A multimedia paediatric cardiology assessment tool for medical students and general paediatric trainees: development and validation.

BACKGROUND: Understanding how cardiovascular structure and physiology guide management is critically important in paediatric cardiology. However, few validated educational tools are available to assess trainee knowledge. To address this deficit, paediatric cardiologists and fellows from four institutions collaborated to develop a multimedia assessment tool for use with medical students and paediatric residents. This tool was developed in support of a novel 3-dimensional virtual reality curriculum created by our group. METHODS: Educational domains were identified, and questions were iteratively developed by a group of clinicians from multiple centres to assess understanding of key concepts. To evaluate content validity, content experts completed the assessment and reviewed items, rating item relevance to educational domains using a 4-point Likert scale. An item-level content validity index was calculated for each question, and a scale-level content validity index was calculated for the assessment tool, with scores of ≥0.78 and ≥0.90, respectively, representing excellent content validity. RESULTS: The mean content expert assessment score was 92% (range 88-97%). Two questions yielded ≤50% correct content expert answers. The item-level content validity index for 29 out of 32 questions was ≥0.78, and the scale-level content validity index was 0.92. Qualitative feedback included suggestions for future improvement. Questions with ≤50% content expert agreement and item-level content validity index scores <0.78 were removed, yielding a 27-question assessment tool. CONCLUSIONS: We describe a multi-centre effort to create and validate a multimedia assessment tool which may be implemented within paediatric trainee cardiology curricula. Future efforts may focus on content refinement and expansion to include additional educational domains.

Virtual reality curriculum increases paediatric residents' knowledge of CHDs.

OBJECTIVES: Virtual reality has emerged as a unique educational modality for medical trainees. However, incorporation of virtual reality curricula into formal training programmes has been limited. We describe a multi-centre effort to develop, implement, and evaluate the efficacy of a virtual reality curriculum for residents participating in paediatric cardiology rotations. METHODS: A virtual reality software program ("The Stanford Virtual Heart") was utilised. Users are placed "inside the heart" and explore non-traditional views of cardiac anatomy. Modules for six common congenital heart lesions were developed, including narrative scripts. A prospective case-control study was performed involving three large paediatric residency programmes. From July 2018 to June 2019, trainees participating in an outpatient cardiology rotation completed a 27-question, validated assessment tool. From July 2019 to February 2020, trainees completed the virtual reality curriculum and assessment tool during their cardiology rotation. Qualitative feedback on the virtual reality experience was also gathered. Intervention and control group performances were compared using univariate analyses. RESULTS: There were 80 trainees in the control group and 52 in the intervention group. Trainees in the intervention group achieved higher scores on the assessment (20.4 ± 2.9 versus 18.8 ± 3.8 out of 27 questions answered correctly, p = 0.01). Further analysis showed significant improvement in the intervention group for questions specifically testing visuospatial concepts. In total, 100% of users recommended integration of the programme into the residency curriculum. CONCLUSIONS: Virtual reality is an effective and well-received adjunct to clinical curricula for residents participating in paediatric cardiology rotations. Our results support continued virtual reality use and expansion to include other trainees.

Competency-based education: programme design and challenges to implementation.

CONTEXT: Competency-based education (CBE) has been widely cited as an educational framework for medical students and residents, and provides a framework for designing educational programmes that reflect four critical features: a focus on outcomes, an emphasis on abilities, a reduction of emphasis on time-based training, and promotion of learner centredness. Each of these features has implications and potential challenges for implementing CBE. METHODS: As an experiment in CBE programme design and implementation, the University of Michigan Master of Health Professions Education (UM-MHPE) degree programme was examined for lessons to be learned when putting CBE into practice. The UM-MHPE identifies 12 educational competencies and 20 educational entrustable professional activities (EPAs) that serve as the vehicle for both learning and assessment. The programme also defines distinct roles of faculty members as assessors, mentors and subject-matter experts focused on highly individualised learning plans adapted to each learner. CONCLUSIONS: Early experience with implementing the UM-MHPE indicates that EPAs and competencies can provide a viable alternative to traditional courses and a vehicle for rigorous assessment. A high level of individualisation is feasible but carries with it significant costs and makes intentional community building essential. Most significantly, abandoning a time-based framework is a difficult innovation to implement in a university structure that is predicated on time-based education.

Assessment challenges in competency-based education: A case study in health professions education.

There is a growing demand for health sciences faculty with formal training in education. Addressing this need, the University of Michigan Medical School created a Master in Health Professions Education (UM-MHPE). The UM-MHPE is a competency-based education (CBE) program targeting professionals. The program is individualized and adaptive to the learner's situation using personal mentoring. Critical to CBE is an assessment process that accurately and reliably determines a learner's competence in educational domains. The program's assessment method has two principal components: an independent assessment committee and a learner repository. Learners submit evidence of competence that is evaluated by three independent assessors. The assessments are presented to an Assessment Committee who determines whether the submission provides evidence of competence. The learner receives feedback on the submission and, if needed, the actions needed to reach competency. During the program's first year, six learners presented 10 submissions for review. Assessing learners in a competency-based program has created challenges; setting standards that are not readily quantifiable is difficult. However, we argue it is a more genuine form of assessment and that this process could be adapted for use within most competency-based formats. While our approach is demanding, we document practical learning outcomes that assess competence.

Promoting medical students' reflection on competencies to advance a global health equities curriculum.

BACKGROUND: The move to frame medical education in terms of competencies - the extent to which trainees "can do" a professional responsibility - is congruent with calls for accountability in medical education. However, the focus on competencies might be a poor fit with curricula intended to prepare students for responsibilities not emphasized in traditional medical education. This study examines an innovative approach to the use of potential competency expectations related to advancing global health equity to promote students' reflections and to inform curriculum development. METHODS: In 2012, 32 medical students were admitted into a newly developed Global Health and Disparities (GHD) Path of Excellence. The GHD program takes the form of mentored co-curricular activities built around defined competencies related to professional development and leadership skills intended to ameliorate health disparities in medically underserved settings, both domestically and globally. Students reviewed the GHD competencies from two perspectives: a) their ability to perform the identified competencies that they perceived themselves as holding as they began the GHD program and b) the extent to which they perceived that their future career would require these responsibilities. For both sets of assessments the response scale ranged from "Strongly Disagree" to "Strongly Agree." Wilcoxon's paired T-tests compared individual students' ordinal rating of their current level of ability to their perceived need for competence that they anticipated their careers would require. Statistical significance was set at p < .01. RESULTS: Students' ratings ranged from "strongly disagree" to "strongly agree" that they could perform the defined GHD-related competencies. However, on most competencies, at least 50 % of students indicated that the stated competencies were beyond their present ability level. For each competency, the results of Wilcoxon paired T-tests indicate - at statistically significant levels - that students perceive more need in their careers for GHD-program defined competencies than they currently possess. CONCLUSION: This study suggests congruence between student and program perceptions of the scope of practice required for GHD. Students report the need for enhanced skill levels in the careers they anticipate. This approach to formulating and reflecting on competencies will guide the program's design of learning experiences aligned with students' career goals.

The educational impact of the Specialty Care Access Network-Extension of Community Healthcare Outcomes program.

BACKGROUND: With the aging hepatitis C cohort and increasing prevalence of fatty liver disease, the burden on primary care providers (PCPs) to care for patients with liver disease is growing. In response, the Veterans Administration implemented initiatives for primary care-specialty referral to increase PCP competency in complex disease management. The Specialty Care Access Network-Extension of Community Healthcare Outcomes (SCAN-ECHO) program initiative was designed to transfer subspecialty knowledge to PCPs through case-based distance learning combined with real-time consultation. There is limited information regarding the initiative's ability to engage PCPs to learn and influence their practice. MATERIALS AND METHODS: We surveyed PCPs to determine the factors that led to their participation in this program and the educational impact of participation. RESULTS: Of 51 potential participants, 24 responded to an anonymous survey. More than 75% of respondents participated more than one time in a SCAN-ECHO clinic. Providers were motivated to participate by a desire to learn more about liver disease, to apply the knowledge gained to future patients, and to save their patients time traveling to another center for specialty consultation. Seventy-one percent responded that the didactic component and case-based discussion were equally important. It is important that participation changed clinical practice: 75% of providers indicated they had personally discussed the information they learned from the case presentations with their colleague(s), and 42% indicated they helped a colleague care for their patient with the knowledge learned during discussions of other participants' cases. CONCLUSIONS: This study shows that the SCAN-ECHO videoconferencing program between PCPs and specialists can educate providers in the delivery of specialty care from a distance and potentially improve healthcare delivery.

Opioid Management Review Committee: Fostering Interdisciplinary Education and Support Amid the Ongoing US Opioid Overdose Crisis.

BACKGROUND: Over the past two decades, pain and suffering caused by the U.S. opioid crisis have resulted in significant morbidity, policy reforms and healthcare resource strain, and affected healthcare providers' efforts to manage their patients' pain. In 2017, Cleveland Clinic's Department of Palliative and Supportive Care established their Opioid Management Review Committee (OMRC), which focuses on patient safety, opioid stewardship, education on specialist pain management and addiction medicine skills, and offers emotional and informational support to colleagues managing complex pain cases. OBJECTIVES: This quality assessment and improvement activity describes the organization and effects of the OMRC on healthcare workers in the department. METHODS: On February 1, 2023, an online survey was distributed to attendees of the OMRC. Participants were asked to provide their demographic information and free text responses to questions about the purpose of the OMRC, their judgment about the extent to which the OMRC has changed their approach to pain management, the OMRC's impact on their approach to opioid management, its impact on the clinicians' confidence in managing nonmedical opioid use or comorbid substance use, and suggestions to improve future meetings. RESULTS: Fifty-nine out of 79 clinicians completed the survey (75% response rate). Participants' aggregate responses indicated that the committee fostered interdisciplinary collaboration, provided emotional and professional support, increased awareness of responsible opioid prescribing, and enhanced confidence in managing complex cases involving non-medical opioid use or comorbid substance use. CONCLUSION: The OMRC represents a comprehensive interdisciplinary approach to safely manage opioid therapy during the contemporary opioid overdose crisis.

Web-streamed didactic instruction on substance use disorders compares favorably with live-lecture format.

OBJECTIVE: Education about substance use disorders in medical schools and, subsequently, physicians' identification of and intervention in these diagnoses lag behind that of most other disabling disorders. To reduce barriers and improve access to education about this major public health concern, medical schools are increasingly adopting web-based instruction on substance use and other psychiatric disorders as part of their curricula; however, it is not well known how a web-streamed lecture compares with a traditional one. The authors hypothesized that both these formats would be equally efficacious in terms of knowledge acquisition and student satisfaction. METHOD: Authors conducted a prospective study to test this hypothesis among third-year medical students who received web-streamed lecture on substance use/addiction versus those who received a traditional live lecture. RESULTS: Of the 243 students, significantly more students completed the on-line lecture series. Of the 216 students in the final study sample, 130 (60%) were assigned to the web-streamed lecture and 86 (40%) to the live lecture. Within-subject comparisons of pre- and post-lecture scores for the entire cohort indicated a significant improvement in the percentage of correct answers (21.0% difference). Although no differences in improved scores between the two groups were found, students in the live-lecture group reported small, but significantly higher levels of satisfaction. CONCLUSIONS: This preliminary work supports the hypothesis that a web-streamed lecture can be at least equally efficacious as a traditional lecture in terms of knowledge acquisition. However, attention needs to be paid to the lower satisfaction levels associated with using the web-streamed format.

Patient-mediated factors predicting early- and late-stage presentation of breast cancer in Egypt.

OBJECTIVE: Breast cancer fatality rates are high in low- and middle-income countries because of the late stage at diagnosis. We investigated patient-mediated determinants for late-stage presentation of breast cancer in Egypt. METHODS: A case-case comparison was performed for 343 women with breast cancer, comparing those who had been initially diagnosed at Stage I or II with those diagnosed at Stage III or IV. Patients were recruited from the National Cancer Institute of Cairo University and Tanta Cancer Center in the Nile delta. Patients were either newly diagnosed or diagnosed within the year preceding the study. Interviews elicited information on disease history and diagnosis, beliefs and attitudes toward screening practices, distance to treatment facility, education, income, and reproductive history. RESULTS: Forty-six per cent of the patients had presented at late stage. Women seen in Cairo were more likely to present at late stages than patients in Tanta (OR=5.05; 95% CI=1.30, 19.70). Women without any pain were more likely to present at later stage (OR=2.68; 95% CI=1.18, 6.08). Knowledge of breast self-examination increased the likelihood of women to present in early stages significantly (OR=0.24; 95% CI=0.06, 0.94). CONCLUSIONS: Despite increasing numbers of cancer centers in Egypt during the past 20 years, additional regional facilities are needed for cancer management. In addition, increasing awareness about breast cancer will have significant long-term impact on breast cancer prevention.

Patients' perception of care during image-guided breast biopsy in a rural community breast center: communication matters.

This retrospective study surveyed women about their experience with image-guided breast biopsies in a rural cancer center. Our study objectives were to determine: women's perception of their emotional and physical comfort during the biopsy; the clarity and acceptability of the communication about the biopsy, as well as the methods used to provide the results of her biopsy and treatment options; and the overall impressions of the technical and personal care she received. A single mailed survey of 500 biopsy patients. The response rate was 43% (n = 215). Prior to their biopsy, 22% had been concerned that the biopsy would be painful and 43% were concerned that the biopsy might show cancer. Almost all women rated the communication about the biopsy procedure as understandable (99%) and accurately reflecting their experience (99%.). Most (77%) patients characterized the biopsy as producing minimal discomfort, although 5% disagreed. Most patients (98%) characterized their physician and technologists as caring about their emotional and physical comfort. Most patients felt that the typical 1-day wait to receive the results of their biopsy was reasonable (90%) and that the use of the phone to convey the results was acceptable (90%). On comparing patients with a diagnosis of cancer to those without, there was no difference in the level of satisfaction with the use of the phone to communicate biopsy results. This study offers encouragement that communication practices can alleviate the anxiety of women undergoing image-guided breast cancer biopsies.

Career development needs assessment in cancer prevention and control: focus on research in minority and international settings.

This study was conducted as a needs assessment to inform the development of an educational program designed to provide mentorship and skills supporting careers in cancer research, with a focus on domestic minority populations and international settings. The objectives were to determine: (1) the level of interest among trainees in careers in cancer research and (2) preferences and constraints constituted by potential components, features, and duration of the proposed extramural training program. The target populations were participants and directors of federal training programs in cancer research, specifically (1) trainees in the NCI-K01, K07, and K08 programs, as well as the Department of Defense (DoD) Breast and Prostate Control Programs and (2) PIs of NCI R25 training programs and federally designated Comprehensive Cancer Centers. We developed, piloted, and administered electronically a survey to elicit perspectives of trainees' career development needs and preferences. Response rates from each training group exceeded 65%, with the exception of the K08 trainees (49%). The proportion of cancer research trainees who are interested in careers that include research on US minority groups was 70% of K01 trainees, 72% of K07 trainees, 45% of K08 trainees, and 75% of DoD trainees. A substantial percent of these trainees indicated their plans also include cancer research in international settings: 60% of K01s; 50% of K07s, 42% of K08s, and 87% of DoD trainees. Trainees identified substantial interest in a program that would provide the following: mentoring, manuscript writing skills, collaborative research in special populations, financial support, and focused modular courses. This study offers encouraging evidence of interest which focused in extramural education to augment skills facilitating cancer-related research in special populations.

Research training of students in minority and international settings: lessons learned from cancer epidemiology education in special populations.

This article describes the development and evaluation of an NCI-sponsored short-term summer cancer research education program. The study questions examined: the feasibility of conducting a cancer education program in special populations at multiple US and international field sites for masters students; the merit and worth that students and faculty attribute to the program; and students' scholarly and cancer-related career outcomes. Developing a new curriculum, increasing the pool of mentors, utilizing and increasing the number of field sites, and program dissemination were also evaluated. Evidence of the program's success included students' completion of field experiences at multiple sites and their subsequent 70% project-related publication rate, with 79% of trainees reporting themselves as likely to pursue future cancer-related careers. Evaluation-guided future plans for the program include implementing faculty development to further enhance the program outcomes.

Development and evaluation of the University of Michigan's Practice-Oriented Research Training (PORT) Program.

We describe the development and evaluation of a clinical research training program designed specifically for such health professionals as occupational and physical therapists. Outcomes of program success included trainees' self-rating of research skills before and after the program, as well as submission of a formal grant application to a grant competition for program participants. At program completion, participants reported improvements in their research skills, with the most gain in formulating research questions and writing a testable hypothesis and the least gain in understanding statistics. Of the 21 participants, 43% submitted a grant proposal to a competitive intramural grant program. In the next year, grantees of the program will continue to be mentored by the program mentors while conducting their research projects. Given the initial successes, this program represents a promising model for providing research training to practicing clinicians.

Eating Problems in Advanced Dementia: Navigating Difficult Conversations.

Introduction: The majority of older adults with advanced dementia (AD) develop difficulties with eating and swallowing, often prompting concerns about nutrition and quality of life. Employing a palliative approach requires providers to attain skills in addressing symptoms and communicating with family caregivers about the trajectory of AD and associated dysphagia, as well as to elicit goals of care. Research suggests internal medicine (IM) residents often perceive minimal education during training addressing skills needed to care for patients with AD. Methods: We developed and piloted a small-group interactive seminar utilizing a trigger video depicting a family meeting addressing eating problems in a patient with AD. Case-based learning, small-group discussion, and learner reflection were employed. We assessed the impact on 82 of the 106 IM, medicine-pediatrics, and neurology residents who participated in the seminar. Results: Participant evaluation indicated residents showed high satisfaction and perceived the educational content of the seminar to be robust and clinically relevant. We found statistically significant (p < .001) improvements in self-reported confidence in dementia-specific skills postseminar. Effect size was large to very large (Cohen's d = 1.3-1.7). Discussion: An interactive, case-based seminar utilizing a video depicting a realistic family meeting improved residents' self-efficacy in skills needed to address nutritional issues, engage in goals-of-care discussions, and reflect on concerns among caregivers of patients with AD. The seminar teaches important geriatric and palliative concepts meant to improve residents' ability to care for older adults with AD in their future careers.

Short-term outcomes and long-term impact of a programme in medical education for medical students.

OBJECTIVES: There is growing appreciation of the value of early preparation of future medical educators. Staff development programmes, conferences and workshops pertaining to the training of educators may be crucial to the pursuit of a school's larger educational mission to educate students, doctors and scholars and to provide comprehensive knowledge, research, patient care and service. This study examined the efficacy of a 1-week educational intervention aimed at preparing medical students to become effective doctor educators by building skills early in their careers. The study asked whether participation in a 5-day teacher training programme led to increased knowledge of instructional methods, more favourable attitudes towards teaching, and the integration of structured instructional design methods in a student-developed teaching project. METHODS: A mixed methods research design was employed with quantitative data captured through pre- and post-test inventories, qualitative components captured through written comments, and a 2-year post-intervention survey. Quantitative analyses included pre-/post-intervention repeated measures with calculated effect sizes. Qualitative analysis was conducted using constant comparative methods. RESULTS: Subjects demonstrated improved content knowledge and more positive attitudes towards motivation, teaching confidence, teacher roles, varied pedagogy, and use of assessment, instructional planning, and evaluation. Subjects were able to incorporate the programme's teaching theory and methods into their teaching projects and assessment of peers' and others' teaching in their own institutions 2 years post-training. CONCLUSIONS: This study demonstrates that a well-designed programme for teacher preparation can be pedagogically effective for training medical students to become better educators and that this learning can be incorporated into long-term practice.

Scaling Up a Global Health and Disparities Path of Excellence Pilot Program at the University of Michigan Medical School.

PROBLEM: Transforming medical school curricula to train physicians to better address society's needs is a complex task, as students must develop expertise in areas other than clinical medicine. APPROACH: In 2010, the University of Michigan Medical School (UMMS) launched the Global Health and Disparities (GHD) Path of Excellence as part of a larger curriculum transformation. The GHD Path is a co-curriculum with the goal of ameliorating health disparities in the United States and abroad. It was developed iteratively based on student and faculty feedback. Student feedback emphasized the value of the relationships with faculty and other students, the capstone project, and exposure to role models and professional networks. Faculty described the joy of interacting with students and the desire for recognition by their departments for their role as an advisor. OUTCOMES: Informed by the GHD Path experience, UMMS embraced the Path model, which emphasized professional relationships, career development, and high-impact scholarly work, making it different from the traditional medical curriculum, and the school implemented 7 other Paths between 2013 and 2018. Elements common to all Paths include a capstone project, a longitudinal advisor separate from the capstone advisor, exposure to role models and leaders, and the dissemination of scholarly work to promote networking. NEXT STEPS: Next steps for the Paths of Excellence include developing methods to systematically monitor students' progress, facilitating mentoring skills in and recognizing faculty advisors, and measuring the long-term impact of the Paths on students and society.

Teaching and Assessing Professionalism in Radiology: Resources and Scholarly Opportunities to Contribute to Required Expectations.

Teaching and assessing trainees' professionalism now represents an explicit expectation for Accreditation Council Graduate Medical Education-accredited radiology programs. Challenges to meeting this expectation include variability in defining the construct of professionalism; limits of traditional teaching and assessment methods, used for competencies historically more prominent in medical education, for professionalism; and emerging expectations for credible and feasible professionalism teaching and assessment practices in the current context of health-care training and practice. This article identifies promising teaching resources and methods that can be used strategically to augment traditional teaching of the cognitive basis for professionalism, including role modeling, case-based scenarios, debriefing, simulations, narrative medicine (storytelling), guided discussions, peer-assisted learning, and reflective practice. This article also summarizes assessment practices intended to promote learning, as well as to inform how and when to assess trainees as their professional identities develop over time, settings, and autonomous practice, particularly in terms of measurable behaviors. This includes assessment tools (including mini observations, critical incident reports, and appreciative inquiry) for authentic assessment in the workplace; engaging multiple sources (self-, peer, other health professionals, and patients) in assessment; and intentional practices for trainees to take responsibility for seeking our actionable feedback and reflection. This article examines the emerging evidence of the feasibility and value added of assessment of medical competency milestones, including professionalism, coordinated by the Accreditation Council Graduate Medical Education in radiology and other medical specialties. Radiology has a strategic opportunity to contribute to scholarship and inform policies in professionalism teaching and assessment practices.

Designing a Curriculum for Professionalism and Ethics Within Radiology: Identifying Challenges and Expectations.

Although professionalism and ethics represent required competencies, they are more challenging than other competencies to design a curriculum for and teach. Reasons include variability in agreed definitions of professionalism within medicine and radiology. This competency is also framed differently whether as roles, duties, actions, skills, behavior, beliefs, and attitudes. Standardizing a curriculum in professionalism is difficult because each learner's (medical student/resident) professional experiences and interactions will be unique. Professionalism is intertwined throughout all (sub) specialties and areas and its teaching cannot occur in isolation as a standalone curriculum. In the past, professionalism was not emphasized enough or at all, with global (or no) assessments, with the potential effect of trainees not valuing it. Although we can teach it formally in the classroom and informally in small groups, much of professionalism is witnessed and learned as "hidden curricula". The formal, informal, and hidden curricula often contradict each other creating confusion, disillusion, and cynicism in trainees. The corporatization of medicine pressurizes us to increase efficiency (throughput) with less focus on aspects of professionalism that add value, creating a disjoint between what we do in practice and preach to trainees. Progressively, expectations for our curriculum include providing evidence for the impacts of our efforts on patient outcomes. Generational differences in the perception of professionalism and the increasingly diverse and multicultural society in which we live affects our interpretation of professionalism, which can add to confusion and misunderstanding. The objectives of this article are to outline challenges facing curriculum design in professionalism and to make suggestions to help educators avoid or overcome them.