educational responsibilities.Results
A facilitated group discussion intervention did not decrease burnout in resident physicians. Future discussion-based interventions for reducing resident burnout should be voluntary and effectively free participants from clinical duties.Conclusions
RIP OUT
PhD
The Challenge
Competency- and milestone-based frameworks are designed to improve assessment of learners on broad domains, such as professionalism, communication, or medical knowledge. In practice, marking trainees on competency scales has been found to be difficult. 1 In addition, these assignments often do not directly translate to judgments to trust trainees to work effectively in an unsupervised fashion. By the end of training, programs must ensure that residents can provide high-quality, safe patient care without supervision.
What Is Known
The concept of entrustable professional activities (EPAs) has recently emerged. It connects competencies with practice 2,3 via
QUALITATIVE RIP OUT SERIES
Design: Selection of Data Collection Methods
Full access
PhD,
PhD,
PhD,
MD, and
PhD
Editor's Note: The online version of this article contains resources for further reading and a table of strengths and limitations of qualitative data collection methods.
The Challenge
Imagine that residents in your program have been less than complimentary about interprofessional rounds (IPRs). The program director asks you to determine what residents are learning about in collaboration with other health professionals during IPRs. If you construct a survey asking Likert-type questions such as “How much are you learning?” you likely will not gather the information you need to answer this question. You understand that qualitative data deal with words rather than
COMMENTARY
MD and
MD
In this issue of the Journal of Graduate Medical Education, the article entitled “Creating a framework for medical professionalism: an initial consensus statement from an Arab nation” 1 by Abdel-Razig and colleagues provides another enlightening contribution to our understanding of professionalism in global terms and adds to the literature on professionalism in the Muslim world. Our comments will be directed to 2 areas of interest: (1) the evolution of our understanding of professionalism, and (2) a brief analysis of the consensus definition developed for the United Arab Emirates as compared to definitions in contemporary use within Western
MD and
PhD
Over the past decades, professionalism education has become a key competency in the medical education continuum. The rising focus on professionalism has been paralleled by an increasing interest in competency-based medical education in graduate medical education globally. However, as professionalism reflects a contract between the medical profession and society, the definition of professionalism in globally accepted competency frameworks developed in Anglo-Saxon contexts may not reflect the societal expectations of other cultures.
In this issue of the Journal of Graduate Medical Education, Abdel-Razig and colleagues 1 reported a qualitative study to develop a locally derived consensus definition of
FRCOG, PhD and
MBChB, MRCP
As medical practice becomes increasingly globalized, students, physicians, and patients move among different countries and, in doing so, may encounter existing local beliefs regarding professionalism. 1 An article in this issue of the Journal of Graduate Medical Education by Abdel-Razig and colleagues 2 that presents an initial consensus definition of professionalism for the United Arab Emirates (UAE), therefore, is timely. Drawing on concerns regarding the predominance of Western views in defining professionalism 3 and the need to consider it within a social and cultural context, 4,5 there have been recent pleas for
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MD, MCR
Once the purview of the research community, clinical reasoning concepts are increasingly used to inform how teachers teach and learners learn. 1 This welcome development has been signaled by the widespread use of clinical reasoning terminology in teaching sessions, conferences, and general medical publications. Technical terminology arises in any community where foundational units of knowledge (eg, terabyte or osmosis) are necessary for members to communicate with precision and brevity. 2 For interdisciplinary fields like clinical reasoning, terminology evolves iteratively as multiple groups think about a problem independently, develop knowledge and language simultaneously, and then
MD
In this issue of the Journal of Graduate Medical Education, an article entitled “Successful resident engagement in quality improvement: the Detroit Medical Center story” by Hussain et al 1 presents an interesting foray into the world of pay-for-performance. The authors focused on a resident-driven pay-for-performance initiative that targeted venous thromboembolism (VTE) prevention and stroke care in a large urban academic medical center. In addition to being predominantly resident-driven, the intervention is unique, in that it successfully obtained full institutional support of an educational endeavor. It thus serves as an excellent example of what can be achieved when
TO THE EDITOR: COMMENTS
MD
A description of the changing scenario of obstetrics and gynecology residency training by Gupta et al in the September 2015 issue of the Journal of Graduate Medical Education confirms what many of us are experiencing in our residency programs. 1 As a junior faculty member of my training program, I witnessed residents suffer less exposure to procedures and high-risk emergent clinical scenarios. The problems we face with decreased exposure to surgical procedures is not unique to my field and permeates throughout all medical specialties. The prevailing question is: What can be done?
As Gupta et al 1
MD
One of my most important tasks in my job as an associate program director is assisting in the selection of new residency candidates. The resident interview is a cornerstone in this process. However, having participated in resident interviews for many years (as interviewee and interviewer), I have had concerns about its true utility. This is especially important in surgery, where there is sizable resident attrition (22% to 27%).
Increasing stipulations for continued accreditation, having public report cards of physicians, and the increasing scrutiny of hospitals make it even more imperative that residency programs select trainees who display behaviors
TO THE EDITOR: OBSERVATIONS
MBBS and
MBBS
Inpatient electroencephalography (EEG) studies are becoming more widely used, 1 with seizures, coma, hypothermia, and altered mental status being some common indications. It is likely that the demand for skilled EEG interpreters will increase in the future; however, studies have found that EEG reads are often erroneous, with resulting overmedication and unnecessary hospitalization. 2
In many academic centers, neurology residents are the first ones asked to interpret EEGs, especially at night. Thus, competence in EEG interpretation is an essential element of the Accreditation Council for Graduate Medical Education's milestones to be met by neurology residents. 3 Many residency
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MD,
MD,
MD,
MD,
MBBS,
MD,
MD,
MD,
MD,
MD,
MD,
PAC, and
MB, BCh
Educating the next generation of physicians is becoming increasingly complex. Advancements in medical knowledge, coupled with an ever-changing health care delivery system, have magnified the challenges facing medical educators. 1 Unfortunately, medical education continues to be grounded more in “tradition, ritual, culture, and history, [rather] than [in] any easily expressed theoretical or conceptual framework.” 2 Ideally, medical curriculum should be able to adapt to these rapid changes in the learning environment while remaining grounded in the fundamental tenants of learning theory.
Engaging a medical trainee as an adult learner requires an appreciation of andragogy, defined as “the art
MD, FACP
Accreditation by the Accreditation Council for Graduate Medical Education–International (ACGME-I) has been an exciting time for academic medical centers in Abu Dhabi. Since accreditation, the entire educational framework and educational outcomes have significantly improved. Residents have greatly benefited from better program organization and structure. A new era of contemporary terminologies has begun, for example, competencies, feedback, outcomes, milestones, and entrustable professional activities. Residents and faculty are completing evaluation forms, and the nursing staff and patients have begun to evaluate residents.
It is also important to keep in mind that there are a few residents who show dissatisfaction with the new
MD,
MD,
MPH,
MD, and
MD
Telemedicine is increasingly being utilized in health care settings as teledermatology programs increase patient access to quality care. 1,2 As teledermatology expands, training and mentorship programs have been slow to adapt. Dermatologists cite no prior training and lack of knowledge in teledermatology as barriers to adoption. 3 To better understand the current involvement and potential interest in telemedicine in dermatology training programs, we performed a descriptive survey among residency program directors within the United States.
In September 2014, a survey assessing the use of teledermatology among allopathic dermatology residencies was circulated to residency program directors during
MRCP (UK)
I congratulate Wright and colleagues for their timely article from the February issue of the Journal of Graduate Medical Education. 1 Research design is fundamental in helping to draw the right conclusions in medical education. The community has moved from little innovation in medical education to new approaches in the domains of teaching, learning, and assessment. Examples include team-based learning, “flipped classrooms,” massive open online courses, entrustment, and situational judgement testing, to name a few.
Despite these innovative approaches, it is consensus rather than evidence that often dictates approaches in medical education, with expert bias possibly playing
ON TEACHING
MD
The first thing is, thank you. Thank you for taking AP Biology. Thank you for memorizing medical school. Thank you all for choosing to spend some of the best years of your lives in this hospital. You didn't have to. There are so many other ways you could have chosen to spend your time and talents. That you are here instead says so much about you.
I spent a recent morning watching a sonogram with my wife and our 2-year-old daughter. The baby has a name, and she's kicking like crazy. And my 2-year-old—she's really into the idea of being
ACGME NEWS & VIEWS
MD,
PhD,
MPP,
PhD, MBA, and
PhD
ABSTRACT
Resident and faculty views of program strengths and opportunities for improvement (OFIs) offer insight into how stakeholders assess key elements of the learning environment.Background
This study sought (1) to assess the degree to which residents and faculty in 359 programs in 5 surgical specialties (obstetrics and gynecology, orthopaedic surgery, otolaryngology, plastic surgery, and surgery) were aligned or divergent in their respective views of program strengths and OFIs; and (2) to evaluate whether responses to selected questions on the Accreditation Council for Graduate Medical Education (ACGME) Resident Survey correlated with strengths or OFIs identified by the residents during the site visit.Objective
Faculty and resident lists of program strengths and OFIs in site visit reports for 2012 and 2013 were aggregated, analyzed, and compared to responses on the Resident Survey.Methods
While there was considerable alignment in resident and faculty perceptions of program strengths and OFIs, some attributes were more important to one or the other group. Collegiality was valued highly by both stakeholder groups. Responses to 2 questions on the ACGME Resident Survey were associated with resident-identified OFIs in site visit reports pertaining to aspects of the didactic program and responsiveness to resident suggestions for improvement.Results
The findings offer program leadership additional insight into how 2 key stakeholder groups view elements of the learning environment as program strengths or OFIs and may serve as useful focal areas for ongoing improvement activities.Conclusions
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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