Incivility in medical education: a scoping review.

Incivility in the workplace, school and political system in the United States has permeated mass and social media in recent years and has also been recognized as a detrimental factor in medical education. In this scoping review, we use the term incivility to encompass a spectrum of behaviors that occur across the continuum of medical education, and which include verbal abuse including rude or dismissive conduct, sexual and racial harassment and discrimination, and sexual and physical assault. We identified research on incivility involving medical students, residents and fellows, and faculty in North America to describe multiple aspects of incivility in medical education settings published since 2000. Our results reinforce that incivility is likely under-reported across the continuum of medical education and also confirmed incidences of incivility involving nursing personnel and patients, not emphasized in previous reviews. The authors suggest a zero-tolerance national policy if this problem is to be resolved.

A different approach to teaching pre-clerkship students physical diagnosis: standardized patient instructor-senior medical student teaching teams.

BACKGROUND: Faculty have traditionally taught the physical examination (PE) to novice medical students (pre-clerkship students.), despite recruiting and cost issues and problems standardizing their approach. ACTIVITY: We present a model using standardized patient instructor (SPI)-fourth year medical student (MS4) teams to teach PE to pre-clerkship students, leveraging the benefits of co-teaching and peer-assisted learning. RESULTS: Surveys of pre-clerkship students, MS4s and SPIs indicate positive perceptions of the program, including MS4s reporting significant growth in their professional identities as educators. Pre-clerkship students' performance on the spring clinical skills exams was equivalent to or better than their peer performance pre-program implementation. IMPLICATIONS: SPI-MS4 teams can effectively teach novice students the mechanics and clinical context of the beginners' physical exam.

Academic clinician educators: Confronting the challenges to successful retirement.

Background: The academic clinician-educator (CE) often has a career spanning 40 or more years. Retirement represents the last stage of one's professional identity. Planning for retirement can be both exciting and challenging. Although it would seem reasonable that there would be research addressing the transition to retirement that incorporates guidance on important decisions or pathways to retirement with outcomes related to satisfaction, adjustment, or fulfillment in retirement, in fact, there is minimal such research. As CEs, the recently retired authors have drawn on our experiences in pediatrics as the foundation for our inquiry. The authors suggest that retirement decisions and needs differ in academic health center (AHC) faculty from those in health-care private practice. As an example, we suggest that CEs in all specialties, and likely other senior faculty in the health sciences, may have unique opportunities in retirement to enrich their institutions and their specialty organizations. The gaps we have encountered and our experiences in the retirement process have resulted in this paper, in which we encourage research that will inform more substantial, timely, and practical advice going forward. Methods: Our exploration of retirement from AHC careers includes two foci: (1) A review of relevant literature on retirement issues the CE, AHC, and national educator organizations might consider important in this transition process; and (2) the description of a theoretical framework known as Conservation of Resources Theory simply to help organize perspectives on the losses, gains, or conservation of tangible and intangible resources to weigh in the planning and transition process. Results: Several considerations relevant to retirement planning, both specific to academic faculty retirement in the health sciences and to retirement planning more broadly, emerged from our literature exploration. However, there were virtually no studies addressing these considerations, both personal and professional, accompanied by tracking their impact on satisfaction or well-being once in retirement. Discussion: Emerging from our examination of literature and our experiences in transitioning to retirement are a number of questions deserving of further study, likely in longitudinal, comparative or more broadly in global inquiries, in the effort to develop models to guide the retiring academic CE. Over the next decade, there will be so many faculty members considering or negotiating retirement that there is an urgent need to develop and study models that both inform this process and monitor outcomes in terms of satisfaction with the retirement years.

An educational intervention to facilitate appropriate subspecialty referrals: a study assessing resident communication skills.

BACKGROUND: Our goal was to improve pediatric residents' advanced communication skills in the setting of referral to address the entrustable professional activity of subspecialty referral identified by the American Board of Pediatrics. To accomplish this aim, we created a referral and consultation curriculum to teach and assess core communication skills in subspecialty referral involving an adolescent with syncope, an anxiety-provoking symptom that is rarely associated with serious pathology. METHODS: We utilized blended multimodal educational interventions to improve resident communication skills in referral of patients. Trainees participated in 1) an interactive online module on syncope focusing on "red-flag" symptoms that would warrant a subspecialty cardiology referral and 2) a 4-h intervention with Standardized Parents (SPs), focusing on the case-based application of communication skills. Communication skills were assessed by two pre- and post- Objective Structured Clinical Examination encounters of patients with syncope, with an SP evaluation using a 20-item checklist. Analysis was performed with Sign test and McNemar's test. Trainees provided feedback on a Critical Incident Questionnaire, which was analyzed qualitatively. RESULTS: Sixty-four residents participated. There was an overall improvement in communication skills based on SP scores (82.7 ± 10.9% to 91.7 ± 5.0%, p < 0.001), and 13/20 items demonstrated significant improvement post-intervention. Residents' improved performance enabled them to address patient/family emotions, explain referral logistics, and clarify concerns to agree on a plan. CONCLUSIONS: By participating in this curriculum, residents' communication skills improved immediately post-intervention. Further research is needed to assess if this intervention improves patient care by providing residents with enduring skills to judiciously manage the referral process.

Does Medical Students' High Expression of Empathy Correlate with Their Choice of Primary Care Residencies?

OBJECTIVES: There are many factors that influence medical students' (MS) decisions when choosing a career. Some prominent factors include life-work balance, indebtedness, and flexibility of work hours. Whereas the expression of empathy has many positive correlates with a trusting and meaningful physician-patient interaction, only a few studies have analyzed the association of MS empathy expression and primary care residency selection. The results of these studies about the relationship of MS expression of empathy and their selection of primary care specialties have been conflicting, depending on the empathy instrument used. In addition, there have been other variables that have affected career decision making in more recent years not previously encountered. The objectives of our study were to analyze the association of The George Washington University School of Medicine and Health Sciences (GWU) MS Interpersonal Reactivity Index (IRI) scores and their residency selection, to compare our results with previous studies to determine whether the IRI provided more definitive relationships between empathy and career choice, and to assess whether our results confirmed the theoretical construct linking empathy with primary care physicians. METHODS: GWU third-year MS (MS3s), representing the classes of 2008-2011, completed the perspective taking and empathy subscales of the IRI, which measure cognitive and affective empathy, respectively. MS empathy scores for individual specialty were compared to those scores in internal medicine (IM) using a linear regression model. Empathy scores for patient-oriented versus technology-oriented specialties and primary versus surgical specialties were compared using the independent t test. RESULTS: A total of 593 (77.5%) MS3s had mean IRI scores of 45.1 (standard error 4.8), higher than a recent study involving MS. There were no significant differences between patient- and technology-oriented specialties (-0.65 to 0.88), primary care versus surgical residencies (-0.87 to 1.4), and women versus men (-0.20 to 1.4). Our study did not clarify previous conflicting studies in the literature. CONCLUSIONS: There are no significant differences in expression of empathy in GWU students who chose patient- versus technology-oriented and primary care versus surgical residencies. The authors can only speculate why students' high expression of empathy was not associated with selecting primary care residencies, namely, women are outnumbering men entering medicine and are selecting technology-related specialties previously identified predominantly with men, and millennials have specific traits inherent in their generation that can affect their specialty choice. The results of our study shed doubt that the theoretical construct linking MS high empathy expression and choice of primary care careers is valid today.

Can the Recruitment of Senior Transitioning Clinician Educators Enhance the Number and Quality of Resident Observations? Thinking Outside the Box.

Issue: The Accreditation Council for Graduate Medical Education's Next Accreditation System has forever changed the way faculty evaluate residents, fellows, and medical students, mandating direct observation by faculty of trainee performance. Evidence: The literature suggests that institutional culture does not support trainee observation, and faculty perceive that they have limited time to observe trainees in an efficient and effective manner. These factors contribute to an inadequate number of trainee observations, limiting faculty ability to assess trainees' achievement of competency. Hiring more faculty to increase observations has not been feasible or a priority, nor have faculty development programs been universally effective in recruiting faculty to enhance observations. Implications: To alleviate this important problem, the author proposes recruiting senior clinician educators transitioning to retirement. These are faculty who in their full-time careers have established themselves as playing a major role in teaching and might be interested in continuing their relationship with the academic health center. The number of these physicians is increasing and therefore there will be a larger pool seeking an opportunity to continue their commitment to education. Recruitment of senior clinician educators transitioning to retirement could significantly increase the number and quality of resident observations, addressing a previously insoluble problem with a relatively significant return on investment to the academic health center.

How the jazz medium can inform interprofessional health care teams in improving patient care.

INTRODUCTION: Interprofessional Health Care Teams (IPHCTs) are essential to provide cost-effective and efficient care to patients with complex illnesses, requiring the skills and expertise of many health care professionals. The jazz medium presents an instructive non-medical analogy. METHODS: We present evidence-based models to compare how effective groups perform in both health care teams and jazz ensembles. RESULTS: The jazz ensemble has implicit dependence on the salient features of leadership, individual attributes, creativity, synchronization, comprehension, communication, self-improvement, group dynamics, and economy of means. CONCLUSIONS: Features of jazz parallel those of the IPHCT and inform medicine how teams can thrive at the highest levels, using characteristics attributed to effective team functioning. Incorporating jazz educators and their approaches to music into IPHCT training may be a strategy to improve patient outcomes.

Medical Students' Professional Development as Educators Revealed Through Reflections on Their Teaching Following a Students-as-Teachers Course.

Phenomenon: Teaching is an important part of the tri-partite mission of every medical center. Although teaching often is given lower priority and recognition as opposed to patient care and/or research, this activity for many physicians in academic medicine ranks second to their patient care responsibilities. Medical teacher training has traditionally been aimed at faculty and residents through faculty development initiatives, continuing education for physicians at professional conferences, formalized degree or certificate programs in education, and residents as teachers programs. More recently medical schools have developed medical-students-as-teachers programs, often offered as 4th-year electives, to introduce learners to the theory of teaching and learning with appropriate application in the clinical setting. Data on learner outcomes and students' perceptions and experiences in these programs consist mostly of their satisfaction after completing such a program. In this article we explore 4th-year medical student trainees' experiences and emerging self-concepts as educators during a teaching elective. APPROACH: The purpose of this project was to explore students' reflections on their experiences in a 4th-year medical students-as-teachers course in their own words through their written self-assessment narratives. We used qualitative content analysis to examine 96 trainees' self-reported, written reflective narratives of how they translated their students-as-teachers course experience into application by applying newly learned educational theories, instructional strategies, and feedback skills while teaching novice peers physical diagnosis skills. FINDINGS: Narratives revealed candid self-assessments and detailed descriptions of their experiences and what they valued most from the course. Content analysis revealed nine key themes: using teaching strategies for adult learning, preparing for class, modeling professionalism, incorporating clinical correlations, exceeding course requirements, giving and receiving feedback, providing mentoring, creating a positive learning climate, and growing as educators. Insights: This study's results reveal how learners perceive and translate their experiences in a teaching course, in terms of incorporating particular knowledge or skills, valuing or displaying certain professional behaviors, and gaining self-awareness and satisfaction from teaching experiences. The findings of this study, specifically major themes from self-assessment narratives, provide us with a better understanding of medical students' developing identities and emerging professional self-concept as educators, specifically as experienced through a combination of formal teaching, and applying education theories and strategies. Findings may be informative from a program evaluation lens but also for faculty development initiatives related to training medical teachers and the larger landscape of the emerging field of Health Professions Education.

Effect of handoff skills training for students during the medicine clerkship: a quasi-randomized study.

Continuity is critical for safe patient care and its absence is associated with adverse outcomes. Continuity requires handoffs between physicians, but most published studies of educational interventions to improve handoffs have focused primarily on residents, despite interns expected to being proficient. The AAMC core entrustable activities for graduating medical students includes handoffs as a milestone, but no controlled studies with students have assessed the impact of training in handoff skills. The purpose of this study was to assess the impact of an educational intervention to improve third-year medical student handoff skills, the durability of learned skills into the fourth year, and the transfer of skills from the simulated setting to the clinical environment. Trained evaluators used standardized patient cases and an observation tool to assess verbal handoff skills immediately post intervention and during the student's fourth-year acting internship. Students were also observed doing real time sign-outs during their acting internship. Evaluators assessed untrained control students using a standardized case and performing a real-time sign-out. Intervention students mean score demonstrated improvement in handoff skills immediately after the workshop (2.6-3.8; p < 0.0001) that persisted into their fourth year acting internship when compared to baseline performance (3.9-3.5; p = 0.06) and to untrained control students (3.5 vs. 2.5; p < 0.001, d = 1.2). Intervention students evaluated in the clinical setting also scored higher than control students when assessed doing real-time handoffs (3.8 vs. 3.3; p = 0.032, d = 0.71). These findings should be useful to others considering introducing handoff teaching in the undergraduate medical curriculum in preparation for post-graduate medical training. Trial Registration Number NCT02217241.

Observing and Giving Feedback to Novice PGY-1s.

OBJECTIVES: In this new era of educational milestones and entrustable professional activities, residency programs have recognized the need to directly observe resident performance. In fact, there is little information about how often residents are observed, what procedures they perform early in training, and whether they receive feedback. Previous publications have addressed these issues exclusively through retrospective survey analyses. The purpose of this naturalistic point-of-care study was to answer the following questions about obstetrics/gynecology (OB/GYN) residents in their second month of training: what activities do residents report performing, how often are they observed and who observes them, how often do they receive feedback and what is their perception of its usefulness, and does the time of shift affect the frequency of observation and feedback? METHODS: Nine of 10 first-year OB/GYN residents at George Washington University Hospital participated in a month-long study during their second month of training. Based on point-of-care experiences, participants prospectively recorded the time of shift, activities performed, the person who observed them, whether they received feedback, and whether it was perceived as helpful. RESULTS: First-year OB/GYN residents (postgraduate year 1 [PGY-1]) perform a variety of activities early in training while being observed by senior residents, nurses, and attending physicians 70% of the time. Residents commented that feedback was helpful almost every time they received it, regardless of who provided the feedback. There were no significant differences in the quantity of observations and feedback received between day and night shifts; however, nurses and senior residents were most likely to observe residents during night shifts. CONCLUSIONS: In this naturalistic pilot study, OB/GYN residents reported performing various procedures in their second month of training, with some observations from faculty, senior residents, and nurses. Feedback, as defined in the study, is an important aspect of their early training, although it is not reported with each patient encounter. This pilot study raises critical issues that need further study, such as the following: What should be the gold standard for observing residents around a particular activity? Where should the bar be set for types and numbers of procedures that residents perform early on in training, either with patients or in simulations? What is an acceptable feedback rate around patient encounters? Should we not consider training nurses and senior residents to deliver effective feedback to residents as part of a 360-degree process, because many trainees were observed most frequently by these members of the medical team?

Do empathy, perspective-taking, sense of power and personality differ across undergraduate education and are they inter-related?

Empathy is desirable in all health care professionals in their interactions with patients and each other. Empathy in its cognitive (perspective-taking) and affective forms has been well-studied in the literature and in fact, is shown in most studies to decline during undergraduate and graduate medical education. Empathy has also been shown to be inversely proportional to one's sense of power (SOP) in the business literature. In addition, the relationship of empathy to personality traits has not been examined. This cross-sectional study of four cohorts of undergraduate medical students at a private mid-Atlantic medical school compares the empathy of first, second, third and fourth year medical students to see if there is a decline across the medical school experience. It also examines the relationship among empathy, SOP and personality type across the 4 years of medical school. Unlike in many previous studies, we found no decline in student empathy. We found no significant relationship between SOP and empathy. Finally, there were no significant differences in power perception and personality measures across all educational years surveyed.

Empathy, Sense of Power, and Personality: Do They Change During Pediatric Residency?

OBJECTIVES: Empathy is a critical competency in medicine. Prior studies demonstrate a longitudinal decrease in empathy during residency; however, they have not included pediatric residents. The relations among the expression of empathy, sense of power (ability to influence other's behavior), and personality traits in residents also have not been addressed. Lastly, there are no data on how residents compare with the general nonmedical population in their expression of empathy. The purposes of our study were to assess whether empathy, sense of power, and personality type were statistically correlated; if resident empathy declines over time; and how resident empathy compares with that of nonmedical peers. METHODS: In 2010, a cohort of individuals entering pediatric residency were given three validated survey instruments at the beginning of their first and third years of training to explore longitudinal changes in empathy, sense of power, and major personality traits. RESULTS: We found no decrease in resident empathy in 2 years of pediatric training, no changes in their sense of power, and no statistically significant correlation between empathetic tendencies and sense of power. When compared with the general nonmedical population, pediatric residents rated themselves higher in empathy. As expected, the two components of empathy (empathic concern and perspective taking) were moderately correlated. Of the major personality traits, only agreeableness showed significant correlation with empathy. CONCLUSIONS: Pediatric resident empathy did not decrease longitudinally, unlike studies in other residents. There was no inverse relation between self-perceptions of sense of power and empathy as is present in the business literature. Finally, pediatric resident empathy was significantly higher when compared with a general nonmedical population.

Developing a curriculum for emergency medicine residency orientation programs.

BACKGROUND: New residents enter emergency medicine (EM) residency programs with varying EM experiences, which makes residency orientation programs challenging to design. There is a paucity of literature to support best practices. OBJECTIVE: We report on a curriculum development project for EM residency orientation using the Kern Model. CURRICULUM: Components of the revised curriculum include administrative inculcation into the program; delivering skills and knowledge training to ensure an entering level of competence; setting expectations for learning in the overall residency curriculum; performing an introductory performance evaluation; and socialization into the program. RESULTS: Post-implementation resident surveys found the new curriculum to be helpful in preparing them for the first year of training. CONCLUSIONS: The Kern Model was a relevant and useful method for redesigning a new-resident orientation curriculum.

Exploring Medical Student Experiences With Direct Observation During the Pediatric Clerkship.

PURPOSE: Direct observation (DO) enables assessment of vital competencies, such as clinical skills. Despite national requirement that medical students experience DOs during each clerkship, the frequency, length, quality, and context of these DOs are not well established. This study examines the quality, quantity, and characteristics of DOs obtained during pediatrics clerkships across multiple institutions. METHOD: This multimethod study was performed at 6 U.S.-based institutions from March to October 2022. In the qualitative phase, focus groups and/or semistructured interviews were conducted with third-year medical students at the conclusion of pediatrics clerkships. In the quantitative phase, the authors administered an internally developed instrument after focus group discussions or interviews. Qualitative data were analyzed using thematic analysis, and quantitative data were analyzed using anonymous survey responses. RESULTS: Seventy-three medical students participated in 20 focus groups, and 71 (97.3%) completed the survey. The authors identified 7 themes that were organized into key principles: before, during, and after DO. Most students reported their DOs were conducted primarily by residents (62 [87.3%]) rather than attendings (6 [8.4%]) in inpatient settings. Participants reported daily attending observation of clinical reasoning (38 [53.5%]), communication (39 [54.9%]), and presentation skills (58 [81.7%]). One-third reported they were never observed taking a history by an inpatient attending (23 [32.4%]), and one-quarter reported they were never observed performing a physical exam (18 [25.4%]). CONCLUSIONS: This study revealed that students are not being assessed for performing vital clinical skills in the inpatient setting by attendings as frequently as previously believed. When observers set expectations, create a safe learning environment, and follow up with actionable feedback, medical students perceive the experience as valuable; however, the DO experience is currently suboptimal. Therefore, a high-quality, competency-based clinical education for medical students is necessary to directly drive future patient care by way of a competent physician workforce.

New educational modules offer tough case studies around humanistic issues.

A new set of teaching modules taken from the Emmy Award-winning documentary about children with cancer, A LION IN THE HOUSE, raises tough questions around humanistic aspects of medical education and seeks to improve the quality of teaching and learning to enhance patient care.

The Enhanced Brief Structured Observation Model: Efficiently Assess Trainee Competence and Provide Feedback.

Introduction: The regular observation of trainees is essential to ascertain trainee proficiency in competency-based assessments. Unfortunately, observation of residents is not frequent enough to facilitate entrustment decisions, and the busy clinician-educator may not have the tools or time to conduct effective and efficient observations. Methods: We created a hands-on faculty development workshop utilizing an enhanced variation of the brief structured observation (BSO) technique to train both primary care and subspecialty pediatric faculty on how to effectively and efficiently observe trainees. The workshop has provided faculty a practical approach to observing trainees in a focused fashion and providing effective feedback on clinical skills based on their observation. In the workshop, faculty had an opportunity to observe residents taking an unrehearsed history from a medical student simulating an acutely ill patient, culminating in feedback on the residents' performance using the subjective, objective, assessment, and plan (SOAP) format. Results: This faculty development workshop has been presented to more than 100 faculty both locally and nationally, and feedback has been uniformly positive, with three institutions incorporating this model into their programs to date. Discussion: This enhanced BSO workshop promotes a model that streamlines the observations of trainees and provides faculty with the tools to encourage more observations.

Student perceptions of effectiveness of the eight step preceptor (ESP) model in the ambulatory setting.

BACKGROUND: Balancing consistently effective clinical teaching with quality patient care is a crucial challenge for ambulatory preceptors. Educators have developed frameworks of specific teaching behaviors to facilitate consistent, efficient precepting, but few have evaluated their effectiveness. We modified an existing precepting model by incorporating additional adult learning principles to create the Eight Step Preceptor (ESP) model. We then determined if students perceived faculty to be more effective teachers when they incorporated more ESP components into their precepting sessions. PURPOSES: The objective was to describe the association between faculty using the ESP behaviors during their precepting and medical students' satisfaction with their learning. METHODS: A trained observer timed the duration of precepting sessions in a children's hospital ambulatory clinic between August and November 2001. Students rated faculty "teaching effectiveness," and both students and observer rated whether faculty effectively incorporated ESP behaviors during each session. RESULTS: Sessions lasted on average 26 +/- 14 min. Faculty gave a teaching point and feedback in over 50% of the precepting sessions but did not consistently incorporate the other ESP behaviors. Faculty use of more ESP behaviors correlated significantly with greater teaching effectiveness (r = .62, p < .003) but not significantly with duration of precepting sessions. CONCLUSIONS: Students perceived faculty as more effective teachers when they incorporated more ESP behaviors while precepting. The ESP model was associated with more effective ambulatory precepting in our study.

Verbal interaction analysis: viewing feedback through a different lens.

BACKGROUND: Verbal interaction analysis, though seldom applied to the feedback-giving process, can be used to assess feedback dimensions not easily assessed by other means. DESCRIPTION: The purpose of this study was to explore verbal interaction analysis as a method to assess feedback interactions between senior medical students trained as teachers and their sophomore learners. We randomly selected 14 videotaped encounters of senior teachers giving feedback to sophomore learners and classified 417 utterances to address (a) verbal dominance, (b) feedback balance, and (c) cognitive level. EVALUATION: Teachers did most of the talking (65.2%). Although some feedback was corrective (20.6%), teacher utterances were mostly positive (33.5%) or neutral (45.9%). Cognitively, the teacher utterances occurred largely at the factual (lowest) level (74.3%). CONCLUSIONS: Interaction analysis enabled us to describe 3 dimensions of teacher-learner feedback not easily assessed by other means: verbal dominance, positive-corrective balance, and cognitive level. Assessing these dimensions provides information about two theoretically important indices of feedback-giving effectiveness: learner involvement and feedback balance. Future study of verbal interaction analysis in this and other populations is warranted to further evaluate its usefulness.

The Evolution of the Clinician-Educator in the United States and Canada: Personal Reflections Over the Last 45 Years.

The challenging and changing face of medicine over the last 45 years of the author's career has dictated where faculty members' primary interaction with patients occurs, how they teach trainees, and how they measure educational outcomes. The transfer of patient care from the inpatient to the ambulatory setting in the late 20th century was instrumental in creating a "new' model for faculty-that is, the clinician-educator (CE). This individual has been defined as a faculty member whose primary responsibility as part of the academic mission is patient care and whose focus is on the theoretical constructs that inform excellent teaching and effective learning, applying these to create and inform educational scholarship. Three major forces have affected the CE over time-namely, faculty development, educational scholarship, and the advent of communities of learners. This Invited Commentary traces the evolvement of the CE from the perspective of the author.