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

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

Virtual reality curriculum increases paediatric residents' knowledge of CHDs.

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

Behavior Change Counseling of Patients with Substance Use Disorders by Health Professions Students.

OBJECTIVE: The purpose of this project was to create an interprofessional substance use disorders (SUDs) course that provided health professions students an opportunity to acquire and apply behavior change counseling skills for patients with SUDs with direct observation, assessment, and feedback. METHODS: The interprofessional SUDs course was offered five times within one academic year as part of a one-month psychiatry clerkship. The course focused on developing empathy and examining personal bias, behavioral change counseling, and recognition, screening, and treatment of SUDs. Students practiced behavior change counseling during the course and with a SUD patient. A faculty member experienced in behavior change counseling assessed students' patient counseling using the validated Behavior Change Counseling Index (BECCI). RESULTS: Seventy-eight students from medicine, nursing, pharmacy, social work, and physician assistant programs completed the one-month course. Fifty-three students counseled a SUD patient. Students' BECCI-rated counseling skills indicated they performed recommended counseling practices and spoke "less than half the time" or "about half the time" when counseling. Ninety-three percent of SUD patients reported a willingness for follow-up care about their substance use after the student-led session with a student. CONCLUSION: Following participation in an innovative interprofessional SUD course that included behavior change counseling, students demonstrated their ability to apply their skills during training and with a SUD patient. The study demonstrated promising patient outcomes following student counseling.

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

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

You have no Choice but to go on: How Physicians and Midwives in Ghana Cope with High Rates of Perinatal Death.

Objectives Healthcare providers in low-resource settings confront high rates of perinatal mortality. How providers cope with such challenges can affect their well-being and patient care; we therefore sought to understand how physicians and midwives make sense of and cope with these deaths. Methods We conducted semi-structured interviews with midwives, obstetrician-gynecologists, pediatricians and trainee physicians at a large teaching hospital in Kumasi, Ghana. Interviews focused on participants' coping strategies surrounding perinatal death. We identified themes from interview transcripts using qualitative content analysis. Results Thirty-six participants completed the study. Themes from the transcripts revealed a continuum of control/self-efficacy and engagement with the deaths. Providers demonstrated a commitment to push on with their work and provide the best care possible. In select cases, they described the transformative power of attitude and sought to be agents of change. Conclusions Physicians and midwives in a low-resource country in sub-Saharan Africa showed remarkable resiliency in coping with perinatal death. Still, future work should focus on training clinicians in coping and strengthening their self-efficacy and engagement.

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

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

Twelve tips for developing, implementing, and sustaining medical education fellowship programs: Building on new trends and solid foundations.

Medical education fellowship programs (MEFPs) are a form of faculty development contributing to an organization's educational mission and participants' career development. Building an MEFP requires a systematic design, implementation, and evaluation approach which aligns institutional and individual faculty goals. Implementing an MEFP requires a team of committed individuals who provide expertise, guidance, and mentoring. Qualified MEFP directors should utilize instructional methods that promote individual and institutional short and long term growth. Directors must balance the use of traditional design, implementation, and evaluation methodologies with advancing trends that may support or threaten the acceptability and sustainability of the program. Drawing on the expertise of 28 MEFP directors, we provide twelve tips as a guide to those implementing, sustaining, and/or growing a successful MEFP whose value is demonstrated by its impacts on participants, learners, patients, teaching faculty, institutions, the greater medical education community, and the population's health.

Medical school handoff education improves postgraduate trainee performance and confidence.

OBJECTIVES: Determine postgraduate first-year (PGY-1) trainees ability to perform patient care handoffs and associated medical school training. METHODS: About 173 incoming PGY-1 trainees completed an OSCE handoff station and a survey eliciting their training and confidence in conducting handoffs. Independent t-tests compared OSCE performance of trainees who reported receiving handoff training to those who had not. Analysis of variance examined differences in performance based on prior handoff instruction and across levels of self-assessed abilities, with significance set at p<0.05. RESULTS: About 35% of trainees reported receiving instruction and 51% reported receiving feedback about their handoff performance in medical school. Mean handoff performance score was 69.5%. Trainees who received instruction or feedback during medical school had higher total and component handoff performance scores (p<0.05); they were also more confident in their handoff abilities (p<0.001). Trainees with higher self-assessed skills and preparedness performed better on the OSCE (p<0.05). CONCLUSIONS: This study provides evidence that incoming trainees are not well prepared to perform handoffs. However, those who received instruction during medical school perform better and are more confident on standardized performance assessments. Given communication failures lead to uncertainty in patient care and increases in medical errors, medical schools should incorporate handoff training as required instruction.

Stimulating and evaluating acquired knowledge of addiction among residents through repeat testing: a pilot study.

BACKGROUND: Addictive disorders receive little attention in medical school and residency program curricula. OBJECTIVE: To evaluate an innovative learning approach encouraging and stimulating residents to focus on key competencies by testing before and after their addiction psychiatry rotation. METHODS: We developed a 50-item test on substance use disorders. Twenty-six general psychiatry residents, post-graduate year I (PGY-I) and II (PGY-II), participated in the pilot study and were divided into three groups. PGY-I residents were divided into Group 1, who were tested the last day of the rotation and again 2 months later, and Group 2, who were tested on the first and the last day of the rotation. Eight of 11 PGY-II residents agreed to participate as controls (Group 3), as they had previously completed their 2-month addiction psychiatry rotation as PGY-I's. All residents were informed that the testing would not affect their individual grade. After taking the first test, all three groups received related study materials. RESULTS: A statistically significant increase in re-test scores occurred in the combined groups (p < .001). The largest changes in scores were among Group 2 (the group taking the test on first and last day of their addiction psychiatry rotation). CONCLUSION: The greatest learning seemed to occur when residents were tested at beginning and end of the rotation. However, all residents' test scores improved to some degree, regardless of their level of training or the timing of the test. SCIENTIFIC SIGNIFICANCE: This study offers support for testing as a learning guide and as a means of stimulating residents' learning.

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

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

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

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

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

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

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

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

Guardianship: The Implications of Resident Physician Perceptions of Caring for Incapacitated Older Adults Without Advocates.

As the incidence of dementia rises, increased utilization of surrogate decision-makers, including legal guardians, is anticipated. This manuscript presents an analysis of resident physicians' experiences and perceptions regarding requirements, roles, and responsibilities of caring for older adults in need of, or already under, legal guardianship. This is a cross-sectional study, conducted at a tertiary academic medical center. A survey was sent, via Qualtrics, to all emergency medicine, family medicine, internal medicine, general surgery, and medicine-pediatric resident physicians. Eighty-eight out of three hundred thirty-three (26.4%) eligible residents physicians completed the survey. Most (98.9%) reported caring for patients under guardianship, yet many resident physicians reported significant uncertainty regarding the roles and responsibilities of guardianship, including its potential benefits and limitations. They also displayed misconceptions and overconfidence about guardians' abilities to facilitate disposition, ensure financial security, and assign code status, among other matters. Our study highlights the importance of structured and directed education on the topic of guardianship for medical trainees.

Self-perceived competence among medical residents in skills needed to care for patients with advanced dementia versus metastatic cancer.

To examine medical residents' perceived competence in caring for patients with dementia we conducted an online survey of all 120 second, third and fourth-year residents in Internal Medicine, Medicine/Pediatrics, and Family Medicine at University of Michigan. A structured survey elicited residents' training, experience, confidence, and perceived career needs for skills in estimating prognosis, symptom management, and communication in caring for patients with dementia, compared to patients with metastatic cancer. Among the 61 (51 %) respondents, a majority report lower confidence in assessing prognosis and eliciting treatment wishes in patients with dementia (vs. metastatic cancer), and in performing skills integral to the care of patients with dementia, including the ability to assess caregiver needs, decisional capacity, advise on place of care, and manage agitation, despite viewing these skills as important to their future careers. These findings support the need for enhanced education on optimal care of patients with advanced dementia.

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

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

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

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