Collective Strategies to Equip Graduating Medical Students from Racial/Ethnic Backgrounds Underrepresented in Medicine to Succeed in Residency.

Phenomenon: Trainees from racial/ethnic backgrounds underrepresented in medicine (RE URiM) in the United States face challenges of racism and micro- and macro-aggressions during residency. Many have learned to navigate these challenges through successes and failures, but there is insufficient literature providing these lessons to graduating URiM medical students. Our study among medical school alumni explores strategies to help graduating URiM students prepare for success in residency. Approach: We conducted an online cross-sectional survey (Qualtrics) from February to March 2022. Graduates from a Northeast U.S. medical school identifying as URiM were invited to participate. With emphasis on "thriving" in residency training, we solicited rating-scale responses on preparedness for residency and open-text responses on strategies for success. Standard statistical and text content analysis were used to determine findings and themes. We used Word Cloud technology to further explore word frequency and patterns. Findings: Of the 43 alumni contacted, 23 (53%) completed the survey. Participants were trained in various specialties. We identified three themes with regard to strategies for thriving in residency: (1) importance of identifying and seeking early mentorship; (2) importance of identifying and having diverse forms of support; and (3) need for more education on navigating macro/microaggressions. Insight: While advocating for systems-level interventions to create inclusive learning environments, we highlight the gap in trainee awareness of the importance of seeking early mentorship. Our study provides strategies for graduating URiM medical students to succeed in residency based on respondent experiences. These recommendations should inform medical school curricula.

Feedback Culture Perceived by Trainees in an Academic Institution: A Mixed Methods Study.

OBJECTIVES: Lack of a well-functioning institutional feedback culture can undermine acquisition of skills essential for high quality patient care. The objective of this study was to assess feedback culture perceived by resident and fellow trainees, utilizing a mixed methods design. METHODS: Pediatric fellows and residents completed an anonymous feedback environment survey consisting of 7 constructs: source credibility, feedback quality, feedback delivery, reinforcing feedback, constructive feedback, source availability, and promotion of feedback seeking, using a 7-point Likert scale. Trainee ratings were compared using two-sided Fisher's exact tests. Multivariable analyses used a linear regression model. For the qualitative study, semistructured interviews of residents were conducted. The constant comparative method was used to incrementally code, categorize data, and derive themes. RESULTS: Fifty-two residents and 21 fellows completed the survey (response rates 65% and 47%, respectively). Scores were more favorable for fellows compared with residents in 6 of 7 feedback constructs (P < .05), including on multivariate analysis. Hispanic ethnicity and female gender were associated with lower scores on source credibility (P = .04) and constructive feedback (P = .03), respectively. Two qualitative themes were identified: expectation of efficiency in patient care compromises the quality and quantity of feedback, and a culture that prioritizes courtesy over candor negatively impacts feedback quality. These themes were more pronounced when residents worked with pediatric subspecialists compared with hospitalists. CONCLUSIONS: We described the feedback culture, which was less favorable in the residency program. The need for efficient patient care and a culture of courtesy adversely impacted the quality of feedback, especially among subspecialists.

Entrustable professional activities as a training and assessment framework in undergraduate medical education: A case study of a multi-institutional pilot.

In 2014, the Association of American Medical Colleges (AAMC) published 13 Core Entrustable Professional Activities (EPAs) that graduating students should be able to perform with indirect supervision when entering residency. A ten-school multi-year pilot was commissioned to test feasibility of implementing training and assessment of the AAMC's 13 Core EPAs. In 2020-21, a case study was employed to describe pilot schools' implementation experiences. Teams from nine of ten schools were interviewed to identify means and contexts of implementing EPAs and lessons learned. Audiotapes were transcribed then coded by investigators using conventional content analysis and a constant comparative method. Coded passages were organized in a database and analyzed for themes. Consensus among school teams regarding facilitators of EPA implementation included team commitment to piloting EPAs; agreement that: proximal EPA adoption with curriculum reform facilitates EPA implementation; EPAs 'naturally fit' in clerkships and provided opportunity for schools to reflect on and adjust curricula and assessments; and inter-school collaboration bolstered individual school progress. Schools did not make high-stakes decisions about student progress (e.g., promotion, graduation), yet EPA assessment results complemented other forms of assessment in providing students with robust formative feedback about their progress. Teams had varied perceptions of school capability to implement an EPA framework, influenced by various levels of dean involvement, willingness, and capability of schools to invest in data systems and provide other resources, strategic deployment of EPAs and assessments, and faculty buy-in. These factors affected varied pace of implementation. Teams agreed on the worthiness of piloting the Core EPAs, but substantial work is still needed to fully employ an EPA framework at the scale of entire classes of students with enough assessments per EPA and with required data validity/reliability. Recommendations stemming from findings may help inform further implementation efforts across other schools adopting or considering an EPA framework.

Variation in medical humanities program mission statements in United States and Canadian Medical Schools.

PURPOSE: In 2019, the American Association of Medical Colleges (AAMC) identified the discipline of medical humanities as a priority in medical education. Although medical humanities programs have existed in medical and osteopathic schools in the U.S. and Canada since the late 1960's, this interdisciplinary field remains difficult to define. We studied the mission statements of medical humanities programs to identify core themes and priorities. MATERIALS AND METHODS: We conducted a content analysis of U.S. and Canada medical humanities MD and DO mission statements and associated descriptions (n = 56). We compared themes across programs whose directors had a clinical degree versus a terminal research degree, conducted comparisons between medical humanities programs housed in medical schools ranked in Top 20 U.S. News and World Report for Research or Primary Care, and conducted a word frequency analysis. RESULTS: Content analysis revealed five themes: improving patient care, improving the provider experience, generating scholarship, cultivating community relationships, and promoting diversity/sociocultural awareness. 70% of programs emphasized patient care and provider experience. Only 34% included the promotion of diversity/sociocultural awareness as a theme. Word frequency analysis corroborated our findings. CONCLUSIONS: U.S. and Canada medical humanities programs focus primarily on improving patient care and provider wellness.

Assessment of a hemodialysis E-curriculum in postgraduate nephrology education: A pilot mixed methods study.

BACKGROUND: Online educational modules support asynchronous E-learning and offer several advantages. This multi-institutional pilot study describes the experience among nephrology trainees, of using a faculty-developed interactive E-curriculum in hemodialysis (HD) and examines its impact on learner knowledge and satisfaction. STUDY DESIGN: A sequential mixed method design was developed for curriculum assessment, using a survey tool and 1 : 1 interview. SETTING AND PARTICIPANTS: Current or recent (within past 2 years) nephrology fellows from four U.S. training programs. MATERIALS AND METHODS: After curriculum completion, a 6-item survey was administered to all conveniently sampled participants followed by a 1 : 1 interview of a sampled subset. Quantitative and qualitative data were analyzed using descriptive statistics and thematic analysis, respectively. RESULTS: 25 participants (18 Yale and 7 non-Yale) were recruited. All participants filled a 6-item Qualtrics survey after curriculum completion; 12/25 were interviewed. The majority were 1st (11/25) or 2nd year (8/25) nephrology fellows. Most self-identified as visual (11/25) or kinesthetic (11/25) learners. 100% participants agreed to the ease of use and clinical applicability of the E-modules; 100% found the animated videos and self-assessment sections valuable. On a scale of 1 (not comfortable at all) to 5 (very comfortable), respondents rated their perceived level of knowledge in 6 key competency areas. Means were 2.2 (range: 2.08 - 2.6) pre-intervention and 4.1 (range: 4.0 - 4.32) post-intervention, representing a significant increase (p-value = 0.0001). Animated videos were the most desired feature of the curriculum. Standardization, repetition, a controlled learning environment, and flexibility were identified as key advantages of an E-curriculum. Need for a self-motivated learner and lack of collaborative learning were its limitations. CONCLUSION: Our study highlights the effectiveness of an asynchronous E-curriculum in promoting active learning in nephrology and provides a framework for E-curricula development. Further study is needed to assess its impact on changes in learner attitude and patient outcomes.

Thriving in Neurology Residency: An Appreciative Inquiry Approach.

BACKGROUND AND OBJECTIVES: Enhancing resident well-being has become a top priority for medical educators as awareness of physician burnout continues to grow. Although substantial effort has been made to understand contributors to resident burnout and develop effective interventions, relatively little is known about what characterizes the opposite of burnout-that is, thriving in medical training. This phenomenologic qualitative study applies appreciative inquiry as an interview technique with the aim of characterizing self-identified experiences of thriving among residents in the Yale Neurology program. METHODS: Eight residents across all years of training in a single neurology residency participated in semi-structured appreciative interviews to identify experiences of thriving during neurology training. These interviews were transcribed and qualitatively analyzed with a phenomenologic perspective for common themes. RESULTS: Numerous themes emerged spanning personal, interpersonal, and organizational domains. Whereas some of these themes were congruent with established foundations of well-being and adult learning theory, others revealed the crucial contributions of stress and challenge to thriving. One of the strongest emergent themes was the tendency of residents to thrive during autonomous, high-challenge, high-stress situations, provided that adequate support was present and psychological safety was ensured. DISCUSSION: These findings resonate with phenomena studied in positive psychology that are not being widely applied in medical education. To the degree that conclusions are transferable to other training contexts, this study suggests an opportunity for medical educators to harness the positive aspects of stress and challenge in a supportive way that facilitates trainee well-being through experiences of thriving.

Multifaceted Approach to Evaluation in a Pediatric and Adolescent Gynecology Rotation for Medical Students.

STUDY OBJECTIVE: We evaluated whether and to what extent a novel medical student rotation in pediatric and adolescent gynecology (PAG) increases clinical knowledge and skills and meets student needs and expectations. DESIGN: Constructivist prospective pre-post study and post-rotation student survey SETTING: Academic medical center PARTICIPANTS: Pilot study of 9 medical students, which represents the entire population of those who completed the rotation. INTERVENTIONS: Four-week clinical rotation in PAG MAIN OUTCOME MEASURES: Changes in clinical knowledge were measured by a pre- and post-intervention multiple-choice assessment, and clinical skills were assessed before and after the intervention using entrustable professional activities (EPAs); these data were analyzed with paired Student's t tests. Student evaluations of the rotation were measured through an anonymous, end-of-rotation, closed- and open-ended survey and were analyzed using descriptive statistics. RESULTS: A statistically significant increase in clinical knowledge was observed post-rotation, with a mean pretest score of 67.0% (standard deviation [SD] 1.7%) and a mean posttest score of 75.2% (SD 3.2%, P = 0.02). Statistically significant increases were observed for all EPAs between the first and final day of the rotation. Eight students who completed the post-rotation survey rated the rotation favorably (5 on a scale from 1 to 5). CONCLUSION: A multipronged evaluation showed that a new PAG clinical rotation significantly increased medical students' clinical skills and knowledge. This multifaceted evaluation method provides valuable insights to educators on how best to tailor a rotation to individual learners' levels of clinical skills and knowledge. If comparable rotations could be instituted and similarly evaluated in other medical schools, a noticeable knowledge/skill gap among trainees might be addressed.

Perspectives on the Effectiveness of a Medical Futility Policy.

BACKGROUND: The principal aim of this study was to investigate the function and effectiveness of an institutional policy that outlines a procedure to limit medically futile interventions. We were interested in the attitudes and opinions of careproviders and the members of the Yale New Haven Hospital Ethics Committee that use this policy, the Conscientious Practice Policy (CPP), to address questions on appropriate interventions in the setting of medical futility. METHODS: In 2019, we conducted three focus groups of members of the Yale New Haven Hospital Ethics Committee and critical care physicians, asking participants questions concerning their use of the Yale New Haven Hospital's policy on limiting futile interventions. Focus group transcript results were coded into common themes using a conventional analysis approach. RESULTS: The overarching finding was that the CPP had various levels of interpretation that prevented its effective and consistent use. This was supported by the four main themes from the focus groups: (1) Mixed perceptions regarding communication between careproviders and family members and surrogates before the CPP was invoked contributed to complexity in decision making. (2) It was ineffective to use an ethics consultation to decide whether or not to invoke the CPP. (3) It was necessary to address moral distress in the absence of a policy. (4) The use of the CPP was inconsistent for different patients, based on the degree to which family members and surrogates persisted in their resistance to limiting medically futile interventions, careproviders' comfort with directly making decisions, and bias towards members of certain groups. CONCLUSION: The CPP, as it has been used at the Yale New Haven Hospital, has been ineffective in rationally, fairly, and consistently resolving conflicts regarding the appropriateness of ending medically futile interventions. The CPP, as well as similar policies at other institutions, may benefit from restructuring the policy to more closely align with policies at other institutions where outcomes have been more successful.

Are Internal Medicine Residents Meeting the Bar? Comparing Resident Knowledge and Self-Efficacy to Published Palliative Care Competencies.

BACKGROUND: There is a need for improved primary palliative care (PC) education and resident comfort with providing end-of-life care. OBJECTIVE: Utilize a new instrument derived from published PC competencies to assess baseline Internal Medicine (IM) resident knowledge and self-efficacy in PC to identify educational gaps and create new PC curricula. DESIGN: We created a 2-part instrument including a Knowledge Test (KT) and a Self-Efficacy Inventory (SEI) addressing 18 PC resident competencies across 5 domains: Pain and Symptom Management (PSM), Communication (COMM), Psychosocial, Spiritual, and Cultural Aspects of Care (PSC), Terminal Care and Bereavement (TCB), and Palliative Care Principles and Practice (PCPP). SETTING/SUBJECTS: The instrument was emailed to IM residents at our institution during academic years 2015-2016 and 2016-2017. MEASUREMENTS: Basic descriptive statistics were performed for the KT and SEI. Mean Rank Analysis and One-way ANOVA were utilized for the KT and SEI, respectively. Congruence was calculated between knowledge and self-efficacy. RESULTS: The mean score on the KT was 73% (range 33-80%). There was no significant difference in knowledge among post-graduate year cohorts. Self-efficacy scores were lower for interns overall and in PCPP, TCB, and COMM domains. Knowledge was concordant with self-efficacy in 42% of participants, higher than self-efficacy in 10% of participants, and lower than self-efficacy in 48% of participants. CONCLUSIONS: For approximately half of respondents, high self-efficacy in PC did not correlate with high PC knowledge. A more focused curriculum is needed to help IM residents facilitate mastery of PC competencies by graduation.

Reviewing the Reviewer: Medical Student Course Feedback as a Marker of Professional Identity Formation.

Professional identity formation refers to the process by which medical trainees develop and internalize their new roles. In this work, we analyze medical student evaluations of teaching (SETs) as a window into students' developing identities as physicians. Our data consisted of 389 open-ended comments written anonymously by first-year (pre-clerkship) students in mid- and end-of-semester evaluations of small group sessions (mandatory attendance) during one full academic year at Yale School of Medicine. Using a combination of existing frameworks on professional identity formation, the purpose of this project was to: (1) describe the characteristics of comments made by medical students about first-year courses and instructors; (2) categorize the student comments; and (3) explore the usefulness of comments as markers of students' professional identity formation as physicians. Having established baseline information, we hope to follow the same cohort of students through their medical school career to assess if and how their evaluative comments shed light on the development of their professional identities as physicians.

Burnout Among Beginning First-Year Students from Three Health Professional Training Programs.

The study objective was to learn about burnout prevalence among beginning first-year students from three health professional programs-Advance Practice Registered Nursing (APRN), Medicine, and Physician Associate (PA) training. All first-year students were invited to anonymously complete a survey measuring burnout. Subscales for exhaustion and disengagement together accounted for burnout. Means and frequencies were derived for categorical variables (gender, program, and direct entry from college). Subscales were summarized with means and standard deviations. Analysis of variance and post hoc t-tests compared unadjusted differences in means. Based on results, multivariable linear regressions for total burnout and exhaustion examined associations for the independent variables. With a 97% response rate, 70% were female (the APRN program is predominantly female), and 32% began training directly after college. Female students had significantly higher average total burnout and exhaustion than males. APRN and PA students had significantly higher total burnout and exhaustion than MD students. There were no other significant associations. In multivariable linear regressions, APRN students had significantly higher, and PA students had not quite significantly higher, burnout and exhaustion compared with medical students, with no moderation by any other variables. Burnout among first-year students in all three programs was more prevalent than anticipated. Consistent with previous literature, the programs with students who experienced higher burnout used more competitive, multi-tiered grading systems and introduced clinical expectations earlier in training. The implication is that educational leaders should consider effects of competitive grading and early clinical exposure on burnout among beginning health professional students.

A New Competency-Based Instrument to Assess Resident Knowledge and Self-Efficacy in Primary Palliative Care.

CONTEXT: There is a need to improve both primary palliative care (PPC) education and its assessment in graduate medical education (GME). We developed an instrument based on published palliative care (PC) competencies to assess resident competency and educational interventions. OBJECTIVES: To describe the development and psychometric properties of a novel, competency-based instrument to measure resident knowledge and self-efficacy in PPC. METHODS: We created a 2-part instrument comprised of a knowledge test (KT) and a self-efficacy inventory (SEI) addressing 18 consensus, core PC resident competencies across 5 domains: pain and symptom management; communication; psychosocial, spiritual, and cultural aspects of care; terminal care and bereavement; and PC principles and practice. The instrument was distributed to 341 internal medicine residents during academic years 2015 to 2016 and 2016 to 2017. A standard item analysis was performed on the KT. Internal consistency (Cronbach α) and variable relationships (factor analysis) were measured for the SEI. RESULTS: One hundred forty-four residents completed the survey (42% response). For 15 KT items, difficulty ranged from 0.17 to 0.98, with 7 items ranging 0.20 to 0.80 (typical optimum difficulty); discrimination ranged from 0.03 to 0.60 with 10 items ≥0.27 (good to very good discrimination). Cronbach α was 0.954 for 35 SEI items. Factor analysis of combined 2015 to 2016 items yielded 4 factors explaining the majority of variance for the entire set of variables. CONCLUSION: Our instrument demonstrates promising psychometric properties and reliability in probing the constructs of PC and can be further utilized in PC GME research to assess learners and evaluate PPC educational interventions.

Establishing a Pediatric and Adolescent Gynecology Subinternship for Medical Students.

Within the pediatric and adolescent gynecology (PAG) community, an important issue deserving of our attention is expansion of formalized PAG training opportunities for medical students. In addition to those in obstetrics and gynecology, many physicians practicing family medicine, internal medicine, and surgery provide care to young female patients. However, residency programs provide inconsistent training in addressing specific PAG health care needs and communication skills required for delivery of care to pediatric and adolescent patients; opportunities for supervised clinical experience in these areas at the medical school level therefore have great importance because they might not be offered again during some residencies. At the undergraduate medical education level, training opportunities in PAG are currently limited, with only 3 PAG subinternships in North American medical schools. In contrast, other available subinternships include 113 in maternal fetal medicine and 82 in gynecologic oncology. To address this gap in opportunities for medical students, we developed a PAG subinternship and elective for medical students, which we describe in this report. Our 4-week PAG subinternship and 2-week elective expose students to a variety of ambulatory and surgical opportunities, with formal, informal, and self-guided learning activities. In this article, we explain the process of developing the curriculum, gaining alignment from key stakeholders, obtaining formal approval for the course, and advertising the opportunity to medical students. We also provide resources and guidance for medical educators who wish to establish a PAG subinternship or elective course at their institutions.

A novel near-peer reflective writing workshop.

BACKGROUND: Training in clinical medicine involves exposure to complex ethical and emotional situations. Reflection aids in the development of personal belief systems and improves self-awareness. Students may be reluctant to participate when reflection is mandatory and may be concerned about retaliation when the facilitator has a role in evaluations. Near-peers are institutional equals with more experience than the participants and may be well suited to facilitate reflection. METHODS: A quarterly near-peer-facilitated reflective writing workshop (RWW) was implemented in the mandatory clinical curriculum at a single institution. Qualitative feedback forms were solicited and were analysed through an iterative and inductive consensus process. An end-of-year web-based survey was distributed to test the hypotheses generated from our analysis of the feedback forms. RESULTS: There were 82 responses (80%) to the web-based survey and 266 (65%) feedback forms were collected. Although few students reported using writing as a coping mechanism, the RWW was viewed favourably, with 62% indicating that they would attend if optional. The structured prompts aided reflection. Students reported a higher likelihood of discussing difficult topics (doubts about medicine as a career, personal shortcomings, harassment and burnout) in sessions led by a near-peer than by a faculty member. The workshop created a safe space to reflect, increased a sense of camaraderie and helped normalise experiences. [The workshop] humanised the clinical experience, gave new perspective and reminded students of their positive personal accomplishments DISCUSSION: The near-peer-facilitated RWW is a novel intervention aimed at developing reflective practice and coping with the challenges of entering clinical medicine. It is highly structured and has been incorporated into the mandatory curriculum. It was well received by students, is generalisable and is easily implementable.

Pediatric Residents' Beliefs and Behaviors About Health Care for Sexual and Gender Minority Youth.

Little is known about provider beliefs related to sexual and gender minority (SGM) youth, and how these have changed over time. Our objective was to compare pediatric residents' beliefs and behaviors about SGM youth to historical data. Forty-eight of 76 (63%) residents completed a survey of items drawn from 2 existing scales. Results were compared with historical data from 1998 to 2012. Compared to historical respondents, residents indicated that they were significantly more likely to take a sexual history from patients under 14 years old and ask about sexual orientation. Residents were significantly less likely to fear offending parents or patients with such discussions. While responses indicated SGM-affirming beliefs, 45% of residents felt they may not know enough about SGM needs to have effective discussions, similar to historical respondents. Ongoing challenges include a perceived lack of knowledge about the needs of SGM youth, representing avenues for future educational intervention.

Principles and Practices for Developing an Integrated Medical School Curricular Sequence About Sexual and Gender Minority Health.

Problem: Sexual and gender minority patients face well-documented health disparities. One strategy to help overcome disparities is preparing medical trainees to competently provide care for sexual and gender minority patients. The Association of American Medical Colleges has identified professional competencies that medical students should develop to meet sexual and gender minority health needs. However, challenges in the medical education environment may hinder the adoption and implementation of curricular interventions to foster these competencies. Intervention: Our medical education community engaged in curriculum evaluation and subsequently developed a sexual and gender minority topical sequence to promote student development of these competencies. This process was guided by explicit principles and curriculum development practices. Context: This work began at the Yale University School of Medicine in 2014, shortly after the Association of American Medical Colleges published sexual and gender minority health competencies and amidst the development and implementation of a new curriculum at the institution. Impact: We identified core principles and practices to guide the development of an integrated sexual and gender minority health sequence. This process resulted in successful creation of an integrated curricular sequence. At this time, 9 new or enhanced curricular components have been adopted through our process-5 in preclinical, 3 in the clinical, and 1 in the elective, curricula-in addition to the 13 preexisting components that have been updated as appropriate. Feedback about the process from students and faculty has been overwhelmingly positive. Evaluation of curricular components and their effectiveness as an integrated sequence is ongoing. Lessons Learned: Core principles consisted of including a wide range of stakeholders to build consensus, establishing complementary student and faculty roles, using the "language of collaboration" rather than the "language of demand," presenting sexual and gender minority content in an intersectional manner whenever possible, and balancing sexual and gender minority components across the curriculum. Key practices included mapping curriculum to identify gaps; developing curriculum "pitches"; identifying early and potential later "adopters" among faculty; focusing on faculty ownership of curriculum to facilitate institutionalization; and performing ongoing tracking, assessment, and revision of curriculum.