Redesigning the Clinical Learning Environment to Improve Interprofessional Care and Education: Multi-Method Program Evaluation of the iPACE Pilot Unit.

BACKGROUND: In 2016, Maine Medical Center received an Accreditation Council for Graduate Medical Education Pursuing Excellence in Innovation grant to redesign the clinical learning environment to promote interprofessional care and education. The Interprofessional Partnership to Advance Care and Education (iPACE) model was developed and piloted on an adult inpatient medicine unit as an attempt achieve these aims. OBJECTIVE: We describe the iPACE model and associated outcomes. METHODS: Surveys and focus groups were employed as part of a multimethod pragmatic observational strategy. Team surveys included relational coordination (RC): a validated proprietary measure of interpersonal communication and relationships within teams. Pre-iPACE respondents were a representative historical sample from comparable inpatient medical units surveyed from March to April 2017. iPACE respondents were model participants surveyed March to August 2018 to allow for adequate sample size. RESULTS: Surveys were administered to pre-iPACE (N = 113, response rate 74%) and iPACE (N = 32, 54%) teams. Summary RC scores were significantly higher for iPACE respondents (iPACE 4.26 [SD 0.37] vs 3.72 [SD 0.44], P < .0001), and these respondents were also more likely to report a professionally rewarding experience (iPACE 4.4 [SD 0.6] vs 3.5 [SD 1.0], P < .0001). Learners felt the model was successful in teaching interprofessional best practices but were concerned it may hinder physician role development. Patient experience was positive. CONCLUSIONS: This pilot may have a positive effect on team functioning and team member professional experience and patient experience. Learner acceptance may be improved by increasing autonomy and preserving traditional learning venues.

The interplay between residency program culture and feedback culture: a cross-sectional study exploring perceptions of residents at three institutions.

BACKGROUND: Giving and receiving feedback that changes performance is influenced significantly by the clinical learning environment. This environment is multi-dimensional but includes both organizational and feedback specific dimensions. OBJECTIVE: The objectives of this research were to investigate the relationship between residents' perceptions of residency program culture and feedback culture; and whether there were differences in resident perceptions of their programs' and feedback cultures based on their disciplines and institution. We hypothesized that residents preferred certain program culture types and that certain aspects of a residency program's culture were related to the feedback culture. DESIGN: Residents from six specialties at three institutions voluntarily completed two validated survey instruments (Organizational Culture Assessment Instrument [OCAI] and Feedback in Medical Education [FEEDME]-Culture survey) to assess the residency program and feedback cultures, respectively. Descriptive statistics were calculated and non-parametric tests were used to analyze the data. RESULTS: The overall response rate was 37.9% (116/306 residents). 'Clan' culture was both the current and preferred culture by 49.3% and 56.8%, respectively, of the residents overall. There were differences across programs with more current 'clan' culture in pediatrics than in surgery (P = 0.01). Multiple regression analysis showed the Hierarchy Now culture type was significantly related to the feedback culture mean score (p = <.01). For every one unit increase in the Hierarchy Now culture type, the FEEDME-Culture mean score decreases by 0.023 units. CONCLUSIONS: The findings of this study add to the literature by describing residents' preferences of their residency program's culture, and providing insights into the interplay between the residency program and feedback cultures.

Aligning Strategic Interests in an Academic Medical Center: A Framework for Evaluating GME Expansion Requests.

BACKGROUND: In 2017, the Maine Medical Center Graduate Medical Education Committee received an unprecedented number of requests (n = 18) to start new graduate medical education (GME) programs or expand existing programs. There was no process by which multiple programs could be prioritized to compete for scarce GME resources. OBJECTIVE: We developed a framework to strategically assess and prioritize GME program expansion requests to yield the greatest benefits for patients, learners, and the institution as well as to meet regional and societal priorities. METHODS: A systems engineering methodology called tradespace exploration was applied to a 6-step process to identify relevant categories and metrics. Programs' final scores were peer evaluated, and prioritization recommendations were made. Correlation analysis was used to evaluate the relevance of each category to final scores. Stakeholder feedback was solicited for process refinement. RESULTS: Five categories relevant to GME expansion were identified: institutional priorities, health care system priorities, regional and societal needs, program quality, and financial considerations. All categories, except program quality, correlated well with final scores (R 2 range 0.413-0.662). Three of 18 requested programs were recommended for funding. A stakeholder survey revealed that almost half of respondents (48%, 14 of 29) agreed that the process was unbiased and inclusive. Focus group feedback noted that the process had been rigorous and deliberate, although communication could have been improved. CONCLUSIONS: Applying a systems engineering approach to develop institution-specific metrics for assessing GME expansion requests provided a reproducible framework, allowing consideration of institutional, health care system, and regional societal needs, as well as program quality and funding considerations.

The Art (and Artifice) of Seeking Feedback: Clerkship Students' Approaches to Asking for Feedback.

PURPOSE: As attention has shifted to learners as significant partners in feedback interactions, it is important to explore what feedback-seeking behaviors medical students use and how the faculty-student relationship affects feedback-seeking behaviors. METHOD: This qualitative study was inspired by the organizational psychology literature. Third-year medical students were interviewed at Maine Medical Center in April-May 2017 after completing a traditional block rotation clerkship or a nine-month longitudinal integrated clerkship (LIC). A constructivist grounded theory approach was used to analyze transcripts and develop themes. RESULTS: Fourteen students participated (eight LIC, six block rotation). Themes associated with why students sought feedback included goal orientations, perceived benefits and costs, and student and feedback provider characteristics. Factors influencing the way students sought feedback included busy environments, timing, and cues students were attuned to. Students described more inquiry than monitoring approaches and used various indirect and noninquiry techniques (artifice) in asking for feedback. Students did not find summative feedback as helpful as seeking feedback themselves, and they suggested training in seeking feedback would be beneficial. Faculty-student relationship dynamics included several aspects affecting feedback-seeking behaviors, and relationship differences in the LIC and block models affected feedback-seeking behaviors. CONCLUSIONS: Medical students have many motives to seek feedback and adapt their feedback-seeking behaviors to actively participate in an intricate dialogic interaction with feedback providers. Students gradually refine the art (and artifice) of obtaining the specific feedback information that meets their needs. The authors offer a prototype curriculum that may facilitate students' development of feedback-seeking skills.

The research contributions of predominantly North American Family Medicine educators to medical learner feedback: a descriptive analysis following a scoping review.

BACKGROUND AND OBJECTIVES: In 2016, we performed a scoping review as a means of mapping what is known in the literature about feedback to medical learners. In this descriptive analysis, we explore a subset of the results to assess the contributions of predominantly North American family medicine educators to the feedback literature. METHODS: Nineteen articles extracted from our original scoping review plus six articles identified from an additional search of the journal Family Medicine are described in-depth. RESULTS: The proportion of articles involving family medicine educators identified in our scoping review is small (n=19/650, 3%) and the total remains low (25) after including additional articles (n=6) from a Family Medicine search. They encompass a broad range of feedback methods and content areas. They primarily originated in the United States (n=19) and Canada (n=3) within Family Medicine Departments (n=20) and encompass a variety of scientific and educational research methodologies. CONCLUSIONS: The contributions of predominantly North American Family Medicine educators to the literature on feedback to learners are sparse in number and employ a variety of focus areas and methodological approaches. More studies are needed to assess for areas of education research where family physicians could make valuable contributions.

The Benefits of Honoring Patients as Teachers: A Qualitative Study.

INTRODUCTION: Medical training could not occur without the contributions of patients. Few programs are available that recognize patients for their essential role in medical education, and even fewer explore their impact. The Patients as Teachers (PaT) program was developed to provide an opportunity for medical students to formally honor patients for their contributions and to evaluate their effect on students' medical education. METHODS: This qualitative study involved the evaluation of transcripts of audiotaped interviews conducted with students and their honorees following participation in the PaT program in 2015 and 2016. Two different sets of authors independently examined transcripts from each year utilizing a descriptive coding strategy. Consensus was reached on theme selection and relationships between themes explored for theory development. A third author ensured grounding of the concepts in the data analyzed. RESULTS: Four themes emerged: (1) appreciating humanism in medicine, (2) expressing gratitude, (3) connecting patients and students, and (4) experiencing a unique event. CONCLUSION: The Patients as Teachers program provides meaningful benefits to both students and patients and has the potential to infuse elements of humanism into medical training.

The Feedback Tango: An Integrative Review and Analysis of the Content of the Teacher-Learner Feedback Exchange.

PURPOSE: To conduct an integrative review and analysis of the literature on the content of feedback to learners in medical education. METHOD: Following completion of a scoping review in 2016, the authors analyzed a subset of articles published through 2015 describing the analysis of feedback exchange content in various contexts: audiotapes, clinical examination, feedback cards, multisource feedback, videotapes, and written feedback. Two reviewers extracted data from these articles and identified common themes. RESULTS: Of the 51 included articles, about half (49%) were published since 2011. Most involved medical students (43%) or residents (43%). A leniency bias was noted in many (37%), as there was frequently reluctance to provide constructive feedback. More than one-quarter (29%) indicated the feedback was low in quality (e.g., too general, limited amount, no action plans). Some (16%) indicated faculty dominated conversations, did not use feedback forms appropriately, or provided inadequate feedback, even after training. Multiple feedback tools were used, with some articles (14%) describing varying degrees of use, completion, or legibility. Some articles (14%) noted the impact of the gender of the feedback provider or learner. CONCLUSIONS: The findings reveal that the exchange of feedback is troubled by low-quality feedback, leniency bias, faculty deficient in feedback competencies, challenges with multiple feedback tools, and gender impacts. Using the tango dance form as a metaphor for this dynamic partnership, the authors recommend ways to improve feedback for teachers and learners willing to partner with each other and engage in the complexities of the feedback exchange.

Trainees' Perceptions of Feedback: Validity Evidence for Two FEEDME (Feedback in Medical Education) Instruments.

Construct: Medical educators consider feedback a core component of the educational process. Effective feedback allows learners to acquire new skills, knowledge, and attitudes. Learners' perceptions of feedback are an important aspect to assess with valid methods in order to improve the feedback skills of educators and the feedback culture. BACKGROUND: Although guidelines for delivering effective feedback have existed for several decades, medical students and residents often indicate that they receive little feedback. A recent scoping review on feedback in medical education did not reveal any validity evidence on instruments to assess learner's perceptions of feedback. The purpose of our study was to gather validity evidence on two novel FEEDME (Feedback in Medical Education) instruments to assess medical students' and residents' perceptions of the feedback that they receive. APPROACH: After the authors developed an initial instrument with 54 items, cognitive interviews with medical students and residents suggested that 2 separate instruments were needed, one focused on the feedback culture (FEEDME-Culture) and the other on the provider of feedback (FEEDME-Provider). A Delphi study with 17 medical education experts and faculty members assessed content validity. The response process was explored involving 31 medical students and residents at 2 academic institutions. Exploratory factor analysis and reliability analyses were performed on completed instruments. RESULTS: Two Delphi consultation rounds refined the wording of items and eliminated several items. Learners found both instruments easy and quick to answer; it took them less than 5 minutes to complete. Learners preferred an electronic format of the instruments over paper. Factor analysis revealed a two- and three-factor solution for the FEEDME-Culture and FEEDME-Provider instruments, respectively. Cronbach's alpha was greater than 0.80 for all factors. Items on both instruments were moderately to highly correlated (range, r = .3-.7). CONCLUSIONS: Our results provide preliminary validity evidence of 2 novel feedback instruments. After further validation of both FEEDME instruments, sharing the results of the FEEDME-Culture instrument with educational leaders and faculty may improve the culture of feedback on specific educational rotations and at the institutional level. The FEEDME-Provider instrument could be useful for faculty development targeting feedback skills. Additional research studies could assess whether both instruments may be used to help learners receive feedback and prompt reflective learning.

Is feedback to medical learners associated with characteristics of improved patient care?

PURPOSE: To investigate the association of medical learner feedback with patient management and outcomes. METHODS: The authors investigated 27 articles that utilized patient data or chart reviews as a subset of a prior feedback scoping review. Data extraction was completed by two authors and all authors reviewed the descriptive data analysis. RESULTS: The studies were predominantly short-term investigations conducted in the US at academic teaching hospitals (89%) with one medical discipline (78%), most commonly internal medicine (56%). Patient-related outcomes primarily involved improved documentation (26%) and adherence to practice guidelines (19%) and were mostly measured through chart reviews (56%) or direct observation (15%). The primary method of feedback delivery involved a written format (30%). The majority of the studies showed a positive effect of feedback on the patient-oriented study outcomes (82%), although most involved a non-rigorous study design. CONCLUSIONS: Published studies focusing on the relationship between medical learner feedback and patient care are sparse. Most involve a single discipline at a single institution and are of a non-rigorous design. Measurements of improved patient outcomes are restricted to changes in management, procedures and documentation. Well-designed studies that directly link learner feedback to patient outcomes may help to support the use of feedback in teaching clinical outcomes improvement in alignment with competency-based milestones.

Is It Time for Entrustable Professional Activities for Residency Program Directors?

Residency program directors (PDs) play an important role in establishing and leading high-quality graduate medical education programs. However, medical educators have failed to codify the position on a national level, and PDs are often not recognized for the significant role they play. The authors of this Commentary argue that the core entrustable professional activities (EPAs) framework may be a mechanism to further this work and define the roles and responsibilities of the PD position. Based on personal observations as PDs and communications with others in the academic medicine community, the authors used work in competency-based medical education to define a list of potential EPAs for PDs. The benefits of developing these EPAs include being able to define competencies for PDs using a deconstructive process, highlighting the increasingly important role PDs play in leading high-quality graduate medical education programs, using EPAs as a framework to assess PD performance and provide feedback, allowing PDs to focus their professional development efforts on the most important areas for their work, and helping guide the PD recruitment and selection processes.

Feedback for Learners in Medical Education: What Is Known? A Scoping Review.

PURPOSE: To conduct a scoping review of the literature on feedback for learners in medical education. METHOD: In 2015-2016, the authors searched the Ovid MEDLINE, ERIC, CINAHL, ProQuest Dissertations and Theses Global, Web of Science, and Scopus databases and seven medical education journals (via OvidSP) for articles published January 1980-December 2015. Two reviewers screened articles for eligibility with inclusion criteria. All authors extracted key data and analyzed data descriptively. RESULTS: The authors included 650 articles in the review. More than half (n = 341) were published during 2010-2015. Many centered on medical students (n = 274) or residents (n = 192); some included learners from other disciplines (n = 57). Most (n = 633) described methods used for giving feedback; some (n = 95) described opinions and recommendations regarding feedback. Few studies assessed approaches to feedback with randomized, educational trials (n = 49) or described changes in learner behavior after feedback (n = 49). Even fewer assessed the impact of feedback on patient outcomes (n = 28). CONCLUSIONS: Feedback is considered an important means of improving learner performance, as evidenced by the number of articles outlining recommendations for feedback approaches. The literature on feedback for learners in medical education is broad, fairly recent, and generally describes new or altered curricular approaches that involve feedback for learners. High-quality, evidence-based recommendations for feedback are lacking. In addition to highlighting calls to reassess the concepts and complex nature of feedback interactions, the authors identify several areas that require further investigation.

Organizing graduate medical education programs into communities of practice.

BACKGROUND: A new organizational model of educational administrative support was instituted in the Department of Medical Education (DME) to better meet increasing national accreditation demands. Residency and fellowship programs were organized into four 'Communities of Practice' (CoOPs) based on discipline similarity, number of learners, and geographic location. Program coordinator reporting lines were shifted from individual departments to a centralized reporting structure within the DME. The goal of this project was to assess the impact on those most affected by the change. METHODS: This was a mixed methods study that utilized structured interviews and the Organizational Culture Assessment Instrument (OCAI). Eleven members of the newly formed CoOPs participated in the study. RESULTS: Three major themes emerged after review and coding of the interview transcripts: improved group identity, improved availability of resources, and increased opportunity for professional growth. OCAI results indicated that respondents are committed to the DME and perceived the culture to be empowering. The 'preferred culture' was very similar to the culture at the time of the study, with some indication that DME employees are ready for more creativity and innovation in the future. CONCLUSION: Reorganization within the DME of residency programs into CoOPs was overwhelmingly perceived as a positive change. Improved resources and accountability may position our DME to better handle the increasing complexity of graduate medical education.

Assessment of Medical Student and Resident/Fellow Knowledge, Comfort, and Training With Sexual History Taking in LGBTQ Patients.

BACKGROUND AND OBJECTIVES: Sexual health is an important aspect of overall health. Barriers to taking an adequate patient sexual history exist. Few studies have explored medical learners' comfort, knowledge, and training surrounding taking sexual histories with lesbian, gay, bisexual, transgender, questioning/queer (LGBTQ) patients specifically. METHODS: A 10-question survey was offered to medical students and resident/fellows at one US institution. Survey questions reflected participants' knowledge, comfort, and training related to sexual history taking with attention to LGBTQ care. RESULTS: A total of 159 surveys were returned (rate of 42%). A significantly lower level of comfort existed with taking sexual histories and managing sexual health issues in the LGBTQ segment of the patient population versus all patients, especially in the advanced training group. Participants recognized the importance of understanding their patients' overall sexual health, though medical students rated this as more important than the resident/fellow group did. A correlation existed between both comfort with taking sexual histories and discussing safe sexual practices and management of sexual issues, suggesting that further training would be helpful in this area. Twenty percent of the respondents reported receiving no training at all in eliciting sexual histories in LGBTQ patients. The most preferred format in this study for future training was interviewing standardized patients. CONCLUSIONS: Medical students and resident/fellows reported a significantly lower level of comfort with sexual history-taking and management of sexual issues in the LGBTQ population. A comprehensive training format that not only views sexual health as an integral part of overall patient health, but also integrates LGBTQ care, is needed in medical education.

Unfreezing the Flexnerian Model: introducing longitudinal integrated clerkships in rural communities.

INTRODUCTION: Physician shortages in rural areas remain severe but may be ameliorated by recent expansions in medical school class sizes. Expanding student exposure to rural medicine by increasing the amount of prolonged clinical experiences in rural areas may increase the likelihood of students pursuing a career in rural medicine. This research sought to investigate the perspective of rural physicians on the introduction of a rurally based nine-month Longitudinal Integrated Clerkship (LIC). METHODS: In this mixed-methods study, nine physician leaders were interviewed from five Maine, USA, rural hospitals participating in an LIC. Semi-structured interviews were audiotaped and transcribed. Qualitative analysis techniques were used to code the transcripts and develop themes. Forty-seven participating rural LIC preceptors were also surveyed through an online survey. RESULTS: Four major themes related to implementing the LIC model emerged: (1) melting old ways, (2) overcoming fears, (3) synergy of energy, and (4) benefits all-around. The faculty were very positive about the LIC, with increased job satisfaction, practice morale, and ongoing learning, but concerned about the financial impact on productivity. CONCLUSIONS: The importance of these themes and perceptions are discussed within the three-stage model of change by Lewin. These results describe how the innovative LIC model can conceptually unfreeze the traditional Flexnerian construct for rural physicians. Highlighting the many stakeholder benefits and addressing the anxieties and fears of rural faculty may facilitate the implementation of a rural LIC. Given the net favorable perception of rural faculty of the LIC, this educational model has the potential to play a major role in increasing the rural workforce.

Physician shadowing by college students: what do patients think?

BACKGROUND: The objective of this study is to determine patients' perceptions of physician shadowing by college students. METHODS: Thirty-two patients who agreed to have a college student shadow their physician participated in semi-structured interviews during July and August 2013 at two outpatient family medicine centers. Qualitative techniques were utilized to analyze the transcripts of the patient interviews and identify common themes. RESULTS: The majority of patients (78.1%) felt the college student had a neutral effect on their visit and denied having concerns about confidentiality (87.5%). No patient felt that having the college student present affected their ability to maintain a trusting relationship with their physician. Three themes emerged from the qualitative analysis: benefits to students, willing participation and sensitive issues. Most patients (78.5%) recognized that the student was in college or was a premedical student. The overwhelming majority of patients stated that they would have a college student shadow their physician again in the future. CONCLUSIONS: Despite concerns raised by other authors about the possible negative effects of physician shadowing by college students, this study shows that patients feel the impact to be primarily neutral and that there are many perceived benefits to both student and patient.

A systematic review of the use and effectiveness of the Objective Structured Teaching Encounter.

BACKGROUND: The Objective Structured Teaching Encounter (OSTE) has been proposed as a means of promoting and assessing the teaching skills of medical faculty. AIMS: To describe the uses of the OSTE and the evidence supporting its effectiveness. METHOD: MEDLINE (January 1966 through February 2010) was searched for English-language studies detailing the use of an OSTE for any educational purpose. Reference lists from relevant review articles and identified studies were also searched. Of the 354 papers initially identified, 22 were included in the review. RESULTS: The OSTE has been used to assess and improve teaching performance and to assess the impact of other means of faculty development. Although qualitative results have been generally positive, there is little quantitative data to support using the OSTE as a means of improving teaching performance. There is moderate evidence suggesting the OSTE is a reliable and valid means of assessing teaching, although few ratings instruments have been adequately studied. CONCLUSIONS: The OSTE is a promising innovation with potential application to assessing and promoting the teaching skills of medical faculty. Further study is required to determine the most effective OSTE design.

Using decentralized medical education to address the workforce needs of a rural state: a partnership between Maine Medical Center and Tufts University school of medicine.

CONTEXT: In February 2008, a new partnership between Maine Medical Center and Tufts University School of Medicine was formed to create a model medical school program. ISSUE: Major forces for change included: the increasing physician workforce needs of Maine, the need to increase access for medical education for Maine students, the opportunity for educational innovation, the societal imperative to increase the number of primary care physicians, and the desire for clinical and research collaborations. LESSONS LEARNED: The authors describe the process for exploring this partnership, and establishing a separate track and campus for 36 students per year. The key components of the 4 year curriculum, which includes clinical training based in Maine, are described, and 13 lessons learned to date are outlined. The authors hope these lessons provide guidance to other academic medical centers and medical schools wishing to address rural physician workforce challenges, through regional models of medical education, and similar partnerships.

Leadership development for program directors.

BACKGROUND: Residency program directors have increasingly challenging roles, but they may not be receiving adequate leadership development. OBJECTIVE: To assess and facilitate program directors' leadership self-awareness and development at a workshop retreat. METHODS: At our annual program director retreat, program directors and associate program directors from a variety of specialties completed the Thomas-Kilmann Conflict Mode Instrument (TKI), which evaluates an individual's behavior in conflict situations, and the Hersey-Blanchard Situational Leadership (HBSL) model, which measures individuals' preferred leadership style in working with followers. Participants received their results during the retreat and discussed their leadership style results in the context of conflict situations experienced in the past. An online survey was distributed 3 weeks after the retreat to assess participant satisfaction and to determine whether participants would make changes to their leadership styles. RESULTS: Seventeen program directors attended the retreat and completed the tools. On the TKI, 47% preferred the Compromising mode for handling conflict, while 18% preferred either the Avoiding or Accommodating modes. On the HBSL, 71% of program directors preferred a Coaching leadership style. Ninety-one percent of postretreat-survey respondents found the leadership tools helpful and also thought they had a better awareness of their conflict mode and leadership style preferences. Eighty-two percent committed to a change in their leadership behaviors in the 6 months following the retreat. CONCLUSIONS: Leadership tools may be beneficial for promoting the professional development of program directors. The TKI and HBSL can be used within a local retreat or workshop as we describe to facilitate positive leadership-behavior changes.