Best Practices for Survey Use in Medical Education: How to Design, Refine, and Administer High-Quality Surveys.

Surveys are a frequently used method to collect data in medical education research. As such, it behooves medical educators involved in scholarly work to understand the best practices in the selection, development, implementation, and reporting of surveys used when conducting research and curriculum development projects. This review article prepares the reader to name the steps of designing and administering high-quality surveys in medical education research, identify the characteristics of both well-written and poorly written survey questions, and apply the principles of survey design to write and revise surveys for use in their own research.

Grit Does Not Predict Burnout among First-Year Internal Medicine Residents.

OBJECTIVES: Grit, defined as passion and perseverance for long-term goals, has been associated with the avoidance of burnout among residents in a number of specialties. We aimed to evaluate the relationship between grit and burnout among first-year Internal Medicine residents. METHODS: During the 2018-2019 academic year, the authors recruited 75 first-year Internal Medicine residents within a large academic program to complete the Short Grit Scale (Grit-S) and the Maslach Burnout Inventory General Survey (MBI-GS) at baseline and after 6 and 12 months. The primary outcome was the association between baseline Grit-S and MBI-GS scores within the domains of emotional exhaustion (EE) or cynicism (CYN) over time using linear mixed models. Secondary outcomes included the association between grit and high burnout at 6 or 12 months, grit and persistently high burnout, and the association of baseline high burnout with later high scores at 6 and 12 months using logistic regression models and trends in grit over time using repeated-measures analysis of variance. RESULTS: A total of 53 of 75 (71%) first-year residents completed the Grit-S and MBI-GS at baseline and at least one other time point. There was no association between grit and EE (P = 0.44) or CYN (P = 0.61) burnout domain scores. High baseline EE and high baseline CYN significantly increased the odds of later high burnout scores within each domain (EE odds ratio 9.66, 95% confidence interval 1.16-80.83; CYN odds ratio 13.37, 95% confidence interval 1.52-117.75). Grit scores and professional efficacy scores remained stable throughout the year (P = 0.15 and 0.46, respectively), while EE and CYN significantly increased (both P < 0.01). CONCLUSIONS: In this single-center study, grit was not associated with burnout among first-year Internal Medicine residents; however, our findings highlight the value of baseline burnout scores in helping to identify first-year residents who may be at higher risk of later burnout.

A Curriculum Innovation on Writing Simulated Patient Cases for Communication Skills Education.

Introduction: Facilitated communication practice with simulated patients (SPs) is a highly effective form of communication training. Unfortunately, little guidance exists on writing SP cases. Methods: We created a curriculum composed of a case-development workbook and case-writing session with input from national communication educators. In November 2017, we implemented the curriculum in a Teaching Communication Skills course for medical educators. Educators divided into four groups to write cases. Primary outcome was the number of criteria that cases fulfilled. Secondary outcomes were SP evaluation and educator-reported confidence and satisfaction. Results: Seventeen medical educators (including 15 fellows) completed the curriculum. Four new cases were analyzed against 24 criteria and compared to eight cases written by educators following a previous curriculum. An SP evaluated ease of portrayal for all 12 cases on a 5-point Likert scale (1 = poor, 5 = excellent). Educators completed precurriculum and postcurriculum surveys. Compared to the previous curriculum, cases based on the new curriculum incorporated 26% more case criteria (70% or 16.8 criteria/case vs. 96% or 23.0 criteria/case, p < .01). Ease-of-portrayal rating improved but did not differ statistically (mean: 2.8 vs. 4.5, p = .11). A moderate correlation was found between number of included case criteria and Likert-scale rating (rs = .61, p = .03). Pre- and postcurriculum, educators reported significant increases in confidence (mean: 1.9 vs. 4.0, p < .01) and high curricular satisfaction (mean: 4.8). Discussion: A case-development workbook and case-writing session increased the quality of newly developed SP cases as assessed by prespecified case criteria.

Optimizing Synchronous Online Teaching Sessions: A Guide to the "New Normal" in Medical Education.

In response to the COVID-19 pandemic, the medical education community was forced to transition to the virtual space seemingly overnight, with little time to prepare. As such, many medical educators are actively seeking ways to improve delivery of online content and utilize features of different technologies. This View from the APPD, informed by existing literature and author experience, was created to guide medical teachers in their transition to hosting synchronous learning sessions in the virtual space. We hope to empower medical educators with the confidence and skills needed to teach effectively from a distance.

Exploring Mentoring Experiences, Perceptions, and Needs of General Internal Medicine Clinician Educators Navigating Academia: a Mixed-Methods Study.

BACKGROUND: Few studies examined specific mentoring needs and preferences of clinician educators (CEs). Further research on CEs' perceptions of mentoring adequacy, as related to educational development and career advancement, is needed. OBJECTIVE: The study aims were to (1) explore general internal medicine CEs' experiences as mentees within various mentoring models; (2) examine the perceived quality, nature, and impact of mentoring on career development; and (3) determine whether specific models of mentoring impact their attitudes towards mentoring. DESIGN: Sequential mixed methods study design answered the study questions. PARTICIPANTS: Society of General Internal Medicine members identifying themselves as CEs. MAIN MEASURES/APPROACH: Participants completed an anonymous online survey and a subsample participated in two semi-structured focus group discussions. Outcomes of interest were perceptions of mentoring experiences, and perspectives on quality of mentoring as well as mentoring needs specific to clinician educators. KEY RESULTS: One hundred thirty-nine participants completed the survey (37% response rate) with 20 participants in focus group discussions. Among CEs with perceived high-quality mentor relationships (e.g., reporting strongly agree), peer mentorship was viewed as adequate mentorship (45% (n = 17) vs 24% (n = 24), p < 0.05), as beneficial for career development (77% (n = 40) vs 48% (n = 41), p < 0.01) and as being challenged to become a better CE (58% (n = 30) vs 35% (n = 29), p < 0.05), compared to reporting agree or lower. Qualitative analysis generated four themes: (1) A mentoring team promotes career advancement, (2) peer mentors are important at every stage of a CE's career, (3) there is inadequate mentoring specific to CE needs, and (4) mentoring needs protected time and skill development. CONCLUSIONS: The traditional dyadic mentoring relationship may not adequately address all professional needs of CEs. A mentoring team can provide valuable perspectives on career goals. Peer mentoring can be powerful for professional growth. Mentoring needs change at different career stages and training in mentoring skills is essential.

Clinician-Educator Training and Its Impact on Career Success: a Mixed Methods Study.

BACKGROUND: Clinician-educator (CE) careers in academic medicine are heterogeneous. Expectations for CEs have grown, along with a need to better prepare CEs for these roles. OBJECTIVE: To assess whether advanced education training is associated with productivity and success. DESIGN: We used a sequential mixed methods approach, collecting quantitative survey data and qualitative focus groups data. We developed a three-tiered categorization of advanced training to reflect intensity by program type. PARTICIPANTS: We surveyed CEs in the Society of General Internal Medicine (SGIM) and conducted two focus groups at an SGIM annual meeting. MAIN MEASURES: Primary outcomes were academic productivity (manuscripts, presentations, etc.) and leadership role attainment. Secondary analysis examined the interactive effect of gender and training intensity on these outcomes. KEY RESULTS: A total of 198 completed the survey (response rate 53%). Compared with medium- or low-intensity training, high-intensity training was associated with a greater likelihood of publishing ≥ 3 first- or senior-author manuscripts (adjusted OR 2.6; CI 0.8-8.6; p = 0.002), teaching ≥ 3 lectures/workshops at the regional/national/international level (adjusted OR 5.7; CI 1.5-21.3; p = 0.001), and having ≥ 3 regional/national committee memberships (adjusted OR 3.4; CI 1.0-11.7; p = 0.04). Among participants in the "no training" and "high-intensity training" categories, men were more likely to have ≥ 3 publications (OR 4.87 and 3.17, respectively), while women in the high intensity category had a likelihood similar to men with no training (OR 4.81 vs. OR 4.87). Participants felt the value of advanced training exists not only in content but also in networking opportunities that programs provide. CONCLUSIONS: While opinions were divided as to whether advanced training is necessary to position oneself for education roles, it is associated with greater academic productivity and reduced gender disparity in the publication domain. Institutions should consider providing opportunities for CEs to pursue advanced education training.

A Robust Faculty Development Program for Medical Educators: A Decade of Experience.

OBJECTIVES: Faculty development programs (FDPs) foster learning communities and enhance professional identity formation for medical educators. Competency-based frameworks for faculty development drive skill development across clinical practice, teaching, and scholarship domains. The aims of this study are to outline the context, content, and evolution of a novel FDP; map the individual conferences that make up the FDP to established faculty development competencies; identify steps to implement similar programming; and demonstrate outcomes to date. METHODS: The FDP consists of four, 1-hour-long conferences held weekly on a rotating basis since 2007 at the University of Pittsburgh School of Medicine: Academy of Master Educators, Medical Education Research, Medical Education Journal Club, and Medical Education Research Methods and Innovative Design conference. Authors outline the relation of each of these four conferences to faculty development competencies and describe early outcomes for each conference over four consecutive academic years from 2014 to 2018. Participants include attendees and presenters in four consecutive academic years from 2014 to 2018. RESULTS: The well-attended FDP meets all established competencies for educator faculty. Presenters and attendees were diverse in terms of academic rank and represented a breadth of clinical and basic science specialties. CONCLUSIONS: This integrated FDP fosters a community of medical educators and develops faculty skills across established medical educator competencies.

Implementation of Case Conferences to Improve Interprofessional Collaboration in Resident Continuity Clinic.

OBJECTIVES: Residents must be trained in skills for interprofessional collaboration and team-based care in the outpatient setting, and successful models are needed to achieve this aim. A longitudinal curriculum was developed to enhance residents' knowledge of interprofessional team members' roles, residents' attitudes toward team-based care, and patient referrals to team members. METHODS: Postgraduate year 1 through postgraduate year 3 internal medicine residents with continuity clinic at a large hospital-based practice received the curriculum. Residents with continuity clinic at another site did not receive the curriculum and served as controls. Intervention residents attended five small-group conferences during the course of 1 year, each dedicated to a specific interprofessional discipline: pharmacy, psychology, diabetes/nurse education, social work, and case management. Conferences involved interactive, case-based discussions of patients who benefit from an interprofessional approach. Control and intervention residents were surveyed with pre- and posttests. The rates of patient referrals to interprofessional team members were assessed. RESULTS: Seventy-one residents received the curriculum. Intervention residents' knowledge of team members' names and roles, indications for patient referral, and communication methods improved after curriculum implementation. Attitudes toward team-based care did not change but were positive at baseline. Following curriculum implementation, new patient referrals increased for the pharmacist (0.1-1/100 patient visits, P = 0.015) and psychologist (1.1-2.2/100 patient visits, P = 0.032). CONCLUSIONS: Case-based interprofessional conferences improved residents' knowledge regarding interprofessional care and increased referrals to team members. This curriculum addresses barriers to team-based care experienced by residents in continuity clinic and is adaptable to other clinic settings.

A Program to Support Scholarship During Internal Medicine Residency Training: Impact on Academic Productivity and Resident Experiences.

Problem: Although scholarship during residency training is an important requirement from the Accreditation Council for Graduate Medical Education, efforts to support resident scholarship have demonstrated inconsistent effects and have not comprehensively evaluated resident experiences. Intervention: We developed the Leadership and Discovery Program (LEAD) to facilitate scholarship among all non-research-track categorical internal medicine (IM) residents. This multifaceted program set expectations for all residents to participate in a scholarly project, supported faculty to manage the program, facilitated access to faculty mentors, established a local resident research day to highlight scholarship, and developed a didactic lecture series. Context: We implemented LEAD at a large university training program. We assessed resident scholarship before and after LEAD implementation using objective metrics of academic productivity (i.e., scientific presentations, peer-reviewed publications, and both presentations and publications). We compared these metrics in LEAD participants and a similar historical group of pre-LEAD controls. We also assessed these outcomes over the same two periods in research track residents who participated in research training independent from and predating LEAD (research track controls and pre-LEAD research track controls). We conducted focus groups to qualitatively assess resident experiences with LEAD. Outcome: Compared to 63 pre-LEAD controls, greater proportions of 52 LEAD participants completed scientific presentations (48.1% vs. 28.6%, p = .03) and scientific presentations and peer-reviewed publications (23.1% vs. 9.5%, p = .05). No significant differences existed for any academic productivity metrics among research track controls and pre-LEAD research track controls (p > .23, all comparisons). Perceived facilitators of participation in LEAD included residents' desire for research experiences and opportunities to publish prior to fellowship training; the main barrier to participation was feeling overwhelmed due to the time constraints imposed by clinical training. Suggestions for improvement included establishing clearer programmatic expectations and providing lists of potential mentors and projects. Lessons Learned: Implementation of a multifaceted program to support scholarship during residency was associated with significant increases in academic productivity among IM residents. Residents perceived that programs to support scholarship during residency training should outline clear expectations and identify available mentors and projects for residents who are challenged by the time constraints of clinical training.

Health Literacy and Clear Bedside Communication: A Curricular Intervention for Internal Medicine Physicians and Medicine Nurses.

Introduction: Communication remains the backbone of patient-provider relationships, and many health outcomes have been directly attributed to both effective and ineffective communication. We developed an educational intervention to improve bedside communication and increase use of health literacy principles, in part as a response to suboptimal inpatient satisfaction scores. Methods: Our intervention consisted of a beside communication curriculum among 37 attending medicine physicians, 76 internal medicine residents, and 85 bedside nurses. The 1- to 1.5-hour curriculum included a didactic session to teach health literacy principles, video demonstrations, group discussion, and role-play. Attending physicians' health literacy knowledge, attitudes, and confidence were evaluated using pre- and postsurveys. Evaluation of the curriculum included Likert-type questions and free-text responses. Results: Attending physicians' knowledge and confidence improved (74% correct pre, 100% correct post, p < .001; 4.41 pre, 4.68 post, p = .002, respectively). Certain attitude domains also improved, including importance of team introductions and nurse contributions to bedside rounds (p < .001). Both residents and nurses found the curriculum valuable and planned to incorporate it into their bedside rounding. Discussion: A brief, low-cost curricular intervention focusing on clear communication skills and health literacy principles resulted in significant improvements in knowledge and attitudes of attending physicians and was readily incorporated by resident physicians and nurses. This curriculum can be easily implemented in a variety of settings to improve bedside patient-physician communication.

Teaching to Teach: An Effective and Feasible Teaching Curriculum for Internal Medicine Interns.

OBJECTIVES: New competency requirements from the Accreditation Council for Graduate Medical Education have prompted greater emphasis on developing residents' teaching skills. Many residents make their first foray into teaching during internship, making it an important yet underrecognized opportunity to develop basic teaching skills. In addition, in the current graduate medical education climate, residents' tasks are compressed into an even shorter time, which has caused teaching opportunities and expectations to be balanced with the need for efficiency. After performing needs assessment surveys of medicine interns and medical students, we developed an interns-as-teachers curriculum to equip internal medicine interns with skills specific to their unique role as medical student teachers. METHODS: We conducted a workshop focused around four specific skills: role modeling, using teachable moments (ie, teaching on the fly), thinking out loud, and coaching. We evaluated the curriculum by comparing pre- and postcurricular teaching knowledge, attitudes, and self-reported teaching behaviors among 51 interns in the intervention group with 20 interns in the comparison group from the previous year's class. RESULTS: Sixty-one interns participated in the curriculum, and 51 (84%) completed both surveys. Knowledge and several self-reported teaching behaviors improved significantly among the intervention group, but not in the comparison group. CONCLUSIONS: Interns participating in a half-day interns-as-teachers workshop aimed at preparing them to teach medical students in clinical settings achieved significant improvement in teaching knowledge and in several core, self-reported teaching behaviors.

Teaching Medical Educators How to Teach Communication Skills: More than a Decade of Experience.

OBJECTIVES: Although opportunities exist for medical educators to gain additional training in teaching, literature that describes how to teach educators to teach communication skills to trainees is limited. The authors developed and evaluated a faculty development course that uses didactics, demonstration, drills, and role-play in a small-group format. METHODS: The course has been offered through the Institute for Clinical Research Education at the University of Pittsburgh for almost 15 years. Course effectiveness was evaluated with a survey of 62 clinicians who completed the course between 2003 and 2012. RESULTS: The response rate was 85%. A total of 98% would recommend the course to a colleague and 98% indicated the course was effective at developing teaching techniques. Their use of standardized patients, teaching in small groups, and role-play increased as a result of participation in the course. A total of 70% went on to formally teach communication skills at various medical education levels. CONCLUSIONS: This structured course effectively taught participants how to teach patient-doctor communication in both classroom and clinical settings. The majority put these techniques to use in formal settings. This course also provided educators with the skills necessary to meet the growing needs of training programs charged with teaching the next generation of providers to effectively communicate with patients. The description presented can serve as a framework for faculty development in teaching communication.

Faculty Communication Knowledge, Attitudes, and Skills Around Chronic Non-Malignant Pain Improve with Online Training.

OBJECTIVE: Many physicians struggle to communicate with patients with chronic, non-malignant pain (CNMP). Through the use of a Web module, the authors aimed to improve faculty participants' communication skills knowledge and confidence, use of skills in clinical practice, and actual communication skills. SUBJECTS: The module was implemented for faculty development among clinician-educators with university faculty appointments, outpatient clinical practices, and teaching roles. METHODS: Participants completed the Collaborative Opioid Prescribing Education Risk Evaluation and Mitigation Strategy (COPE-REMS®) module, a free Web module designed to improve provider communication around opioid prescribing. Main study outcomes were improvements in CNMP communication knowledge, attitudes, and skills. Skills were assessed by comparing a subset of participants' Observed Structured Clinical Exam (OSCE) performance before and after the curriculum. RESULTS: Sixty-two percent of eligible participants completed the curriculum in 2013. Knowledge-based test scores improved with curriculum completion (75% vs. 90%; P < 0.001). Using a 5-point Likert-type scale, participants reported improved comfort in managing patients with CNMP both immediately post-curriculum and at 6 months (3.6 pre vs. 4.0 post vs. 4.1 at 6 months; P = 0.02), as well as improvements in prescribing opioids (3.3 vs. 3.8 vs. 3.9, P = 0.01) and conducting conversations about discontinuing opioids (2.8 vs. 3.5 vs. 3.9, P < 0.001). Additionally, CNMP-specific communication skills on the OSCE improved after the curriculum (mean 67% vs. 79%, P = 0.03). CONCLUSIONS: Experienced clinician-educators improved their communication knowledge, attitudes, and skills in managing patients with CNMP after implementation of this curriculum. The improvements in attitudes were sustained at six months. A Web-based curriculum such as COPE-REMS® may be useful for other programs seeking improvement in faculty communication with patients who have CNMP.

Addressing health literacy through clear health communication: a training program for internal medicine residents.

OBJECTIVE: To develop, pilot, and test the effectiveness of a clear health communication curriculum to improve resident knowledge, attitudes, and skills regarding health literacy. METHODS: Thirty-one internal medicine residents participated in a small group curriculum that included didactic teaching, practice with a standardized patient, and individualized feedback on videotaped encounters with real patients. Outcomes were assessed using a pre-post survey and a communication skills checklist. RESULTS: Mean knowledge scores increased significantly from 60.3% to 77.6% (p<0.001). Residents also reported increased familiarity with the concept of health literacy (mean response 3.2 vs. 4.5 on a 5 point scale), importance placed on health literacy (4.2 vs. 4.9), frequency of considering health literacy in patient care (3.3 vs. 4.0), and confidence in communicating with low literacy patients (3.3 vs. 4.1) (all p<0.001). Use of plain language increased significantly from 33% to 86% (p=0.023). There were nonsignificant increases in the use of teach-back (0-36%, p=0.116) and encouraging questions (0-14%, p=0.502). CONCLUSION: Training in clear health communication improves resident knowledge, attitudes, and skills regarding health literacy. PRACTICE IMPLICATIONS: The increased use of clear health communication techniques can significantly improve the care and outcomes of vulnerable patients with limited health literacy.

Giving residents tools to talk about behavior change: a motivational interviewing curriculum description and evaluation.

OBJECTIVE: To determine whether a motivational interviewing (MI) curriculum is effective in teaching internal medicine residents core MI skills and the empathic, nonjudgmental MI style. METHODS: Nineteen third-year residents met for 12 h with a faculty instructor. Teaching methods included lecture, written exercises, a simulated patient exercise, and discussion of residents' behavior change issues. RESULTS: Residents' adoption of MI skills was evaluated before and after the course with the Helpful Responses Questionnaire. Residents decreased use of closed-ended questions (from a score of 1.13 to 0.37, p=0.036) and MI roadblocks (4.00-1.08, p<0.001), and increased the use of reflections (1.87-4.87, p<0.001), and use of MI strategies (0.45-0.97, p=0.017). Residents' use of open-ended questions decreased from 1.97 to a mean of 1.05, p=0.023. Residents' ratings of the course on a 5-point scale varied from 3.7 for written exercises to 4.6/5 for the simulated patient exercise. After the course, residents rated behavior change counseling skills as more important. DISCUSSION AND CONCLUSION: A 12-h course increased residents' use of core MI communication skills in a written measure, and was highly rated. PRACTICE IMPLICATIONS: Future work should examine whether teaching of the empathic, collaborative MI stance impacts patient outcomes.

Teaching internal medicine residents to care for reproductive-age and pregnant women: an effective Web-based curriculum.

BACKGROUND: We sought to determine whether a Web-based curriculum could improve internal medicine residents' perceived preparedness and knowledge in the areas of preconception care, infertility evaluation, and management of medical conditions during pregnancy. Training in these areas has been previously identified as inadequate. DESCRIPTION: Three Web-based modules were developed to teach these topics. Seventy residents at one institution were invited to complete the modules and to participate in the curriculum's evaluation over 6 months. EVALUATION: Paper questionnaires assessed preparedness and comfort level among all participants. Web-based surveys that assessed pre/postknowledge and satisfaction among module completers accompanied each module. Ninety-seven percent completed paper questionnaires, and 59% completed 1 or more modules. At the end of the study period, module completers felt significantly more prepared than noncompleters, and improvement in comfort level was strongly associated with the number of modules completed. Knowledge improved significantly with module completion and curricular satisfaction was high. CONCLUSIONS: A Web-based approach to teaching these topics to internal medicine residents increased knowledge and perceived preparedness and was well received.