Evaluating and implementing an opportunity for diversity and inclusion in case-based learning.

Problem-based learning (PBL) and case-based learning (CBL) often mention social identities only if this information is directly relevant to diagnosis, which can inadvertently perpetuate stereotypes in trainee learning. Using a student-developed resource entitled "Portraying Social Identities in Medical Curriculum: A Primer," we analyzed cases for social identities, identified gaps, and proposed changes, including use of a validated name bank to reflect diversity as represented by local census data. Through this innovation, suggestions were provided to represent the social determinants of health in CBL cases. Other medical schools can use our innovation to improve the social diversity of their medical curriculums.

Bien souvent, l'apprentissage par résolution de problèmes (ARP) et l'apprentissage par les cas (APC) ne touchent aux identités sociales que si ce type d'information contribue directement au diagnostic, ce qui peut involontairement perpétuer les stéréotypes dans l'apprentissage des étudiants. À l'aide d'une ressource élaborée par les étudiants, intitulée « Portraying Social Identities in Medical Curriculum : A Primer ¼ (la représentation des identités sociales dans les programmes d'études médicales : une introduction), nous avons analysé des cas d'identités sociales, identifié des lacunes et proposé des changements, notamment l'utilisation d'une banque de noms validée reflétant la diversité qui ressort des données du recensement local. Grâce à cette innovation, des suggestions ont été faites pour représenter les déterminants sociaux de la santé dans les cas étudiés dans l'APC. Nous invitons les facultés de médecine à se servir de notre ressource pour mieux rendre compte de la diversité sociale dans leurs programmes d'études.

Design of an orthopaedic-specific discharge summary.

BACKGROUND: Patients undergoing orthopaedic procedures experience major changes in function and daily routines upon their return home. Discharge summaries are an important communication tool that may play a role in optimizing a safe transition from hospital. Current care gaps and key elements of an ideal discharge summary specific for orthopaedic population are unknown. We sought to identify the challenges of current orthopaedic discharge summaries and to determine key elements of an ideal document. METHODS: Qualitative study survey using semi-structured interviews with a sample of 17 patients and clinicians representing diverse professions, backgrounds, and practice settings. We used the constant comparative method of qualitative analysis to define the experiences and perceptions of quality gaps and strategies to improve orthopaedic-specific discharge summaries. RESULTS: We identified 3 major themes describing factors perceived to be limiting the quality of current discharge summaries: 1) physician-centric documentation and the absence of a comprehensive, inter-professional perspective; 2) access to resources and health informatics; and 3) process variations in document creation and dissemination. CONCLUSIONS: Clinicians and patients identified several factors limiting the quality of discharge summaries among orthopaedic inpatients. Incorporating these elements could improve hospital transitions.

Putting performance in context: the perceived influence of environmental factors on work-based performance.

INTRODUCTION: Context shapes behaviours yet is seldom considered when assessing competence. Our objective was to explore attending physicians' and trainees' perceptions of the Internal Medicine Clinical Teaching Unit (CTU) environment and how they thought contextual factors affected their performance. METHOD: 29 individuals recently completing CTU rotations participated in nine level-specific focus groups (2 with attending physicians, 3 with senior and 2 with junior residents, and 2 with students). Participants were asked to identify environmental factors on the CTU and to describe how these factors influenced their own performance across CanMEDS roles. Discussions were analyzed using constructivist grounded theory. RESULTS: Five major contextual factors were identified: Busyness, Multiple Hats, Other People, Educational Structures, and Hospital Resources and Policies. Busyness emerged as the most important, but all factors had a substantial perceived impact on performance. Participants felt their performance on the Manager and Scholar roles was most affected by environmental factors (mostly negatively, due to decreased efficiency and impact on learning). CONCLUSIONS: In complex workplace environments, numerous factors shape performance. These contextual factors and their impact need to be considered in observations and judgements made about performance in the workplace, as without this understanding conclusions about competency may be flawed.

Do post discharge phone calls improve care transitions? A cluster-randomized trial.

IMPORTANCE: The transition from hospital to home can expose patients to adverse events during the post discharge period. Post discharge care including phone calls may provide support for patients returning home but the impact on care transitions is unknown. OBJECTIVE: To examine the effect of a 72-hour post discharge phone call on the patient's transition of care experience. DESIGN: Cluster-randomized control trial. SETTING: Urban, academic medical center. PARTICIPANTS: General medical patients age 18 and older discharged home after hospitalization. MAIN OUTCOMES AND MEASURES: Primary outcome measure was the Care Transition Measure (CTM-3) score, a validated measure of the quality of care transitions. Secondary measures included self-reported adherence to medication and follow up plans, and 30-day composite of emergency department (ED) visits and hospital readmission. RESULTS: 328 patients were included in the study over an 6-month period. 114 (69%) received a post discharge phone call, and 214 of all patients in the study completed the follow outcome survey (65% response rate). A small difference in CTM-3 scores was observed between the intervention and control groups (1.87 points, 95% CI 0.47-3.27, p = 0.01). Self-reported adherence to treatment plans, ED visits, and emergency readmission rates were similar between the two groups (odds ratio 0.57, 95% CI 0.13-2.45, 1.20, 95% CI 0.61-2.37, and 1.18, 95% CI 0.53-2.61, respectively). CONCLUSIONS AND RELEVANCE: A single post discharge phone call had a small impact on the quality of care transitions and no effect on hospital utilization. Higher intensity post discharge support may be required to improve the patient experience upon returning home. TRIAL REGISTRATION: ClinicalTrials.gov NCT01580774.

Competencies "plus": the nature of written comments on internal medicine residents' evaluation forms.

BACKGROUND: Comments on residents' in-training evaluation reports (ITERs) may be more useful than scores in identifying trainees in difficulty. However, little is known about the nature of comments written by internal medicine faculty on residents' ITERs. METHOD: Comments on 1,770 ITERs (from 180 residents in postgraduate years 1-3) were analyzed using constructivist grounded theory beginning with an existing framework. RESULTS: Ninety-three percent of ITERs contained comments, which were frequently easy to map onto traditional competencies, such as knowledge base (n = 1,075 comments) to the CanMEDs Medical Expert role. Many comments, however, could be linked to several overlapping competencies. Also common were comments completely unrelated to competencies, for instance, the resident's impact on staff (813), or personality issues (450). Residents' "trajectory" was a major theme (performance in relation to expected norms [494], improvement seen [286], or future predictions [286]). CONCLUSIONS: Faculty's assessments of residents are underpinned by factors related and unrelated to traditional competencies. Future evaluations should attempt to capture these holistic, integrated impressions.

Professing professionalism: are we our own worst enemy? Faculty members' experiences of teaching and evaluating professionalism in medical education at one school.

PURPOSE: To explore clinical faculty members' knowledge and attitudes regarding their teaching and evaluation of professionalism. METHOD: Clinical faculty involved in medical education at University of Toronto Faculty of Medicine were recruited to participate in focus groups between 2006 and 2007 to discuss their knowledge, beliefs, and attitudes about teaching and evaluating professionalism and to determine their views regarding faculty development in this area. Focus groups were transcribed, analyzed, and coded for themes using a grounded theory approach. RESULTS: Five focus groups consisting of 14 faculty members from surgical specialties, psychiatry, anesthesia, and pediatrics were conducted. Grounded theory analysis of the 188 pages of text identified three major themes: Professionalism is not a static concept, a gap exists between faculty members' real and ideal experience of teaching professionalism, and "unprofessionalism" is a persistent problem. Important subthemes included the multiple bases that exist for defining professionalism, how professionalism is learned and taught versus how it should be taught, institutional and faculty tolerance and silence regarding unprofessionalism, stress as a contributor to unprofessionalism, and unprofessionalism arising from personality traits. CONCLUSIONS: All faculty expressed that teaching and evaluating professionalism posed a challenge for them. They identified their own lapses in professionalism and their sense of powerlessness and failure to address these with one another as the single greatest barrier to teaching professionalism, given a perceived dominance of role modeling as a teaching tool. Participants had several recommendations for faculty development and acknowledged a need for culture change in teaching hospitals and university departments.