Assessing changes in the quality of quantitative health educations research: a perspective from communities of practice.

BACKGROUND: As a community of practice (CoP), medical education depends on its research literature to communicate new knowledge, examine alternative perspectives, and share methodological innovations. As a key route of communication, the medical education CoP must be concerned about the rigor and validity of its research literature, but prior studies have suggested the need to improve medical education research quality. Of concern in the present study is the question of how responsive the medical education research literature is to changes in the CoP. We examine the nature and extent of changes in the quality of medical education research over a decade, using a widely cited study of research quality in the medical education research literature as a benchmark to compare more recent quality indicators. METHODS: A bibliometric analysis was conducted to examine the methodologic quality of quantitative medical education research studies published in 13 selected journals from September 2013 to December 2014. Quality scores were calculated for 482 medical education studies using a 10-item Medical Education Research Study Quality Instrument (MERSQI) that has demonstrated strong validity evidence. These data were compared with data from the original study for the same journals in the period September 2002 to December 2003. Eleven investigators representing 6 academic medical centers reviewed and scored the research studies that met inclusion and exclusion criteria. Primary outcome measures include MERSQI quality indicators for 6 domains: study design, sampling, type of data, validity, data analysis, and outcomes. RESULTS: There were statistically significant improvements in four sub-domain measures: study design, type of data, validity and outcomes. There were no changes in sampling quality or the appropriateness of data analysis methods. There was a small but significant increase in the use of patient outcomes in these studies. CONCLUSIONS: Overall, we judge this as equivocal evidence for the responsiveness of the research literature to changes in the medical education CoP. This study identified areas of strength as well as opportunities for continued development of medical education research.

Dealing with uncertainty in clinical reasoning: A threshold model and the roles of experience and task framing.

INTRODUCTION: Uncertainty is integral to clinical practice and clinical reasoning but has proven difficult to study and model. Little is known about how clinicians manage uncertainty. According to evidence-based medicine theory, clinicians should utilise new information to reduce uncertainty until reaching action thresholds for further information gathering or treatment. We examined the impact of experience and task framing on uncertainty thresholds and the extent to which these thresholds guided clinical decisions. Finally, we sought to determine the impact of framing by having participants provide threshold responses as a range or as specific numbers. METHODS: One hundred sixty-eight fourth-year medical students, 93 residents and 72 faculty were presented a case of viral pneumonia with a suspected superimposed bacterial infection. Participants identified their testing and treatment thresholds with either a specific number or an inter-threshold range of probabilities that would compel them to test further. Afterwards, they were told the patient had a 20% pre-test probability of a superimposed infection and asked whether they would treat the patient with antibiotics, order additional testing or neither. Responses were compared with their previously stated threshold values to assess decision-making consistency. RESULTS: Testing thresholds were 15.8%, 20.6% and 25.8%, treatment thresholds were 78.5%, 71.6% and 73.4% and threshold spans (difference between testing and treatment thresholds) were 62.7, 51 and 47.6 for students, residents and faculty, respectively. Sixty-four percent of respondents made judgements consistent with their thresholds, 28% escalated their decision (doing more than their thresholds predicted) and 7.6% de-escalated their decision (doing less than their thresholds predicted). Framing had an impact on both faculty and resident decisions and a larger impact on students. DISCUSSION: These findings help us understand how clinical reasoning and threshold determinations vary with clinical experience. As uncertainty can lead to unnecessary testing and cognitive discomfort, examining decision thresholds helps us ascertain how diagnostic and treatment decisions are made.

Twelve tips for the integration of medical students into telemedicine visits.

The use of telemedicine in clinical care has grown significantly in the last few years and has only increased during the COVID-19 pandemic. Given that many physicians will be expected to deliver virtual care moving forward, it is important for medical students to gain exposure via this modality during their clinical training. Many medical schools are actively working to integrate students into telemedicine. This article aims to provide guidance for readers incorporating medical students in telemedicine visits at an institutional or departmental level. This article covers essential topics such as coordinating key stakeholders, conducting needs assessments, addressing technological or software considerations, and creating appropriate workflows for students and physicians.

Persistent influence of a narrative educational program on physician attitudes regarding patient care.

PURPOSE: Educational approaches involving patient stories aim at enhancing empathy and patient-centered care; however, it is not known whether the influence of such programs on physician attitudes persists beyond medical school. MATERIALS AND METHODS: The Family Centered Experience (FCE) paired preclinical medical students with patient families over two years and engaged students in reflective dialogs about the volunteers' stories. This study examined possible long-term influences on attitudes toward medicine and doctoring. Interviews were conducted with former students at the end of or after post-graduate training. All had completed the FCE between 4 and 10 years before the study. Thematic analysis was informed by a constructivist Grounded Theory approach. RESULTS: Several themes were identified. The FCE made graduates aware of the patients' perspectives and impacted their clinical practice in specific ways, such as developing collaborative partnerships, conducting family meetings, and breaking bad news. The course had influenced career choices and interest in teaching. Finally, the FCE enhanced appreciation of the human dimensions of medicine, which graduates had drawn upon in subsequent years. CONCLUSIONS: A program based on longitudinal interactions with individuals with chronic illness can have persistent influence by stimulating reflection on the patient's perspective and humanistic approaches to patient care.

Educational Interventions to Improve Handover in Health Care: An Updated Systematic Review.

PURPOSE: Effective handovers (handoffs) are vital to patient safety. Medical educators investigated educational interventions to improve handovers in a 2011 systematic review. The number of publications on handover education has increased since then, so authors undertook this updated review. METHOD: The authors considered studies involving educational interventions to improve handover amongst undergraduate or postgraduate health professionals in acute care settings. In September 2016, two authors independently conducted a standardized search of online databases and completed a data extraction and quality assessment of the articles included. They conducted a content analysis of and extracted key themes from the interventions described. RESULTS: Eighteen reports met the inclusion criteria. All but two were based in the United States. Interventions most commonly involved single-patient exercises based on simulation and role-play. Many studies mentioned multiprofessional education or practice, but interventions occurred largely in single-professional contexts. Analysis of interventions revealed three major themes: facilitating information management, reducing the potential for errors, and improving confidence. The majority of studies assessed Kirkpatrick's outcomes of satisfaction and knowledge/skill improvement (Levels 1 and 2). The strength of conclusions was generally weak. CONCLUSIONS: Despite increased interest in and publications on handover, the quality of published research remains poor. Inadequate reporting of interventions, especially as they relate to educational theory, pedagogy, curricula, and resource requirements, continues to impede replication. Weaknesses in methodologies, length of follow-up, and scope of outcomes evaluation (Kirkpatrick levels) persist. Future work to address these issues, and to consider the role of multiprofessional and multiple-patient handovers, is vital.

A Randomized Cohort Study of Diagnostic and Therapeutic Thresholds in Medical Student Clinical Reasoning.

PURPOSE: Learning to make decisions under uncertain conditions is a critical component of diagnostic and therapeutic reasoning. This study sought to determine treatment decisions medical students make when presented with different thresholds of diagnostic uncertainty and whether they appropriately adjust diagnostic probabilities with test information. METHOD: Two classes (2015, 2016) of fourth-year students (N = 342) were presented a patient with viral pneumonia and given 10%, 20%, or 50% pretest probabilities of that patient having a superimposed bacterial infection. Students decided to not treat, order a diagnostic test to guide management, or treat without testing based on these probabilities. The 2015 class was provided a posttest probability of 10% or 50% and asked to adjust their initial treatment decision. RESULTS: When given a low (10%) pretest probability, students were less likely to decide to treat (6%) and more likely to decide not to treat (36%). The percentage of students deciding to treat increased as the pretest probability of a superimposed infection increased from 10% to 50%, while the percentage of students not wanting to treat decreased. Interestingly, at 10%, 20%, and 50% pretest probability levels, most students were unable to decide and chose to order another test (57%, 67%, and 64%, respectively). When provided low and high posttest probabilities, students appropriately adjusted their decision making, but 29% to 32% still wanted additional testing. CONCLUSIONS: Students adjusted treatment decisions to reflect different levels of diagnostic uncertainty, but varied considerably in their individual thresholds to make decisions, possibly contributing to unnecessary testing.

Medical school handoff education improves postgraduate trainee performance and confidence.

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