Important Factors in Conducting Remediation Sessions
In this study remediation sessions with small groups of medical student were audio recorded and analyzed to understand what constitutes effective remediation, as well as effective facilitators. Experienced teachers often modeled effective inquiry, posed “disruptive questions” and flagged student “uncertainty, inconsistency and disagreement” with timing and context identified as key. However, inexperienced teachers employed less use of “metacognitive voice”, allowed “premature closure of discussion” and often failed to appreciate the importance of language. A correlation was observed between long-term positive student outcomes and more experienced educators facilitating the sessions. This study also illustrates effective methods of remediation and facilitator-student interactions.- Lee Ann Schein, Ph.D.
Winston KA, Van Der Vleuten CPM, Scherpbier AJJA. Remediation of at-risk medical students: theory in action. BMC Medical Education 2013, 13:132 (27 September 2013)
Basic Science Knowledge Retention Depends on Perceived Relevance to Clinical Medicine
This study looked at a cohort of students in their undergraduate years of medical education who were increasingly exposed to clinical, cased-based learning exercises. Participants in the study were distributed over the M2 to M5 years of their education, and were given assessments testing basic science knowledge. Participants were also instructed to rate each question based on their perception of its relevance to clinical medicine. The outcomes showed that, especially in the later years of education, “perceived clinical relevance was significantly and positively correlated with item performance” and retention of the material.- Lee Ann Schein, Ph.D.
Malau-Aduli BS, Lee AYS, Cooling N, Catchpole MJ, Jose M, Turner R. Retention of knowledge and perceived relevance of basic sciences in an integrated case-based learning (CBL) curriculum. BMC Medical Education 2013, 13:139 (8 October 2013)
How To Do More With Fewer Primary Care Doctors
Both of these articles discuss ways to use outpatient physicians more efficiently through the utilization of nurses, nurse practitioners (NPs), physician assistants (PAs), and non-professional staff such as medical assistants and patient navigators. NPs and PAs may function as full primary care providers, while RNs may take on major responsibility for care coordination for patients with complex conditions. Other providers may take on jobs such as chart review to identify care gaps or overdue services, motivational interviewing, health coaching, monitoring of medication adherence, or home visits for recently discharged patients. Physicians then would be mainly concerned with the most complex patients, requiring more advanced decision-making.-- Laura Willett, MD
Garson A Jr. New Systems of Care Can Leverage the Health Care Workforce: How Many Doctors Do We Really Need? Acad Med 88(12): Dec 2013.
Link for non-RU users
Ladden MD, Bodenheimer T, Fishman NW, Flinter M, Hsu C, Parchman M, Wagner EH. The Emerging Primary Care Workforce: Preliminary Observations From the Primary Care Team: Learning From Effective Ambulatory Practices Project. Acad Med. 88(12): Dec 2013 .
Link for non-RU users
Who Are The Newly-Minted MDs?
The US is in the middle of a rapid expansion of its yearly output of MDs. This has resulted from both an expansion of the class size of many existing medical schools, and the addition of 16 new schools (with 4 more in the pipeline). What are the projected results on this expansion on the primary care physician workforce? This descriptive study compares cohorts from 1999-2001 and 2009-2011. Those schools which expanded a lot had a history of producing slightly more primary care physicians than those schools which did not expand (30.5% vs. 24.1% of graduates). New medical schools admitted more students from under-represented minorities, which has in the past been a predictor of primary-care career choice. Both of these trends might suggest an increase in primary care physicians in the future. However, the percentage of matriculants stating that they wanted to enter a non-primary care specialty increased from 34.4% in the early cohort to 50.3% in the later cohort.-- Laura Willett, MD
Shipman SA, Jones KC, Erikson CE, Sandberg SF.
Exploring the Workforce Implications of a Decade of Medical School Expansion:
Variations in Medical School Growth and Changes in Student Characteristics and
Career Plans. Acad Med. 88(12): 2013 Dec .
Link for non-RU users
Watch for more complex communication skills requirements on Step 2 Clinical Skills examination
The National Board of Medical Examiners decided to expand their emphasis on physician-patient communication skills, in line with research showing that these skills are linked to better patient outcomes. Starting in June, 2012, standardized patient training has included items related to: “paying attention to the patient”, “exploring the patient’s reaction to illness”, “providing understandable information about the working diagnosis”, “finalizing plans for next steps”, and “facilitating the patient’s expression of feelings”. The Board plans future work on “enabling disease and treatment-related behaviors”, “advanced decision making”, and “advanced responding to emotions”. Look for angry and manipulative standardized patients on your next clinical skills exam! -- Laura Willett, MD
Hoppe RB, King AM, Mazor KM, Furman GE, Wick-Garcia P, Corcoran-Ponisciak H,
Katsufrakis PJ. Enhancement of the Assessment of Physician-Patient Communication
Skills in the United States Medical Licensing Examination. Acad Med. 2013 Sep 25.
Link for non-RU users
The clinical years remain an ethical quagmire
This is depressing commentary on more than 500 written reports regarding ethically challenging situations brought up by third-year students during a class on ethics, truth-telling and communication. Major themes included lying, poor team dynamics, medical errors, powerlessness, confidentiality, poor communication, shaming, missed teaching opportunities, uncertainty of student responsibility, and other professionalism lapses. The authors explored the reasons students did not want to report these lapses: fear of reprisal, fear of a lower grade, apathy, desire to avoid confrontation, disillusionment with medical practice in general, perception that reporting would not lead to changes, and perception that reporting would be perceived as “whining”. The authors suggest some (non-evidence-based) actions to change the culture at academic medical centers. -- Laura Willett, MD
Myers MF, Herb A. Ethical Dilemmas in Clerkship Rotations. Acad Med. 88(11), November 2013.
Link for non-RU users
Medical Educators’ Opinion on Teaching.
This research article looks at the characteristics of an effective teacher using feedback from medical educators themselves and not the usual yardstick of students’ evaluations. The three top qualities identified, in descending order, are knowledge of the subject, enthusiasm, and good communication skills. An interesting outcome of this study was that the more experienced educators deemed “classroom behavior and instruction delivery” higher than did less experienced teachers. — Lee Ann Schein, Ph.D.
Singh S, Pai DR, Sinha NK, Kaur A, Soe HH, Barua A. Qualities of an effective
teacher: what do medical teachers think? BMC Med Educ. 2013 Sep 17;13(1):128.
[Epub ahead of print] PubMed PMID: 24044727.
To Take the Formative Assessment or Not?
Feedback Results in Effective Learning
This pilot study investigated the use of detailed feedback as a learning tool for students. Two groups of students took online tests after participating in patient – case exercises. One group received only the result s of the test and the correct answers. The other group additionally received detailed feedback explaining why the correct answer was right and why the incorrect answers were wrong. The performance on the course final exam of each group of students was compared. The group of students who, throughout the course, received detailed feedback scored significantly higher on the final exam than the group who only received the correct answers. This finding suggests that detailed feedback can be beneficial to increased learning. – Lee Ann Schein, Ph.D.
Wojcikowski K, Kirk L. Immediate detailed feedback to test-enhanced learning:
An effective online educational tool. Med Teach. 2013 Sep 4. [Epub ahead of
print] PubMed PMID: 24003913.
Interns spend even less time with their patients
This fascinating time-motion study of interns is compared with results from a similar study in 1989. Despite the fact that current interns spent much less time in the hospital, the percentage of time spent directly with patients decreased from about 20% to about 12%. No one will be surprised that 40% of their time was spent in front of a computer screen.-- Laura Willett, MD
Block L, Habicht R, Wu AW, Desai SV, Wang K, Novello Silva K, Niessen T, Oliver N, Feldman L. In the Wake of the 2003 and 2011 Duty Hours Regulations, How Do Internal Medicine Interns Spend Their Time? J Gen Intern Med. 2013 Aug; 28(8): 1042–1047.
“Block” ambulatory schedules for residents have advantages and disadvantages
Two articles discuss new ways of scheduling continuity clinic for internal medicine residents. Both systems keep residents completely out of their continuity clinic during their inpatient rotations, and increase the total number of hours spent in clinic. Comparisons were made to the previous year’s traditional weekly clinic model. In both new systems, there were modest increases in resident patient panel sizes. In the “4+1” model (4 weeks inpatient alternating with 1 week outpatient), residents were overall more satisfied with clinic and felt less conflicted between inpatient and outpatient responsibilities. However, they were less likely to think that outpatient medicine was an enjoyable field. Problems with the new systems included diminished continuity of care, difficulties with evaluations of residents, and difficulty following up on teaching points. – Laura Willett, MD
Wieland ML, Halvorsen AJ, Chaudhry R, Reed DA, McDonald FS, Thomas KG. An Evaluation of Internal Medicine Residency Continuity Clinic Redesign to a 50/50 Outpatient–Inpatient Model. J Gen Intern Med. 2013 Aug; 28(8): 1014–1019.
Saima I. Chaudhry, Sandy Balwan, Karen A. Friedman, Suzanne Sunday, Basit Chaudhry, Deborah DiMisa, Alice Fornari Moving Forward in GME Reform: A 4+1 Model of Resident Ambulatory Training. J Gen Intern Med. 2013 Aug; 28(8): 1100–1104.
Incentives may be needed to increase the number of primary care physicians
Norman Edelman, our former dean, heads a survey study of institutions with ACGME-accredited residency programs. Hospitals are looking to start or expand residency programs mostly in NON-primary care fields, including emergency medicine, plastic surgery, radiology, general surgery and neurology. There were also projected increases in program slots in pediatrics and internal medicine, but most internal medicine residents pursue subspecialty care training. – Laura Willett, MD
Edelman NH, Goldsteen RL, Goldsteen K, Yagudayev S, Lima F, Chiu L. Institutions With Accredited Residencies in New York State With an Interest in Developing New Residencies or Expanding Existing Ones. Acad Med. 2013 Sep;88(9):1287-1292.
Evidence That There Are A Lot Of Barriers To Doctors Using Evidence
In this synthesis of qualitative studies evaluating physicians' attitudes towards and use of evidence-based medicine (EBM), many barriers and a few facilitators to utilitzation of EBM were identified. The main facilitators were: having a positive attitude toward EBM; having supervisors, clinical role models, or respected colleagues who valued EBM; access to "summarized, clinically oriented, and user-friendly information", and being in a culture that fostered "respectful and reciprocal communication" about evidence. Barriers were much more numerous: disagreeing with the definition of EBM as "the translation of best evidence and clinical expertise into individualized patient care"; suspicion of potential abuse of EBM by others; fear of losing professional autonomy; satisfaction with familiar routines; older age; having a "very strong, inflexible, or insecure personality"; being in a culture dominated by an "expert-based pecking order and nonreciprocal communication"; lack of EBM knowledge and skills; view of EBM as too time consuming; appreciation of the "rapid growth and replacement of evidence"; unawareness of own knowledge gaps; preference for getting information from colleagues and pharmaceutical representatives; attitude that patients are "unable to understand research evidence or to tolerate its inherent uncertainty"; wishing to avoid conflicts with patients; systemic and organizational barriers; and lack of EBM resources, time, mentors, training, and financial incentives. This reviewer found the synthesis depressing, as without the incorporation of best evidence into our care, doctors will "make the same mistakes with increasing confidence over an impressive number of years." – Laura Willett, MD
Swennen MH, van der Heijden GJ, Boeije HR, van Rheenen N, Verheul FJ, van der Graaf Y, Kalkman CJ., Doctors' Perceptions and Use of Evidence-Based Medicine: A Systematic Review and Thematic Synthesis of Qualitative Studies. Acad Med. 2013 Sep; 88(9):1384-1396.
Verbal And Electronic Signouts May Improve Patient Handoffs
Authors report the results of a before/after study where a face-to-face verbal sign out was implemented along with a change in the electronic sign out template that included cues for appropriate content. The authors found improved resident satisfaction in the handoff process, no change in patient safety events, and improved quality of written signout content based on blinded investigator review. Limitations of this study include its before/after design as it is difficult to attribute the changes in outcomes to the study interventions, and with 2 interventions being implemented, one cannot determine which component was associated with the changes observed. The blinded investigator review of written sign out quality showed high inter-rater reliability (kappa = 0.95) and statistically significant improvements and perfect or near perfect rates of adherence post intervention for many of the areas assessed (documenting past medical history 100%, active problem list and current clinical status both at 96%), but this is largely explained by the change in the template which included those content areas, and therefore the investigator review could not have been truly blinded as the signouts clearly looked different. Nevertheless, the study highlights useful insights into consideration of systems-based issues, such as changes in electronic sign out templates, to capture vital information needed for better communication between residents.— Sarang Kim, MD
Graham, KL, Marcantonio, ER, Huang, GC, Yang, J, Davis RB, Smith, CC. Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. J Gen Intern Med. 2013 Aug;28(8): 986-993.
10-12 Evaluations Are Needed To Reliably Assess Handoff Skills
Authors report the feasibility and psychometric properties of a new instrument to assess handoff skills using an iPAD app. The assessment tool was developed based on review of published instruments and recommended best practices. The results of this pilot study show that limited network connectivity and inability to locate the nighttime intern by the research assistant led to only 59% of possible evaluations being completed. The authors find that one would need to obtain 10 to 12 evaluations to allow for reliable assessment of handoff skills. More practical ways to collect evaluations would be useful, and data regarding validity of peer ratings for handoffs are needed before this tool is adopted.-- Sarang Kim, MD.
Dine, CJ, Wingate N, Rosen, IM, Myers, JS, Lapin, J, Kogan, JR., Shea, JA. Using peers to assess handoffs: a pilot study. J Gen Intern Med. 2013 Aug;28(8): 1008-1013.
Medical Students Are Participating In Handoffs, Too.
Authors report results of a survey regarding medical students' experience with handoffs during their third year clerkships (79% response rate). Overall, 58% of students reported participating in handoffs, such as updating a written signout. Of note, 98% reported witnessing an error in written sign out, and 64% reported an error due to verbal handoffs. While most studies on handoffs have focused on residents, this paper raises important questions about whether, when, and how medical students should be trained and assessed in handoff skills. – Sarang Kim, MD.
Arora, VM, Eastment, MC, Bethea, ED, Farnan, JM, Friedman, ES. Participation and Experience of third-year medical students in handoffs: Time to sign out? J Gen Intern Med. 2013 Aug;28(8): 994-998.
Students Build Exam Question Pool
Fourth year medical students were asked to construct a multiple choice question bank for use on their curricular exams. Educators hypothesized that this would promote student communication and study. One and a half out of four exams were composed of questions that the lecturers picked from the students’ pool. Lower-performing students performed better on the students’ constructed questions, however group study time was not increased.—Lee Ann Schein, Ph.D.
Jobs A, Twesten C, Göbel A, Bonnemeier H, Lehnert H, Weitz G. Question-writing as a learning tool for students -- outcomes from curricular exams.
BMC Medical Education 2013, 13:89 (21 June 2013)
Students were given their summative exam results as blueprinted feedback, which mapped assessment items to learning objectives. This type of formative feedback gave the students a more focused picture of their strengths and weaknesses in the material as opposed to just a numerical score of their performance. This is also advantageous to the instructor since it enumerates which objectives were assessed and how well the students grasped the information. Although 88-96% of the students viewed their feedback and rated this type of feedback as a 4.19 on a 5 point scale, only 39% used the feedback to direct further learning and correction. .—Lee Ann Schein, Ph.D.
Burr SA, Brodier E, Wilkinson S. Delivery and use of individualised feedback in large class medical teaching.
BMC Medical Education 2013, 13:63 (3 May 2013)
Laboratory Exercises Based on TBL Model
Integrated laboratory classes (ILCs) have been shown to promote higher short and long term information retention in medical students than do conventional laboratory exercises. ILCs are multi-discipline, small group cases designed to fit into an integrated medical school curriculum, using a Team Based Learning (TBL) model. Each laboratory exercise is designed around parallel body systems and integrates problem based learning into the laboratory methodology. The focus is on students working together with minimal instructor intervention to solve a case using hands on techniques such as reading lab results and doing assays. ILCs encourage self-directed, active learning.—Lee Ann Schein, Ph.D.
Azer SA, Hasanato R, Al-Nassasr S, Somily A, AlSaadi MM. Introducing integrated laboratory classes in a PBL curriculum: impact on student's learning and satisfaction.
BMC Medical Education 2013, 13:71 (24 May 2013)
Probably illegal questions during residency interviews are very prevalent!
In this disturbing study, nearly two-thirds of fourth-year medical students replying to a survey reported that they were asked potentially illegal questions during their residency interviews. The most common categories of inappropriate questions were those regarding marital status, presence of children, and childbearing plans. Other common questions related to ethnicity, religion, and age. Being female and applying to a procedural specialty were associated with a higher rate of potentially illegal questions. These questions led to candidates being less likely to rank the program involved. – Laura Willett, MD
Hern HG Jr., Alter HJ, Wills CP, Snoey ER, and Simon BC. How Prevalent Are Potentially Illegal Questions During Residency Interviews? Acad Med. 2013 Jun 26.
Can we teach empathy?
The answer from this systematic review is, Maybe. Many of the reviewed studies show a small, short-term effect on measures of empathy in medical students. The literature is plagued by a lack of a clear “gold standard” for measurement of empathy and severe methodological flaws in the bulk of the studies.– Laura Willett, MD
Batt-Rawden SA, Chisolm MS, Anton B, and Flickinger TE. Teaching Empathy to Medical Students: An Updated, Systematic Review. Acad Med. 2013 Jun 26.
Pharmacotherapy in the Fourth Year?
One of the central roles of clinical pharmacists is to recognize and prevent prescribing errors, making them perfect candidates for improving pharmacotherapy knowledge in medical students. In this randomized controlled trial by RWJMS faculty, fourth year students participated in four 1-hour didactic, case-based sessions with a dynamic and highly rated clinical pharmacist which did not result in improvements in an exam administered at the end of the rotation. Although didactic sessions are commonly used to address knowledge deficiencies, this study highlights how that approach may not always be effective. Interestingly, the results are at odds with the finding that most of the participants were satisfied with the sessions and felt that pharmacotherapy should be taught formally in the clinical years. The Medical Education article on program evaluation suggests that studies should ask why or how the intervention worked or did not work. In this case, the authors propose two important possibilities, inadequate length or intensity of the intervention and a test that is too challenging to distinguish small differences, given overall poor test scores. There is still a potential that a similar intervention under different circumstances might bring to light positive results. –Shirin Hasting, MD.
Kim S, Willett L, Hughes F, Sunderram J, Walker JA, Shea JA. Pharmacist-led workshops to enhance pharmacotherapy knowledge for medical students. Teach Learn Med. 2013;25(2):118-21.
Crowdsourcing to Success?
New software developed at John Hopkins University School of Medicine uses medical student crowd sourcing to create a bank of 16,000 student generated flashcard questions. Year-to-year exam scores rose slightly, yet several limitations to this study and method are noted. When comparing exam scores, there was no correlation of score with student, so it is not known if the increase in performance was correlated with students who used the system. In addition, without faculty oversight of the content, the possibility of misinformation being disseminated rises. – Lee Ann Schein, Ph. D.
Bow, HC, Dattilo, JR, Jonas, AM, Lehmann, CU. A Crowdsourcing Model for Creating Pre-Clinical Medical Education Study Tools .
Acad Med. 2013 Jun;88(6):766-70.
Teaching Medical Error Disclosure to Physicians-in-Training: A Scoping Review.
Pertinent to the safety culture, this review examines how we should teach medical students and residents to disclose errors to patients and families. Most of the studied interventions were brief (1-3 hours) sessions, either stand-alone or part of a larger curriculum in patient safety or communication skills. Role play was the most commonly used teaching technique, often in combination with other modalities such as lecture or video. Most studies showed marked improvements in attitudes or test scores; five showed improvements in a structured assessment of disclosure skills, but none tracked retention of these skills over time. – Laura Willett, MD
Stroud L, Wong BM, Hollenberg E, Levinson W.
Teaching Medical Error Disclosure to Physicians-in-Training: A Scoping Review .
Acad Med. 2013 Jun;88(6):884-892.
The (lack of) safety culture
Fourth-year medical students, reflecting on their medicine and surgery clerkships, report a depressingly low impression of the safety culture they observed. More than half of students reported a negative perception of the overall safety culture, physician-to-physician handoffs, punitive responses to error, and communication openness. Students identified many unmet educational needs around patients safety, particularly practicing safe handoffs and disclosing medical errors to patients. – Laura Willett, MD
Bowman, C, Neeman, N, Sehgal, NL. Enculturation of Unsafe Attitudes and Behaviors: Student Perceptions of Safety Culture.
Acad Med. 2013 Jun;88(6):802-10.
The good, the bad, and the ugly as the EMR (electronic medical record) collides with education.
This timely perspective lists many of the beneficial and harmful effects of the EMR on medical education. EMRs may help with data retrieval, track trainees’ clinical activity, and educate via decision-support software. They may also not allow for documentation by students, undercut the development of critical thinking skills, erode the usefulness of physician notes as a communication tool, and lead to a shift from time with patients to time with “iPatients”. Not mentioned by the authors is the ease of over-documentation with automated history and exam entry. Most EMR systems were not designed with the needs of students or residents in mind; medical educators need to attempt to make our voices heard in this marketplace. – Laura Willett, MD
Michael JT, Pageler, NM, Kahana, M, Pantaleoni, JL, Longhurst, CA. Medical Education in the Electronic Medical Record Era: Benefits, Challenges, and Future Directions.
Acad Med. 2013 Jun;88(6):748-752. Acad Med. 2013 Jun;88(6):748-752.
Yes! Your doctor uses Google too.
A survey of internal medicine residents found that UptoDate and Google were the most commonly used resources for answering clinical questions at the point of care. Although the response rate was only 56%, the findings are consistent with prior studies. Speed, trust, and portability were the biggest factors for driving resource selection. Which resource provides both speed and accuracy? This study does not address that question, but available data suggests there is no convincing reason to discourage use of Google. What's clear is that most of us need better training in information literacy. – Sarang Kim, MD
Duran-Nelson A, Gladding S, Beattie J, Nixon LJ. Should We Google It? Resource Use by Internal Medicine Residents for Point-of-Care Clinical Decision Making.
Acad Med. 2013 Jun;88(6):788-794.
All you ever wanted to know about admissions!
This issue of Academic Medicine has a large number of articles, including one by our own Dr. Terregino, dealing with aspects of medical school admission. (four articles)
The venerable MCAT (Schwartzstein et al) will be undergoing a major transformation in 2015. There will be a new psychology/sociology section which includes some probability. The science section will have less physics and organic chemistry, and more biochemistry. The critical analysis section will include more ethics and philosophy questions. The writing section has been eliminated, as it provided very little predictive value.— Laura Willett
Schwartzstein RM, Rosenfeld GC, Hilborn R, Oyewole SH, Mitchell K. Redesigning the MCAT Exam: Balancing Multiple Perspectives. Acad Med. 2013 May;88(5):560-567.
The current MCAT (Dunleavy et al) appears to have quite good ability to predict the likelihood of a medical student having “unimpeded progress” through medical school. Unimpeded progress was defined as graduating within 5 years of entry and passing Step 1 and both Step 2 exams on the first attempt. MCAT scores added additional predictive value to undergraduate GPA, particularly for lower GPAs.—Laura Willett
Dunleavy DM, Kroopnick MH, Dowd KW, Searcy CA, Zhao X. The Predictive Validity of the MCAT Exam in Relation to Academic Performance Through Medical School: A National Cohort Study of 2001-2004 Matriculants. Acad Med. 2013 May;88(5):666-671.
Admissions deans were surveyed (Monroe et al ) in 1986 and in 2008 regarding their admissions process and the importance of various types of applicant data. The applicant pool has changed over this time, reflecting an increase in Asian applicants from 8% to 22% of the total, with a corresponding drop in Caucasian applicants. African-American and Hispanic applicant percentages have stayed at stable low levels over this period. The majority of schools have variations on a two-step process, with MCAT scores and GPA having the major influence on the decision to grant an interview, and interview outcomes and letters of recommendation having the major influence on the decision regarding which interviewees to admit. Current admissions deans said they place less importance on the quality of the undergraduate institution and the difficulty of undergraduate coursework, and more importance on the personal statement and community service, as compared to deans in 1986.—Laura Willett
Monroe, A, Quinn E, Samuelson W, Dunleavy DM, Dowd KW. An Overview of the Medical School Admission Process and Use of Applicant Data in Decision Making: What Has Changed Since the 1980s? Acad Med. 2013 May;88(5):672-681.
Admissions deans (Koenig et al) are interested in our ability to quantify personal competencies important in medicine and many other fields. These include ethical responsibility, reliability and dependability, service orientation, social skills, capacity for improvement, resilience and adaptability, cultural competence, oral communication, and teamwork. Several different measurement tools are described which could be used economically to screen large numbers of applicants. Potential problems include “coaching or faking” responses.—Laura Willett
Koenig TW, Parrish SK, Terregino CA, Williams JP, Dunleavy DM, Volsch JM. Core Personal Competencies Important to Entering Students' Success in Medical School: What Are They and How Could They Be Assessed Early in the Admission Process? Acad Med. 2013 May;88(5):603-613.
Experimenting with resident conferences.
Three internal medicine programs describe their independent decisions to change from daily one-hour conferences to longer weekly conferences. Each program dealt with similar issues: a decision to change from passive to active learning; a need for faculty development in active-learning techniques; a need to provide clinical coverage during the longer conference; and an emphasis on resident preparation and accountability for conference topics, including testing.—Laura Willett
Batalden, MK et al. Beyond a Curricular Design of Convenience: Replacing the Noon Conference With an Academic Half Day in Three Internal Medicine Residency Programs. Acad Med. 2013 May;88(5):644-651.
Outcomes are not enough: a call for a more comprehensive (and useful) program evaluation.
This article provides a brief overview of the history of program evaluation and the major paradigms that have driven program evaluation research while providing a good argument for why outcomes-based models are not good enough. Instead, to address the complexities and dynamic context in which educational interventions occur, the authors argue that program evaluation should ask did it work, how did it work, why did it work, and what (else) happened.—Sarang Kim
Haji F, et al. Rethinking programme evaluation in health professions education: beyond "did it work?" Med Educ. 2013 Apr;47(4):342-51.
Top 10 methodologic and statistical flaws in medical studies.
Warren Buffet said "bad terminology is the enemy of good thinking." This articles reviews common errors investigators make when conducting and reporting medical research. Included are choosing inappropriate unit of analysis (e.g., events rather than patients), confusing correlation with association, and failure to address reliability, among others. It's an interesting read, and may even serve as a quick reference for refreshing your memory about definitions of commonly used statistical terms.—Sarang Kim
Markert, RJ. Enhancing medical education by improving statistical methodology in journal articles. Teach Learn Med. 2013 Apr-Jun;25(2):159-64.
Don't pay for that test prep course yet!
In this observational study, investigators assessed whether students taking the Australian/New Zealand version of our MCAT performed better if they took a test preparation course or not, and found that taking prep courses was not associated with better test scores. Although the study was not randomized, the investigators were able to control for baseline academic performance, which did not change the results. Students who took prep courses and those who spent more money were more likely to think they performed better, although they did not.—Sarang Kim
Wilkinson TM, et al. Preparation courses for a medical admission test: effectiveness contrasts with opinion. Med Educ. 2013 Apr;47(4):417-24.
50% Fewer Students Needed For Course Evaluations.
A multi-site, multi-country study shows that far fewer students are needed to evaluate a course, if they are asked to predict the opinion of their classmates instead of give their own. The predictive model of evaluation required input from 50% fewer students to produce stable ratings compared to the traditional personal opinion-based evaluations. "Gender, estimated general level of achievement or satisfaction after having completed the final examination" were not significant factors in the findings. The predictive model of evaluation used in this study borrows from the political science literature on predicting election results, and is consistent with prior findings that a random sample of the class using only 30-40 respondents may adequately represent the general opinion of the class. The potential to reduce evaluation fatigue is a highly attractive feature of this model.—Sarang Kim
Schönrock-Adema J, et al. ‘What would my classmates say?’ An international study of the prediction-based method of course evaluation. Med Educ. 2013 May;47(5):453-62.
A centralized biostatistics group is good for academic medical centers.
This consortium makes a well-reasoned argument that all major academic medical centers should have a centralized biostatistics group. This model benefits biostatisticians as well as researchers from all departments and units of the medical center.—Laura Willett
Welty LJ, et al. Strategies for Developing Biostatistics Resources in an Academic Health Center. Acad Med 2013, 88:454-460
The secret to effective bedside rounds: good teachers prepare.
In a qualitative study of highly rated teaching attendings from 10 US medical schools, preparation was key to conducting effective bedside rounds. Good teachers planned ahead to address several specific components of effective bedside rounds, including:
1. getting trainee buy-in for conducting bedside rounds and establish roles and expectations for each member of the team at the bedside.
2. reviewing patient data prior to rounds to identify identify patients best suited for bedside rounds and to prepare teaching points or scripts.--Sarang Kim
Gonzalo JD, et al. The art of bedside rounds: a multi-center qualitative study of strategies used by experienced bedside teachers. JGIM 2013, 28:412-420
Attendings compare learners to each other, not to a fixed standard.
In this elegant and provocative study, investigators asked attending physicians to score videos of residents with “borderline” clinical performance on a mini-CEX under two different circumstances, after seeing several good trainee videos, or after seeing several bad trainee videos. The prior exposure had a large effect on the grades given the “borderline” performances. For example, attendings gave failing grades to 55% borderline trainees after viewing good performances but to only 24% after viewing poor performances. This difference is concerning if these evaluations were to be used for high-stakes decisions. Evaluators in this study were not trained in grading the mini-CEX, but this might improve the results.—Laura Willett
Yeates P et al.
Effect of Exposure to Good vs Poor Medical Trainee Performance on Attending Physician Ratings of Subsequent Performances.
Does Analytical Reasoning increase Diagnostic Accuracy?
Yes, according to a randomized control study performed with 145 medical students during their 4th year OSCEs. After encountering a patient, students in the test group made a diagnosis with the aid of a differential diagnoses and symptoms table. The control group omitted table and only submitted diagnosis. The diagnostic accuracy scores on OSCEs were higher in the group using analytical reasoning (table). Although this method seemed to reduce cognitive bias in 4th medical students, the approach works best on medical students and residents as opposed to more experienced doctors and may not work on very complex cases where students’ medical knowledge is the rate limiting factor. –Lee Ann Schein, Ph. D.
Myung SJ et al.
Effect of enhanced analytic reasoning on diagnostic accuracy: A randomized controlled study.
Medical Teacher 2013, 1–3, Early Online(Posted online on January 18, 2013)
Are Artificial Students Better Than The Real Thing?
This small pilot study suggests that preclinical medical students conducting respiratory and/or cardiovascular system examinations on a life-size patient manikin (SimMan) showed greater improvement in their ability and confidence to perform physical exams above those using peer examinations. In particular, students reported better ability to differentiate between normal and abnormal signs. The manikin, which can be programmed with a range of clinical findings, is seen by the study authors as a self and effective means of teaching without any harm to patients. –Lee Ann Schein, Ph. D.
Swamy M et al.
Role of SimMan in teaching clinical skills to preclinical medical students
BMC Medical Education 2013, 13:20
The Faculties’ Side of the Story.
This qualitative study identified several key aspects of small group sessions which improved students’ learning. The study focused on interactive small group learning seminars consisting of approximately 25 students and one content expert facilitator. After a semester 24 facilitators attended focus groups aimed at investigating which features of the small group seminar format were considered by the teachers to be important for optimal seminar learning. The result was concrete tips for the construction of high-quality small group sessions and improved curriculum development, such as quality and quantity of reading material, non-threatening learning environments, stability of groups throughout the semester, and alignment of topics throughout all course learning elements. –Lee Ann Schein, Ph. D.
Spruijt A et al.
Teachers' perceptions of aspects affecting seminar learning: a qualitative study
BMC Medical Education 2013, 13:22
Can we let attending physicians do 2-week vs. 4-week ward rotations?
The quick answer is yes. Attendings were much less likely to experience sever burnout (16% vs. 35%). Patient outcomes were not changed. Learner evaluations showed that both residents and students felt that the attendings were less able to fairly evaluate them with the shorter exposure, but other evaluations were fairly similar.—Laura Willett
Lucas BP et al.
Effects of 2- vs 4-Week Attending Physician Inpatient Rotations on Unplanned Patient Revisits, Evaluations by Trainees, and Attending Physician Burnout: A Randomized Trial
M&Ms go systems-based
In a comparison of department of medicine mortality and morbidity conferences at one institution from the 1999-2000 academic year to 2010-11, discussion of systems-based practice issues increased remarkably. For example, the chief resident made systems-based practice comments in 12% of the earlier sessions vs. 69% of the more recent sessions. Explicit discussion of adverse events also became more common.-- LW
Gonzalo JD, et al. Systems-Based Content in Medical Morbidity and Mortality Conferences: A Decade of Change. JGME 2012, 4:438
Faculty can make their lectures more interactive
A 1-hour faculty development workshop for presenters at a pediatric residency conference series led to a large increase in active learning behaviors in subsequent conferences. The results might have been exaggerated given the lack of blinding in observers. -- LW
Desselle BC, et al. Evaluation of a Faculty Development Program Aimed at Increasing Residents' Active Learning in Lectures. JGME 2012, 4:516-520.
How good are our standardized patients (SPs)?
Now we can find out. Investigators from the Netherlands developed an internally validated scale to evaluate both the SPs role-play and feedback skills. Under conservative assumptions, 20 evaluations were needed to obtain a reliable assessment, but those numbers are easily obtained in typical medical school clinical examination settings. -- LW
Bouter S, et al. Construction and Validation of the Nijmegen Evaluation of the Simulated Patient (NESP): Assessing Simulated Patients’ Ability to Role Play and Provide Feedback to Students. Acad Med. 2012, Dec 23. [Epub ahead of print].
Gender does not affect medical students’ decisions about the severity of unprofessional behavior.
In this reassuring survey study of vignettes of potentially unprofessional behavior, neither the gender of the medical student evaluating the vignette, nor the gender of the “actor” in the vignettes, had a substantial effect on the students’ evaluations of the severity of the behavior described. -- LW
Stratton TD, et al. Does gender moderate medical students’ assessments of unprofessional behavior? JGIM 2012, 27:1643-1648
Simulations to Ease Student-to-Resident Transition (4 articles)
Lots of new information on simulations, mostly for early residents. Both procedural (Cohen, Augustine) and non-procedural (Cohen, Miloslavsky) simulations increase learner confidence and/or competence for trained tasks. Even better, for faculty-poor settings, senior residents are perceived as excellent preceptors for these sessions (Cooper, Miloslavsky). -- LW
Cohen ER, et al. Making July Safer: Simulation-Based Mastery Learning During Intern Boot Camp. Acad Med. 201,2 Dec 23. [Epub ahead of print]
Augustine EM, et al. Effect of Procedure Simulation Workshops on Resident Procedural Confidence and Competence. JGME 2012, 4:479-485.
Cooper DD, et al. Medical Students' Perception of Residents as Teachers: Comparing Effectiveness of Residents and Faculty During Simulation Debriefings. JGME 2012, 4:486-489.
Miloslavsky EM, et al. Pilot Program Using Medical Simulation in Clinical Decision-Making Training for Internal Medicine Interns. JGME 2012, 4:490-495
Surprise, Surprise. Primary Care Doesn’t Pay Very Well
No news here, except for the crushing debt burden our medical students face. 86% have some debt at graduation, averaging $161,000. A group from Boston and the AAMC did a number of calculations using financial planning software. They found that a medical student with the average debt and standard repayment plan could (barely) achieve a middle-class lifestyle if they elect to go into primary care. Those with a debt burden of $250,000 or more (15% of graduates) would have a negative cash flow in their 30’s if they elect a primary care specialty and use the standard repayment plan. Graduates who elect a highly-paid subspecialty, under most assumptions, have about $3,000 a month more disposable income than those who elect to go into primary care. Politicians, please stop wondering why we have a shortage of primary care physicians! -- LW
Youngclaus JA, et al. Can medical students afford to choose primary care? An economic analysis of physician education debt repayment. Acad Med. 2013 Jan;88(1):16-25.
Resident Remediation Is Successful…Usually
This large observational study of all University of Toronto residency programs may be of interest to residency directors. Overall, about 3% of residents were referred to a university-wide board for remediation; similar percentages of residents were referred from all programs, except none were referred by pediatrics. Medicine and family medicine tended to refer residents in their first year, whereas surgical programs tended to refer residents in later years. Residents referred for remediation tended to have deficiencies identified in multiple competencies, most commonly medical expertise, professionalism, communication skills, and managerial skills. Eighty percent of referred residents successfully completed their programs, after remediation which averaged about 6 months in length. The remediation is otherwise not well described in this article. -- LW
Zbieranowski I., et al.
Remediation of Residents in Difficulty: A Retrospective 10-Year Review of the Experience of a Postgraduate Board of Examiners. Acad Med. 2013 Jan;88(1):111-116.
“Don’t Know Much About”…The Effects Of Duty Hours Restrictions
This insightful opinion piece, written by trainees, points out we have undertaken duty hours restrictions with a marked impact on programs with no conclusive data that they benefit anyone. “There are data to support every opinion.” – LW
Rosenbaum L. et al. Residents' duty hours--toward an empirical narrative.
N Engl J Med. 2012 Nov 22;367(21):2044-9. doi: 10.1056/NEJMsr1210160.
You Too Can Be A Successful Ward Attending
In a study of attendings and learners, researchers identified major domains of importance in determining the quality of the ward attending rounds: learning atmosphere (being non-intimidating and respectful); clinical teaching style (modeling bedside manner and thought process); communicating expectations for residents and students; and team management (especially being “organized, efficient, and timely”). –LW
Roy B et al. Using Cognitive Mapping to Define Key Domains for Successful Attending Rounds. J Gen Intern Med 2012 Nov;27(11):1492-8. doi: 10.1007/s11606-012-2121-6. Epub 2012 Jun 22.
Do Fewer Work Hours = Less Learning? Kinda.
In this retrospective study, investigators at a Canadian teaching hospitals examined medical-surgical ICU patient and procedure volumes from 2001 to 2010 and matched them to resident on-call schedules to identify maximum experiential learning opportunities. Over the 9 year period, they found a decrease in the number of calls per resident, a 32% reduction in resident opportunity to admit patients and 34% reduction in resident opportunity to perform procedures. The study did not measure residents' clinical competence or directly track actual number of patients residents admitted, but less work hours seems to have led to less opportunities for learning.
Peets, AD. Changes in residents’ opportunities for experiential learning over time. Medical Education 2012; 46:1189-1193
Patients and colleagues tend to like doctors
Wright C. et al.
Multisource Feedback in Evaluating the Performance of Doctors: The Example of the UK General Medical Council Patient and Colleague Questionnaires.
Academic Medicine Volume 87(12), December 2012, p 1668–1678
Multi-source feedback is felt to be useful in the evaluation of practicing physicians. In this UK study, patients and colleagues tended to give evaluations that were very skewed toward positive. Also, very large numbers of surveys are required to generate stable estimates. This suggests major weaknesses in the use of such surveys for the analysis of physician excellence.
Academic Medicine (December 2012)--LW
What makes a great doctor?
Mahant, S et al.
The Nature of Excellent Clinicians at an Academic Health Science Center: A Qualitative Study
Academic Medicine Volume 87(12), December 2012, p 1715–1721
Peer-nominated (see above) excellent physicians were interviewed and several common themes emerged: high intrinsic motivation; humility; scholarship; reflection upon practice; and “everyday practice skills”. These included cognitive skills, dealing with uncertainty, being pragmatic, good people skills, enthusiasm, adaptability, and recognition of one’s own limits.
Academic Medicine (December 2012)--LW
Worrisome changes in medical school financing
Miller, JC, et al.
Perspective: Follow the Money: The Implications of Medical Schools’ Funds Flow Models
Volume 87(12), December 2012, p 1746–1751
This interesting report on medical school financing compares sources of income in 1960 vs. 2008. During this time, the number of US medical students doubled, full-time faculty increased by more than 10 fold, and revenues increased by nearly 20 fold. Overall government funding as a percentage of revenue went from 58% to 30% (federal research funding from 31% to 19%), while clinical service provision increased dramatically as a percentage of medical school revenues, from 6% to 52%. Tuition remains a minor contribution, declining from 6% to 3% of revenues. In the current economic climate, it is unlikely that any of the traditional sources of medical school revenues – research funding, state appropriations, clinical revenues, tuition, or philanthropic donations – will be increasing.
Can residents be taught to be empathetic? Yes!
Reiss H et al.
Empathy training for resident physicians: a randomized controlled trial of a neuroscience-informed curriculum. JGIM Oct 2012; 27:1280.
In a randomized trial of three 1-hour sessions for residents in multiple specialties, patients of residents randomized to training graded their doctors better at “showing care and compassion” than patients of those who were not. Training focused on the neurobiology of emotion and physician responses to “difficult” patients and situations—LW
Not so CLER!
Development, Testing, and Implementation of the ACGME Clinical Learning Environment Review (CLER) Program
Journal Of Graduate Medical Education (Sep 2012).
CLER visits are the new process by which a sponsoring institution will have visits from the ACGME every 18 months. All levels, from executive leadership to staff to resident, will be involved. Site visitors will examine how GME programs are integrated into institutional activities with regard to patient safety, quality improvement, transitions in care, supervision, duty hours and professionalism. How the institution and sites evaluate these areas and use that information to improve care is a focus of CLER. The project is currently starting beta testing, which will take 18 months and then the process will be finalized.—MK
Looking to improve your EBM teaching skills?
BMC MEd Educ 2009;9:59
This article describes the EU-EBM Trainer the Trainer project, which offers free on-line modules to help clinicians be effective EBM teachers in a variety of clinical setting including the inpatient wards and outpatient clinics. The modules can be accessed at http://ebm-unity.pc.unicatt.it/
Are you teaching your trainees to provide VALUE-based care?
J Gen Intern Med. 2012 Sep;27(9):1210-4. (Patel)
There is a national move to provide training in value-based, cost conscious care. This article describes a simple framework for assessing whether an intervention may provide value for patients. VALUE is an acronym for Validation/variability, Affordability/Access, Long-term benefit/Less side effects, Utility/Usability, and Effectiveness/Errors. The authors also describe specific and practical examples of how this framework can be used in residency training, including in daily rounds.--SK
Free curriculum on high-value, cost-conscious care
Annals of Internal Medicine. 2012 Aug;157(4):284-286. (Smith)
ABIM (AM Board of Internal Medicine), AAIM (Alliance for Academic Internal Medicine) and ACP (American College of Physicians) have created a free curriculum to train internal medicine residents on providing high-value, cost conscious care. The curriculum consists of ten 1-hour interactive sessions that include discussions about benefits, harms and costs of interventions. Curricular materials, including faculty development material, are available online (www.highvaluecarecurriculum.org).--SK
Residents reflect on their errors
Academic Medicine. 87(10):1361-1367, October 2012. (Ogdie, etal)
Forty-one medical residents analyzed diagnostic errors made on their patients. Common contributors were: holding onto a diagnosis made early in the course, coming easily to mind, or presented by other providers; over-reliance on authority figures or consultants; personal reactions to patients; time pressures; poor transitions of care; and complex or incomplete information.--LW
Longer (vs. shorter) interactions with attendings are preferable
Academic Medicine. 87(10):1389-1396, October 2012. (Hauer, et al)
Third year medical students in traditional block and year-long longitudinal clerkships were interviewed about successful and unsuccessful relationships with their teachers. In both groups, longer interactions (days to weeks for block students, year-long for longitudinal students) were viewed as more conducive to learning. Block students tried to match their behaviors to their attendings' expectations, while longitudinal students described less-hierarchical relationships with their preceptors. A major caveat is that longitudinal students and preceptors were self-selected.--LW
Do residents like evaluating their attendings?
Academic Medicine. 87(10):1397-1400, October 2012. (Myers, et al)
The quick answer is no - they find it time-consuming and wonder whether it is worth it. Residents felt it was most important that they provide feedback on attendings perceived as either much better or much worse than average. Some residents expressed worries that their evaluations would not be strictly confidential and could be damaging to them.--LW
Student Uncertainties Drive Teaching During Case Presentations: More So With SNAPPS
Academic Medicine Volume 87(9), September 2012, p1210-1217 (Wolpaw)
In a study of a small number of audiotaped presentations by medical students to family medicine preceptors, researchers found that preceptors directly aligned their teaching towards 80% of questions posed during the presentation. Students posed about 2 questions per presentation. A small number of students had been trained in the presentation technique known as SNAPPS (Summarize, Narrow, Analyze, Probe, Plan, Select). These students asked slightly more questions, and more of their questions had to do with diagnostic reasoning.—LW
This small, but timely study in data visualization grapples with the challenge of showing large data sets of residency skill level information in a easily readable format. Using New Innovations, Microsoft Access and Excel, researchers at Lehigh Valley Health Network’s Family Medicine program built several radar graphs, which show targets, trends and gaps in residency competency. The authors provide practical tips on compiling data from multiple assessments vehicles into an easy-to-read visualization.
No news here. This compendium of clerkship grades from 119 medical schools shows that grades are all over the map. The percentage of students earning the top grade in a clerkship ranges from 2% to 93%. Schools have grading systems with anywhere from 2 (Pass/Fail) to 11 (A/A-/B+, etc.) tiers of grades. Extra grading tiers seem to contribute to grade inflation: 97% of students end up with one of the three highest grades regardless of the number of tiers. Fewer than 1% of students fail any clerkship.