Practice Implications of Expanded Genetic Testing in Oncology.

Genetic test use in oncology is growing, yet providers' experiences with evolving testing norms and their implications for patient care remain under-explored. In interviews with oncologists and cancer genetics professionals, 22 key informants described the increasing importance of germline results for therapeutic decision-making, preference for ordering tests directly rather than referring, and rapid adoption of cancer gene panels for testing. Implications for informed consent, result interpretation, and patient management were identified. These results suggest concerns raised by the transition of genetic test delivery from cancer genetics professionals to oncologists that must be addressed in practice guidelines and provider training.

A survey on financial support and research achievement of medical education research units in China.

AIM: To investigate the current situation of financial support and research achievement of medical education research units in China. METHODS: A total of 46 individuals in 46 medical schools completed a questionnaire including information about affiliation of the unit, financial support, published articles and achievement awards of the units. RESULT: Of the 46 schools, 24 had independent medical education research units, 36 had financial support, and 30 had research funding. The mean number of published articles was 2.53 per staff. The mean number of achievement awards was 3.80 per unit. There was a significant difference in funding and published articles between independent medical education research units and other types of units; and in published articles and achievement awards between the units with funding and without funding. CONCLUSION: The financial support from the school was the main source of medical education research units in China. More attention should be paid to the development of medical education research units, to their ability to produce high quality research and support the improvement of medical care in China.

Innovation Reports: Successes and Limitations for Promoting Innovation in Medical Education.

In 2013, Academic Medicine introduced a new article type, Innovation Reports, with the intent to promote innovation by providing a forum for publishing promising new ideas at an early stage of development. In this article, the authors examine Innovation Reports as a means for promoting innovation within the medical education community.The authors undertook a 2-part analysis. In July 2018, they examined submission data, Altmetric scores, and citations for the first 5 years of the feature. To explore authors' perceptions of the impact of publishing an Innovation Report, in October 2018, they conducted a web-based survey of corresponding authors.Between October 2013 and May 2018, 920 manuscripts were submitted under the Innovation Report category, of which 335 were sent for review and 151 were published (16% overall acceptance rate). The mean citation rate for the published Innovation Reports was 4.3 (range 0-47). The mean Altmetric Attention Score was 14.3 (range 0-441). An Altmetric score of 14 places an article in the top 20% of articles published in Academic Medicine.The 151 published Innovation Reports had 148 unique corresponding authors, of whom 85 (57%) responded to the survey. Almost all respondents (n = 82; 96%) reported that publishing an Innovation Report promoted their individual career growth. For many corresponding authors, the publication of early ideas in an Innovation Report appeared to be an end point rather than a springboard for further development and innovation, as only 14 (16%) reported publication of a subsequent related study.Reflecting on the successes and limitations of Innovation Reports over the first 5 years, the authors suggest that soliciting input from more stakeholders and being explicit about the goals of this article type would help inform how Innovation Reports should evolve in the future so they can better launch creative thought and spur innovation.

Crafting Successful Relationships with the IRB.

BACKGROUND: Medical educational researchers face frustration with IRBs for activities that formerly were exempt from review or were not treated as biomedical research with patients. The authors sought to identify methods for improving relationships between IRBs and medical education researchers. METHOD: The authors conducted interviews with medical school representatives about factors leading to relationships in which all parties feel that their concerns are being met, subjects are appropriately protected, and that the progress of evaluation or research activities is not unnecessarily inhibited. RESULTS: Successful relationships require efforts at education of the IRB and the researchers. All institutions acknowledged the need to establish and maintain good communication. Some schools developed structures or procedures that resulted in more rapid review and increased satisfaction that interests of all parties were protected. CONCLUSIONS: A relationship must be crafted between medical education researchers and the IRB. The authors found key elements to successful approaches.

A Survey of Perceived Effectiveness of Part 4 Maintenance of Certification.

OBJECTIVES: Evaluative assessment is needed to inform improvement of Part 4 Maintenance of Certification (MOC), a large-scale program that aims to improve physician knowledge, engagement, and skills in quality improvement (QI). We sought to determine if Part 4 MOC participation improves perceived educational and clinical outcomes by piloting a new physician survey. METHODS: We administered a new online survey (MOC Practice, Engagement, Attitude, and Knowledge Survey) to physicians at the beginning and end of a Part 4 MOC project sponsored by a pediatric hospital's American Board of Medical Specialties' portfolio program during 2015. Participants worked in academic and community settings and in various accredited specialties. The main outcome was change in survey response on a 5-point Likert scale (1 = best) for 3 learning domains (QI engagement and attitude; QI method application, and improved patient care). RESULTS: Of 123 complete responses and a 97% response rate, mean baseline responses were positive or neutral (2.2, 2.3, 1.9, respectively). Responses improved in QI engagement and attitude (-0.15, z score = -2.78, P = .005), QI method application (-0.39, z score = -7.364, P < .005), and improved patient care (-0.11, z score = -1.728, P = .084). CONCLUSIONS: A Part 4 MOC physician survey provides valuable data to evaluate and improve the learning activity. In this children's hospital program, physicians view Part 4 favorably. Participation was associated with modest improvements in perceptions of QI engagement and attitude, application of QI methods, and patient care. Systematic evaluation of all Part 4 MOC projects and programs has the potential to improve the program nationally.

Promoting minority access to health careers through health profession-public school partnerships: a review of the literature.

Partnerships between health profession schools and public schools provide a framework for developing comprehensive, creative solutions to the problem of minority underrepresentation in health careers. This review examines the functioning of partner relationships, focusing on elements of the social context that determine success or failure, and stages of partnership development. Influential aspects of the social context include cultural differences between personnel in higher education and K-12 institutions, the resources available to the partnership, and constraints on partnership activity. Stages of the process that partner institutions must negotiate include initiation, ongoing management, and institutionalization. Strategies to improve minority student achievement are reviewed, including specific types of programmatic interventions and best practices. Strategies available to partnerships for improving minority achievement include academic enhancement, science or math instructional enrichment, career awareness and motivation, mentoring, research apprenticeship, reward incentives, and parental involvement. Of these, academic enhancement and instructional enrichment have the greatest potential for improving minority student outcomes. Partnerships need to take a sustained multipronged approach, providing intensive interventions that target students, teachers, and curricula at appropriate educational stages. Documenting program impact is critical for attracting more resources to increase minority access to health careers: sponsoring organizations should dedicate funds for assessment of the partnership's functioning and for rigorous evaluation of interventions.

Competing professionalism values among community-based family physicians.

BACKGROUND: Professionalism has received considerable attention in recent years, mostly within academic settings. Little attention has been given to the perspectives of practicing physicians on professionalism. This study was designed to determine whether prevailing definitions of and guidelines for professionalism accurately reflect the perspectives and experiences of practicing community-based family physicians. METHOD: Eighteen practicing family physicians in Seattle were recruited from nonacademic settings to participate in focus groups during 2003. Transcripts were analyzed for content themes related to professionalism. RESULTS: Analysis revealed several tensions among values that the physician participants described balancing in their practices. Balancing organizational expectations and individual physician or patient values was a major source of tension. CONCLUSIONS: Practicing family physicians describe various tensions as they attempt to balance their own values with competing values of their patients, the organizations for which many work, and stated values of their profession. Such tensions among values have seldom been described in past literature and should be considered in designing medical curricula at all levels.

Is There a Consensus on Consensus Methodology? Descriptions and Recommendations for Future Consensus Research.

The authors of this article reviewed the methodology of three common consensus methods: nominal group process, consensus development panels, and the Delphi technique. The authors set out to determine how a majority of researchers are conducting these studies, how they are analyzing results, and subsequently the manner in which they are reporting their findings. The authors conclude with a set of guidelines and suggestions designed to aid researchers who choose to use the consensus methodology in their work.Overall, researchers need to describe their inclusion criteria. In addition to this, on the basis of the current literature the authors found that a panel size of 5 to 11 members was most beneficial across all consensus methods described. Lastly, the authors agreed that the statistical analyses done in consensus method studies should be as rigorous as possible and that the predetermined definition of consensus must be included in the ultimate manuscript. More specific recommendations are given for each of the three consensus methods described in the article.

Patients' perspectives on physician skill in end-of-life care: differences between patients with COPD, cancer, and AIDS.

OBJECTIVES: Patients' views of physician skill in providing end-of-life care may vary across different diseases, and understanding these differences will help physicians improve the quality of care they provide for patients at the end of life. The objective of this study was to examine the perspectives of patients with COPD, cancer, or AIDS regarding important aspects of physician skill in providing end-of-life care. DESIGN: Qualitative study using focus groups and content analysis based on grounded theory. SETTING: Outpatients from multiple medical settings in Seattle, WA. PATIENTS: Eleven focus groups of 79 patients with three diseases: COPD (n = 24), AIDS (n = 36), or cancer (n = 19). RESULTS: We identified, from the perspectives of patients, the important physician skills for high-quality end-of-life care. Remarkable similarities were found in the perspectives of patients with COPD, AIDS, and cancer, including the importance of emotional support, communication, and accessibility and continuity. However, each disease group identified a unique theme that was qualitatively more important to that group. For patients with COPD, the domain concerning physicians' ability to provide patient education stood out as qualitatively and quantitatively more important. Patients with COPD desired patient education in five content areas: diagnosis and disease process, treatment, prognosis, what dying might be like, and advance care planning. For patients with AIDS, the unique theme was pain control; for patients with cancer, the unique theme was maintaining hope despite a terminal diagnosis. CONCLUSIONS: Patients with COPD, AIDS, and cancer demonstrated many similarities in their perspectives on important areas of physician skill in providing end-of-life care, but patients with each disease identified a specific area of end-of-life care that was uniquely important to them. Physicians and educators should target patients with COPD for efforts to improve patient education about their disease and about end-of-life care, especially in the areas defined above. Physicians caring for patients with advanced AIDS should discuss pain control at the end of life, and physicians caring for patients with cancer should be aware of many patients' desires to maintain hope. Physician understanding of these differences will provide insights that allow improvement in the quality of care.

Physicians' interactions with health care teams and systems in the care of dying patients: perspectives of dying patients, family members, and health care professionals.

This study investigated the specific physician skills required to interact with health care systems in order to provide high quality care at the end of life. We used focus groups of patients with terminal diseases, family members, nurses and social workers from hospice or acute care settings, and physicians. We performed content analysis based on grounded theory. Groups were interviewed. Two domains were found related to physician interactions with health care systems: 1) access and continuity, and 2) team communication and coordination. Components of these domains most frequently mentioned included taking as much time as needed with the patient, accessibility, and respect shown in working with health team members. This study highlights the need for both physicians and health care systems to improve accessibility for patients and families and increase coordination of efforts between health care team members when working with dying patients and their families.

Dying patients' need for emotional support and personalized care from physicians: perspectives of patients with terminal illness, families, and health care providers.

This study addressed the emotional and personal needs of dying patients and the ways physicians help or hinder these needs. Twenty focus groups were held with 137 individuals, including patients with chronic and terminal illnesses, family members, health care workers, and physicians. Content analyses were performed based on grounded theory. Emotional support and personalization were 2 of the 12 domains identified as important in end-of-life care. Components of emotional support were compassion, responsiveness to emotional needs, maintaining hope and a positive attitude, and providing comfort through touch. Components of personalization were treating the whole person and not just the disease, making the patient feel unique and special, and considering the patient's social situation. Although the levels of emotional support and personalization varied, there was a minimal level, defined by compassion and treating the whole person and not just the disease, that physicians should strive to meet in caring for all dying patients. Participants also identified intermediate and advanced levels of physician behavior that provide emotional and personal support.

Funding medical education research: opportunities and issues.

Medical education research is underfunded. Little research focuses on basic issues of learning and teaching in medicine, and few educational innovations are tested across institutions to insure their generalizability. Despite repeated calls for the development of research organizations that would deal with substantial issues in medical education, funding remains a miniscule portion of the total budget for medical education. The author discusses how medical education research is supported in the present economic environment. The majority of published research is accomplished during the course of the researcher's employment. Many universities support pilot studies that lead to larger grants. Faculty development programs and career or academic awards support some research. Small to moderate amounts of funding are available through a variety of sources including medical specialty associations and private foundations. The author lists a variety of resources and strategies for finding foundations to fund research. Funding for larger research projects, particularly those that require more than a few years to accomplish or that involve multiple institutions, is more difficult to obtain. Federal training grants provide the laboratory for innovation and education research, but include inadequate funds to accomplish in-depth evaluation or research. The lack of emphasis on theory building and failure to prove the usefulness of innovations across schools cannot be overcome with current levels of funding. Medical educators must be advocates for the research support needed to move medical education research from a field with limited influence on practice to one that is able to connect sound insights and ideas with actual practices in education and improved patient health.

Characteristics of health professions schools, public school systems, and community-based organizations in successful partnerships to increase the numbers of underrepresented minority students entering health professions education.

PURPOSE: To identify characteristics of health professions schools, public schools, and community-based organizations in successful partnerships to increase the number of underrepresented minority students entering health professions. The Robert Wood Johnson Foundation and the W. K. Kellogg Foundation funded the Health Professions Partnership Initiative program developed from Project 3000 by 2000 of the Association of American Medical Colleges. METHOD: Semi-structured interviews were completed with awardees and representatives of the funding agencies, the national program office, and the national advisory committee between the fall of 2000 and the summer of 2002. Site visits were conducted at ten sites, with representatives of partner institutions, teachers, parents, and children. Characteristics that supported and hindered development of successful partnerships were identified using an iterative qualitative approach. RESULTS: Successful partnerships included professional schools that had a commitment to community service. Successful leaders could work in both cultures of the professional and public schools. Attitudes of respect and listening to the needs of partners were essential. Public school governance supported innovation. Happenstance and convergence of interests played significant roles in partnership development. The most telling statement was "We did it, together." CONCLUSIONS: This study identifies characteristics associated with smoothly working partnerships, and barriers to successful program development. Successful partnerships can form the basis on which educational interventions are built. The study is limited by the definition of success used, and its focus on one funded program. The authors were unable to identify outcomes in terms of numbers of children influenced by programs or instances in which lasting changes in health professions schools had occurred.

Examination room presentations in general internal medicine clinic: patients' and students' perceptions.

PURPOSE: To determine if patients are more satisfied with their health care when medical students present in the exam room to both the attending physician and patient than they are when medical students present outside the exam room to only the attending. To determine medical students' preference for location of presentation and the reasons for their preference. To determine if exam-room presentations promote the education of medical students to a greater degree than presentations outside of the exam room. METHOD: In 2001, 108 patients and 142 fourth-year medical students at internal medicine (IM) clinics affiliated with the University of Washington School of Medicine were asked to complete an 11-point ordinal scale questionnaire on their attitudes toward medical student presentations. RESULTS: One hundred patients (93%) and 68 medical students (48%) responded. Patients with in-room presentations enjoyed working with the medical student more than did patients with out-of-room presentations. Both groups expressed a preference for in-room presentations on future visits and a high level of comfort with student and physician discussing their health. Medical students reported a slight preference for presenting out of the room. When presenting in the room, students reported learning more about physical diagnosis and bedside manner and less about mechanism of disease than when presenting out-of-room. CONCLUSIONS: Patients preferred in-room case presentations and were comfortable with medical students and physicians discussing their health in their presence. In-room presentations also foster instruction on bedside manner and physical diagnosis. These data suggest that both patients and students would benefit from participating in more in-room presentations.

Medical education research at the University of Washington School of Medicine: lessons from the past and potential for the future.

Faculty in the Department of Medical Education and Biomedical Informatics at the University of Washington School of Medicine received over $1.2 million in direct grant and contract support in 2003. In this case study, the authors provide some of the history and background of the evolution of the department's structure and its role in providing leadership in medical education research at the university, as well as regionally, nationally, and internationally. The authors offer their observations and reflections on what has helped and hindered the department's success, and end with some predictions on medical education research in the future. The University of Washington's five-state regional WWAMI educational program, establishing a single medical school for the states of Washington, Wyoming, Alaska, Montana, and Idaho, has been an important environmental influence on the direction of the department's educational and research activities. External support has helped the department to create the Northwest Consortium for Clinical Performance Assessment, the Center for Medical Education Research, the Teaching Scholars Program, and a Biomedical and Health Informatics graduate and fellowship training program, as well as a number of international programs.

Influence of Third-Year Clerkships on Medical Student Specialty Preferences.

Purpose - The purpose of this study was to investigate influences on third-year medical students' specialty preferences.Method - A survey questionnaire was mailed to third-year medical students at two medical schools. The questionnaire asked students to rate the degree to which various aspects of the third-year curriculum and perceived specialty characteristics influenced their specialty preferences.Results - A total of 214 (70%) of eligible students responded, of whom 46% were female and 57% preferred primary care (PC) specialties. The most frequently cited influential clerkship was internal medicine. Most clerkships (72%) had a positive influence on students' preferences. PC clerkships had more positive influences than non-primary care (NPC) clerkships, especially among PC-oriented students. The most influential aspects of clerkships were faculty and residents, especially in PC clerkships. For both PC- and NPS-oriented students, the diagnostic and patient-related characteristics of their preferred specialties were highly influential. PC-oriented students were more likely to be attracted to prevention and biopsychosocial aspects of specialties, and NPC-oriented students to the opportunity to do procedures and intervene in illnesses. Student gender appeared to have little influence on response patterns, except as a proxy for specialty preference, which, for women, was more likely to be a primary care specialty.Conclusion - These findings suggest that the third-year clerkships, especially at non-university sites, play an important role in specialty choice, and that factors attracting students to PC differ significantly from those attracting students to NPC.

Measuring the quality of end-of-life care.

CONTEXT: Although there is a documented need to improve end-of-life care, there are few validated and brief questionnaires that are available as outcome measures for use in improving that care. OBJECTIVES: To examine the measurement characteristics of the Quality of End-of-Life Care (QEOLC) questionnaire. METHODS: In a multisite, cross-sectional study of a mailed questionnaire, patients with life-limiting illnesses, their families, and nurses completed the QEOLC questionnaire. Patients and nurses were identified by physicians, and families were identified by participating patients. Physicians included general internists, oncologists, cardiologists, and pulmonologists from the Southeast and Pacific Northwest of the United States. RESULTS: Eight hundred one patients, 310 of their families, and 885 nurses were identified by 85 physicians. Using structural equation modeling techniques corrected for clustering under physicians, we identified a patient-specific factor based on 11 items, a family-specific factor based on 22 items, a nurse-specific factor based on 11 items, and a common single-factor solution based on 10 items. Construct validity was supported by significant associations in the hypothesized direction between the identified QEOLC factors and each of the following: physician palliative care knowledge, patients' and families' ratings of overall quality of care, and patients' levels of symptom distress. CONCLUSION: Although continued testing in heterogeneous samples is necessary, the current study supported the construct validity of the QEOLC questionnaire to assess physician skill at end-of-life care, thereby providing valid measures of quality end-of-life care. Furthermore, this approach is a model for development and validation of patient- and family-centered assessments of quality of care.