Mapping hospital data to characterize residents' educational experiences.

BACKGROUND: Experiential learning through patient care is fundamental to graduate medical education. Despite this, the actual content to which trainees are exposed in clinical practice is difficult to quantify and is poorly characterized. There remains an unmet need to define precisely how residents' patient care activities inform their educational experience.  METHODS: Using a recently-described crosswalk tool, we mapped principal ICD-10 discharge diagnosis codes to American Board of Internal Medicine (ABIM) content at four training hospitals of a single Internal Medicine (IM) Residency Program over one academic year to characterize and compare residents' clinical educational experiences. Frequencies of broad content categories and more specific condition categories were compared across sites to profile residents' aggregate inpatient clinical experiences and drive curricular change. RESULTS: There were 18,604 discharges from inpatient resident teams during the study period. The crosswalk captured > 95% of discharges at each site. Infectious Disease (ranging 17.4 to 39.5% of total discharges) and Cardiovascular Disease (15.8 to 38.2%) represented the most common content categories at each site. Several content areas (Allergy/Immunology, Dermatology, Obstetrics/Gynecology, Ophthalmology, Otolaryngology/Dental Medicine) were notably underrepresented (≤ 1% at each site). There were significant differences in the frequencies of conditions within most content categories, suggesting that residents experience distinct site-specific clinical content during their inpatient training. CONCLUSIONS: There were substantial differences in the clinical content experienced by our residents across hospital sites, prompting several important programmatic and curricular changes to enrich our residents' hospital-based educational experiences.

Theory-guided teaching: Implementation of a clinical reasoning curriculum in residents.

Introduction: Educators have theorized that interventions grounded in dual process theory (DPT) and script theory (ST) may improve the diagnostic reasoning process of physicians but little empirical evidence exists. Methods: In this quasi-experimental study, we assessed the impact of a clinical reasoning (CR) curriculum grounded in DPT and ST on medicine residents participating in one of three groups during a 6-month period: no, partial, or full intervention. Residents completed the diagnostic thinking inventory (DTI) at baseline and 6 months. At 6 months, participants also completed a post-survey assessing application of concepts to cases. Results: There was a significant difference between groups in application of concepts (no intervention 1.6 (0.65) compared to partial 2.3 (0.81) and full 2.2 (0.91), p = 0.05), as well as describing cases in problem representation format (no intervention 1.2 (0.38) and partial 1.5 (0.55) compared to full 2.1 (0.93), p = 0.004). There was no significant difference in change in DTI scores (no intervention 7.0 (16.3), partial 8.8 (9.8), full 7.8 (12.0)). Conclusions: Residents who participated in a CR curriculum grounded in DPT and ST were effective in applying principles of CR in cases from their practice. To our knowledge, this is the first workplace-based CR educational intervention study showing differences in the reasoning process residents apply to patients.

Faculty feedback that begins with resident self-assessment: motivation is the key to success.

CONTEXT: The seeking and incorporating of feedback are necessary for continuous performance improvement in medicine. We know that beginning feedback conversations with resident self-assessment may reduce some of the tensions experienced by faculty staff. However, we do not fully understand how residents experience feedback that begins with self-assessment, and whether any existing theoretical frameworks can explain their experiences. METHODS: We conducted a constructivist grounded theory study exploring physical medicine and rehabilitation residents' experiences as they engaged in a structured self-assessment and faculty staff feedback programme. Utilising purposive sampling, we conducted 15 individual interviews and analysed verbatim transcripts iteratively. We implemented several procedures to enhance the credibility of the findings and the protection of participants during recruitment, data collection and data analysis. After defining the themes, we reviewed a variety of existing frameworks to determine if any fitted the data. RESULTS: Residents valued self-assessment followed by feedback (SAFF) and had clear ideas of what makes the process useful. Time pressures and poor feedback quality could lead to a process of 'just going through the motions'. Motivation coloured residents' experiences, with more internalised motivation related to a more positive experience. There were no gender- or year of training-related patterns. CONCLUSIONS: Self-determination theory provided the clearest lens for framing our findings and fitted into a conceptual model linking the quality of the SAFF experience and residents' motivational loci. We identified several study limitations including time in the field, evolving characteristics of the SAFF programme and the absence of faculty voices. We believe that by better understanding residents' experiences of SAFF, educators may be able to tailor the feedback process, enhance clinical performance and ultimately improve patient care.

Experience and Education in Residency Training: Capturing the Resident Experience by Mapping Clinical Data.

PROBLEM: Internal medicine training programs operate under the assumption that the 3-year residency training period is sufficient for trainees to achieve the depth and breadth of clinical experience necessary for independent practice; however, the medical conditions to which residents are exposed in clinical practice are not easily measured. As a result, residents' clinical educational experiences are poorly understood. APPROACH: A crosswalk tool (a repository of International Classification of Diseases [ICD]-10 codes linked to medical content areas) was developed to query routinely collected inpatient principal diagnosis codes and translate them into an educationally meaningful taxonomy. This tool provides a robust characterization of residents' inpatient clinical experiences. OUTCOMES: This pilot study has provided proof of principle that the crosswalk tool can effectively map 1 year of resident-attributed diagnosis codes to both the broad content category level (e.g., "cardiovascular disease") and to the more specific condition category level (e.g., "myocardial disease"). The authors uncovered content areas in their training program that are overrepresented and some that are underrepresented relative to material on the American Board of Internal Medicine (ABIM) Certification Exam. NEXT STEPS: The crosswalk tool introduced here translated residents' patient care activities into discrete, measurable educational content and enabled 1 internal medicine residency program to characterize residents' inpatient educational experience with a high degree of resolution. Leaders of other programs seeking to profile the clinical exposure of their trainees may adopt this strategy. Such clinical content mapping drives innovation in the experiential curriculum, enables comparison across practice sites, and lays the groundwork to test associations between individual clinical exposure and competency-based outcomes, which, in turn, will allow medical educators to draw conclusions regarding how clinical experience reflects clinical competency.

Mapping the Clinical Experience of a New York City Residency Program During the COVID-19 Pandemic.

The COVID-19 pandemic has dramatically disrupted the educational experience of medical trainees. However, a detailed characterization of exactly how trainees' clinical experiences have been affected is lacking. Here, we profile residents' inpatient clinical experiences across the four training hospitals of NYU's Internal Medicine Residency Program during the pandemic's first wave. We mined ICD-10 principal diagnosis codes attributed to residents from February 1, 2020, to May 31, 2020. We translated these codes into discrete medical content areas using a newly developed "crosswalk tool." Residents' clinical exposure was enriched in infectious diseases (ID) and cardiovascular disease content at baseline. During the pandemic's surge, ID became the dominant content area. Exposure to other content was dramatically reduced, with clinical diversity repopulating only toward the end of the study period. Such characterization can be leveraged to provide effective practice habits feedback, guide didactic and self-directed learning, and potentially predict competency-based outcomes for trainees in the COVID era.

Critical events in the lives of interns.

BACKGROUND: Early residency is a crucial time in the professional development of physicians. As interns assume primary care for their patients, they take on new responsibilities. The events they find memorable during this time could provide us with insight into their developing professional identities. OBJECTIVE: To evaluate the most critical events in the lives of interns. PARTICIPANTS: Forty-one internal medicine residents at one program participated in a two-day retreat in the fall of their first year. Each resident provided a written description of a recent high point, low point, and patient conflict. MEASUREMENTS: We used a variant of grounded theory to analyze these critical incidents and determine the underlying themes of early internship. Independent inter-rater agreement of >90% was achieved for the coding of excerpts. MAIN RESULTS: The 123 critical incidents were clustered into 23 categories. The categories were further organized into six themes: confidence, life balance, connections, emotional responses, managing expectations, and facilitating teamwork. High points were primarily in the themes of confidence and connections. Low points were dispersed more generally throughout the conceptual framework. Conflicts with patients were about negotiating the expectations inherent in the physician-patient relationship. CONCLUSION: The high points, low points, and conflicts reported by early residents provide us with a glimpse into the lives of interns. The themes we have identified reflect critical challenges interns face the development of their professional identity. Program directors could use this process and conceptual framework to guide the development and promotion of residents' emerging professional identities.

International medical school faculty development: the results of a needs assessment survey among medical educators in China.

To explore the need for faculty development among Chinese medical educators. Leaders at each medical school in China were asked to complete a 123-item survey to identify interest in various topics and barriers and perceived benefits of participating in faculty development programs. Interest levels were high for all topics. Experience with Hospital Management and Research positively correlated with interest in learning more (p < 0.001). Ninety-two percent believe that international experiences are very or extremely important to medical educators' career advancement. Chinese medical education faculty members have a strong interest in faculty development programs.

Disciplinary action by medical boards and prior behavior in medical school.

BACKGROUND: Evidence supporting professionalism as a critical measure of competence in medical education is limited. In this case-control study, we investigated the association of disciplinary action against practicing physicians with prior unprofessional behavior in medical school. We also examined the specific types of behavior that are most predictive of disciplinary action against practicing physicians with unprofessional behavior in medical school. METHODS: The study included 235 graduates of three medical schools who were disciplined by one of 40 state medical boards between 1990 and 2003 (case physicians). The 469 control physicians were matched with the case physicians according to medical school and graduation year. Predictor variables from medical school included the presence or absence of narratives describing unprofessional behavior, grades, standardized-test scores, and demographic characteristics. Narratives were assigned an overall rating for unprofessional behavior. Those that met the threshold for unprofessional behavior were further classified among eight types of behavior and assigned a severity rating (moderate to severe). RESULTS: Disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school (odds ratio, 3.0; 95 percent confidence interval, 1.9 to 4.8), for a population attributable risk of disciplinary action of 26 percent. The types of unprofessional behavior most strongly linked with disciplinary action were severe irresponsibility (odds ratio, 8.5; 95 percent confidence interval, 1.8 to 40.1) and severely diminished capacity for self-improvement (odds ratio, 3.1; 95 percent confidence interval, 1.2 to 8.2). Disciplinary action by a medical board was also associated with low scores on the Medical College Admission Test and poor grades in the first two years of medical school (1 percent and 7 percent population attributable risk, respectively), but the association with these variables was less strong than that with unprofessional behavior. CONCLUSIONS: In this case-control study, disciplinary action among practicing physicians by medical boards was strongly associated with unprofessional behavior in medical school. Students with the strongest association were those who were described as irresponsible or as having diminished ability to improve their behavior. Professionalism should have a central role in medical academics and throughout one's medical career.

Quality of life, optimism/pessimism, and knowledge and attitudes toward HIV Screening among pregnant women in Ghana.

OBJECTIVE: We sought to explore optimism/pessimism, knowledge of HIV, and attitudes toward HIV screening and treatment among Ghanaian pregnant women. METHOD: Pregnant women in Accra, Ghana, completed a self-administered questionnaire including the Life Orientation Test-Revised (LOT-R, an optimism/pessimism measure), an HIV knowledge and screening attitudes questionnaire, the Short Form 12 (SF-12, a measure of health-related quality of life [HRQOL]), and a demographic questionnaire. Data were analyzed using t-tests, ANOVA, correlations, and the chi2 test. RESULTS: There were 101 participants; 28% were nulliparous. Mean age was 29.7 years, and mean week of gestation was 31.8. All women had heard of AIDS, 27.7% had been tested for HIV before this pregnancy, 46.5% had been tested during this pregnancy, and 59.4% of the sample had ever been tested for HIV. Of those not tested during this pregnancy, 64.2% were willing to be tested. Of all respondents, 89% said they would get tested if antiretroviral drugs (ARVs) were readily available and might prevent maternal-to-child transmission. Neither optimism/pessimism nor HRQOL was associated with attitudes toward HIV screening. Optimism was negatively correlated with HIV knowledge (p = .001) and was positively correlated with having never been tested before this pregnancy (p = .007). CONCLUSION: The relationship between optimism/pessimism and HIV knowledge and screening behavior is worthy of further study using larger samples and objective measures of testing beyond self-report.

Can there be a single system for peer assessment of professionalism among medical students? A multi-institutional study.

PURPOSE: Peer assessment is a valuable source of information about medical students' professionalism. How best to facilitate peer assessment of students' professional behavior remains to be answered, however. This report extends previous research through a multi-institutional study of students' perspectives about system characteristics for peer assessment of professionalism. It examines whether students from different schools and year levels prefer different characteristics of peer assessment to assess each other candidly, or whether a single system can be designed. It then identifies the characteristics of the resulting preferred system(s). METHOD: At the beginning of academic year 2004-2005, students (1,661 of 2,115; 78%) in years one through four at four schools replied to a survey about which peer assessment characteristics - related to, for example, who receives the assessment, its anonymity, and timing - would prevent or encourage their participation. Multivariate analysis of variance was used to detect differences among institutions and students from each year level. RESULTS: Students across year levels and schools generally agreed about the characteristics of peer assessment. They prefer a system that is 100% anonymous, provides immediate feedback, focuses on both unprofessional and professional behaviors, and uses peer assessment formatively while rewarding exemplary behavior and addressing serious repetitive professional lapses. The system, they emphasize, must be embedded in a supportive environment. CONCLUSIONS: Students' agreement about peer-assessment characteristics suggests that one system can be created to meet the majority of students' preferences. Once implemented, the system should be monitored for student acceptability to maximize participation and to determine the formative and summative value of the process.

Ethics and professionalism: what does a resident need to learn?

Training in ethics and professionalism is a fundamental component of residency education, yet there is little empirical information to guide curricula. The objective of this study is to describe empirically derived ethics objectives for ethics and professionalism training for multiple specialties. Study design is a thematic analysis of documents, semi-structured interviews, and focus groups conducted in a setting of an academic medical center, Veterans Administration, and community hospital training more than 1000 residents. Participants were 84 informants in 13 specialties including residents, program directors, faculty, practicing physicians, and ethics committees. Thematic analysis identified commonalities across informants and specialties. Resident and nonresident informants identified consent, interprofessional relationships, family interactions, communication skills, and end-of-life care as essential components of training. Nonresidents also emphasized formal ethics instruction, resource allocation, and self-monitoring, whereas residents emphasized the learning environment and resident-attending interactions. Conclusions are that empirically derived learning needs for ethics and professionalism included many topics, such as informed consent and resource allocation, relevant for most specialties, providing opportunities for shared curricula and resources.

Bedside interactions from the other side of the bedrail.

OBJECTIVE: To assess the importance to patients of various aspects of bedside interactions with physician teams. DESIGN: Cross-sectional survey. SETTING: VA hospital. PATIENTS: Ninety-seven medical inpatients. INTERVENTION: Survey of 44 questions including short answer, multiple choice, and Likert-type questions. MEASUREMENTS AND MAIN RESULTS: Data analysis included descriptive statistics. The sample was predominantly male, with a mean age of 62. Overall satisfaction with the hospital experience and with the team of doctors were both high (95% and 96% reported being very or mostly satisfied, respectively). Patients reported learning about several issues during their interactions with the teams; the 3 most highly rated areas were new problems, tests that will be done, and treatments that will be done. Most patients (76%) felt that their teams cared about them very much. Patients were made comfortable when the team showed that they cared, listened, and appeared relaxed (reported by 63%, 57%, and 54%, respectively). Patients were made uncomfortable by the team using language they did not understand (22%) and when several people examined them at once (13%). Many (58%) patients felt personally involved in teaching. The majority of patients liked having medical students and residents involved in their care (69% and 64%, respectively). CONCLUSIONS: Patients have much to teach about what is important about interacting with physician teams. Although patients' reactions to team interactions are generally positive, patients are different with respect to what makes them comfortable and uncomfortable. Taking their preferences into account could improve the experience of being in a teaching hospital.

Medical students' views on peer assessment of professionalism.

BACKGROUND: Although peer assessment holds promise for assessing professionalism, reluctance and refusal to participate have been noted among learners and practicing physicians. Understanding the perspectives of potential participants may therefore be important in designing and implementing effective peer assessment. OBJECTIVE: To identify factors that, according to students themselves, will encourage or discourage participation in peer assessment. DESIGN: A qualitative study using grounded theory to interpret views shared during 16 focus groups that were conducted by leaders using a semi-structured guide. PARTICIPANTS: Sixty-one students in Years 1, 3, and 4 in 2 mid-western public medical schools. RESULTS: Three themes students say would promote or discourage peer assessment emerged: personal struggles with peer assessment, characteristics of the assessment system itself, and the environment in which the system operates. Students struggle with reporting an unprofessional peer lest they bring harm to the peer, themselves, or their clinic team or work group. Who receives the assessment and gives the peer feedback and whether it is formative or summative and anonymous, signed, or confidential are important system characteristics. Students' views of characteristics promoting peer assessment were not unanimous. Receptivity to peer reports and close positive relationships among students and between students and faculty mark an environment conducive to peer assessment, students say. CONCLUSIONS: The study lays a foundation for creating acceptable peer assessment systems among students by soliciting their views. Merely introducing an assessment tool will not result in students' willingness to assess each other.

Trading health services across borders: GATS, markets, and caveats.

The General Agreement on Trade in Services (GATS) is the result of an ongoing process of opening national markets to foreign health services within an international framework of trade agreements that prohibit discriminatory treatment of foreign suppliers. Developing markets are growing, as is demand for health care services, and most of this demand is being met by the private market. The globalization of health services requires the resources of the academic and corporate sectors of the developed world for equitable and sustainable growth. Health services trade should be seen as a tool for achieving these goals, rather than as an end in itself.

Maximizing participation in peer assessment of professionalism: the students speak.

BACKGROUND: Medical students have unique information about peers' professionalism but are reluctant to share it through peer assessment. METHOD: Students (231 of 375; 62%) in one school replied to a survey about whether various characteristics of peer assessment (e.g., who receives the assessment, its anonymity, implications for the classmate) would prevent or encourage their participation. RESULTS: Sixty-six percent of the students agreed that there should be peer assessment of professionalism as long as the assessment reflected their preferences for how the assessment should take place. Some of their preferences included reporting unprofessional behavior to an impartial counselor, a 100% anonymous process, and having the classmate receive corrective instruction. Students across year levels generally agreed about the characteristics of peer assessment. Men and women disagreed about some characteristics. CONCLUSION: Most students are willing to participate in peer assessment as long as their preferences are taken into consideration.

Initial use of a novel instrument to measure professionalism in surgical residents.

BACKGROUND: No universally accepted method to measure professionalism exists. We developed an instrument to measure specific aspects of professionalism in surgical residents. METHODS: Professionalism was deconstructed into 15 domains. Behavioral descriptors were determined for extreme and selected intermediate anchors. It became evident that residents could "go too far" in some professional behaviors. Therefore, although a 7-point continuous ordinal scale forms the framework, a score of 7 does not necessarily indicate the ideal. This characteristic minimizes the problem of inflated ratings. RESULTS: The instrument was utilized by attending faculty to evaluate residents and also by residents as a self-evaluation. Calculated from ordinal values, mean (SD) of the ratings across domains for faculty evaluations of residents was 4.95 (0.38) while mean for self-evaluations was 4.95 (0.39). Reliability was high (coefficient alpha 0.85). CONCLUSIONS: This instrument provides a means to measure professional behaviors during surgical residency. Repeated use will be required to thoroughly establish validity and reliability.

The economic impact of quarantine: SARS in Toronto as a case study.

OBJECTIVES: Over time, quarantine has become a classic public health intervention and has been used repeatedly when newly emerging infectious diseases have threatened to spread throughout a population. Here, we weigh the economic costs and benefits associated with implementing widespread quarantine in Toronto during the SARS outbreaks of 2003. METHODS: We compared the costs of two outbreak scenarios: in Scenario A, SARS is able to transmit itself throughout a population without any significant public health interventions. In Scenario B, quarantine is implemented early on in an attempt to contain the virus. By evaluating these situations, we can investigate whether or not the use of quarantine is justified by being either cost-saving, life saving, or both. RESULTS: Our results indicate that quarantine is effective in containing newly emerging infectious diseases, and also cost saving when compared to not implementing a widespread containment mechanism. CONCLUSIONS: This paper illustrates that it is not only in our humanitarian interest for public health and healthcare officials to remain aggressive in their response to newly emerging infections, but also in our collective economic interest. Despite somewhat daunting initial costs, quarantine saves both lives and money.

The Courteous Consult: A CONSULT Card and Training to Improve Resident Consults.

BACKGROUND: Communication and courtesy are important elements of consultations, but there is limited published data about the quality of trainee consults. OBJECTIVES: This study assessed residents' views on consult interactions, evaluated the impact of the consult interactions on patient care, and developed and implemented a pocket card and training on trainee consults. METHODS: We surveyed resident and fellow physicians at Mount Sinai Hospital to assess perceptions, created a CONSULT card that uses a mnemonic for key elements, and developed a training session for how to call consults. We also conducted a consult training session using the CONSULT card as part of orientation in 2011 for all interns. We assessed the acceptability, feasibility, and sustainability of this intervention. RESULTS: Of 1001 trainees, 403 (40%) responded. Respondents reported that the most important components of calling consults included giving patient name, medical record number, and location (91%), and giving a clear question/reason (89%). Respondents also reported that these behaviors are done consistently for only 64%, and 10% of consults, respectively. Trainees reported that consult interactions affect the timeliness of treatment (62%), timeliness of tests performed (57%), appropriateness of diagnosis (56%), and discharge planning (49%). Approximately 300 interns attended the consult training session, and their feedback demonstrated acceptability and utility of the session. CONCLUSIONS: Trainees believe that consult interactions impact patient care, but important components of the consult call are often missing. Our training and CONSULT card is an acceptable, feasible, and novel training intervention. Once developed, the training session and CONSULT card require minimal faculty time to deliver.