Reimagining a pass/fail clinical core clerkship: a US residency program director survey and meta-analysis.

Pass/fail (P/F) grading has emerged as an alternative to tiered clerkship grading. Systematically evaluating existing literature and surveying program directors (PD) perspectives on these consequential changes can guide educators in addressing inequalities in academia and students aiming to improve their residency applications. In our survey, a total of 1578 unique PD responses (63.1%) were obtained across 29 medical specialties. With the changes to United States Medical Licensure Examination (USMLE), responses showed increased importance of core clerkships with the implementation of Step 2CK cutoffs. PDs believed core clerkship performance was a reliable representation of an applicant's preparedness for residency, particularly in Accreditation Council for Graduate Medical Education's (ACGME)Medical Knowledge and Patient Care and Procedural Skills. PDs disagreed with P/F core clerkships because it more difficult to objectively compare applicants. No statistically significant differences in responses were found in PD preferential selection when comparing applicants from tiered and P/F core clerkship grading systems. If core clerkships adopted P/F scoring, PDs would further increase emphasis on narrative assessment, sub-internship evaluation, reference letters, academic awards, professional development and medical school prestige. In the meta-analysis, of 6 studies from 2,118 participants, adjusted scaled scores with mean difference from an equal variance model from PDs showed residents from tiered clerkship grading systems overall performance, learning ability, work habits, personal evaluations, residency selection and educational evaluation were not statistically significantly different than from residents from P/F systems. Overall, our dual study suggests that while PDs do not favor P/F core clerkships, PDs do not have a selection preference and do not report a difference in performance between applicants from P/F vs. tiered grading core clerkship systems, thus providing fertile grounds for institutions to examine the feasibility of adopting P/F grading for core clerkships.

Racism and Bioethics: The Myth of Color Blindness.

Like many fields, bioethics has been constrained to thinking to race in terms of colorblindness, the idea that ideal deliberation would ignore race and hence prevent bias. There are practical and ethically significant problems with colorblind approaches to ethical deliberation, and important reasons why race is ethically relevant. Future discourse needs to understand how and why race is relevant in bioethics.

The TRANSFORM Patient Safety Project: a microsystem approach to improving outcomes on inpatient units.

BACKGROUND: Improvements in hospital patient safety have been made, but innovative approaches are needed to accelerate progress. Evidence is emerging that microsystem approaches to quality and safety improvement in hospital care are effective. OBJECTIVE: We aimed to evaluate the effects of a multifaceted, microsystem-level patient safety program on clinical outcomes and safety culture on inpatient units. DESIGN: A 1-year prospective interventional study was conducted, followed by a 6-month sustainability phase. SETTING AND PARTICIPANTS: Four medical and surgical inpatient units within an academic university medical center were included, with registered nurses and residents representing study participants. INTERVENTIONS: In situ simulation training; debriefing of medical emergencies; monthly patient safety team meetings; patient safety champion role; interdisciplinary patient safety conferences; recognition program for exemplary teamwork. OUTCOMES: Hospital-acquired severe sepsis/septic shock and acute respiratory failure; unplanned transfers to higher level of care (HLOC); weighted risk-adjusted mortality. Safety culture was measured using a widely accepted, validated survey. RESULTS: Rates of hospital-acquired severe sepsis/septic shock and acute respiratory failure decreased on study units, from 1.78 to 0.64 (p = 0.04) and 2.44 to 0.43 per 1,000 unit discharges (p = 0.03), respectively. The mean number of days between cases of severe sepsis/septic shock increased from baseline to the intervention period (p = 0.03). Unplanned transfers to HLOC increased from 715 to 764 per 1,000 unit transfers (p = 0.08). The weighted risk-adjusted observed-to-expected mortality ratio on all study units decreased from 0.50 to 0.40 (p < 0.001). Overall scores of safety culture on study units improved after the 1-year intervention, significantly for nurses (p < 0.001), but not for residents (p = 0.06). Scores significantly improved in nine of twelve survey dimensions for nurses, compared to in four dimensions for residents. CONCLUSION: A multifaceted patient safety program suggested an association with improved hospital-acquired complications and weighted, risk-adjusted mortality, and improved nurses' perceptions of safety culture on inpatient study units.

The patient-centered medical home: an ethical analysis of principles and practice.

The patient-centered medical home (PCMH), with its focus on patient-centered care, holds promise as a way to reinvigorate the primary care of patients and as a necessary component of health care reform. While its tenets have been the subject of review, the ethical dimensions of the PCMH have not been fully explored. Consideration of the ethical foundations for the core principles of the PCMH can and should be part of the debate concerning its merits. The PCMH can align with the principles of medical ethics and potentially strengthen the patient-physician relationship and aspects of health care that patients value. Patient choice and these ethical considerations are central and at least as important as the economic and practical arguments in support of the PCMH, if not more so. Further, the ethical principles that support key concepts of the PCMH have implications for the design and implementation of the PCMH. This paper explores the PCMH in light of core principles of ethics and professionalism, with an emphasis both on how the concept of the PCMH may reinforce core ethical principles of medical practice and on further implications of these principles.

Listening in on difficult conversations: an observational, multi-center investigation of real-time conversations in medical oncology.

BACKGROUND: The quality of communication in medical care has been shown to influence health outcomes. Cancer patients, a highly diverse population, communicate with their clinical care team in diverse ways over the course of their care trajectory. Whether that communication happens and how effective it is may relate to a variety of factors including the type of cancer and the patient's position on the cancer care continuum. Yet, many of the routine needs of cancer patients after initial cancer treatment are often not addressed adequately. Our goal is to identify areas of strength and areas for improvement in cancer communication by investigating real-time cancer consultations in a cross section of patient-clinician interactions at diverse study sites. METHODS/DESIGN: In this paper we describe the rationale and approach for an ongoing observational study involving three institutions that will utilize quantitative and qualitative methods and employ a short-term longitudinal, prospective follow-up component to investigate decision-making, key topics, and clinician-patient-companion communication dynamics in clinical oncology. DISCUSSION: Through a comprehensive, real-time approach, we hope to provide the fundamental groundwork from which to promote improved patient-centered communication in cancer care.

Patient whiteboards to improve patient-centred care in the hospital.

BACKGROUND: Patient whiteboards facilitate communication between patients and hospital providers, but little is known about their impact on patient satisfaction and awareness. Our objectives were to: measure the impact in improving patients' understanding of and satisfaction with care; understand barriers for their use by physicians and how these could be overcome; and explore their impact on staff and patients' families. METHODS: In 2012, we conducted a 3-week pilot of multidisciplinary whiteboard use with 104 inpatients on the general medicine service at Stanford University Medical Center. A brief, inperson survey was conducted with two groups: (1) 56 patients on two inpatient units with whiteboards and (2) 48 patients on two inpatient units without whiteboards. Questions included understanding of: physician name, goals of care, discharge date and satisfaction with care. We surveyed 25 internal medicine residents regarding challenges of whiteboard use, along with physical therapists, occupational therapists, case managers, consulting physicians and patients' family members (n=40). RESULTS: The use of whiteboards significantly increased the proportion of patients who knew: their physician (p≤=0.0001), goals for admission (p≤=0.0016), their estimated discharge date (p≤=0.049) and improved satisfaction with the hospital stay overall (p≤=0.0242). Physicians, ancillary staff and patient families all found the whiteboards to be helpful. In response, residents were also more likely to integrate whiteboard use into their daily work flow. CONCLUSIONS: Inpatient whiteboards help physicians and ancillary staff with communication, improve patients' awareness of their care team, admission plans and duration of admission, and significantly improve patient overall satisfaction.

Someone Like Me: An Examination of the Importance of Race-Concordant Mentorship in Urology.

OBJECTIVE: To describe differences in urology mentorship exposure for medical students across race/ethnicity and to explore how much potential mentees valued the importance of race-concordant mentorship. METHODS: All medical students at UCLA received a cross-sectional survey. Dependent variables were perceived quality of mentorship in urology and association between race-concordant mentorship and perceived importance of race-concordant mentorship. Mentors were self-selected by medical students. Variables were compared across race/ethnicity using descriptive statistics and multivariate analyses. Subset analyses looking at race-concordance between mentor and student was performed using stratified Cochran-Mantel-Haenszel tests. This was performed to determine if there were differences, across race/ethnicity, in rating of importance of having a race-concordant mentor. RESULTS: The likelihood of having a urologist as a mentor was similar across race/ethnicity. Under-Represented in Medicine (URiM) students were more likely to report that having a mentor of the same race/ethnicity was extremely important (Asian 9%, Black 58%, Latinx 55% and White 3%, P < .001) compared to their non-URiM peers who were more likely to rate having a race-concordant mentor as not at all important (Asian 34%, Black 5%, Latinx 8%, White 79%, P < .001). URiM students with race-concordant mentors were still more likely to rate having a mentor of the same race/ethnicity as extremely/very important (73%) compared to their non-URiM peers (9%, P = .001). URiM students with race-discordant mentors also rated importance of mentors of the same race/ethnicity as extremely/very important (67%) compared to their non-URiM peers (11%, P = .006). CONCLUSION: URiM medical students regard race-concordant mentorship as extremely important. Interventions addressing mentor racial/ethnic concordance and those promoting culturally responsive mentorship may optimize recruitment of URiM students into urology.

Racial and Ethnic Differences in Medical Student Timing and Perceived Quality of Exposure to Urology.

OBJECTIVE: To contextualize the low representation of Under-Represented in Medicine (URiM) in urology, we examine differences in timing and perceived quality of urology clinical and research exposures for medical students across race/ethnicity. METHODS: A cross-sectional survey was distributed to all medical students at University of California, Los Angeles. Dependent variables were timing of urology exposure and perceived quality of urology exposure. Descriptive statistics and multivariate analyses were used to compare variables across race/ethnicity. Logistic regression was used to determine odds of early exposure to urology across race/ethnicity. RESULTS: Black and Latinx students were significantly less likely to discover urology before MS3 (P <.001). Although URiM students were more likely to recall receiving a urology interest group invitation (Asian 46%, Black 53%, Latinx 67%, White 48%, P = .03), they were less likely to attend an event (Asian 23%, Black 4%, Latinx 3% and White 15%, P <.001) despite being more likely to be interested in urology (Asian 32%, Black 38%, Latinx 50%, White 28%, P = .01). Black students were more likely to gain exposure via family/friend with a urological diagnosis. Black and Latinx students were twice as dissatisfied with timing and method of medical school exposure to urology versus their peers. There were differences across race/ethnicity for whether or not a student had engaged in urology research (Asian 10%, Black 5%, Latinx 2%, White 2%, P = .01). CONCLUSION: Racial/ethnic disparities exist in early exposure to urology, involvement in urology interest group, access to research, and satisfaction with exposure to urology. Interventions addressing the timing and quality of urology exposures may optimize recruitment of URiM students into urology.

Trends in the Racial and Ethnic Diversity in the US Urology Workforce.

OBJECTIVE: To examine the historical trends and factors underlying the current state of racial/ethnic representation within the urology workforce at each stage of the educational pipeline. METHODS: Using data from the US Census Bureau and the Association of American Medical Colleges, trends in racial/ethnic distribution for 2007-2008 to 2019-2020 were tracked in the educational pipeline for academic urologists. This pipeline was defined as progressively diminishing cohorts, starting with the US population, leading to medical school application, acceptance, and graduation, through to urology residency application, matching, and graduation, and ending with urology faculty appointment. A comparative cohort analysis was performed for academic year 2018-2019 for differences in racial/ethnic distribution across cohorts by binomial tests. RESULTS: From 2007-2008 to 2019-2020, while the proportion of Latinx/Hispanic urology applicants increased by 0.38% per year (95% CI 0.24, 0.52), their proportion in the urology resident population remained unchanged (0.07% per year, 95% CI -0.20, 0.06) from 2011-2012 to 2019-2020. There was a decrease in the proportion of Black urology applicants (-0.13% per year, 95% CI -0.24, -0.02) and no change in the resident population (-0.03% per year, 95% CI -0.11, 0.05), despite an increase in total number of residents (n = 1043 to n = 1734) from 2009-2010 to 2019-2020. In 2018-2019, there were step-wise decreases in proportion of Black and Latinx/Hispanic members represented at critical stages of the educational pipeline (P <0.0001). CONCLUSION: Attrition in URM urologists occur at key educational stages. This paper offers opportunities for the design of interventions to diversify the urology workforce.

Prospective, Randomized Trial Comparing Simulator-based versus Traditional Teaching of Direct Ophthalmoscopy for Medical Students.

OBJECTIVE: To compare results of simulator-based vs traditional training of medical students in direct ophthalmoscopy. DESIGN: Randomized controlled trial. METHODS: First-year medical student volunteers completed 1 hour of didactic instruction regarding direct ophthalmoscopes, fundus anatomy, and signs of disease. Students were randomized to an additional hour of training on a direct ophthalmoscope simulator (n = 17) or supervised practice examining classmates (traditional method, n = 16). After 1 week of independent student practice using assigned training methods, masked ophthalmologist observers assessed student ophthalmoscopy skills (technique, efficiency, and global performance) during examination of 5 patient volunteers, using 5-point Likert scales. Students recorded findings and lesion location for each patient. Two masked ophthalmologists graded answer sheets independently using 3-point scales. Students completed surveys before randomization and after assessments. Training groups were compared for grades, observer- and patient-assigned scores, and survey responses. RESULTS: The simulator group reported longer practice times than the traditional group (P = .002). Observers assigned higher technique scores to the simulator group after adjustment for practice time (P = .034). Combined grades (maximum points = 20) were higher for the simulator group (median: 5.0, range: 0.0-11.0) than for the traditional group (median: 4.0, range: 0.0-9.0), although the difference was not significant. The simulator group was less likely to mistake the location of a macular scar in 1 patient (odds ratio: 0.28, 95% confidence interval: 0.056-1.35, P = .013). CONCLUSIONS: Direct ophthalmoscopy is difficult, regardless of training technique, but simulator-based training has apparent advantages, including improved technique, the ability to localize fundus lesions, and a fostering of interest in learning ophthalmoscopy, reflected by increased practice time.

Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research.

BACKGROUND: Cultural competency training has been proposed as a way to improve patient outcomes. There is a need for evidence showing that these interventions reduce health disparities. OBJECTIVE: The objective was to conduct a systematic review addressing the effects of cultural competency training on patient-centered outcomes; assess quality of studies and strength of effect; and propose a framework for future research. DESIGN: The authors performed electronic searches in the MEDLINE/PubMed, ERIC, PsycINFO, CINAHL and Web of Science databases for original articles published in English between 1990 and 2010, and a bibliographic hand search. Studies that reported cultural competence educational interventions for health professionals and measured impact on patients and/or health care utilization as primary or secondary outcomes were included. MEASUREMENTS: Four authors independently rated studies for quality using validated criteria and assessed the training effect on patient outcomes. Due to study heterogeneity, data were not pooled; instead, qualitative synthesis and analysis were conducted. RESULTS: Seven studies met inclusion criteria. Three involved physicians, two involved mental health professionals and two involved multiple health professionals and students. Two were quasi-randomized, two were cluster randomized, and three were pre/post field studies. Study quality was low to moderate with none of high quality; most studies did not adequately control for potentially confounding variables. Effect size ranged from no effect to moderately beneficial (unable to assess in two studies). Three studies reported positive (beneficial) effects; none demonstrated a negative (harmful) effect. CONCLUSION: There is limited research showing a positive relationship between cultural competency training and improved patient outcomes, but there remains a paucity of high quality research. Future work should address challenges limiting quality. We propose an algorithm to guide educators in designing and evaluating curricula, to rigorously demonstrate the impact on patient outcomes and health disparities.

Patient-centered discussions about prostate cancer screening: a real-world approach.

National guidelines recommend that primary care providers discuss the risks and benefits of prostate cancer screening with their patients but give little guidance on how to fit such a complex discussion into a busy clinic encounter. The authors propose a process-oriented approach (Ask-Tell-Ask) that promotes tailored conversations and value-based recommendations. The Ask-Tell-Ask approach includes diagnosing a patient's informational needs, providing targeted education based on those needs, and making a shared decision about testing. This time-efficient model emphasizes the provider's role as an interactive guide rather than a one-way supplier of information. Although there is no way to make these discussions simple, this streamlined strategy can help patients and providers efficiently negotiate the complex and important decision of screening for prostate cancer.

Addressing Conflicts of Interest in Health and Medicine: Current Evidence and Implications for Patient Decision Aid Development.

BACKGROUND: More stringent policies for addressing conflicts of interest have been implemented around the world in recent years. Considering the value of revisiting conflict of interest quality standards set by the International Patient Decision Aid Standards (IPDAS) Collaboration, we sought to review evidence relevant to 2 questions: 1) What are the effects of different strategies for managing conflicts of interest? and 2) What are patients' perspectives on conflicts of interest? METHODS: We conducted a narrative review of English-language articles and abstracts from 2010 to 2019 that reported relevant quantitative or qualitative research. RESULTS: Of 1743 articles and 118 abstracts identified, 41 articles and 2 abstracts were included. Most evidence on the effects of conflict of interest management strategies pertained only to subsequent compliance with the management strategy. This evidence highlighted substantial noncompliance with prevailing requirements. Evidence on patient perspectives on conflicts of interest offered several insights, including the existence of diverse views on the acceptability of conflicts of interest, the salience of conflict of interest type and monetary value to patients, and the possibility that conflict of interest disclosure could have unintended effects. We identified no published research on the effects of IPDAS Collaboration conflict of interest quality standards on patient decision making or outcomes. LIMITATIONS: Because we did not conduct a systematic review, we may have missed some evidence relevant to our review questions. In addition, our team did not include patient partners. CONCLUSIONS: The findings of this review have implications for the management of conflicts of interest not only in patient decision aid development but also in clinical practice guideline development, health and medical research reporting, and health care delivery.

Surmounting the unique challenges in health disparities education: a multi-institution qualitative study.

BACKGROUND: The National Consortium for Multicultural Education for Health Professionals (Consortium) comprises educators representing 18 US medical schools, funded by the National Institutes of Health. Collective lessons learned from curriculum implementation by principal investigators (PIs) have the potential to guide similar educational endeavors. OBJECTIVE: Describe Consortium PI's self-reported challenges with curricular development, solutions and their new curricular products. METHODS: Information was collected from PIs over 2 months using a 53-question structured three-part questionnaire. The questionnaire addressed PI demographics, curriculum implementation challenges and solutions, and newly created curricular products. Study participants were 18 Consortium PIs. Descriptive analysis was used for quantitative data. Narrative responses were analyzed and interpreted using qualitative thematic coding. RESULTS: Response rate was 100%. Common barriers and challenges identified by PIs were: finding administrative and leadership support, sustaining the momentum, continued funding, finding curricular space, accessing and engaging communities, and lack of education research methodology skills. Solutions identified included engaging stakeholders, project-sharing across schools, advocacy and active participation in committees and community, and seeking sustainable funding. All Consortium PIs reported new curricular products and extensive dissemination efforts outside their own institutions. CONCLUSION: The Consortium model has added benefits for curricular innovation and dissemination for cultural competence education to address health disparities. Lessons learned may be applicable to other educational innovation efforts.

Beyond knowledge, toward linguistic competency: an experiential curriculum.

INTRODUCTION/AIMS: Training is essential for future health care providers to effectively communicate with limited English proficient (LEP) patients during interpreted encounters. Our aim is to describe an innovative skill-based medical school linguistic competency curriculum and its impact on knowledge and skills. SETTING: At Stanford University School of Medicine, we incorporated a linguistic competency curriculum into a 2-year Practice of Medicine preclinical doctoring course and pediatrics clerkship over three cohorts. PROGRAM DESCRIPTION: First year students participated in extensive interpreter-related training including: a knowledge-based online module, interactive role-play exercises, and didactic skill-building sessions. Students in the pediatrics clerkship participated in interpreted training exercises with facilitated feedback. PROGRAM EVALUATION: Knowledge and skills were evaluated in the first and fourth years. First year students' knowledge scores increased (pre-test = 0.62, post-test = 0.89, P < 0.001), and they demonstrated good skill attainment during an end-year performance assessment. One cohort of students participated in the entire curriculum and maintained performance into the fourth year. DISCUSSION: Our curriculum increased knowledge and led to skill attainment, each of which showed good durability for a cohort of students evaluated 3 years later. With a growing LEP population, these skills are essential to foster in future health care providers to effectively communicate with LEP patients and reduce health disparities.

A behavioral and systems view of professionalism.

Professionalism may not be sufficient to drive the profound and far-reaching changes needed in the US health care system, but without it, the health care enterprise is lost. Formal statements defining professionalism have been abstract and principle based, without a clear description of what professional behaviors look like in practice. This article proposes a behavioral and systems view of professionalism that provides a practical approach for physicians and the organizations in which they work. A more behaviorally oriented definition makes the pursuit of professionalism in daily practice more accessible and attainable. Professionalism needs to evolve from being conceptualized as an innate character trait or virtue to sophisticated competencies that can and must be taught and refined over a lifetime of practice. Furthermore, professional behaviors are profoundly influenced by the organizational and environmental context of contemporary medical practice, and these external forces need to be harnessed to support--not inhibit--professionalism in practice. This perspective on professionalism provides an opportunity to improve the delivery of health care through education and system-level reform.

High-Value Care Culture Among the Future Physician Workforce in Internal Medicine.

PURPOSE: Training in high-spending regions correlates with higher spending patterns among practicing physicians. This study aimed to evaluate whether trainees' exposure to a high-value care culture differed based on type of health system in which they trained. METHOD: In 2016, 517 internal medicine residents at 12 California graduate medical education programs (university, community, and safety-net medical centers) completed a cross-sectional survey assessing perceptions of high-value care culture within their respective training program. The authors used multilevel linear regression to assess the relationship between type of medical center and High-Value Care Culture Survey (HVCCS) scores. The correlation between mean institutional HVCCS and Centers for Medicare and Medicaid Services' Value-Based Purchasing (VBP) scores was calculated using Spearman rank coefficients. RESULTS: Of 517 residents, 306 (59.2%), 83 (16.1%), and 128 (24.8%) trained in university, community, and safety-net programs, respectively. Across all sites, the mean HVCCS score was 51.2 (standard deviation [SD] 11.8) on a 0-100 scale. Residents reported lower mean HVCCS scores if they were from safety-net-based training programs (ß = -4.4; 95% confidence interval: -8.2, -0.6) with lower performance in the leadership and health system messaging domain (P < .001). Mean institutional HVCCS scores among university and community sites positively correlated with institutional VBP scores (Spearman r = 0.71; P < .05). CONCLUSIONS: Safety-net trainees reported less exposure to aspects of high-value care culture within their training environments. Tactics to improve the training environment to foster high-value care culture include training, increasing access to data, and improving open communication about value.