Trainee Physician Milestone Ratings and Patient Complaints in Early Posttraining Practice.

Importance: Evaluation of trainees in graduate medical education training programs using Milestones has been in place since 2013. It is not known whether trainees who have lower ratings during the last year of training go on to have concerns related to interactions with patients in posttraining practice. Objective: To investigate the association between resident Milestone ratings and posttraining patient complaints. Design, Setting, and Participants: This retrospective cohort study included physicians who completed Accreditation Council for Graduate Medical Education (ACGME)-accredited programs between July 1, 2015, and June 30, 2019, and worked at a site that participated in the national Patient Advocacy Reporting System (PARS) program for at least 1 year. Milestone ratings from ACGME training programs and patient complaint data from PARS were collected. Data analysis was conducted from March 2022 to February 2023. Exposures: Lowest professionalism (P) and interpersonal and communication skills (ICS) Milestones ratings 6 months prior to the end of training. Main Outcomes and Measures: PARS year 1 index scores, based on recency and severity of complaints. Results: The cohort included 9340 physicians with median (IQR) age of 33 (31-35) years; 4516 (48.4%) were women physicians. Overall, 7001 (75.0%) had a PARS year 1 index score of 0, 2023 (21.7%) had a score of 1 to 20 (moderate), and 316 (3.4%) had a score of 21 or greater (high). Among physicians in the lowest Milestones group, 34 of 716 (4.7%) had high PARS year 1 index scores, while 105 of 3617 (2.9%) with Milestone ratings of 4.0 (proficient), had high PARS year 1 index scores. In a multivariable ordinal regression model, physicians in the 2 lowest Milestones rating groups (0-2.5 and 3.0-3.5) were statistically significantly more likely to have higher PARS year 1 index scores than the reference group with Milestones ratings of 4.0 (0-2.5 group: odds ratio, 1.2 [95% CI, 1.0-1.5]; 3.0-3.5 group: odds ratio, 1.2 [95% CI, 1.1-1.3]). Conclusions and Relevance: In this study, trainees with low Milestone ratings in P and ICS near the end of residency were at increased risk for patient complaints in their early posttraining independent physician practice. Trainees with lower Milestone ratings in P and ICS may need more support during graduate medical education training or in the early part of their posttraining practice career.

Comparing and Contrasting the Experiences of U.S. Medical Students During the COVID-19 and 1918 Influenza Pandemics.

In March 2020, medical students across the United States were pulled from their in-person responsibilities and learning in response to COVID-19. Leaders in the U.S. medical education system then began the arduous task of determining when, and how, to restore their full scope of training. This challenge was complicated by a paucity of readily available historical information about U.S. medical students in pandemics. To fill this knowledge gap, the authors collaborated with a medical history archivist to describe the experience of U.S. medical students during the 1918 influenza pandemic and compare it with the modern day. The experiences and responsibilities of medical students differed tremendously between the 2 pandemics. In 1918, U.S. medical students typically were conscripted into clinical service if they did not volunteer, assuming the roles of physicians, physician assistants, and nurses, often with atypically high levels of autonomy. Medical students were at great risk during the 1918 pandemic; multiple medical schools recorded students dying from influenza. In contrast, during the early COVID-19 pandemic, U.S. medical students were removed from the clinical environment, even if they wanted to volunteer, assuming ancillary roles instead. Upon returning to the clinical environment, most were not permitted to care for COVID-19 patients. The few medical students who recorded personal narratives about 1918 felt that caring for patients with influenza significantly influenced their growth and development as future physicians. One of the few things U.S. medical education had in common between the 1918 and COVID-19 pandemics was a lack of preparedness that impaired readiness and increased confusion among medical students. As U.S. medical education reflects on its response to COVID-19, the authors hope that their findings will provide context for future discussions and decisions about the role of medical students in pandemics.

Development of an interprofessional clinical learning environment report card.

Multiple factors in the learning environment can encourage or impede student learning. Unanswered questions regarding the shared learning environment for graduate nursing and medical education and the desire for an ongoing improvement process drove creation of an interprofessional collaborative and development of an Interprofessional Clinical Learning Environment Report Card (I-CLERC) at one U.S. academic medical center. The I-CLERC offers a process and a product for institutionalizing a shared assessment tool to inform improvement efforts, track progress and promote accountability. In addition, it enhances interprofessional collaboration, with students and faculty from both nursing and medicine working together to define excellence, monitor performance, and identify areas for improvement in the shared clinical learning environment. The purpose of this manuscript is to describe development and implementation of an interdisciplinary, institutional collaborative for ongoing evaluation of the shared clinical learning environment.

Deimplementation of Routine Chest X-rays in Adult Intensive Care Units.

BACKGROUND: Choosing Wisely® is a national initiative to deimplement or reduce low-value care. However, there is limited evidence on the effectiveness of strategies to influence ordering patterns. OBJECTIVE: We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. DESIGN: We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. SETTING: The study was performed in the medical intensive care unit (MICU) and cardiovascular intensive care unit (CVICU) of an academic medical center in the United States from October 2015 to June 2016. PARTICIPANTS: The initiative included the staff of the MICU and CVICU (physicians, surgeons, nurse practitioners, fellows, residents, medical students, and X-ray technologists). INTERVENTION COMPONENTS: We utilized provider education, peer champions, and weekly data feedback of CXR ordering rates. MEASUREMENTS: We analyzed the CXR ordering rates and factors facilitating or inhibiting deimplementation. RESULTS: Segmented linear time-series analysis suggested a small but statistically significant decrease in CXR ordering rates in the CVICU (P < .001) but not in the MICU. Facilitators of deimplementation, which were more prominent in the CVICU, included engagement of peer champions, stable staffing, and regular data feedback. Barriers included the need to establish goal CXR ordering rates, insufficient intervention visibility, and waning investment among medical residents in the MICU due to frequent rotation and competing priorities. CONCLUSIONS: Intervention modestly reduced CXRs ordered in one of two ICUs evaluated. Understanding why adoption differed between the two units may inform future interventions to deimplement low-value diagnostic tests.

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.

BACKGROUND: Open communication between healthcare professionals about care concerns, also known as 'speaking up', is essential to patient safety. OBJECTIVE: Compare interns' and residents' experiences, attitudes and factors associated with speaking up about traditional versus professionalism-related safety threats. DESIGN: Anonymous, cross-sectional survey. SETTING: Six US academic medical centres, 2013-2014. PARTICIPANTS: 1800 medical and surgical interns and residents (47% responded). MEASUREMENTS: Attitudes about, barriers and facilitators for, and self-reported experience with speaking up. Likelihood of speaking up and the potential for patient harm in two vignettes. Safety Attitude Questionnaire (SAQ) teamwork and safety scales; and Speaking Up Climate for Patient Safety (SUC-Safe) and Speaking Up Climate for Professionalism (SUC-Prof) scales. RESULTS: Respondents more commonly observed unprofessional behaviour (75%, 628/837) than traditional safety threats (49%, 410/837); p<0.001, but reported speaking up about unprofessional behaviour less commonly (46%, 287/628 vs 71%, 291/410; p<0.001). Respondents more commonly reported fear of conflict as a barrier to speaking up about unprofessional behaviour compared with traditional safety threats (58%, 482/837 vs 42%, 348/837; p<0.001). Respondents were also less likely to speak up to an attending physician in the professionalism vignette than the traditional safety vignette, even when they perceived high potential patient harm (20%, 49/251 vs 71%, 179/251; p<0.001). Positive perceptions of SAQ teamwork climate and SUC-Safe were independently associated with speaking up in the traditional safety vignette (OR 1.90, 99% CI 1.36 to 2.66 and 1.46, 1.02 to 2.09, respectively), while only a positive perception of SUC-Prof was associated with speaking up in the professionalism vignette (1.76, 1.23 to 2.50). CONCLUSIONS: Interns and residents commonly observed unprofessional behaviour yet were less likely to speak up about it compared with traditional safety threats even when they perceived high potential patient harm. Measuring SUC-Safe, and particularly SUC-Prof, may fill an existing gap in safety culture assessment.

Thawing the Landscape of the Era of High Throughput: Signs of Spring?

In his latest book, Dr. Kenneth Ludmerer examines the history of graduate medical education (GME) in the United States, including its "era of high throughput" during which residents admitted more patients for shorter periods of time as hospitals focused on decreasing length of stay secondary to prospective payment reform. The author of this Commentary considers the implications of the era of high throughput and how the U.S. health care system must change to address its lasting effects.The era of high throughput initially had incomplete penetrance across the health care system landscape and a variable effect on GME. Trainees were variably aware of the financial forces bearing down on the health care system. Over time, the pervasiveness of the financial pressures and managed care became more complete, and the ubiquity of information through the Internet and social media ensured that residents became more acutely aware of how the changes to the health care system were affecting their education. There is now an opportunity for GME to be the nidus for ushering in an era of cost consciousness focused on patient needs and higher-quality GME rather than on the financial pressures that characterized the era of high throughput.

Potentially discriminatory questions during residency interviews: frequency and effects on residents' ranking of programs in the national resident matching program.

BACKGROUND: Medical students rank residency programs as part of the selection process in the National Resident Matching Program, also known as the match. Applicants to medical residency positions are protected against discriminatory employment practices by federal employment laws. OBJECTIVES: To explore students' recall of being asked potentially illegal or discriminatory questions during the selection interview, and whether these questions affected students' ranking of the programs in the match. METHODS: Fourth-year medical students from a single medical school were surveyed after the match. Students were questioned about their recall of the frequency of potentially illegal or discriminatory interview questions and their effect on the program's rank. RESULTS: Ninety percent of the 63 respondents in the study remember being asked at least one potentially discriminatory question. Among these, students were asked about their marital status (86%), about children (31%), about plans for pregnancy (10%), where they were born (54%) and/or about their national origin (15%), and about religious and ethical beliefs (24%). The majority of students did not think the questions changed their decision to rank the program, although the questions changed the way some students ranked the program, either lowering or raising the rank. CONCLUSION: Nearly all students reported that they were asked at least one potentially discriminatory question, although these questions for the most part do not appear to affect whether they ranked the programs.

Personal growth during internship: a qualitative analysis of interns' responses to key questions.

BACKGROUND: During clinical training, house officers frequently encounter intense experiences that may affect their personal growth. The purpose of this study was to explore processes related to personal growth during internship. DESIGN: Prospective qualitative study conducted over the course of internship. PARTICIPANTS: Thirty-two postgraduate year (PGY)-1 residents from 9 U.S. internal medicine training programs. APPROACH: Every 8 weeks, interns responded by e-mail to an open-ended question related to personal growth. Content analysis methods were used to analyze the interns' writings to identify triggers, facilitators, and barriers related to personal growth. RESULTS: Triggers for personal growth included caring for critically ill or dying patients, receiving feedback, witnessing unprofessional behavior, experiencing personal problems, and dealing with the increased responsibility of internship. Facilitators of personal growth included supportive relationships, reflection, and commitment to core values. Fatigue, lack of personal time, and overwhelming work were barriers to personal growth. The balance between facilitators and barriers may dictate the extent to which personal growth occurs. CONCLUSIONS: Efforts to support personal growth during residency training include fostering supportive relationships, encouraging reflection, and recognizing interns' core values especially in association with powerful triggers.

Teaching the psychosocial aspects of care in the clinical setting: practical recommendations.

Communication skills and the psychosocial dimensions of patient care are increasingly taught in medical schools and generalist residency programs. Evidence suggests they are not reinforced or optimally implemented in clinical training. The authors present the product of an iterative process that was part of a national faculty development program and involved both experts and generalist teachers concerning teaching psychosocial medicine while precepting medical students and residents in clinical settings. Using scientific evidence, educational theory, and experience, the authors developed recommendations, presented them in workshops, and revised them based on input from other experts and teachers, who gave feedback and added suggestions. The results are practical, expert consensus recommendations for clinical preceptors on how to teach and reinforce learning in this area. General skills to use in preparing the trainee for improved psychosocial care are organized into the mnemonic "CAARE MORE": Connect personally with the trainee; Ask psychosocial questions and Assess the trainee's knowledge/attitudes/skills/behaviors; Role model desired attitudes/skills/behaviors; create a safe, supportive, enjoyable learning Environment; formulate specific Management strategies regarding psychosocial issues; Observe the trainee's affect and behavior; Reflect and provide feedback on doctor-patient and preceptor-trainee interactions; and provide Educational resources and best Evidence. The preceptor-trainee teaching skills that are recommended parallel good doctor-patient interaction skills. They can be used during both preceptor-trainee and preceptor-trainee-patient encounters. Important common psychosocial situations that need to be managed in patients include substance abuse, depression, anxiety, somatoform disorder, physical and sexual abuse, and posttraumatic stress disorder. For these problems, where high-level evidence exists, specific psychosocial questions for screening and case finding are provided.