Comparing Entrustment Decision-Making Outcomes of the Core Entrustable Professional Activities Pilot, 2019-2020.

Importance: Gaps in readiness for indirect supervision have been identified for essential responsibilities encountered early in residency, presenting risks to patient safety. Core Entrustable Professional Activities (EPAs) for entering residency have been proposed as a framework to address these gaps and strengthen the transition from medical school to residency. Objective: To assess progress in developing an entrustment process in the Core EPAs framework. Design, Setting, and Participants: In this quality improvement study in the Core EPAs for Entering Residency Pilot, trained faculty made theoretical entrustment determinations and recorded the number of workplace-based assessments (WBAs) available for each determination in 2019 and 2020. Four participating schools attempted entrustment decision-making for all graduating students or a randomly selected subset of students. Deidentified, individual-level data were merged into a multischool database. Interventions: Schools implemented EPA-related curriculum, WBAs, and faculty development; developed systems to compile and display data; and convened groups to make theoretical summative entrustment determinations. Main Outcomes and Measures: On an EPA-specific basis, the percentage of students for whom an entrustment determination could be made, the percentage of students ready for indirect supervision, and the volume of WBAs available were recorded. Results: Four participating schools made 4525 EPA-specific readiness determinations (2296 determinations in 2019 and 2229 determinations in 2020) for 732 graduating students (349 students in 2019 and 383 students in 2020). Across all EPAs, the proportion of determinations of "ready for indirect supervision" increased from 2019 to 2020 (997 determinations [43.4%] vs 1340 determinations [60.1%]; 16.7 percentage point increase; 95% CI, 13.8-19.6 percentage points; P < .001), as did the proportion of determinations for which there were 4 or more WBAs (456 of 2295 determinations with WBA data [19.9%] vs 938 [42.1%]; 22.2 percentage point increase; 95% CI, 19.6-24.8 percentage points; P < .001). The proportion of EPA-specific data sets considered for which an entrustment determination could be made increased from 1731 determinations (75.4%) in 2019 to 2010 determinations (90.2%) in 2020 (14.8 percentage point increase; 95% CI, 12.6-16.9 percentage points; P < .001). On an EPA-specific basis, there were 5 EPAs (EPA 4 [orders], EPA 8 [handovers], EPA 10 [urgent care], EPA 11 [informed consent], and EPA 13 [patient safety]) for which few students were deemed ready for indirect supervision and for which there were few WBAs available per student in either year. For example, for EPA 13, 0 of 125 students were deemed ready in 2019 and 0 of 127 students were deemed ready in 2020, while 0 determinations in either year included 4 or more WBAs. Conclusions and Relevance: These findings suggest that there was progress in WBA data collected, the extent to which entrustment determinations could be made, and proportions of entrustment determinations reported as ready for indirect supervision. However, important gaps remained, particularly for a subset of Core EPAs.

Mission-Based Filters in the Electronic Residency Application Service: Saving Time and Promoting Diversity.

BACKGROUND: Holistic review promotes diversity, but widespread implementation remains limited. OBJECTIVE: We aimed to develop a practical approach to incorporate holistic review principles in screening applicants in the Electronic Residency Application Service (ERAS) and to assess the impact on diversity. METHODS: Three residency programs (internal medicine [IM], pediatrics, and surgery) at McGovern Medical School developed filters to identify applicants with experiences/attributes aligned with the institutional mission. These filters were retroactively applied to each program's 2019-2020 applicant pool using built-in ERAS capabilities to group applicants by user-defined features. We compared the demographics of applicants reviewed during the cycle with those identified retrospectively through experiences/attributes filters. RESULTS: The IM, pediatrics, and surgery programs received 3527, 1341, and 1313 applications, respectively, in 2019-2020. Retrospective use of experiences/attributes filters, without scores, narrowed the IM applicant pool for review to 1301 compared to 1323 applicants reviewed during actual recruitment, while the pediatrics filters identified 514 applicants compared to 384 at baseline. The surgery filters resulted in 582 applicants, but data were missing for baseline comparison. Compared to the baseline screening approach utilizing scores, mission-based filters increased the proportions of underrepresented in medicine applicants selected for review in IM (54.8% [95% CI 52.1-57.5] vs 22.7% [20.4-24.9], P < .0001) and pediatrics (63.2% [95% CI 59.1-67.4] vs 25.3% [20.9-29.6], P < .0001). CONCLUSIONS: Program directors can leverage existing ERAS features to conduct application screening in alignment with holistic review principles. Widespread implementation could have important repercussions for enhancing physician workforce diversity.

Utility of intermittent online quizzes as an early warning for residents at risk of failing the pediatric board certification examination.

BACKGROUND: Traditionally, quizzes have been applied as a tool for summative assessment, though literature suggests their use as a formative assessment can improve motivation and content retention. With this premise, we implemented a series of intermittent, online quizzes known as the Board Examination Simulation Exercise (BESE). We sought to demonstrate an association between BESE participation and scores and performance on the American Board of Pediatrics (ABP) Certifying Examination (CE). METHODS: Residents were assigned online quizzes on a single topic at 2 week intervals that consisted of 20 multiple choice questions written by the study authors. This analysis includes graduates of 3 Pediatric and Internal Medicine-Pediatrics residency programs. RESULTS: Data were available for 329 residents. The overall BESE score weakly correlated with ABP CE score (n = 287; r = 0.39, p < 0.0001). ABP CE pass rates increased from 2009 to 2016 at all programs combined (p = 0.0001). A composite BESE score ≤ 11 had sensitivity of 54% and specificity of 80% for predicting ABP CE failure on the first attempt. There was no difference in ABP CE failure rates or scores by number of completed quizzes. CONCLUSION: Intermittent online quizzes implemented at three pediatric residency programs were associated with overall increasing ABP CE pass rates. BESE increased program emphasis on board preparation. Residents with lower BESE scores more often failed ABP CE. Though additional data are needed, BESE is a promising tool for pediatric resident learning and board preparation. It may also aid in earlier identification of residents at higher risk of failing the ABP CE and facilitate targeted interventions.

Linking service-learning with community-based participatory research: an interprofessional course for health professional students.

Service-learning is a valued strategy for educating health professionals. Linking service-learning with community-based participatory research (CBPR) engages students with community stakeholders and faculty in a collaborative process to bring about social change and improved health. The purpose of this paper is to describe a strategy for involving interprofessional students in ongoing faculty CBPR in an underserved community. The process includes the design and implementation of a course that combines weekly seminars with field experiences in the targeted community, emphasizing community assessment, and working with community members to find solutions to health problems. Nursing, public health, and medical students were recruited to the initial course, and offered the opportunity to meet objectives of required components of their disciplinary curriculum. Community members became actively involved in educating students while working to solve identified health problems. Important principles of CBPR--trust, collaboration, excellence in science, and ethics--are emphasized throughout the initiative. This course is now a regular offering for interprofessional students, providing valuable learning experiences for students, faculty, and the community. Ongoing faculty CBPR continues a trusting community-academic relationship and gives the community a voice in the solution for health problems.

The impact of preclinical preceptorships on learning the fundamentals of clinical medicine and physical diagnosis skills.

PURPOSE: To learn whether preclinical primary care preceptorships resulted in demonstrable clinical performance benefits to medical students. METHOD: This was a retrospective cohort study of 267 medical students who elected and 310 students who did not elect to take a four-week primary care preceptorship following the first year of training at the University of Texas Medical School at Houston in 2001-2003. Outcome variables were the students' performances on a written examination testing their integration of basic science and fundamentals of clinical medicine and performances on a comprehensive objective structured clinical examination (OSCE). After adjusting for factors that might have explained differences in the students' performances, logistic regression models were used to assess the association of the outcome variables with participation in a preceptorship. RESULTS: Students who participated in any one of the preceptorships performed better on the OSCE and on the fundamentals of clinical medicine examination than students who did not participate (p < .01). Students who participated in the family medicine or pediatric preceptorship scored higher on an OSCE (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.01-2.78 and OR, 2.26; 95% CI, 1.18-4.36, respectively) than those students who did not participate in a preceptorship. Students who participated in the internal medicine preceptorship scored higher on the fundamentals of clinical medicine examination (OR, 3.18; 95% CI, 1.92-5.23). CONCLUSIONS: Preliminary evidence indicates that a short preclinical primary care preceptorship can help medical students to consolidate and integrate the fundamental cognitive and clinical skills they will apply during the clinical years of medical training.

A vertically integrated core pediatric education.

The objective of this study was to implement and evaluate a vertically integrated general pediatrics rotation that includes inpatient ward, newborn nursery, and ambulatory components in a format intended to mimic real-world pediatric practice. Separate ward, well-baby nursery, and ambulatory rotations were combined into a 4-month block rotation. Two parallel teams staff the inpatient ward and newborn nursery; on alternating days, the admitting team staffs an afternoon clinic, seeing ward and nursery patients in follow-up as well as regular clinic and referral patients. Two group meetings were held during each rotation for 2 years, and questionnaires were distributed to participating residents. All 90 residents who rotated through the combined service participated in at least 1 group meeting, only 26 returned questionnaires that limited evaluation of the program. The most important positive feature of the rotation was the continuity of patient care allowed by combining the venues into 1 rotation and by the longer duration of the rotation. Concerns included the challenges of time management and fluctuations in workload across the 3 patient care venues. Upper level residents reported that the rotation confirmed career decisions for primary care. These preliminary observations suggest that a vertically integrated rotation provides improvement in perceived continuity of care and introduces residents to the time management challenges of primary care pediatrics.

Neisseria meningitidis: presentation, treatment, and prevention.

Neisseria meningitidis is a leading cause of meningitis and septicemia in children and young adults in the United States. Highly publicized outbreaks of disease caused by this organism in communities and on college campuses have resulted in a heightened public awareness of its potentially devastating effects. The rapid progression of signs and symptoms of meningococcemia necessitate early recognition and institution of appropriate therapeutic measures. Identifying contacts of index cases who are at high risk of acquiring the disease allows health care providers to institute appropriate chemoprophylaxis. During community outbreaks, health care providers play an equally important role in calming the fears of low-risk contacts and their families. Familiarity with the risks and benefits of the meningococcal vaccine allows health care providers to offer this immunization to appropriate patients.