Self-Directed Learning in Medical Education: Training for a Lifetime of Discovery.

Issue: Life-long learning is a skill that is central to competent health professionals, and medical educators have sought to understand how adult professionals learn, adapt to new information, and independently seek to learn more. Accrediting bodies now mandate that training programs teach in ways that promote self-directed learning (SDL) but do not provide adequate guidance on how to address this requirement. Evidence: The model for the SDL mandate in physician training is based mostly on early childhood and secondary education evidence and literature, and may not capture the unique environment of medical training and clinical education. Furthermore, there is uncertainty about how medical schools and postgraduate training programs should implement and evaluate SDL educational interventions. The Shapiro Institute for Education and Research, in conjunction with the Association of American Medical Colleges, convened teams from eight medical schools from North America to address the challenge of defining, implementing, and evaluating SDL and the structures needed to nurture and support its development in health professional training. Implications: In this commentary, the authors describe SDL in Medical Education, (SDL-ME), which is a construct of learning and pedagogy specific to medical students and physicians in training. SDL-ME builds on the foundations of SDL and self-regulated learning theory, but is specifically contextualized for the unique responsibilities of physicians to patients, inter-professional teams, and society. Through consensus, the authors offer suggestions for training programs to teach and evaluate SDL-ME. To teach self-directed learning requires placing the construct in the context of patient care and of an obligation to society at large. The SDL-ME construct builds upon SDL and SRL frameworks and suggests SDL as foundational to health professional identity formation.KEYWORDSself-directed learning; graduate medical education; undergraduate medical education; theoretical frameworksSupplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1938074 .

Questioning medical competence: Should the Covid-19 crisis affect the goals of medical education?

The COVID-19 pandemic has disrupted many societal institutions, including health care and education. Although the pandemic's impact was initially assumed to be temporary, there is growing conviction that medical education might change more permanently. The International Competency-based Medical Education (ICBME) collaborators, scholars devoted to improving physician training, deliberated how the pandemic raises questions about medical competence. We formulated 12 broad-reaching issues for discussion, grouped into micro-, meso-, and macro-level questions. At the individual micro level, we ask questions about adaptability, coping with uncertainty, and the value and limitations of clinical courage. At the institutional meso level, we question whether curricula could include more than core entrustable professional activities (EPAs) and focus on individualized, dynamic, and adaptable portfolios of EPAs that, at any moment, reflect current competence and preparedness for disasters. At the regulatory and societal macro level, should conditions for licensing be reconsidered? Should rules of liability be adapted to match the need for rapid redeployment? We do not propose a blueprint for the future of medical training but rather aim to provoke discussions needed to build a workforce that is competent to cope with future health care crises.

Entrustment Decision Making: Extending Miller's Pyramid.

The iconic Miller's pyramid, proposed in 1989, characterizes 4 levels of assessment in medical education ("knows," "knows how," "shows how," "does"). The frame work has created a worldwide awareness of the need to have different assessment approaches for different expected outcomes of education and training. At the time, Miller stressed the innovative use of simulation techniques, geared at the third level ("shows how"); however, the "does" level, assessment in the workplace, remained a largely uncharted area. In the 30 years since Miller's conference address and seminal paper, much attention has been devoted to procedures and instrument development for workplace-based assessment. With the rise of competency-based medical education (CBME), the need for approaches to determine the competence of learners in the clinical workplace has intensified. The proposal to use entrustable professional activities as a framework of assessment and the related entrustment decision making for clinical responsibilities at designated levels of supervision of learners (e.g., direct, indirect, and no supervision) has become a recent critical innovation of CBME at the "does" level. Analysis of the entrustment concept reveals that trust in a learner to work without assistance or supervision encompasses more than the observation of "doing" in practice (the "does" level). It implies the readiness of educators to accept the inherent risks involved in health care tasks and the judgment that the learner has enough experience to act appropriately when facing unexpected challenges. Earning this qualification requires qualities beyond observed proficiency, which led the authors to propose adding the level "trusted" to the apex of Miller's pyramid.

The Change to Pass/Fail Scoring for Step 1 in the Context of COVID-19: Implications for the Transition to Residency Process.

In this Invited Commentary, the author considers the February 2020 announcement that scoring on the United States Medical Licensing Examination (USMLE) Step 1 will change to pass/fail no sooner than January 2022 and its effects on the transition to residency process in the context of both the recommendations of the Invitational Conference on USMLE Scoring (InCUS) held in March 2019 and the disruptions caused by the COVID-19 pandemic in the spring of 2020. The author suggests that the medical education community must embrace any positive changes that come about as a result of the pandemic while continuing to systematically review the strengths and areas for improvement in the current transition to residency process.In its recommendations, InCUS provided a thoughtful set of action priorities and an effective process to work together, which can inform and guide the work ahead. The COVID-19 pandemic is dominating the educational and clinical environments and is now the biggest disruptor in all aspects of life, not just medical education. It is the responsibility of leaders in medical education to have a vision for and then implement an improved continuum of education that maintains the core values of the field and fits the health care delivery needs of today and the future.

Medical Education in the United States and Canada, 2020.

For the third time this century, the Association of American Medical Colleges has coordinated a collection of reports from their member medical schools that collectively reflect the state of medical education in the United States and Canada. This introduction to the September 2020 supplement to Academic Medicine provides an overview of the collection, with 145 out of 171 eligible medical schools participating in the project. The authors observe trends and similarities across the reports from participating schools, structuring the introduction to mirror the main questions posed to the schools: highlights of each school's medical education program, curriculum description, curricular governance, education staff, faculty development and support in medical education, regional medical campuses, and initiatives in progress. Key findings from the authors include expansion of student enrichment tracks, early clinical encounters, focus on wellness, expansion in competency-based medical education, and continued evolution of approaches to assessment. The authors note that this supplement was produced before COVID-19, and although it robustly chronicles the prepandemic state of medical education, medical education has already evolved and will continue to do so. This view offers important opportunities to observe and study changes in the curricula.

What Regulatory Requirements and Existing Structures Must Change If Competency-Based, Time-Variable Training Is Introduced Into the Continuum of Medical Education in the United States?

As competency-based medical education is adopted across the training continuum, discussions regarding time-variable medical education have gained momentum, raising important issues that challenge the current regulatory environment and infrastructure of both undergraduate and graduate medical education in the United States. Implementing time-variable medical training will require recognizing, revising, and potentially reworking the multiple existing structures and regulations both internal and external to medical education that are not currently aligned with this type of system. In this article, the authors explore the impact of university financial structures, hospital infrastructures, national accrediting body standards and regulations, licensure and certification requirements, government funding, and clinical workforce models in the United States that are all intimately tied to discussions about flexible training times in undergraduate and graduate medical education. They also explore the implications of time-variable training to learners' transitions between medical school and residency, residency and fellowship, and ultimately graduate training and independent practice. Recommendations to realign existing structures to support and enhance competency-based, time-variable training across the continuum and suggestions for additional experimentation/demonstration projects to explore new training models are provided.

Preventing Egregious Ethical Violations in Medical Practice: Evidence-Informed Recommendations from a Multidisciplinary Working Group.

This article reports the consensus recommendations of a working group that was convened at the end of a 4-year research project funded by the National Institutes of Health that examined 280 cases of egregious ethical violations in medical practice. The group reviewed data from the parent project, as well as other research on sexual abuse of patients, criminal prescribing of controlled substances, and unnecessary invasive procedures that were prosecuted as fraud. The working group embraced the goals of making such violations significantly less frequent and, when they do occur, identifying them sooner and taking necessary steps to ensure they are not repeated. Following review of data and previously published recommendations, the working group developed 10 recommendations that provide a starting point to meet these goals. Recommendations address leadership, oversight, tracking, disciplinary actions, education of patients, partnerships with law enforcement, further research and related matters. The working group recognized the need for further refinement of the recommendations to ensure feasibility and appropriate balance between protection of patients and fairness to physicians. While full implementation of appropriate measures will require time and study, we believe it is urgent to take visible actions to acknowledge and address the problem at hand.

ADULT syndrome due to an R243W mutation in TP63.

Acro-dermato-ungual-lacrimal-tooth (ADULT) syndrome is a rare, autosomal dominant form of ectodermal dysplasia due to TP63 mutations. ADULT syndrome is much less common than the more classical forms of TP63-associated ectodermal dysplasias, such as ectrodactyly-ectodermal dysplasia-cleft lip/palate (EEC) syndrome and ankyloblepharon-ectodermal defects-cleft lip/palate syndrome. ADULT syndrome is characterized by ectrodactyly, syndactyly, and excessive freckling, in addition to more typical ectodermal defects, including hypodontia, lacrimal duct anomalies, hypotrichosis, and onychodysplasia. Unlike some of the other TP63-associated ectodermal dysplasias, ADULT syndrome lacks clefting and ankyloblepharon. Here, we report a three-generation family with ADULT syndrome due to an R243W mutation in TP63, a mutation that has previously been described in one patient with ADULT syndrome and eight unrelated patients with EEC syndrome.

Primary care specialty choices of United States medical graduates, 1997-2006.

PURPOSE: To describe trends in specialty choice and to identify predictors of primary care specialty choices among graduates of U.S. MD-granting medical schools. METHOD: A longitudinal study evaluated 1997-2006 medical school graduates who completed the Association of American Medical Colleges' Matriculating Student Questionnaire and Graduation Questionnaire. Multivariate logistic regression identified significant predictors of graduates' choice of primary care specialty (general internal medicine, general pediatrics, internal medicine subspecialties, pediatrics subspecialties, family medicine, and obstetrics-gynecology) or "no-board-certification specialty," compared with all other specialties (reference). RESULTS: The sample included 102,673 graduates (64.9% of all 1997-2006 graduates). General internal medicine, family medicine, general pediatrics, and obstetrics-gynecology choice decreased, whereas internal medicine subspecialties, pediatrics subspecialties, and no-board-certification specialty choice increased over time (each: P < .001). Female graduates and those who planned to practice in underserved communities, espoused more-altruistic beliefs about health care, and ascribed greater importance to social responsibility in their choice of medicine at matriculation were more likely to choose general internal medicine, general pediatrics, family medicine, or obstetrics-gynecology, whereas graduates who had a physician parent and who planned full-time academic medicine careers were less likely to do so (each: P < .01). Graduates with higher debt were less likely to choose internal medicine and pediatrics specialties (each: P < .001) and more likely to choose obstetrics-gynecology (P = .001). CONCLUSIONS: Generalist-primary care specialty choices declined since 1997, whereas primary care subspecialty and no-board-certification specialty choices increased. Associations between primary care specialty choices and demographic, attitudinal, and career intention variables can inform the design of interventions to address expected primary care workforce shortages.

Epitope-positive truncating MLH1 mutation and loss of PMS2: implications for IHC-directed genetic testing for Lynch syndrome.

We assessed mismatch repair by immunohistochemistry (IHC) and microsatellite instability (MSI) analysis in an early onset endometrial cancer and a sister's colon cancer. We demonstrated high-level MSI and normal expression for MLH1, MSH2 and MSH6. PMS2 failed to stain in both tumors, strongly implicating a PMS2 defect. This family did not meet clinical criteria for Lynch syndrome. However, early onset endometrial cancers in the proband and her sister, a metachronous colorectal cancer in the sister as well as MSI in endometrial and colonic tumors suggested a heritable mismatch repair defect. PCR-based direct exonic sequencing and multiplex ligation-dependent probe amplification (MLPA) were undertaken to search for PMS2 mutations in the germline DNA from the proband and her sister. No mutation was identified in the PMS2 gene. However, PMS2 exons 3, 4, 13, 14, 15 were not evaluated by MLPA and as such, rearrangements involving those exons cannot be excluded. Clinical testing for MLH1 and MSH2 mutation revealed a germline deletion of MLH1 exons 14 and 15. This MLH1 germline deletion leads to an immunodetectable stable C-terminal truncated MLH1 protein which based on the IHC staining must abrogate PMS2 stabilization. To the best of our knowledge, loss of PMS2 in MLH1 truncating mutation carriers that express MLH1 in their tumors has not been previously reported. This family points to a potential limitation of IHC-directed gene testing for suspected Lynch syndrome and the need to consider comprehensive MLH1 testing for individuals whose tumors lack PMS2 but for whom PMS2 mutations are not identified.

DICER1 mutations in familial pleuropulmonary blastoma.

Pleuropulmonary blastoma (PPB) is a rare pediatric lung tumor that is often part of an inherited cancer syndrome. PPBs consist of mesenchymal cells that are susceptible to malignant transformation and cysts lined by epithelial cells. In a subset of patients, overgrowth of the cysts by mesenchymal cells leads to sarcoma formation. Here, we show that 11 multiplex PPB families harbor heterozygous germline mutations in DICER1, a gene encoding an endoribonuclease critical to the generation of small noncoding regulatory RNAs. Expression of DICER1 protein was undetectable in the epithelial component of PPB tumors but was retained in the malignant mesenchyme (sarcoma). We hypothesize that loss of DICER1 in the epithelium of the developing lung alters the regulation of diffusible factors that promote mesenchymal proliferation.

Mutations in the GGCX and ABCC6 genes in a family with pseudoxanthoma elasticum-like phenotypes.

A characteristic feature of classic pseudoxanthoma elasticum (PXE), an autosomal recessive disorder caused by mutations in the ABCC6 gene, is aberrant mineralization of connective tissues, particularly the elastic fibers. Here, we report a family with PXE-like cutaneous features in association with multiple coagulation factor deficiency, an autosomal recessive disorder associated with GGCX mutations. The proband and her sister, both with severe skin findings with extensive mineralization, were compound heterozygotes for missense mutations in the GGCX gene, which were shown to result in reduced gamma-glutamyl carboxylase activity and in undercarboxylation of matrix gla protein. The proband's mother and aunt, also manifesting with PXE-like skin changes, were heterozygous carriers of a missense mutation (p.V255M) in GGCX and a null mutation (p.R1141X) in the ABCC6 gene, suggesting digenic nature of their skin findings. Thus, reduced gamma-glutamyl carboxylase activity in individuals either compound heterozygous for a missense mutation in GGCX or with haploinsufficiency in GGCX in combination with heterozygosity for ABCC6 gene expression results in aberrant mineralization of skin leading to PXE-like phenotype. These findings expand the molecular basis of PXE-like phenotypes, and suggest a role for multiple genetic factors in pathologic tissue mineralization in general.

Attrition during graduate medical education: medical school perspective.

OBJECTIVE: To identify predictors of attrition during graduate medical education (GME) in a single medical school cohort of contemporary US medical school graduates. DESIGN: Retrospective cohort study. SETTING: Single medical institution. PARTICIPANTS: Recent US allopathic medical school graduates. MAIN OUTCOME MEASURE: Attrition from initial GME program. RESULTS: Forty-seven of 795 graduates (6%) did not complete the GME in their initial specialty of choice. At bivariate analysis, attrition was associated with election to the Alpha Omega Alpha Honor Medical Society, being an MD-PhD degree holder, and specialty choice (all P < .05). Attrition was not associated with graduation year (P = .91), sex (P = .67), or age (P = .12). In a multivariate logistic regression model, MD-PhD degree holder (odds ratio, 3.43; 95% confidence interval, 1.27-9.26; P = .02), election to Alpha Omega Alpha (2.19; 1.04-4.66; P = .04), choice of general surgery for GME (5.32; 1.98-14.27; P < .001), and choice of 5-year surgical specialty including those surgical specialties with a GME training requirement of 5 years or longer (2.74; 1.16-6.44; P = .02) each independently predicted greater likelihood of attrition. CONCLUSION: Academically highly qualified graduates and graduates who chose training in general surgery or in a 5-year surgical specialty were at increased risk of attrition during GME.

Characteristics and career intentions of the emerging MD/PhD workforce.

CONTEXT: MD/PhD program participants represent only a small proportion of all US medical students, yet they are expected to play a major role in the future physician-scientist workforce. The characteristics and career intentions of recent MD/PhD program and other MD program graduates have not been compared. OBJECTIVE: To identify factors associated with MD/PhD program graduation among recent medical graduates. DESIGN, SETTING, AND PARTICIPANTS: Deidentified data were obtained from a nationally representative sample of 88,575 US medical graduates who completed the national Association of American Medical Colleges Graduation Questionnaire from 2000-2006. Multivariate logistic regression was used to test responses to items regarding graduates' characteristics and career plans in association with program graduation, reporting adjusted odds ratios (ORs). MAIN OUTCOME MEASURE: MD/PhD program graduation. RESULTS: Of the 79,104 respondents with complete data (71.7% of all 2000-2006 graduates), 1833 (2.3%) were MD/PhD program graduates. Variables associated with greater likelihood of MD/PhD program graduation included planned substantial career involvement in research (OR, 10.30; 95% confidence interval [CI], 8.89-11.93); lower educational debt (compared with > or = $150,000: $100,000-$149,999, OR, 1.85; 95% CI, 1.35-2.52; $50,000-$99,999, OR, 5.50; 95% CI, 4.14-7.29; $1-$49,999, OR, 17.50; 95% CI, 13.30-23.03; no debt, OR, 17.41; 95% CI, 13.22-22.92); and receipt of medical school scholarships or grants (OR, 3.22; 95% CI, 2.82-3.69). Compared with planned training in internal medicine, MD/PhD graduation was positively associated with planned training in dermatology, neurology, ophthalmology, pathology, pediatrics, or radiology. Variables associated with lower likelihood of MD/PhD graduation included female sex (OR, 0.68; 95% CI, 0.60-0.77); race/ethnicity underrepresented in medicine (OR, 0.64; 95% CI, 0.52-0.80); and, compared with internal medicine, planned training in emergency medicine (OR, 0.58; 95% CI, 0.40-0.84) or surgery (OR, 0.70; 95% CI, 0.57-0.85). CONCLUSION: Compared with graduates of other MD degree programs, MD/PhD graduates tend to be less demographically diverse, have a lower debt burden, favor different medical specialties, and have greater planned career involvement in research.

Reaping what we sow: the emerging academic medicine workforce.

National efforts to increase diversity of academic medicine faculty led us to study the evolution of medical graduates' academic medicine career intentions. We conducted a retrospective cohort study of 1997-2004 U.S. allopathic medical graduates who completed both the Association of American Medical Colleges' Matriculating Student Questionnaire and Graduation Questionnaire, categorizing the evolution of academic medicine career intentions (sustained, emerging, diminished and no intent) by similarities/differences in graduates' responses to the career choice question on both questionnaires. Multivariable logistic regression models identified independent predictors of sustained and emerging intent (compared with no intent) and diminished intent (compared with sustained intent). Of 87,763 graduates, 67% indicated no intent, 20% emerging intent, 8% sustained intent and 5% diminished intent to pursue an academic medicine career. Asians were more likely and underrepresented minorities less likely to have sustained and emerging intent. Women were more likely to have emerging intent. Graduates planning more extensive career involvement in research at matriculation and reporting greater satisfaction with the quality of their medical education, higher clinical clerkship ratings, and lower debt were more likely to have sustained and emerging intent and less likely to have diminished intent. Graduates planning to practice in underserved areas and choosing family medicine were less likely to have sustained and emerging intent and more likely to have diminished intent (all p < 0.05). Findings can inform efforts to develop an academic medicine workforce that can meet our nation's healthcare needs and more equitably reflect the diversity of our society and medical student population.

Clustering of Lynch syndrome malignancies with no evidence for a role of DNA mismatch repair.

OBJECTIVES: We ascertained a large kindred with an excess of Lynch syndrome-associated cancers. Our objective was to determine if a defect in one of the DNA mismatch repair (DMMR) genes was the probable cause of cancer susceptibility as microsatellite instability (MSI) and immunohistochemical (IHC) analysis of the probands' tumors did not provide a clear indication. METHODS: A detailed history and review of medical records was undertaken to construct a four-generation pedigree. Blood samples were obtained for analysis of germline DNA. Polymorphic repeats from the MLH1, MSH2, MSH6, and PMS2 loci were genotyped and the co-segregation of markers and disease was assessed. DMMR gene expression for all available tumors was evaluated by IHC. Combined bisulfite restriction analysis (COBRA) of MLH1 was utilized to test for germline epimutation. RESULTS: Four gynecologic carcinomas, 3 colon carcinomas, and 13 cases of adenomatous polyps were identified. The family met Amsterdam II criteria. The mean age of cancer diagnosis in the kindred was 63 years (range 44-82 years). DNA marker analyses excluded linkage to MLH1, MSH2, MSH6, and PMS2. Furthermore, MSI and IHC analysis of tumors did not suggest a role for DMMR. Methylation of the MLH1 promoter was identified in the peripheral blood leukocytes (PBLs) of a family member with an early onset colon cancer. CONCLUSIONS: We identified a large family with multiple Lynch malignancies and no evidence for an inherited defect in DMMR. This family represents an important but poorly understood form of autosomal dominant inherited cancer susceptibility. Aberrant MLH1 promoter methylation in normal tissues may be a marker for cancer susceptibility in families such as this.

The changing paradigm of contemporary U.S. allopathic medical school graduates' career paths: analysis of the 1997-2004 national AAMC Graduation Questionnaire database.

PURPOSE: During the last 15 years, the proportion of U.S. allopathic medical graduates planning to pursue alternative careers (other than full-time clinical practice) has been increasing. The authors sought to identify factors associated with contemporary medical graduates' career-setting plans. METHOD: The authors obtained anonymous data from the 108,408 U.S. allopathic medical graduates who completed the 1997-2004 national Association of American Medical Colleges Graduation Questionnaire (GQ). Using multinomial logistic regression, responses to eight GQ items regarding graduates' demographics, medical school characteristics, and specialty choice were tested in association with three career-setting plans (full-time university faculty; other, including government agencies, non-university-based research, or medical or health care administration; or undecided) compared with full-time (nonacademic) clinical practice. RESULTS: The sample included 94,101 (86.8% of 108,408) GQ respondents with complete data. From 1997 to 2004, the proportions of graduates planning full-time clinical practice careers decreased from 51.3% to 46.5%; the proportions selecting primary care and obstetrics-gynecology specialties also decreased. Graduates reporting Hispanic race/ethnicity or no response to race/ethnicity, lower debt, dual advanced degrees at graduation, and psychiatric-specialty choice were consistently more likely to plan to pursue alternative careers. Graduates selecting an obstetrics-gynecology specialty/ subspecialty were consistently less likely to plan to pursue alternative careers. Being female, Asian/Pacific Islander, Black or Native American/Alaskan, and selecting non-primary-care specialties were variably associated with alternative career plans. CONCLUSIONS: As the medical student population becomes more demographically diverse, as graduates increasingly select non-primary-care specialties, and as dual-degree-program graduates and alternative career opportunities for physicians expand, the proportion of U.S. graduates planning full-time clinical practice careers likely will continue to decline.

Which U.S. medical graduates plan to become specialty-board certified? Analysis of the 1997-2004 national association of American Medical Colleges Graduation Questionnaire database.

BACKGROUND: Predictors of U.S. allopathic medical-school graduates' board-certification plans have not been characterized. METHOD: Using multivariable logistic regression, graduates' responses to 11 questions on the 1997-2004 Association of American Medical Colleges Graduation Questionnaire were analyzed to identify independent predictors of plans for specialty-board certification. RESULTS: The proportion of 108,408 graduates planning specialty-board certification decreased from 97.3% in 1997 to 88.4% in 2004. Among 101,805 (93.9%) graduates with complete data, graduates who were Hispanic, rated their clinical clerkships, quality of medical education, and confidence in clinical skills more highly, had any debt, and planned "University-faculty" careers were more likely to plan becoming board certified. Females, Asians/Pacific Islanders, and graduates who planned to practice in underserved areas, planned "other" nonclinical-practice careers, and graduated with MD/other (non-PhD) degrees were less likely to plan becoming board certified. CONCLUSION: Specialty-board certification does not appear to be among the professional goals for a growing proportion of U.S. medical graduates.