Dynamic Opportunities for Medical Students to Assume the Roles of "Medical Teacher".

The traditional undergraduate medical education curriculum focuses on bolstering knowledge for practice and building clinical skills. However, as future clinicians, medical students will be tasked with teaching throughout their careers, first as residents and then as attendings. Here, we describe teaching opportunities for students that foster their development as future teachers and potential clinician educators. These offerings are diverse in their focus and duration and are offered across various levels of the curriculum - including course-based learning, longitudinal electives, and extra-curricular opportunities for medical students who have a passion for teaching.

Making Use of Natural Language Processing to Better Understand Medical Students' Self-Assessment of Clinical Skills.

PROBLEM: Reflective practice is necessary for self-regulated learning. Helping medical students develop these skills can be challenging since they are difficult to observe. One common solution is to assign students' reflective self-assessments, which produce large quantities of narrative assessment data. Reflective self-assessments also provide feedback to faculty regarding students' understanding of content, reflective abilities, and areas for course improvement. To maximize student learning and feedback to faculty, reflective self-assessments must be reviewed and analyzed, activities that are often difficult for faculty due to the time-intensive and cumbersome nature of processing large quantities of narrative assessment data. APPROACH: The authors collected narrative assessment data (2,224 students' reflective self-assessments) from 344 medical students' reflective self-assessments. In academic years 2019-2020 and 2021-2022, students at the University of Cincinnati College of Medicine responded to 2 prompts (aspects that surprised students, areas for student improvement) after reviewing their standardized patient encounters. These free-text entries were analyzed using TopEx, an open-source natural language processing (NLP) tool, to identify common topics and themes, which faculty then reviewed. OUTCOMES: TopEx expedited theme identification in students' reflective self-assessments, unveiling 10 themes for prompt 1 such as question organization and history analysis, and 8 for prompt 2, including sensitive histories and exam efficiency. Using TopEx offered a user-friendly, time-saving analysis method without requiring complex NLP implementations. The authors discerned 4 education enhancement implications: aggregating themes for future student reflection, revising self-assessments for common improvement areas, adjusting curriculum to guide students better, and aiding faculty in providing targeted upcoming feedback. NEXT STEPS: The University of Cincinnati College of Medicine aims to refine and expand the utilization of TopEx for deeper narrative assessment analysis, while other institutions may model or extend this approach to uncover broader educational insights and drive curricular advancements.

The Impact of Words: Multisource Feedback Provides Students With a Deeper Understanding and Reflection on Goals of Care Discussions.

Background: Physician communication during goals of care (GOC) discussions impact experiences for patients and families at end-of-life (EOL). Simulation allows training in a safe environment where feedback from simulated patients (SP), clinicians, and self-reflection can be incorporated. Objectives: To determine if multisource feedback from SP scenarios enriches feedback provided to trainees. Design: Fourth-medical students participated in two SP GOC discussions during an advanced care planning (ACP) curriculum. Students received feedback from SPs and faculty and completed a video review with self-reflection. Setting and Subjects: Forty-seven fourth-year medical students at the University of Cincinnati College of Medicine participated in the curriculum from 2019-2021. Measurements: An inductive thematic analysis of the narrative data was performed examining all sources of feedback from the SP sessions. Results: Six themes emerged from the feedback: the warning shot: words to say and why it helps; acknowledging emotion: verbal vs non-verbal responses; organization: necessity of a clear path; body language: adding to and distracting from the conversation; terminology to avoid: what jargon encompasses and how it impacts patients; and silence: perceived importance by everyone. SP feedback focused on the personal emotional impact of a student's word choice and body language. Faculty feedback focused on specific learning points through examples from the conversation and expanded to hypothetical scenarios. Student self-reflection after video review allowed students to see challenges that they did not notice while immersed in the encounter. Conclusion: Multisource feedback from simulated GOC discussions provides unique insights for students to guide their development in leading difficult conversations.

Improving the Quality of Written Discharge Instructions: A Multisite Collaborative Project.

BACKGROUND AND OBJECTIVES: Written discharge instructions help to bridge hospital-to-home transitions for patients and families, though substantial variation in discharge instruction quality exists. We aimed to assess the association between participation in an Institute for Healthcare Improvement Virtual Breakthrough Series collaborative and the quality of pediatric written discharge instructions across 8 US hospitals. METHODS: We conducted a multicenter, interrupted time-series analysis of a medical records-based quality measure focused on written discharge instruction content (0-100 scale, higher scores reflect better quality). Data were from random samples of pediatric patients (N = 5739) discharged from participating hospitals between September 2015 and August 2016, and between December 2017 and January 2020. These periods consisted of 3 phases: 1. a 14-month precollaborative phase; 2. a 12-month quality improvement collaborative phase when hospitals implemented multiple rapid cycle tests of change and shared improvement strategies; and 3. a 12-month postcollaborative phase. Interrupted time-series models assessed the association between study phase and measure performance over time, stratified by baseline hospital performance, adjusting for seasonality and hospital fixed effects. RESULTS: Among hospitals with high baseline performance, measure scores increased during the quality improvement collaborative phase beyond the expected precollaborative trend (+0.7 points/month; 95% confidence interval, 0.4-1.0; P < .001). Among hospitals with low baseline performance, measure scores increased but at a lower rate than the expected precollaborative trend (-0.5 points/month; 95% confidence interval, -0.8 to -0.2; P < .01). CONCLUSIONS: Participation in this 8-hospital Institute for Healthcare Improvement Virtual Breakthrough Series collaborative was associated with improvement in the quality of written discharge instructions beyond precollaborative trends only for hospitals with high baseline performance.

Reconstructing Neurath's Ship: A Case Study in Reevaluating Equity in a Program of Assessment.

Inequity in assessment has been described as a "wicked problem"-an issue with complex roots, inherent tensions, and unclear solutions. To address inequity, health professions educators must critically examine their implicit understandings of truth and knowledge (i.e., their epistemologies) with regard to educational assessment before jumping to solutions. The authors use the analogy of a ship (program of assessment) sailing on different seas (epistemologies) to describe their journey in seeking to improve equity in assessment. Should the education community repair the ship of assessment while sailing or should the ship be scrapped and built anew? The authors share a case study of a well-developed internal medicine residency program of assessment and describe efforts to evaluate and enable equity using various epistemological lenses. They first used a postpositivist lens to evaluate if the systems and strategies aligned with best practices, but found they did not capture important nuances of what equitable assessment entails. Next, they used a constructivist approach to improve stakeholder engagement, but found they still failed to question the inequitable assumptions inherent to their systems and strategies. Finally, they describe a shift to critical epistemologies, seeking to understand who experiences inequity and harm to dismantle inequitable systems and create better ones. The authors describe how each unique sea promoted different adaptations to their ship, and challenge programs to sail through new epistemological waters as a starting point for making their own ships more equitable.

Using participatory research to identify actionable facilitators and barriers to effective inpatient interdisciplinary communication.

BACKGROUND: Communication failures occur often in the inpatient setting. Efforts to understand and improve communication often exclude patients or are siloed by discipline. OBJECTIVE: We aimed to identify barriers and facilitators to effective communication within interdisciplinary inpatient internal medicine (IM) teams using a participatory research approach. DESIGN: We conducted a single-center participatory mixed methods study using group-level assessment (GLA) and concept mapping to iteratively engage stakeholders. Stakeholder groups included patients/families, IM faculty, IM residents, nurses and ancillary staff, and care managers. Stakeholder-specific GLA sessions were conducted. Participants responded to prompts addressing interdisciplinary communication then worked in small groups to synthesize the qualitative data into unique ideas. A subset of each stakeholder group then sorted ideas through a concept mapping exercise. Multidimensional scaling and hierarchical cluster analysis were used to generate a concept map of the data. RESULTS: Participants generated 97 unique ideas that were then sorted. The research team chose an eight-cluster concept map representing patient inclusion and engagement, processes and resources, team morale and inclusive dynamics, attitudes and behaviors, effective communication, barriers to communication, the culture of healthcare, and clear expectations. Three larger domains of patient inclusion and engagement, organizational conditions and role clarity, and team dynamics and behaviors were noted. CONCLUSION: Use of a participatory research approach made it feasible to engage diverse stakeholders including patients. Our results highlight the need to identify context-specific facilitators and barriers of interdisciplinary communication. The importance of clear expectations was identified as a prioritized area to target communication improvement efforts.

A Novel Curriculum to Improve Medical Student Preparedness to have Advance Care Planning Discussions.

Background: Physicians report inadequate training in advance care planning (ACP) discussions despite the importance of these skills for practicing physicians including new residents. Objectives: To evaluate the effectiveness of a novel curriculum to prepare graduating medical students to have ACP discussions. Design: An ACP curriculum was implemented within a new fourth-year medical student elective with a focus on interactive educational methods and simulated experiences. Setting/Subjects: Forty-seven students received the curriculum over 3 years at a medium-sized, urban medical school. Measurements: Students were surveyed regarding attitudes and comfort related to ACP discussions and end-of-life (EOL) topics before and after the course. Additionally, students were asked about baseline experiences in the pre-course survey and perceived effectiveness of the educational methods in the post-course survey. Results: Comfort discussing EOL care decisions without supervision rose from 4% to 36% after the course with none of the students feeling they needed maximal help from a supervisor after the course compared to 51% before the course. All students agree or strongly agreed (Likert 4 or 5) that they felt prepared to discuss patient's wishes and values in EOL care with a real patient or family after the course. Conclusions: An ACP curriculum can increase student comfort and preparedness to have these conversations as residents. Students found small group discussions and the chance for direct practice with simulated patients to be most helpful. These findings can help guide implementation of ACP curricula in medical education.

Improving trainee clinical documentation through a novel curriculum in internal medicine.

BACKGROUND: Clinical documentation is a key component of practice. Trainees rarely receive formal training in documentation or assessment of their documentation. Effective methods of improving documentation remain unknown. OBJECTIVE: The objective of this study was to determine if the implementation of a documentation curriculum led to improvement in admission note quality. DESIGNS: Admission notes written prior to implementation of the curriculum and after the curriculum intervention were assessed. Notes were assessed from two-time frames for both years to account for improvement with time not associated with the intervention. SETTINGS AND PARTICIPANTS: Admission notes written by University of Cincinnati interns were assessed. INTERVENTIONS: The documentation curriculum consisted of educational sessions and routine admission note assessments with feedback. MAIN OUTCOMES AND MEASURES: Admission notes were assessed via the 16 checklist items and two global assessment items of the Admission Note Assessment Tool (ANAT). RESULTS: Six ANAT items showed statistically significant differences. The review of systems item improved with the intervention only (odds ratio: 3.61, p < .001) while the assessment and plan item 1 and global assessment item 2 improved with time only (ß = .08, p = .03 and ß = .25, p = .02, respectively) in univariate models. In univariate models the physical exam item, diagnostic data item 2, and global assessment item 1 showed improvement with both intervention and time, respectively, with additive effects seen in models with both intervention and time. CONCLUSION: Several aspects of documentation can improve with a formal documentation curriculum which includes a routine assessment with feedback, and some aspects of documentation improve with time.

Warnings in early narrative assessment that might predict performance in residency: signal from an internal medicine residency program.

INTRODUCTION: Narrative assessment data are valuable in understanding struggles in resident performance. However, it remains unknown which themes in narrative data that occur early in training may indicate a higher likelihood of struggles later in training, allowing programs to intervene sooner. METHODS: Using learning analytics, we identified 26 internal medicine residents in three cohorts that were below expected entrustment during training. We compiled all narrative data in the first 6 months of training for these residents as well as 13 typically performing residents for comparison. Narrative data were blinded for all 39 residents during initial phases of an inductive thematic analysis for initial coding. RESULTS: Many similarities were identified between the two cohorts. Codes that differed between typical and lower entrusted residents were grouped into two types of themes: three explicit/manifest and three implicit/latent with six total themes. The explicit/manifest themes focused on specific aspects of resident performance with assessors describing 1) Gaps in attention to detail, 2) Communication deficits with patients, and 3) Difficulty recognizing the "big picture" in patient care. Three implicit/latent themes, focused on how narrative data were written, were also identified: 1) Feedback described as a deficiency rather than an opportunity to improve, 2) Normative comparisons to identify a resident as being behind their peers, and 3) Warning of possible risk to patient care. DISCUSSION: Clinical competency committees (CCCs) usually rely on accumulated data and trends. Using the themes in this paper while reviewing narrative comments may help CCCs with earlier recognition and better allocation of resources to support residents' development.

Development and Establishment of Initial Validity Evidence for a Novel Tool for Assessing Trainee Admission Notes.

BACKGROUND: Documentation is a key component of practice, yet few curricula have been published to teach trainees proper note construction. Additionally, a gold standard for assessing note quality does not exist, and no documentation assessment tools integrate with established competency-based frameworks. OBJECTIVE: To develop and establish initial validity evidence for a novel tool that assesses key components of trainee admission notes and maps to the Accreditation Council for Graduate Medical Education (ACGME) milestone framework. DESIGN: Using an iterative, consensus building process we developed the Admission Note Assessment Tool (ANAT). Pilot testing was performed with both the supervising attending and study team raters not involved in care of the patients. The finalized tool was piloted with attendings from other institutions. PARTICIPANTS: Local experts participated in tool development and pilot testing. Additional attending physicians participated in pilot testing. MAIN MEASURES: Content, response process, and internal structure validity evidence was gathered using Messick's framework. Inter-rater reliability was assessed using percent agreement. KEY RESULTS: The final tool consists of 16 checklist items and two global assessment items. Pilot testing demonstrated rater agreement of 72% to 100% for checklist items and 63% to 70% for global assessment items. Note assessment required an average of 12.3 min (SD 3.7). The study generated validity evidence in the domains of content, response process, and internal structure for use of the tool in rating admission notes. CONCLUSIONS: The ANAT assesses individual components of a note, incorporates billing criteria, targets note "bloat," allows for narrative feedback, and provides global assessments mapped to the ACGME milestone framework. The ANAT can be used to assess admission notes by any attending and at any time after note completion with minimal rater training. The ANAT allows programs to implement routine note assessment for multiple functions with the use of a single tool.

Are medical students being taught invasive skills using simulation?

INTRODUCTION: Basic invasive procedural skills are traditionally taught during clerkships. Using simulation to teach invasive skills provides students the opportunity to practice in a structured environment without risking patient safety. We surveyed incoming interns at Thomas Jefferson University Hospital to assess the prevalence of simulation training for invasive and semi-invasive procedural skills during medical school. METHODS: From 2008 to 2010, we surveyed 357 incoming interns at Thomas Jefferson University Hospital. The questionnaire asked incoming interns if they received formal instruction or procedural training with or without a simulation component for 34 procedures during medical school. Interns indicated their number of attempts and successes for each procedure in clinical care. RESULTS: All 357 incoming interns completed the survey. Experience in 28 procedures is reported in this article. For all but three basic procedures, more than 75% of interns received formal didactic instruction. Only 3 advanced procedures were formally taught to most interns. The prevalence of simulation training for the basic and advanced procedures was 46% and 23%, respectively. For the basic procedures, the average number of attempts and successes was 6.5 (range, 0-13.9) and 6.2 (range, 0-13.4), respectively. For the advanced procedures, the average number of attempts and successes was 1.5 (range, 0-4.8) and 1.3 (range, 0-4.7), respectively. CONCLUSIONS: Although most medical students receive formal instruction in basic procedures, fewer receive formal instruction in advanced procedures. The use of simulation to complement this training occurs less often. Simulation training should be increased in undergraduate medical education and integrated into graduate medical education.