Transforming remediation for competency-based medical education.

We care about the future experiences of all health professions trainees as competency-based medical education evolves. It is an exciting new era with many possibilities for progress in learning and competency development. Yet we are concerned that remediation remains a troubled and stigmatized detour from routine learning that can persist as a feared off-ramp from competency development rather than a central avenue for improvement and competency achievement. We believe that it is time to acknowledge that all trainees struggle and to recognize that remediation is an essential aspect of individualized learning. Decisive steps are possible to revitalize remediation and to launch its transformation towards growth-oriented pathways for change.

Librarian-Led Assessment of Medical Students' Evidence-Based Medicine Competency: Facilitators and Barriers.

Introduction: We must ensure, through rigorous assessment that physicians have the evidence-based medicine (EBM) skills to identify and apply the best available information to their clinical work. However, there is limited guidance on how to assess EBM competency. With a better understanding of their current role in EBM education, Health Sciences Librarians (HSLs), as experts, should be able to contribute to the assessment of medical student EBM competence. The purpose of this study is to explore the HSLs perspective on EBM assessment practices, both current state and potential future activities. Methods: We conducted focus groups with librarians from across the United States to explore their perceptions of assessing EBM competence in medical students. Participants had been trained to be raters of EBM competence as part of a novel Objective Structured Clinical Examination (OSCE). This OSCE was just the starting point and the discussion covered topics of current EBM assessment and possibility for expanded responsibilities at their own institutions. We used a reflexive thematic analysis approach to construct themes from our conversations. Results: We constructed eight themes in four broad categories that influence the success of librarians being able to engage in effective assessment of EBM: administrative, curricular, medical student, and librarian. Conclusion: Our results inform medical school leadership by pointing out the modifiable factors that enable librarians to be more engaged in conducting effective assessment. They highlight the need for novel tools, like EBM OSCEs, that can address multiple barriers and create opportunities for deeper integration of librarians into assessment processes.

Validity evidence for the clinical communication skills assessment tool (CCSAT) from 9 years of implementation in a high stakes medical student OSCE.

OBJECTIVES: Communication and other clinical skills are routinely assessed in medical schools using Objective Structured Clinical Examinations (OSCEs) so routinely that it can be difficult to monitor and maintain validity. We report on the accumulation of validity evidence for the Clinical Communication Skills Assessment Tool (CCSAT) based on its use with 9 cohorts of medical students in a high stakes OSCE. METHODS: We describe the implementation of the CCSAT including information on the underlying model, the tool's items, domains, scales and scoring, and its role in curriculum. Internal structure is explored through item, internal consistency, and confirmatory factor analyses. Evidence for CCSAT validity is synthesized within prevailing frameworks (Messick12 and Kane13) based on continuous quality improvement and use of the CCSAT for feedback, remediation, curricular design, and research. RESULTS: Implementation of the CCSAT over time has facilitated our communication skills curriculum and training. Thoughtful case development and investment in standardized patient training has contributed to data quality. Item analysis supports our behaviorally anchored scale (not done, partly and well done) and the skills domains suggested by an a priori evidence-based clinical communication model were confirmed via analysis of actual student data. Evidence synthesized across the frameworks suggests consistent validity of the CCSAT for generalization inferences (that it captures the construct), responsiveness (sensitivity to change/difference), content validity/internal structure, relationships to other variables, and consequences/implications. More evidence is needed to strengthen validity of CCSAT scores for understanding extrapolation inferences and real-world implications. CONCLUSIONS AND PRACTICE IMPLICATIONS: This pragmatic approach to evaluating validity within a program of assessment serves as a model for medical schools seeking to continuously monitor the quality of clinical skill assessments, a need made particularly relevant since the US NBME no longer requires the Step 2 Clinical Skills exam, leaving individual schools with the responsibility for ensuring graduates have acquired the requisite core clinical skills. We document strong evidence for CCSAT validity over time and across cohorts as well as areas for improvement and further examination.

Racial Implicit Bias and Communication Among Physicians in a Simulated Environment.

Importance: Racial implicit bias can contribute to health disparities through its negative influence on physician communication with Black patients. Interventions for physicians to address racial implicit bias in their clinical encounters are limited by a lack of high-fidelity (realistic) simulations to provide opportunities for skill development and practice. Objective: To describe the development and initial evaluation of a high-fidelity simulation of conditions under which physicians might be influenced by implicit racial bias. Design, Setting, and Participants: This cross-sectional study, performed on an online platform from March 1 to September 30, 2022, recruited a convenience sample of physician volunteers to pilot an educational simulation. Exposures: In the simulation exercise, physicians saw a 52-year-old male standardized patient (SP) (presenting as Black or White) seeking urgent care for epigastric pain, nausea, and vomiting. The case included cognitive stressors common to clinical environments, including clinical ambiguity, stress, time constraints, and interruptions. Physicians explained their diagnosis and treatment plan to the SP, wrote an assessment and management plan, completed surveys, and took the Race Implicit Association Test (IAT) and Race Medical Cooperativeness IAT. The SPs, blinded to the purpose of the study, assessed each physician's communication using skills checklists and global rating scales. Main Outcomes and Measures: Association between physicians' IAT scores and SP race with SP ratings of communication skills. Results: In 60 physicians (23 [38.3%] Asian, 4 [6.7%] Black, 23 [38.3%] White, and 10 [16.7%] other, including Latina/o/x, Middle Eastern, and multiracial; 31 [51.7%] female, 27 [45.0%] male, and 2 [3.3%] other), the interaction of physicians' Race IAT score and SP race was significant for overall communication (mean [SD] ß = -1.29 [0.41]), all subdomains of communication (mean [SD] ß = -1.17 [0.52] to -1.43 [0.59]), and overall global ratings (mean [SD] ß = -1.09 [0.39]). Black SPs rated physicians lower on communication skills for a given pro-White Race IAT score than White SPs; White SP ratings increased as physicians' pro-White bias increased. Conclusions and Relevance: In this cross-sectional study, a high-fidelity simulation calibrated with cognitive stressors common to clinical environments elicited the expected influence of racial implicit bias on physicians' communication skills. The outlined process and preliminary results can inform the development and evaluation of interventions that seek to address racial implicit bias in clinical encounters and improve physician communication with Black patients.