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.