"What's Going to Happen?": Internal Medicine Resident Experiences of Uncertainty in the Care of Older Adults.

PURPOSE: Internal medicine residents care for clinically complex older adults and may experience increased moral distress due to knowledge gaps, time constraints, and institutional barriers. We conducted a phenomenological study to explore residents' experiences and challenges through the lens of uncertainty. METHODS: Between January and March 2022, six focus groups were conducted comprising a total of 13 internal medicine residents in postgraduate years 2 and 3, who had completed a required 2-week geriatrics rotation. Applying the Beresford taxonomy of uncertainty as a conceptual model, data were analyzed using the framework method. RESULTS: All challenging experiences described by residents caring for older adults were linked to uncertainty. Sources of uncertainty were categorized and mapped to the Beresford taxonomy: (1) lack of geriatrics knowledge or clinical guidelines (technical); (2) difficulty applying knowledge to complex older adults (conceptual); and (3) lack of longitudinal relationship with the older patient (personal). Residents identified capacity evaluation and discharge planning as two major geriatric knowledge areas linked with uncertainty. While the majority of residents reacted to uncertainty with some degree of distress, several reported positive coping strategies. CONCLUSIONS: Internal medicine residents face uncertainty when caring for older adults, particularly related to technical and conceptual factors. Strategies for mitigating uncertainty in the care of older adults are needed given links with moral distress and trainee well-being.

Do we teach critical thinking? A mixed methods study of faculty and student perceptions of teaching and learning critical thinking at three professional schools.

INTRODUCTION: Critical thinking (CT) is an essential set of skills and dispositions for professionals. While viewed as an important part of professional education, approaches to teaching and assessing critical thinking have been siloed within disciplines and there are limited data on whether student perceptions of learning align with faculty perceptions of teaching. MATERIALS AND METHODS: The authors used a convergent mixed methods approach in required core courses in schools of education, government, and medicine at one university in the Northeast United States. Faculty surveys and student focus groups (FG) addressed definitions, strategies, and barriers to teaching CT. RESULTS AND CONCLUSIONS: Sixty-four (51.6%) faculty completed the survey, and 34 students participated in FGs. Among faculty, 54.0% (34/63) reported explicitly teaching CT; but students suggested teaching CT was predominantly implicit. Faculty-reported strategies differed among schools. Faculty defined CT in process terms such as 'analyzing'; students defined CT in terms of viewpoints and biases. Our results reveal a lack of explicit, shared CT mental models between faculty and students and across professional schools. Explicit teaching of CT may help develop a shared language and lead to better understanding and application of the skills and dispositions necessary to succeed in professional life.

"Two Years Later I'm Still Just as Angry": A Focus Group Study of Emergency and Internal Medicine Physicians on Disrespectful Communication.

Phenomenon: Disrespectful behavior between physicians across departments can contribute to burnout, poor learning environments, and adverse patient outcomes. Approach: In this focus group study, we aimed to describe the nature and context of perceived disrespectful communication between emergency and internal medicine physicians (residents and faculty) at patient handoff. We used a constructivist approach and framework method of content analysis to conduct and analyze focus group data from 24 residents and 11 faculty members from May to December 2019 at a large academic medical center. Findings: We organized focus group results into four overarching categories related to disrespectful communication: characteristics and context (including specific phrasing that members from each department interpreted as disrespectful, effects of listener engagement/disengagement, and the tendency for communication that is not in-person to result in misunderstanding and conflict); differences across training levels (with disrespectful communication more likely when participants were at different training levels); the individual correspondent's tendency toward perceived rudeness; and negative/long-term impacts of disrespectful communication on the individual and environment (including avoidance and effects on patient care). Insights: In the context of predominantly positive descriptions of interdepartmental communication, participants described episodes of perceived disrespectful behavior that often had long-lasting, negative impacts on the quality of the learning environment and clinical work. We created a conceptual model illustrating the process and outcomes of these interactions. We make several recommendations to reduce disrespectful communication that can be applied throughout the hospital to potentially improve patient care, interdepartmental collaboration, and trainee and faculty quality of life.

Who Is Teaching Residents in the Intensive Care Unit? Perceptions of Interprofessional Teaching at an Academic Medical Center.

Background: Teamwork is essential for high-quality care in the intensive care unit (ICU). Interprofessional education has been widely endorsed as a way of promoting collaborative practice. Interprofessional providers (IPPs), including nurses, pharmacists, and respiratory therapists (RTs), routinely participate in multidisciplinary rounds in the ICU, but their role in teaching residents at academic medical centers has yet to be characterized. Objective: To characterize perceptions of interprofessional teaching during and outside of rounds in the ICU. Methods: The authors conducted a cross-sectional survey of critical care physicians, internal medicine residents, nurses, pharmacists, and RTs across three ICUs at a tertiary academic medical center from September 2019 to March 2020. The frequency of different types of rounds contributions was rated on a Likert scale. Means and medians were compared across groups. Results: A total of 221 of 285 participants completed the survey (78% response rate). All IPPs described that they report data, provide clinical observations, and make recommendations frequently during ICU rounds, but teaching occurred infrequently (mean values, nurses = 2.9; pharmacists = 3.5; RTs = 3.7; 1 = not at all; 5 = always). Nurses were least likely to report teaching (P = 0.0017). From residents' and attendings' perspectives, pharmacists taught most frequently (mean values, 3.7 and 3.4, respectively). RTs self-report of teaching was higher than physicians' reports of RT teaching (P < 0.0001). Outside of rounds, residents reported a low frequency of teaching by nurses and RTs (means, nurses = 3.1; RTs = 3.1), but they reported a high rate of teaching by pharmacists (mean, 4.4). Conclusion: Nonphysician IPPs routinely participate in ICU rounds but teach medical trainees infrequently. Physicians' perception of IPP teaching frequency was generally lower than self-reports by IPPs. Exploring modifiers of interprofessional teaching may enhance education and collaboration.

"A Lot to Offer": Nurses as Educators for Medical Residents in an Academic Medical Center Intensive Care Unit.

INTRODUCTION: The role of fully trained interprofessional clinicians in educating residents has not been rigorously explored. The intensive care unit (ICU), where multiprofessional teamwork is essential to patient care, represents an ideal training environment in which to study this role. This study aimed to describe the practices, perceptions, and attitudes of ICU nurses regarding teaching medical residents and to identify potential targets to facilitate nurse teaching. METHODS: Using a concurrent mixed-methods approach, we administered surveys and focus groups to ICU nurses from September to November 2019 at a single, urban, tertiary, academic medical center. Survey data were analyzed with descriptive and comparative statistics. Focus group data were analyzed using the Framework method of content analysis. RESULTS: Of nurses surveyed, 75 of 96 (78%) responded. Nurses generally held positive attitudes about teaching residents, describing it as both important (52%, 36/69) and enjoyable (64%, 44/69). Nurses reported confidence in both clinical knowledge base (80%, 55/69) and teaching skills (71%, 49/69), but identified time, uncertainty about teaching topics, and trainee receptiveness as potential barriers. Ten nurses participated in focus groups. Qualitative analysis revealed three major themes: nurse-specific factors that impact teaching, the teaching environment, and facilitators of teaching. DISCUSSION: ICU nurses carry positive attitudes about teaching residents, particularly when facilitated by the attending, but this enthusiasm can be attenuated by the learning environment, unknown learner needs, and trainee attitudes. Identified facilitators of nurse teaching, including resident presence at the bedside and structured opportunities for teaching, represent potential targets for interventions to promote interprofessional teaching.

An age-friendly residency: Geriatrician and internist perspectives on geriatric education in an internal medicine residency.

BACKGROUND: General internists and subspecialists need skills to deliver age-friendly care to older adults, yet a minority of Internal Medicine (IM) residency programs provide robust geriatric-specific clinical instruction. We sought to explore internist and geriatrician perspectives regarding current strengths and weakness of geriatric education, and perceived supports, barriers, and strategies to enhance geriatric education in an IM residency program. METHODS: Using social learning theory as a conceptual framework, we conducted a needs assessment using focus groups and semi-structured interviews with IM residency leadership and geriatricians at an academic medical center. Interviews were recorded and transcribed; thematic analysis was performed on deidentified transcripts. RESULTS: We recruited faculty by e-mail in 2021; eight geriatricians and seven internists participated (60% female, 13% Hispanic/Latino, and 73% White). Six participated in two virtual focus groups and nine participated in virtual one-on-one interviews. All had at least monthly teaching contact with residents and six were associate program directors. We identified five key themes: (1) professional role models, (2) personal attitudes toward aging, (3) the powerful influence of patients, (4) clinical complexity of geriatrics, and (5) branding and prestige of the field. Participants offered multiple suggestions for improvement, especially faculty development for non-geriatrician faculty. CONCLUSIONS: Geriatric education for IM residents is impacted by multiple factors, but uniformly viewed as important. Moving forward, programs could capitalize on opportunities for closer collaboration between residency leadership, internists, and geriatricians to train the next generation of IM residency graduates to deliver age-friendly care.

A multisite randomized trial of implicit versus explicit modeling in clinical teaching.

PURPOSE: Faculty modeling of desired behaviors has historically been a part of the apprenticeship model of clinical teaching, yet little is known about best practices for modeling. This study compared the educational impact of implicitly versus explicitly modeled communication skills among U.S. medical students. METHOD: Fourth-year medical students from six U.S. academic medical centers were randomly assigned one simulated clinical encounter in which faculty provided either implicit or explicit modeling of important communication skills. Outcomes were assessed by electronic surveys immediately before and after the simulations. Students were blinded to the purpose of the study. RESULTS: Students in the explicit arm were more likely to correctly cite two of the three key specific communication elements modeled by faculty: deliberate body position (53.3% vs. 18.6%, p < 0.001) and summarizing patient understanding (62.2% vs. 11.6%, p < 0.001). More students in the explicit study arm reported faculty 'demonstrated a key behavior that they wanted me to be able to perform in the future' (93.2% versus 62.8%, p = 0.002). Participating faculty stated they would modify their teaching approach in response to their experiences in the study. CONCLUSIONS: In a multi-center randomized trial, explicit faculty role-modeling led to greater uptake of communication knowledge, greater recognition of skills, and a greater sense that faculty expected these skills to be adopted by students. These results must be considered in the context, however, of a simulated environment and a short timeframe for assessing learning with students who volunteered for a simulated experience.

Enhancing Clinical Teaching in Critical Thinking, High-Value Care, and Health Care Equity.

INTRODUCTION: Faculty development in the clinical setting is challenging to implement and assess. This study evaluated an intervention (IG) to enhance bedside teaching in three content areas: critical thinking (CT), high-value care (HVC), and health care equity (HCE). METHODS: The Communities of Practice model and Theoretical Domains Framework informed IG development. Three multidepartmental working groups (WGs) (CT, HVC, HCE) developed three 2-hour sessions delivered over three months. Evaluation addressed faculty satisfaction, knowledge acquisition, and behavior change. Data collection included surveys and observations of teaching during patient care. Primary analyses compared counts of post-IG teaching behaviors per hour across intervention group (IG), comparison group (CG), and WG groups. Statistical analyses of counts were modeled with generalized linear models using the Poisson distribution. RESULTS: Eighty-seven faculty members participated (IG n = 30, CG n = 28, WG n = 29). Sixty-eight (IG n = 28, CG n = 23, WG n = 17) were observed, with a median of 3 observation sessions and 5.2 hours each. Postintervention comparison of teaching (average counts/hour) showed statistically significant differences across groups: CT CG = 4.1, IG = 4.8, WG = 8.2; HVC CG = 0.6, IG = 0.9, WG = 1.6; and HCE CG = 0.2, IG = 0.4, WG = 1.4 ( P < .001). DISCUSSION: A faculty development intervention focused on teaching in the context of providing clinical care resulted in more frequent teaching of CT, HVC, and HCE in the intervention group compared with controls. WG faculty demonstrated highest teaching counts and provide benchmarks to assess future interventions. With the creation of durable teaching materials and a cadre of trained faculty, this project sets a foundation for infusing substantive content into clinical teaching.

Out of the classroom, into the home: Medical and dental students' lessons learned from a Geriatrics home visit.

BACKGROUND: Home visits are an important part of Geriatrics education for medical and dental students (MS), and the lessons learned by students from these experiences inform further curriculum development. A mixed methods analysis of students' lessons learned from a single Geriatrics home visit shapes the future focus and impact of similar educational programs to ultimately improve the care of older adults. METHODS: Over a 3-year period at Harvard Medical School, approximately 495 first year MS participated in an educational Geriatrics home visit to learn about the geriatric assessment. Three hundred and forty-eight students completed voluntary anonymous evaluation forms, rating whether their interest in geriatrics increased after the home visit and describing two lessons learned. We analyzed the student responses and conducted a qualitative content analysis of the lessons learned, identifying major themes within the Geriatrics 5Ms Framework (Mobility, Mind, Medications, Multicomplexity, and Matters Most). RESULTS: Most students (70.7%) reported their interest in Geriatrics somewhat or greatly increased after the home visit. Three hundred and ten students (89% of participants) reported 605 lessons learned; 174 students' lesson learned related to Multicomplexity (56.1%), and 158 students reported a lesson related to Mobility (51%). DISCUSSION: After a Geriatrics home visit, a majority of students report an increase interest in Geriatrics. The most common lessons learned relate to Mobility and Multicomplexity, essential areas of focus in a Geriatrics curriculum. Educational home visits are an important opportunity to increase student interest in geriatrics and build their skills to improve the care of older adults using the Geriatrics 5Ms Framework.

'Educator with a capital E': Comparing medical education experiences of student-as-teacher elective participants and peers.

PURPOSE: Student-as-teacher electives are increasingly offered at medical schools, but little is known about how medical education experiences among enrolled students compare with those of their peers. The study's aim was to characterize medical students' education-related experiences, attitudes, knowledge, and skills based on their enrollment status in a student-as-teacher course. MATERIALS/METHODS: We conducted four focus groups at a medical school in the United States: two with graduating students in a student-as-teacher elective (n = 11) and two with unenrolled peers (n = 11). Transcripts were analyzed using the Framework Method to identify themes. RESULTS: Four themes emerged: interest in and attitudes towards medical education; medical education skills, knowledge, and frameworks; strategies for giving/receiving feedback; medical education training as part of medical school. Course participants demonstrated higher-level education-related knowledge and skills. Both groups endorsed teaching skills as important and identified opportunities to incorporate medical education training into medical school curricula. CONCLUSIONS: Medical education knowledge and teaching skills are self-reported as important learning outcomes for medical students, independent of enrollment status in a student-as-teacher course. The structure of such courses, best understood through a deliberate practice-based model, supports students' achievement of key learning outcomes. Certain course elements may warrant inclusion in standard medical school curricula.

"Friction by Definition": Conflict at Patient Handover Between Emergency and Internal Medicine Physicians at an Academic Medical Center.

INTRODUCTION: Patient handoffs from emergency physicians (EP) to internal medicine (IM) physicians may be complicated by conflict with the potential for adverse outcomes. The objective of this study was to identify the specific types of, and contributors to, conflict between EPs and IM physicians in this context. METHODS: We performed a qualitative focus group study using a constructivist grounded theory approach involving emergency medicine (EM) and IM residents and faculty at a large academic medical center. Focus groups assessed perspectives and experiences of EP/IM physician interactions related to patient handoffs. We interpreted data with the matrix analytic method. RESULTS: From May to December 2019, 24 residents (IM = 11, EM = 13) and 11 faculty (IM = 6, EM = 5) from the two departments participated in eight focus groups and two interviews. Two key themes emerged: 1) disagreements about disposition (ie, whether a patient needed to be admitted, should go to an intensive care unit, or required additional testing before transfer to the floor); and 2) contextual factors (ie, the request to discuss an admission being a primer for conflict; lack of knowledge of the other person and their workflow; high clinical workload and volume; and different interdepartmental perspectives on the benefits of a rapid emergency department workflow). CONCLUSIONS: Causes of conflict at patient handover between EPs and IM physicians are related primarily to disposition concerns and contextual factors. Using theoretical models of task, process, and relationship conflict, we suggest recommendations to improve the EM/IM interaction to potentially reduce conflict and advance patient care.

Receiving Real-Time Clinical Feedback: A Workshop and OSTE Assessment for Medical Students.

BACKGROUND: Many programs designed to improve feedback to students focus on faculty's ability to provide a safe learning environment, and specific, actionable suggestions for improvement. Little attention has been paid to improving students' attitudes and skills in accepting and responding to feedback effectively. Effective "real-time" feedback in the clinical setting is dependent on both the skill of the teacher and the learner's ability to receive the feedback. Medical students entering their clinical clerkships are not formally trained in receiving feedback, despite the significant amount of feedback received during this time. METHODS: We developed and implemented a one-hour workshop to teach medical students strategies for effectively receiving and responding to "real-time" (formative) feedback in the clinical environment. Subjective confidence and skill in receiving real-time feedback were assessed in pre- and post-workshop surveys. Objective performance of receiving feedback was evaluated before and after the workshop using a simulated feedback encounter designed to re-create common clinical and cognitive pitfalls for medical students, called an objective structured teaching exercise (OSTE). RESULTS: After a single workshop, students self-reported increased confidence (mean 6.0 to 7.4 out of 10, P<0.01) and skill (mean 6.0 to 7.0 out of 10, P=0.10). Compared to pre-workshop OSTE scores, post-workshop OSTE scores objectively measuring skill in receiving feedback were also significantly higher (mean 28.8 to 34.5 out of 40, P=0.0131). CONCLUSION: A one-hour workshop dedicated to strategies in receiving real-time feedback may improve effective feedback reception as well as self-perceived skill and confidence in receiving feedback. Providing strategies to trainees to improve their ability to effectively receive feedback may be a high-yield approach to both strengthen the power of feedback in the clinical environment and enrich the clinical experience of the medical student.

The Mindful Manager: Validation of a Rounding Leadership Instrument for Residents.

BACKGROUND: In the context of inpatient general medicine, "rounding" refers to the process of seeing, assessing, and caring for patients as a team. The clinical leadership skills required of residents to lead rounds are essential to inpatient care and clinical education. Assessment of these skills has relevance to developing competent physicians; however, there is an absence of widely accepted tools to specifically measure this competency. OBJECTIVE: To develop and collect validity evidence for a direct observation instrument of internal medicine residents' leadership skills during daily inpatient care rounds for future formative assessment. DESIGN: Prospective observational study. PARTICIPANTS: PGY2 and PGY3 internal medicine residents. MAIN MEASURES: The authors collected inferences of validity evidence according to Kane's validity model. They performed direct observations of PGY2 and PGY3 residents by individual faculty and trained raters and measured inter-rater reliability, using the kappa statistic. Mixed linear regression models were used to compare PGY2 and PGY3 residents. Surveys captured faculty perceptions about value of the instrument. KEY RESULTS: A total of 223 observations were performed in 92 unique individuals. Twenty-four faculty used the observation instrument, of which 18 (75%) completed the post-survey, and 100% agreed that the instrument represented the resident's global leadership abilities. Inter-rater reliability was strong, with an overall kappa statistic equaling 0.82. The mean performance for PGY2 and PGY3 residents was 15.9 (SD 5.1) and 17.7 (SD 4.1), respectively. Adjusting for repeated measures, there was no statistically significant difference between groups. CONCLUSIONS: The authors reported evidence for all four stages of validity and use of the instrument in clinical practice. Their work provides a codification of best practices of rounding leadership, which directly impacts the education of trainees, care of hospitalized patients, and use for formative assessment. The instrument also has the potential to be used for summative assessment.