Barriers and Facilitators for Under-Represented in Medicine (URiM) Medical Students Interested in Surgical Sub-specialties.

Background: Little is known on drivers and detractors underrepresented in medicine (URiM) medical students face. Methods: Using the nominal group technique (NGT), we explored experiences that strengthen or weaken the enthusiasm to pursue a career in surgery among URiM medical students (October 2021- April 2022); participants voted on the three most important experiences (weight of 3= top rated, = 1 for the lowest rated). Responses from NGT with at least one vote were weighted, ranked, and categorized. Results: Seventeen students participated. Experiences that strengthen enthusiasm (36 responses with at least one vote) involved mentorship and role models (weighted sum percentage, 35%), demonstrating grit (15%), lifestyle (15%), patient interactions (14%), technical skills (11%), community and team (10%), and intellectual stimulation (1%). Experiences that weaken enthusiasm (33 responses with at least one vote) include the minority experience (weighted sum percentage, 51%), quality of life (25%), toxic environment (13%), lack of information (7%), and finances (5%). Conclusions: Mentorship, demonstrating grit, and feeling a sense of community were important positive experiences or attitudes. The minority experience, toxic environment, perceptions of self-worth, and lifestyle misconceptions perceived by URiM must be addressed to increase diversity, equity, and inclusion.

Impact of Virtual Interviewing on Geographic Placement for Cardiology Fellowship Recruitment.

Background Virtual interviewing for cardiology fellowship was instituted in the 2021 fellowship application cycle because of the COVID-19 pandemic and restricted travel. The impact on geographic patterns of fellow-training program matching is unknown. This study sought to determine if there was a difference in geographic placement of matched fellows for cardiology fellowship match after initiation of virtual interviews compared with in-person interviewing. Methods and Results All US-based accredited cardiovascular disease fellowship programs that participated in the 2019 to 2021 fellowship match cycles and had publicly available data with fellowship and residency training locations and training year were included. Each fellow was categorized based on whether their fellowship and residency programs were in the same institution, same state, same US census region, or different census region. Categories were mutually exclusive. Of 236 eligible programs, 118 (50%) programs were identified, composed of 1787 matched fellows. Compared with the previrtual cohort (n=1178 matched fellows), there was no difference in the geographic placement during the 2021 virtual cycle (n=609 matched fellows) (P=0.19), including the proportion matched at the same program (30.6% versus 31.5%), same state but different program (13% versus 13.8%), same region but different state (24.2% versus 19.7%), or different region (35% versus 33.1%). There was also no difference when stratified by program size or geographic region. Conclusions The use of virtual interviewing in the 2021 cardiology fellowship application cycle showed no significant difference in the geographic placement of matched fellows compared with in-person interviewing. Further study is needed to evaluate the impact of virtual interviewing and optimize its use in fellowship recruitment.

What Defines an Honors Student? Survey of Pediatric and Internal Medicine Faculty Perspectives.

OBJECTIVE: Although considerable emphasis is placed on the attainment of honors in core medical school clerkships, little is known about what student characteristics are used by attending physicians to earn this designation. The purpose of this study was to evaluate what values and characteristics that attending physicians consider important in the evaluation of Pediatrics and Internal Medicine clerkship students for clinical honors designation. METHODS: This cross-sectional survey study was framed around Accreditation Council for Graduate Medical Education (ACGME) competencies. It was administered at three tertiary care hospitals associated with one large medical school in an urban setting. Teaching ward attendings in Pediatrics and Internal Medicine who evaluated third-year medical students between 2013 and 2016 were surveyed. RESULTS: Overall, Pediatric and Internal Medicine faculty demonstrated close agreement in which competencies were most important in designating clinical honors. Both groups believed that professionalism was the most important factor and that systems-based practice and patient care were among the least important factors. The only competency with a significant difference between the two groups was systems-based practice, with Internal Medicine placing more emphasis on the coordination of patient care and understanding social determinants of health. CONCLUSIONS: Professionalism, communication skills, and medical knowledge are the most important characteristics when determining clinical honors on Pediatrics and Internal Medicine clerkships.

Clinical Reasoning Assessment Methods: A Scoping Review and Practical Guidance.

PURPOSE: An evidence-based approach to assessment is critical for ensuring the development of clinical reasoning (CR) competence. The wide array of CR assessment methods creates challenges for selecting assessments fit for the purpose; thus, a synthesis of the current evidence is needed to guide practice. A scoping review was performed to explore the existing menu of CR assessments. METHOD: Multiple databases were searched from their inception to 2016 following PRISMA guidelines. Articles of all study design types were included if they studied a CR assessment method. The articles were sorted by assessment methods and reviewed by pairs of authors. Extracted data were used to construct descriptive appendixes, summarizing each method, including common stimuli, response formats, scoring, typical uses, validity considerations, feasibility issues, advantages, and disadvantages. RESULTS: A total of 377 articles were included in the final synthesis. The articles broadly fell into three categories: non-workplace-based assessments (e.g., multiple-choice questions, extended matching questions, key feature examinations, script concordance tests); assessments in simulated clinical environments (objective structured clinical examinations and technology-enhanced simulation); and workplace-based assessments (e.g., direct observations, global assessments, oral case presentations, written notes). Validity considerations, feasibility issues, advantages, and disadvantages differed by method. CONCLUSIONS: There are numerous assessment methods that align with different components of the complex construct of CR. Ensuring competency requires the development of programs of assessment that address all components of CR. Such programs are ideally constructed of complementary assessment methods to account for each method's validity and feasibility issues, advantages, and disadvantages.

Physician Order Entry Clerical Support Improves Physician Satisfaction and Productivity.

OBJECTIVES: To examine the impact of clerical support personnel for physician order entry on physician satisfaction, productivity, timeliness with electronic health record (EHR) documentation, and physician attitudes. METHODS: All seven part-time physicians at an academic general internal medicine practice were included in this quasi-experimental (single group, pre- and postintervention) mixed-methods study. One full-time clerical support staff member was trained and hired to enter physician orders in the EHR and conduct previsit planning. Physician satisfaction, productivity, timeliness with EHR documentation, and physician attitudes toward the intervention were measured. RESULTS: Four months after the intervention, physicians reported improvements in overall quality of life (good quality, 71%-100%), personal balance (43%-71%), and burnout (weekly, 43%-14%; callousness, 14%-0%). Matched for quarter, productivity increased: work relative value unit (wRVU) per session increased by 20.5% (before, April-June 2014; after, April-June 2015; range -9.2% to 27.5%). Physicians reported feeling more supported, more focused on patient care, and less stressed and fatigued after the intervention. CONCLUSIONS: This study supports the use of physician order entry clerical personnel as a simple, cost-effective intervention to improve the work lives of primary care physicians.

Rapid antigen group A streptococcus test to diagnose pharyngitis: a systematic review and meta-analysis.

BACKGROUND: Pharyngitis management guidelines include estimates of the test characteristics of rapid antigen streptococcus tests (RAST) using a non-systematic approach. OBJECTIVE: To examine the sensitivity and specificity, and sources of variability, of RAST for diagnosing group A streptococcal (GAS) pharyngitis. DATA SOURCES: MEDLINE, Cochrane Reviews, Centre for Reviews and Dissemination, Scopus, SciELO, CINAHL, guidelines, 2000-2012. STUDY SELECTION: Culture as reference standard, all languages. DATA EXTRACTION AND SYNTHESIS: Study characteristics, quality. MAIN OUTCOME(S) AND MEASURE(S): Sensitivity, specificity. RESULTS: We included 59 studies encompassing 55,766 patients. Forty three studies (18,464 patients) fulfilled the higher quality definition (at least 50 patients, prospective data collection, and no significant biases) and 16 (35,634 patients) did not. For the higher quality immunochromatographic methods in children (10,325 patients), heterogeneity was high for sensitivity (inconsistency [I(2)] 88%) and specificity (I(2) 86%). For enzyme immunoassay in children (342 patients), the pooled sensitivity was 86% (95% CI, 79-92%) and the pooled specificity was 92% (95% CI, 88-95%). For the higher quality immunochromatographic methods in the adult population (1,216 patients), the pooled sensitivity was 91% (95% CI, 87 to 94%) and the pooled specificity was 93% (95% CI, 92 to 95%); however, heterogeneity was modest for sensitivity (I(2) 61%) and specificity (I(2) 72%). For enzyme immunoassay in the adult population (333 patients), the pooled sensitivity was 86% (95% CI, 81-91%) and the pooled specificity was 97% (95% CI, 96 to 99%); however, heterogeneity was high for sensitivity and specificity (both, I(2) 88%). CONCLUSIONS: RAST immunochromatographic methods appear to be very sensitive and highly specific to diagnose group A streptococcal pharyngitis among adults but not in children. We could not identify sources of variability among higher quality studies. The present systematic review provides the best evidence for the wide range of sensitivity included in current guidelines.

Mastering improvement science skills in the new era of quality and safety: the Veterans Affairs National Quality Scholars Program.

RATIONALE, AIMS AND OBJECTIVES: Healthcare professionals need a new skill set to ensure the success of quality improvement in healthcare. The Department of Veterans Affairs (VA) initiated the VA National Quality Scholars fellowship in 1998; its mission is to improve the quality of care, ensure safety, accelerate healthcare re-design, and advance the improvement science by educating the next generation of leaders in quality and safety. We describe the critical need for leadership in quality and safety and interprofessional education, illustrate the curriculum, provide lessons learned by fellows, summarize key lessons learned from the implementation of an interprofessional education approach, and present most recent accomplishments. METHODS: Narrative review. RESULTS: As of 2011, 106 program alumni are embedded in the health care delivery system across the United States. Since 2009, when nurse fellows joined the program, of the first nine graduating interdisciplinary fellows, the tailored curriculum has resulted in five advanced academic degrees, 42 projects, 29 teaching activities, 44 presentations, 36 publications, six grants funded or submitted, and two awards. CONCLUSIONS: The VA National Quality Scholars program continues to nurture and develop leaders for the new millennium focusing on interprofessional education. The nations' health care systems need strong interdisciplinary leaders in advanced quality improvement science who are dedicated to improving the overall quality of health and health care.

Marketing to increase participation in a Web-based continuing medical education cultural competence curriculum.

INTRODUCTION: CME providers may be interested in identifying effective marketing strategies to direct users to specific content. Online advertisements for recruiting participants into activities such as clinical trials, public health programs, and continuing medical education (CME) have been effective in some but not all studies. The purpose of this study was to compare the impact of 2 marketing strategies in the context of an online CME cultural competence curriculum (www.c-comp.org). METHODS: In an interrupted time-series quasi-experimental design, 2 marketing strategies were tested: (1) wide dissemination to relevant organizations over a period of approximately 4 months, and (2) Internet paid search using Google Ads (5 consecutive 8-week periods--control 1, cultural/CME advertisement, control 2, hypertension/ content advertisement, control 3). Outcome measures were CME credit requests, Web traffic (visits per day, page views, pages viewed per visit), and cost. RESULTS: Overall, the site was visited 19,156 times and 78,160 pages were viewed. During the wide dissemination phase, the proportion of visits requesting CME credit decreased between the first (5.3%) and second (3.3%) halves of this phase (p = .04). During the Internet paid search phase, the proportion of visits requesting CME credit was highest during the cultural/CME advertisement period (control 1, 1.4%; cultural/CME ad, 4.3%; control 2, 1.5%; hypertension/content ad, 0.6%; control 3, 0.8%; p < .001). All measures of Web traffic changed during the Internet paid search phase (p < .01); however, changes were independent of the advertisement periods. The incremental cost for the cultural advertisement per CME credit requested was US $0.64. DISCUSSION: Internet advertisement focusing on cultural competence and CME was associated with about a threefold increase in requests for CME credit at an incremental cost of under US $1; however, Web traffic changes were independent of the advertisement strategy.

What should we include in a cultural competence curriculum? An emerging formative evaluation process to foster curriculum development.

PURPOSE: To identify, prioritize, and organize components of a cultural competence curriculum to address disparities in cardiovascular disease. METHOD: In 2006, four separate nominal group technique sessions were conducted with medical students, residents, community physicians, and academic physicians to generate and prioritize a list of concepts (i.e., ideas) to include in a curriculum. Afterward, 45 educators and researchers organized and prioritized the concepts using a card-sorting exercise. Multidimensional scaling (MDS) and hierarchical cluster analysis produced homogeneous groupings of related concepts and generated a cognitive map. The main outcome measures were the number of cultural competence concepts, their relative ranks, and the cognitive map. RESULTS: Thirty participants generated 61 concepts; 29 were identified by at least two participants. The cognitive map organized concepts into four clusters, interpreted as (1) patient's cultural background (e.g., information on cultures, habits, values), (2) provider and health care (e.g., clinical skills, awareness of one's bias, patient centeredness, professionalism), communication skills (e.g., history, stereotype avoidance, health disparities epidemiology), (3) cross-culture (e.g., idiomatic expressions, examples of effective communication), and (4) resources to manage cultural diversity (e.g., translator guides, instructions, community resources). The MDS two-dimensional solution demonstrated a good fit (stress = 0.07; R² = 0.97). CONCLUSIONS: A novel, combined approach allowed stakeholders' inputs to identify and cognitively organize critical domains used to guide development of a cultural competence curriculum. Educators may use this approach to develop and organize educational content for their target audiences, especially in ill-defined areas like cultural competence.

Use of ecological momentary assessment to guide curricular change in graduate medical education.

PURPOSE: To assess whether a novel evaluation tool could guide curricular change in an internal medicine residency program. METHOD: The authors developed an 8-item Ecological Momentary Assessment tool and collected daily evaluations from residents of the relative educational value of 3 differing ambulatory morning report formats (scale: 8  =  best, 0  =  worst). From the evaluations, they made a targeted curricular change and used the tool to assess its impact. RESULTS: Residents completed 1388 evaluation cards for 223 sessions over 32 months, with a response rate of 75.3%. At baseline, there was a decline in perceived educational value with advancing postgraduate (PGY) year for the overall mean score (PGY-1, 7.4; PGY-2, 7.2; PGY-3, 7.0; P < .01) and for percentage reporting greater than 2 new things learned (PGY-1, 77%; PGY-2, 66%; PGY-3, 50%; P < .001). The authors replaced the format of a lower scoring session with one of higher cognitive content to target upper-level residents. The new session's mean score improved (7.1 to 7.4; P  =  .03); the adjusted odds ratios before and after the change for percentage answering, "Yes, definitely" to "Area I need to improve" was 2.53 (95% confidence interval [CI], 1.45-4.42; P  =  .001) and to "Would recommend to others," it was 2.08 (95% CI, 1.12-3.89; P  =  .05). CONCLUSIONS: The Ecological Momentary Assessment tool successfully guided ambulatory morning report curricular changes and confirmed successful curricular impact. Ecological Momentary Assessment concepts of multiple, frequent, timely evaluations can be successfully applied in residency curriculum redesign.

The Department of Veterans Affairs National Quality Scholars Fellowship Program: experience from 10 years of training quality scholars.

The Department of Veterans Affairs (VA) National Quality Scholars Fellowship Program (VAQS) was established in 1998 as a postgraduate medical education fellowship to train physicians in new methods of improving the quality and safety of health care for veterans and the nation. The VAQS curriculum is based on adult learning theory, with a national core curriculum of face-to-face components, technologically mediated distance learning components, and a unique local curriculum that draws from the strengths of regional resources. VAQS has established strong ties with other VA programs. Fellows' research and quality improvement projects are integrated with local and regional VA leaders' priorities, enhancing the relevance and visibility of the fellows' efforts and promoting recruitment of fellows to VA positions. VAQS has enrolled 98 fellows since 1999; 75 have completed the program and 24 are currently enrolled. Fellowship graduates have pursued a variety of career paths: 17% are continuing training (most in VA), 31% hold a VA faculty/staff position, 66% are academic faculty, and 80% conduct clinical or research work related to health care improvement. Graduates have held leadership positions in VA, Department of Defense, academic medicine, and public health agencies. Combining knowledge about the improvement of health care with adult learning strategies, distance learning technologies, face-to-face meetings, local mentorship, and experiential projects has been successful in improving care in VA and preparing physicians to participate in, study, and lead the improvement of health care quality and safety.

Outcomes and perioperative hyperglycemia in patients with or without diabetes mellitus undergoing coronary artery bypass grafting.

BACKGROUND: The association between perioperative hyperglycemia and outcomes in patients with and without diabetes mellitus undergoing coronary artery bypass grafting is not well defined. We measured the association between perioperative hyperglycemia and outcomes among patients undergoing coronary artery bypass grafting. METHODS: We report a historic cohort study of 1574 patients who had undergone coronary artery bypass grafting between 1998 and 1999, 545 (34.6%) with diabetes. Perioperative blood glucose level was defined as the average of all blood glucose tests obtained on the day of and the day after surgery. Outcomes were 30-day mortality, infection rates (sternum, harvest site, sepsis, pneumonia, urinary tract), and resource utilization. RESULTS: After adjusting for diabetes status and calculated preoperative mortality or mediastinitis risk scores, each 50 mg/dL (2.78 mmol/L) blood glucose increase was not statistically associated with higher mortality (odds ratio 1.37; 95% confidence interval, 0.98 to 1.92; p = 0.07), or higher infection rate (odds ratio 1.23, 95% confidence interval 0.94 to 1.60; p = 0.14). Each 50 mg/dL blood glucose increase was associated with longer postoperative days by 0.76 days (95% confidence interval 0.36 to 1.17 days; p < 0.001), increased hospitalization charges by 2824 dollars (95% confidence interval 1599 dollars to 4049 dollars; p < 0.001), and increased hospitalization cost by 1769 dollars (95% confidence interval 928 dollars to 2610 dollars; p < 0.001). In the unadjusted analysis, infections occurred more frequently in patients with diabetes (6.6% vs 4.1%, p = 0.03). CONCLUSIONS: Perioperative hyperglycemia is associated with increased resource utilization in patients undergoing coronary artery bypass grafting with and without diabetes.

Administrative data versus corrected administrative data.

The purpose of this research was to provide insight into the use of existing administrative data and to identify changes that could be made to improve broad-based use of administrative data. Data were collected on patients hospitalized with pneumonia at a 715 bed hospital in North Carolina in 1996-1997. Patients were selected from administrative databases via diagnosis and charge codes. Outcome variables were length of stay and total hospital charges. Explanatory variables were age, sex, race, insurance type, season of year, admission source (emergency department or other), comorbidity score, care path designation, physician specialty and teaching appointment. These data were collected from administrative data and then from a limited chart review to correct the administrative data. We found no significant differences in economic outcomes between the administrative data and the corrected administrative data. Administrative data appear to be a reliable and cost-effective data source for quality assessment.