Mapping hospital data to characterize residents' educational experiences.

BACKGROUND: Experiential learning through patient care is fundamental to graduate medical education. Despite this, the actual content to which trainees are exposed in clinical practice is difficult to quantify and is poorly characterized. There remains an unmet need to define precisely how residents' patient care activities inform their educational experience.  METHODS: Using a recently-described crosswalk tool, we mapped principal ICD-10 discharge diagnosis codes to American Board of Internal Medicine (ABIM) content at four training hospitals of a single Internal Medicine (IM) Residency Program over one academic year to characterize and compare residents' clinical educational experiences. Frequencies of broad content categories and more specific condition categories were compared across sites to profile residents' aggregate inpatient clinical experiences and drive curricular change. RESULTS: There were 18,604 discharges from inpatient resident teams during the study period. The crosswalk captured > 95% of discharges at each site. Infectious Disease (ranging 17.4 to 39.5% of total discharges) and Cardiovascular Disease (15.8 to 38.2%) represented the most common content categories at each site. Several content areas (Allergy/Immunology, Dermatology, Obstetrics/Gynecology, Ophthalmology, Otolaryngology/Dental Medicine) were notably underrepresented (≤ 1% at each site). There were significant differences in the frequencies of conditions within most content categories, suggesting that residents experience distinct site-specific clinical content during their inpatient training. CONCLUSIONS: There were substantial differences in the clinical content experienced by our residents across hospital sites, prompting several important programmatic and curricular changes to enrich our residents' hospital-based educational experiences.

Experience and Education in Residency Training: Capturing the Resident Experience by Mapping Clinical Data.

PROBLEM: Internal medicine training programs operate under the assumption that the 3-year residency training period is sufficient for trainees to achieve the depth and breadth of clinical experience necessary for independent practice; however, the medical conditions to which residents are exposed in clinical practice are not easily measured. As a result, residents' clinical educational experiences are poorly understood. APPROACH: A crosswalk tool (a repository of International Classification of Diseases [ICD]-10 codes linked to medical content areas) was developed to query routinely collected inpatient principal diagnosis codes and translate them into an educationally meaningful taxonomy. This tool provides a robust characterization of residents' inpatient clinical experiences. OUTCOMES: This pilot study has provided proof of principle that the crosswalk tool can effectively map 1 year of resident-attributed diagnosis codes to both the broad content category level (e.g., "cardiovascular disease") and to the more specific condition category level (e.g., "myocardial disease"). The authors uncovered content areas in their training program that are overrepresented and some that are underrepresented relative to material on the American Board of Internal Medicine (ABIM) Certification Exam. NEXT STEPS: The crosswalk tool introduced here translated residents' patient care activities into discrete, measurable educational content and enabled 1 internal medicine residency program to characterize residents' inpatient educational experience with a high degree of resolution. Leaders of other programs seeking to profile the clinical exposure of their trainees may adopt this strategy. Such clinical content mapping drives innovation in the experiential curriculum, enables comparison across practice sites, and lays the groundwork to test associations between individual clinical exposure and competency-based outcomes, which, in turn, will allow medical educators to draw conclusions regarding how clinical experience reflects clinical competency.

Mapping the Clinical Experience of a New York City Residency Program During the COVID-19 Pandemic.

The COVID-19 pandemic has dramatically disrupted the educational experience of medical trainees. However, a detailed characterization of exactly how trainees' clinical experiences have been affected is lacking. Here, we profile residents' inpatient clinical experiences across the four training hospitals of NYU's Internal Medicine Residency Program during the pandemic's first wave. We mined ICD-10 principal diagnosis codes attributed to residents from February 1, 2020, to May 31, 2020. We translated these codes into discrete medical content areas using a newly developed "crosswalk tool." Residents' clinical exposure was enriched in infectious diseases (ID) and cardiovascular disease content at baseline. During the pandemic's surge, ID became the dominant content area. Exposure to other content was dramatically reduced, with clinical diversity repopulating only toward the end of the study period. Such characterization can be leveraged to provide effective practice habits feedback, guide didactic and self-directed learning, and potentially predict competency-based outcomes for trainees in the COVID era.

Theory-guided teaching: Implementation of a clinical reasoning curriculum in residents.

Introduction: Educators have theorized that interventions grounded in dual process theory (DPT) and script theory (ST) may improve the diagnostic reasoning process of physicians but little empirical evidence exists. Methods: In this quasi-experimental study, we assessed the impact of a clinical reasoning (CR) curriculum grounded in DPT and ST on medicine residents participating in one of three groups during a 6-month period: no, partial, or full intervention. Residents completed the diagnostic thinking inventory (DTI) at baseline and 6 months. At 6 months, participants also completed a post-survey assessing application of concepts to cases. Results: There was a significant difference between groups in application of concepts (no intervention 1.6 (0.65) compared to partial 2.3 (0.81) and full 2.2 (0.91), p = 0.05), as well as describing cases in problem representation format (no intervention 1.2 (0.38) and partial 1.5 (0.55) compared to full 2.1 (0.93), p = 0.004). There was no significant difference in change in DTI scores (no intervention 7.0 (16.3), partial 8.8 (9.8), full 7.8 (12.0)). Conclusions: Residents who participated in a CR curriculum grounded in DPT and ST were effective in applying principles of CR in cases from their practice. To our knowledge, this is the first workplace-based CR educational intervention study showing differences in the reasoning process residents apply to patients.

Faculty feedback that begins with resident self-assessment: motivation is the key to success.

CONTEXT: The seeking and incorporating of feedback are necessary for continuous performance improvement in medicine. We know that beginning feedback conversations with resident self-assessment may reduce some of the tensions experienced by faculty staff. However, we do not fully understand how residents experience feedback that begins with self-assessment, and whether any existing theoretical frameworks can explain their experiences. METHODS: We conducted a constructivist grounded theory study exploring physical medicine and rehabilitation residents' experiences as they engaged in a structured self-assessment and faculty staff feedback programme. Utilising purposive sampling, we conducted 15 individual interviews and analysed verbatim transcripts iteratively. We implemented several procedures to enhance the credibility of the findings and the protection of participants during recruitment, data collection and data analysis. After defining the themes, we reviewed a variety of existing frameworks to determine if any fitted the data. RESULTS: Residents valued self-assessment followed by feedback (SAFF) and had clear ideas of what makes the process useful. Time pressures and poor feedback quality could lead to a process of 'just going through the motions'. Motivation coloured residents' experiences, with more internalised motivation related to a more positive experience. There were no gender- or year of training-related patterns. CONCLUSIONS: Self-determination theory provided the clearest lens for framing our findings and fitted into a conceptual model linking the quality of the SAFF experience and residents' motivational loci. We identified several study limitations including time in the field, evolving characteristics of the SAFF programme and the absence of faculty voices. We believe that by better understanding residents' experiences of SAFF, educators may be able to tailor the feedback process, enhance clinical performance and ultimately improve patient care.

The Courteous Consult: A CONSULT Card and Training to Improve Resident Consults.

BACKGROUND: Communication and courtesy are important elements of consultations, but there is limited published data about the quality of trainee consults. OBJECTIVES: This study assessed residents' views on consult interactions, evaluated the impact of the consult interactions on patient care, and developed and implemented a pocket card and training on trainee consults. METHODS: We surveyed resident and fellow physicians at Mount Sinai Hospital to assess perceptions, created a CONSULT card that uses a mnemonic for key elements, and developed a training session for how to call consults. We also conducted a consult training session using the CONSULT card as part of orientation in 2011 for all interns. We assessed the acceptability, feasibility, and sustainability of this intervention. RESULTS: Of 1001 trainees, 403 (40%) responded. Respondents reported that the most important components of calling consults included giving patient name, medical record number, and location (91%), and giving a clear question/reason (89%). Respondents also reported that these behaviors are done consistently for only 64%, and 10% of consults, respectively. Trainees reported that consult interactions affect the timeliness of treatment (62%), timeliness of tests performed (57%), appropriateness of diagnosis (56%), and discharge planning (49%). Approximately 300 interns attended the consult training session, and their feedback demonstrated acceptability and utility of the session. CONCLUSIONS: Trainees believe that consult interactions impact patient care, but important components of the consult call are often missing. Our training and CONSULT card is an acceptable, feasible, and novel training intervention. Once developed, the training session and CONSULT card require minimal faculty time to deliver.

What factors create a humanistic doctor? A nationwide survey of fourth-year medical students.

PURPOSE: The authors sought to develop a conceptual framework of the factors that most influence medical students' development of humanism and to explore students' opinions regarding the role these factors play in developing or inhibiting humanism. METHOD: In 2006-2007, the authors conducted 16 focus groups with fourth-year students and first-year residents at four universities to design a conceptual framework. They used the framework to develop a survey, which they administered to fourth-year medical students at 20 U.S. medical schools in 2007-2008. RESULTS: Data from 80 focus-group participants suggested that the key influences on students' development of humanism were their authentic, unique, and participatory experiences before and during medical school, and the opportunity to process these experiences. Students who completed the survey (N = 1,170) reported that experiences of greatest intensity (e.g., being involved in a case where the patient dies), participatory learning experiences (e.g., volunteer work, international clinical rotations), and positive role models had the greatest effect on their development of humanism, whereas stressful conditions, such as a busy workload or being tired or postcall, inhibited their humanism. Women and students going into primary care placed significantly greater importance on experiences promoting humanism than did men and those not going into primary care. In addition, students with lower debt burdens viewed such experiences as more important than did those with higher debt burdens. CONCLUSIONS: Students viewed a variety of factors as influencing their development of humanism. This research provides a starting point for enhancing curricula to promote humanism.

Critical events in the lives of interns.

BACKGROUND: Early residency is a crucial time in the professional development of physicians. As interns assume primary care for their patients, they take on new responsibilities. The events they find memorable during this time could provide us with insight into their developing professional identities. OBJECTIVE: To evaluate the most critical events in the lives of interns. PARTICIPANTS: Forty-one internal medicine residents at one program participated in a two-day retreat in the fall of their first year. Each resident provided a written description of a recent high point, low point, and patient conflict. MEASUREMENTS: We used a variant of grounded theory to analyze these critical incidents and determine the underlying themes of early internship. Independent inter-rater agreement of >90% was achieved for the coding of excerpts. MAIN RESULTS: The 123 critical incidents were clustered into 23 categories. The categories were further organized into six themes: confidence, life balance, connections, emotional responses, managing expectations, and facilitating teamwork. High points were primarily in the themes of confidence and connections. Low points were dispersed more generally throughout the conceptual framework. Conflicts with patients were about negotiating the expectations inherent in the physician-patient relationship. CONCLUSION: The high points, low points, and conflicts reported by early residents provide us with a glimpse into the lives of interns. The themes we have identified reflect critical challenges interns face the development of their professional identity. Program directors could use this process and conceptual framework to guide the development and promotion of residents' emerging professional identities.

International medical school faculty development: the results of a needs assessment survey among medical educators in China.

To explore the need for faculty development among Chinese medical educators. Leaders at each medical school in China were asked to complete a 123-item survey to identify interest in various topics and barriers and perceived benefits of participating in faculty development programs. Interest levels were high for all topics. Experience with Hospital Management and Research positively correlated with interest in learning more (p < 0.001). Ninety-two percent believe that international experiences are very or extremely important to medical educators' career advancement. Chinese medical education faculty members have a strong interest in faculty development programs.

Teaching humanism.

As the "passion that animates authentic professionalism," humanism must be infused into medical education and clinical care as a central feature of medicine's professionalism movement. In this article, we discuss a current definition of humanism in medicine. We will also provide detailed descriptions of educational programs intended to promote humanism at a number of medical schools in the United States (and beyond) and identify the key factors that make these programs effective. Common elements of programs that effectively teach humanism include: (1) opportunities for students to gain perspective in the lives of patients; (2) structured time for reflection on those experiences; and (3) focused mentoring to ensure that these events convert to positive, formative learning experiences. By describing educational experiences that both promote and sustain humanism in doctors, we hope to stimulate the thinking of other medical educators and to disseminate the impact of these innovative educational programs to help the profession meet its obligation to provide the public with humanistic physicians.

Quality of life, optimism/pessimism, and knowledge and attitudes toward HIV Screening among pregnant women in Ghana.

OBJECTIVE: We sought to explore optimism/pessimism, knowledge of HIV, and attitudes toward HIV screening and treatment among Ghanaian pregnant women. METHOD: Pregnant women in Accra, Ghana, completed a self-administered questionnaire including the Life Orientation Test-Revised (LOT-R, an optimism/pessimism measure), an HIV knowledge and screening attitudes questionnaire, the Short Form 12 (SF-12, a measure of health-related quality of life [HRQOL]), and a demographic questionnaire. Data were analyzed using t-tests, ANOVA, correlations, and the chi2 test. RESULTS: There were 101 participants; 28% were nulliparous. Mean age was 29.7 years, and mean week of gestation was 31.8. All women had heard of AIDS, 27.7% had been tested for HIV before this pregnancy, 46.5% had been tested during this pregnancy, and 59.4% of the sample had ever been tested for HIV. Of those not tested during this pregnancy, 64.2% were willing to be tested. Of all respondents, 89% said they would get tested if antiretroviral drugs (ARVs) were readily available and might prevent maternal-to-child transmission. Neither optimism/pessimism nor HRQOL was associated with attitudes toward HIV screening. Optimism was negatively correlated with HIV knowledge (p = .001) and was positively correlated with having never been tested before this pregnancy (p = .007). CONCLUSION: The relationship between optimism/pessimism and HIV knowledge and screening behavior is worthy of further study using larger samples and objective measures of testing beyond self-report.

Patients speak: what's really important about bedside interactions with physician teams.

BACKGROUND: Although it may take up relatively little time, hospitalized patients' interactions with their physicians are important elements of their hospital experience. PURPOSE: We conducted a qualitative study to explore what is important to patients about bedside interactions with their physician teams. METHODS: We interviewed medical inpatients and used grounded theory methodology to analyze interview transcripts. RESULTS: We recruited 17 patients from an academic medical center including a university hospital and a Veterans Administration (VA) hospital. We found that important aspects of patient-team interactions included the exchange of information, evidence of caring from their team, involvement in teaching, knowing the team members, and bedside manner. Patients also described team characteristics that were important to them such as team attributes and intrateam collaboration. CONCLUSIONS: This model clarifies the aspects of bedside interactions that patients value and will allow physicians to focus their limited time to the benefit of their patients.

Can there be a single system for peer assessment of professionalism among medical students? A multi-institutional study.

PURPOSE: Peer assessment is a valuable source of information about medical students' professionalism. How best to facilitate peer assessment of students' professional behavior remains to be answered, however. This report extends previous research through a multi-institutional study of students' perspectives about system characteristics for peer assessment of professionalism. It examines whether students from different schools and year levels prefer different characteristics of peer assessment to assess each other candidly, or whether a single system can be designed. It then identifies the characteristics of the resulting preferred system(s). METHOD: At the beginning of academic year 2004-2005, students (1,661 of 2,115; 78%) in years one through four at four schools replied to a survey about which peer assessment characteristics - related to, for example, who receives the assessment, its anonymity, and timing - would prevent or encourage their participation. Multivariate analysis of variance was used to detect differences among institutions and students from each year level. RESULTS: Students across year levels and schools generally agreed about the characteristics of peer assessment. They prefer a system that is 100% anonymous, provides immediate feedback, focuses on both unprofessional and professional behaviors, and uses peer assessment formatively while rewarding exemplary behavior and addressing serious repetitive professional lapses. The system, they emphasize, must be embedded in a supportive environment. CONCLUSIONS: Students' agreement about peer-assessment characteristics suggests that one system can be created to meet the majority of students' preferences. Once implemented, the system should be monitored for student acceptability to maximize participation and to determine the formative and summative value of the process.

Ethics and professionalism: what does a resident need to learn?

Training in ethics and professionalism is a fundamental component of residency education, yet there is little empirical information to guide curricula. The objective of this study is to describe empirically derived ethics objectives for ethics and professionalism training for multiple specialties. Study design is a thematic analysis of documents, semi-structured interviews, and focus groups conducted in a setting of an academic medical center, Veterans Administration, and community hospital training more than 1000 residents. Participants were 84 informants in 13 specialties including residents, program directors, faculty, practicing physicians, and ethics committees. Thematic analysis identified commonalities across informants and specialties. Resident and nonresident informants identified consent, interprofessional relationships, family interactions, communication skills, and end-of-life care as essential components of training. Nonresidents also emphasized formal ethics instruction, resource allocation, and self-monitoring, whereas residents emphasized the learning environment and resident-attending interactions. Conclusions are that empirically derived learning needs for ethics and professionalism included many topics, such as informed consent and resource allocation, relevant for most specialties, providing opportunities for shared curricula and resources.

Setting school-level outcome standards.

BACKGROUND: To establish international standards for medical schools, an appropriate panel of experts must decide on performance standards. A pilot test of such standards was set in the context of a multidimensional (multiple-choice question examination, objective structured clinical examination, faculty observation) examination at 8 leading schools in China. METHODS: A group of 16 medical education leaders from a broad array of countries met over a 3-day period. These individuals considered competency domains, examination items, and the percentage of students who could fall below a cut-off score if the school was still to be considered as meeting competencies. This 2-step process started with a discussion of the borderline school and the relative difficulty of a borderline school in achieving acceptable standards in a given competency domain. Committee members then estimated the percentage of students falling below the standard that is tolerable at a borderline school and were allowed to revise their ratings after viewing pilot data. RESULTS: Tolerable failure rates ranged from 10% to 26% across competency domains and examination types. As with other standard-setting exercises, standard deviations from initial to final estimates of the tolerable failure rates fell, but the cut-off scores did not change significantly. Final, but not initial cut-off scores were correlated with student failure rates (r = 0.59, P = 0.03). DISCUSSION: This paper describes a method to set school-level outcome standards at an international level based on prior established standard-setting methods. Further refinement of this process and validation using other examinations in other countries will be needed to achieve accurate international standards.

Disciplinary action by medical boards and prior behavior in medical school.

BACKGROUND: Evidence supporting professionalism as a critical measure of competence in medical education is limited. In this case-control study, we investigated the association of disciplinary action against practicing physicians with prior unprofessional behavior in medical school. We also examined the specific types of behavior that are most predictive of disciplinary action against practicing physicians with unprofessional behavior in medical school. METHODS: The study included 235 graduates of three medical schools who were disciplined by one of 40 state medical boards between 1990 and 2003 (case physicians). The 469 control physicians were matched with the case physicians according to medical school and graduation year. Predictor variables from medical school included the presence or absence of narratives describing unprofessional behavior, grades, standardized-test scores, and demographic characteristics. Narratives were assigned an overall rating for unprofessional behavior. Those that met the threshold for unprofessional behavior were further classified among eight types of behavior and assigned a severity rating (moderate to severe). RESULTS: Disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school (odds ratio, 3.0; 95 percent confidence interval, 1.9 to 4.8), for a population attributable risk of disciplinary action of 26 percent. The types of unprofessional behavior most strongly linked with disciplinary action were severe irresponsibility (odds ratio, 8.5; 95 percent confidence interval, 1.8 to 40.1) and severely diminished capacity for self-improvement (odds ratio, 3.1; 95 percent confidence interval, 1.2 to 8.2). Disciplinary action by a medical board was also associated with low scores on the Medical College Admission Test and poor grades in the first two years of medical school (1 percent and 7 percent population attributable risk, respectively), but the association with these variables was less strong than that with unprofessional behavior. CONCLUSIONS: In this case-control study, disciplinary action among practicing physicians by medical boards was strongly associated with unprofessional behavior in medical school. Students with the strongest association were those who were described as irresponsible or as having diminished ability to improve their behavior. Professionalism should have a central role in medical academics and throughout one's medical career.