What the experts see: A qualitative analysis of the behaviors of master adaptive learners in emergency medicine.

Objectives: The Master Adaptive Learner (MAL) model postulates that learners develop adaptive expertise through cycles of self-regulated learning. Despite a robust theoretical basis, the actual observable behaviors of MALs are not well characterized. We sought to define behaviors that characterize MALs within emergency medicine (EM) training. Methods: Using a constructivist grounded theory approach, we analyzed semistructured interviews with expert EM educators. These experts reflected on observable behaviors as well as factors in the clinical learning environment that may modulate these behaviors. We recruited using purposive sampling until thematic saturation. Results: We identified four overall themes, of which three described groups of learner behaviors and a fourth described modifiers of these behaviors. Learner behaviors include: (1) critical interrogation of practice, (2) intellectual risk-taking, and (3) intentional curation of a learning network. Critical interrogation of practice encompasses several observable behaviors including learner-driven feedback conversations, independent synthesis of clinical information, appropriate deviation from algorithms based on their conceptual understanding of core principles, intentional use of case variation and hypothetical questioning, and continuous refinement of decisions. MALs also engage in intellectual risk-taking for their development by communicating clinical decision-making processes even at the risk of being wrong, openly addressing errors and gaps, and intentionally seeking out uncomfortable experiences. Intentional curation of a learning network is the deliberate development of a consortium of trusted individuals who serve as mentors and sounding boards. We also identified a fourth theme related to the expression of learner behaviors: learning environment modulates behaviors. Active promotion of psychological safety is necessary for learners to express these behaviors. This safety is mediated through trusting relationships and expert supervisors who serve as colearners and role models. Conclusions: We present several behaviors that allow identification of MALs among EM trainees. These data expand our understanding of MALs and the critical influence of the learning environment. Identification of these behaviors may allow for more precise categorization of targeted curricular interventions and meaningful learning outcomes.

Training for Adaptive Expertise: Why, What, and How.

BACKGROUND: Routine expertise is the efficient use of mastered skills at a high level of competency in familiar situations. PROBLEM: Novel case variation and continuous scientific advances preclude reliance on routine expertise alone. SOLUTION: Medical training programs must prepare learners to solve unfamiliar problems by cultivating adaptive expertise. Adaptive expertise is the ability to transfer existing knowledge to innovate a solution for an unfamiliar problem.

Practical tips for navigating a program director transition.

Residency and fellowship program directors profoundly impact trainees, institutions, and patient safety. Yet, there is concern for rapid attrition in the role. The average program director tenure is only 4-7 years, and that timeline is likely a result of burnout or opportunities for career advancement. Program director transitions must be carefully executed to ensure minimal disruption to the program. Transitions benefit from clear communication with trainees and other stakeholders, well-planned successions or searches for a replacement, and clearly delineated expectations and responsibilities of the outgoing program director. In this Practical Tips, four former residency program directors offer a roadmap for a successful program director transition, with specific recommendations to guide critical decisions and steps in the process. Themes emphasized include readiness for a transition, communication strategies, alignment of program mission and search efforts, and anticipatory support to ensure the success of the new director.

Rejecting Reforms, Yet Calling for Change: A Qualitative Analysis of Proposed Reforms to the Residency Application Process.

PURPOSE: Annual increases in the number of residency applications burden students and challenge programs. Several reforms to the application process have been proposed; however, stakeholder input is often overlooked. The authors examined key stakeholders' opinions about several proposed reforms to the residency application process and identified important factors to guide future reforms. METHOD: Using semistructured interviews, the authors asked educational administrators and trainees to consider 5 commonly proposed reforms to the residency application process: Match to obtain residency interviews, preference signaling, application limits, geographic preference disclosure, and abolishing the Match. The authors conducted a modified content analysis of interview transcripts using qualitative and quantitative analytic techniques. Frequency analysis regarding the acceptability of the 5 proposed reforms and thematic analysis of important factors to guide reform were performed. Fifteen-minute interviews were conducted between July and October 2019, with data analysis completed during a 6-month period in 2020 and 2021. RESULTS: Participants included 30 stakeholders from 9 medical specialties and 15 institutions. Most participants wanted to keep the Match process intact; however, they noted several important flaws in the system that disadvantage students and warrant change. Participants did not broadly support any of the 5 proposed reforms. Two themes were identified: principles to guide reform (fairness, transparency, equity, reducing costs to students, reducing total applications, reducing work for program directors, and avoiding unintended consequences) and unpopular reform proposals (concern that application limits threaten less competitive students and signaling adds bias to the system). CONCLUSIONS: Key stakeholders in the residency application process believe the system has important flaws that demand reform. Despite this, the most commonly proposed reforms are unacceptable to these stakeholders because they threaten fairness to students and program workload. These findings call for a larger investigation of proposed reforms with a more nationally representative stakeholder cohort.

Bridging the Gap from Student to Doctor: Developing Coaches for the Transition to Residency.

BACKGROUND: A lack of educational continuity creates disorienting friction at the onset of residency. Few programs have harnessed the benefits of coaching, which can facilitate self-directed learning, competency development, and professional identity formation, to help ease this transition. OBJECTIVE: To describe the process of training faculty Bridge Coaches for the Transition to Residency Advantage (TRA) program for interns. METHODS: Nineteen graduate faculty educators participated in a coaching training course with formative skills assessment as part of a faculty development program starting in January 2020. Surveys (n = 15; 79%) and a focus group (n = 7; 37%) were conducted to explore the perceived impact of the training course on coaching skills, perceptions of coaching, and further program needs during the pilot year of the TRA program. RESULTS: Faculty had strong skills around establishing trust, authentic listening, and supporting goal-setting. They required more practice around guiding self-discovery and following a coachee-led agenda. Faculty found the training course to be helpful for developing coaching skills. Faculty embraced their new roles as coaches and appreciated having a community of practice with other coaches. Suggestions for improvement included more opportunities to practice and receive feedback on skills and additional structures to further support TRA program encounters with coaches. CONCLUSIONS: The faculty development program was feasible and had good acceptance among participants. Faculty were well-suited to serve as coaches and valued the coaching mindset. Adequate skills reinforcement and program structure were identified as needs to facilitate a coaching program in graduate medical education.

Educating for adaptive expertise: case examples along the medical education continuum.

Adaptive expertise represents the combination of both efficient problem-solving for clinical encounters with known solutions, as well as the ability to learn and innovate when faced with a novel challenge. Fostering adaptive expertise requires careful approaches to instructional design to emphasize deeper, more effortful learning. These teaching strategies are time-intensive, effortful, and challenging to implement in health professions education curricula. The authors are educators whose missions encompass the medical education continuum, from undergraduate through to organizational learning. Each has grappled with how to promote adaptive expertise development in their context. They describe themes drawn from educational experiences at these various learner levels to illustrate strategies that may be used to cultivate adaptive expertise.At Vanderbilt University School of Medicine, a restructuring of the medical school curriculum provided multiple opportunities to use specific curricular strategies to foster adaptive expertise development. The advantage for students in terms of future learning had to be rationalized against assessments that are more short-term in nature. In a consortium of emergency medicine residency programs, a diversity of instructional approaches was deployed to foster adaptive expertise within complex clinical learning environments. Here the value of adaptive expertise approaches must be balanced with the efficiency imperative in clinical care. At Mayo Clinic, an existing continuous professional development program was used to orient the entire organization towards an adaptive expertise mindset, with each individual making a contribution to the shift.The different contexts illustrate both the flexibility of the adaptive expertise conceptualization and the need to customize the educational approach to the developmental stage of the learner. In particular, an important benefit of teaching to adaptive expertise is the opportunity to influence individual professional identity formation to ensure that clinicians of the future value deeper, more effortful learning strategies throughout their careers.

The Best Laid Plans? A Qualitative Investigation of How Resident Physicians Plan Their Learning.

PURPOSE: Adaptive expertise (AE) has been identified as a critical trait to cultivate in future physicians. The 4-phase master adaptive learner (MAL) conceptual model describes the learning skills and behaviors necessary to develop AE. Though prior work has elucidated skills and behaviors used by MALs in the initial planning phase of learning, most resident learners are not thought to be MALs. In this study, the authors investigated how these majority "typical" learners develop AE by exploring the strategies they used in the planning phase of learning. METHOD: Participants were resident physicians at graduate medical education (GME) training programs located at 4 academic medical centers in the United States. Participants participated in semistructured individual interviews in 2021, and interview transcripts were analyzed using constant comparative analysis of grounded theory. RESULTS: Fourteen subjects representing 8 specialties were interviewed, generating 152 pages of transcripts for analysis. Three themes were identified: "Typical" learners were challenged by the transition from structured undergraduate medical education learning to less-structured GME learning, lacked necessary skills to easily navigate this transition, and relied on trial and error to develop their learning skills. CONCLUSIONS: Participants used trial and error to find learning strategies to help them manage the systemic challenges encountered when transitioning from medical school to residency. The success (or failure) of these efforts was tied to learners' efficacy with the self-regulated learning concepts of agency, metacognitive goal setting, and motivation. A conceptual model is provided to describe the impact of these factors on residents' ability to be adaptive learners, and actionable recommendations are provided to help educators' efforts to foster adaptive learning skills and behaviors. These findings also provided valuable evidence of validity of the MAL model that has thus far been lacking.

Creating a better learning environment: a qualitative study uncovering the experiences of Master Adaptive Learners in residency.

BACKGROUND: Adaptive expertise is an important physician skill, and the Master Adaptive Learner (MAL) conceptual model describes learner skills and behaviors integral to the acquisition of adaptive expertise. The learning environment is postulated to significantly impact how MALs learn, but it is unclear how these successful learners experience and interact with it. This study sought to understand the authentic experience of MALs within the learning environment and translate those experiences into practical recommendations to improve the learning environment for all trainees. METHODS: Following a constructivist paradigm, we conducted a thematic analysis of transcripts from focus groups composed of MALs to identify commonalities in experiences and practices of successful postgraduate trainees in the learning environment. Saturation was achieved after seven focus groups, consisting of thirty-eight participants representing fourteen specialties from four institutions. Researchers coded transcripts using constant comparison analysis, which served as the foundation for our thematic analysis. RESULTS: We identified eight themes and situated them within a 4-component model of the learning environment. Four themes were identified within the personal component: (1) patients drive learning; (2) learning has no endpoint; (3) management of emotions is crucial for learning; (4) successful learning requires a structured approach. Two themes were identified in the social component: (5) positive social relationships are leveraged to maximize learning; (6) teaching facilitates personal learning. Two themes were identified in the organizational component: (7) transitions challenge learners to adapt; (8) the learning environment dictates goal setting strategy. No major themes were identified in the physical/virtual component, although participants frequently used technology when learning. CONCLUSIONS: Master Adaptive Learners experience similar facilitators of, and barriers to, success in the learning environment. Overall, our data show that acquisition of many successful strategies and skills that support learning are relegated to the hidden curriculum of residency training. Educators could support a more effective learning environment for all trainees by: (1) highlighting patients as the focal point of learning, (2) building a professional 'learner' identity, (3) teaching learning skills, and (4) creating opportunities for collaborative learning.

Geographic mobility in the emergency medicine residency match and the influence of gender.

OBJECTIVES: Women are underrepresented in emergency medicine (EM) leadership. Some evidence suggests that geographic mobility improves career advancement. We compared movement between medical school and residency by gender. Our hypothesis was that women move a shorter distance than men. METHODS: We collected National Residency Matching Program (NRMP) lists of ranked applicants from eight EM residency programs from the 2020 Main Residency Match. We added the gender expressed in interviews and left the Association of American Medical Colleges (AAMC) number as the unique identifier. Applicant data for matched osteopathic and allopathic seniors in the continental United States was included. We obtained street addresses for medical schools from an AAMC database and residency program addresses from the ACGME website. We performed geospatial analysis using ArcGIS Pro and compared results by gender. NRMP approved the data use and our institutional review board granted exempt status. RESULTS: A total of 881 of 944 unique applicants met inclusion criteria and included 48.5% (830/1,713) of matched allopaths and 37% of all matched seniors; 48% (420) were female. There was no significant difference between genders for distance moved (p = 0.31). Women moved a mean (±SD) 619 (±698) miles (median = 341 miles, range = 0-2,679 miles); and men, a mean (±SD) 641 (±717) miles (median = 315 miles, range = 0-2,671 miles). Further analysis of applicants traveling less than 50 miles (49 women, 51 men) and by census division showed no significant frequency differences. CONCLUSION: Women and men travel similar distances for EM residency with the majority staying within geographic proximity to their medical school. This suggests that professional mobility at this stage is not a constraint. Our study findings are limited because we do not know which personal and professional factors inform relocation decisions. Gender is not associated with a difference in distance moved by students for residency. This finding may have implications for resident selection and career development.

The Summer Match: A qualitative study exploring a two-stage residency match option.

BACKGROUND: The number of residency applications submitted by medical students rises annually, resulting in increased work and costs for residency programs and applicants, particularly in emergency medicine. We propose a solution to this problem: an optional, two-stage Match with a "summer match" stage, in which applicants can submit a limited number of applications early. This would be conducted similarly to the early decision process for college admissions. The study objectives were to explore stakeholder opinions on the feasibility of a summer match and to identify the ideal logistic parameters to operationalize this proposal. METHODS: We used exploratory qualitative methodology following a constructivist paradigm to develop an understanding of the potential impact of a summer match. We interviewed 34 key stakeholders in the U.S. residency application process identified through purposive sampling including educational administrators (program directors, designated institutional officials, medical school deans) and trainees (students, residents). We coded and thematically analyzed interview data in two stages using an inductive approach. RESULTS: We identified six themes from the participant interviews that broadly reflected issues of the residency application process, value, and equity. These themes included disrupting the status quo, logistic concerns, match strategy, differential benefits, unintended consequences, and return on investment. Most study participants supported the summer match concept, with medical students and residents most in favor. We developed a theoretical summer match protocol based on these findings. CONCLUSIONS: A summer match may reduce the burdens of increasing residency applications and associated costs. Pilot testing is necessary to confirm this hypothesis and determine the impact of the proposed summer match protocol. Unintended consequences must be considered carefully during implementation.

Sustainable Engaged Accountable Learners.

The development of lifelong learners is among the most challenging goals for medical educators. The authors identify two important scholarly works that profoundly altered their understanding and approach to lifelong learning and curriculum design: L. Dee Fink's Taxonomy of Significant Learning and Cutrer et al.'s Master Adaptive Learner model. By applying these guides to their teaching and related research, three important characteristics of lifelong learning became evident: sustainability, engagement, and accountability. These are abbreviated "SEALs," for sustainable engaged accountable learners. This paper defines these qualities as they relate to emergency medicine training, significant learning, and the development of adaptive expertise. Connections to Fink's and Cutrer's works are offered for each learner characteristic. Educational and psychological theories that support the SEALs model are paired with practical suggestions for educators to promote these desired qualities in their trainees. Relevant features of adult learning are highlighted, including self-regulation, motivation, agency, and autonomy.

An Observation Medicine Curriculum for Emergency Medicine Education.

Audience and type of curriculum: This curriculum, designed and implemented at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, primarily targets third- and fourth-year emergency medicine (EM) residents, and is an immersive observation medicine rotation that can be integrated into existing emergency medicine residency training. Length of curriculum: The curriculum is designed for a dedicated rotation of two weeks for senior residents and can be expanded to 4 weeks. Introduction: Observation medicine is an extension of emergency medicine and is increasingly playing a role in the delivery of acute healthcare, with over half of all observation units (OUs) in the nation being led by emergency medicine.1 Despite this, many emergency medicine residencies have yet to establish a formal observation medicine curriculum. In a 2002 study by Mace and Shah, only 10% of emergency medicine residencies had a dedicated observation medicine rotation, despite 85% of emergency medicine residency directors believing this was an important part of emergency medicine training.2 The first description of a model longitudinal observation medicine curriculum did not appear until 2016.3 In order to prepare our graduates for the evolving demands of the EM workplace, we must provide diverse educational experiences that train and showcase the expanding skill set of future emergency physicians. Educational Goals: The primary goal of this observation medicine curriculum is to train current EM residents in short-term acute care beyond the initial ED visit. This entails caring for patients from the time of their arrival to the OU to the point when a final disposition from the OU is determined, be it inpatient admission or discharge to home. Educational Methods: The educational strategies used in this curriculum include experiential learning through supervised direct patient care, independent learning based on prescribed literature, and didactic teaching. Research Methods: Education content was evaluated by the learners through pre- and post-rotation surveys, as well as written attending evaluations describing the progress of the learners during the rotation. Results: All residents reported increases in the confidence of their abilities to perform observation care. Discussion: Observation medicine is an increasingly vital aspect of emergency medicine, but education in observation medicine has not developed in tandem with its implementation. A lack of observation medicine training represents a missed opportunity for each trainee to gain a robust understanding of the interface between inpatient and outpatient care, and how to arrive at the most appropriate disposition for ED patients. Considering the wide breadth of clinical conditions managed in OUs and the variability of OU management at various learning sites, the curriculum must be tailored to the specific unit to maximize effectiveness of the learning experience. Topics: Observation medicine, curriculum, education, clinical rotation.

The Implementation of a National Multifaceted Emergency Medicine Resident Wellness Curriculum Is Not Associated With Changes in Burnout.

BACKGROUND: The Accreditation Council for Graduate Medical Education Common Program Requirements effective 2017 state that programs and sponsoring institutions have the same responsibility to address well-being as they do other aspects of resident competence. OBJECTIVES: The authors sought to determine if the implementation of a multifaceted wellness curriculum improved resident burnout as measured by the Maslach Burnout Inventory (MBI). METHODS: We performed a multicenter educational interventional trial at 10 emergency medicine (EM) residencies. In February 2017, we administered the MBI at all sites. A year-long wellness curriculum was then introduced at five intervention sites while five control sites agreed not to introduce new wellness initiatives during the study period. The MBI was readministered in August 2017 and February 2018. RESULTS: Of 523 potential respondents, 437 (83.5%) completed at least one MBI assessment. When burnout was assessed as a continuous variable, there was a statistically significant difference in the depersonalization component favoring the control sites at the baseline and final survey administrations. There was also a higher mean personal accomplishment score at the control sites at the second survey administration. However, when assessed as a dichotomous variable, there were no differences in global burnout between the groups at any survey administration and burnout scores did not change over time for either control or intervention sites. CONCLUSIONS: In this national study of EM residents, MBI scores remained stable over time and the introduction of a multifaceted wellness curriculum was not associated with changes in global burnout scores.

The Vice Chair of Education in Emergency Medicine: A Workforce Study to Establish the Role, Clarify Responsibilities, and Plan for Success.

OBJECTIVES: Despite increasing prevalence in emergency medicine (EM), the vice chair of education (VCE) role remains ambiguous with regard to associated responsibilities and expectations. This study aimed to identify training experiences of current VCEs, clarify responsibilities, review career paths, and gather data to inform a unified job description. METHODS: A 40-item, anonymous survey was electronically sent to EM VCEs. VCEs were identified through EM chairs, residency program directors, and residency coordinators through solicitation e-mails distributed through respective listservs. Quantitative data are reported as percentages with 95% confidence intervals and continuous variables as medians with interquartiles (IQRs). Open- and axial-coding methods were used to organize qualitative data into thematic categories. RESULTS: Forty-seven of 59 VCEs completed the survey (79.6% response rate); 74.4% were male and 89.3% were white. Average time in the role was 3.56 years (median = 3.0 years, IQR = 4.0 years), with 74.5% serving as inaugural VCE. Many respondents held at least one additional administrative title. Most had no defined job description (68.9%) and reported no defined metrics of success (88.6%). Almost 78% received a reduction in clinical duties, with an average reduction of 27.7% protected time effort (median = 27.2%, IQR = 22.5%). Responsibilities thematically link to faculty affairs and promotion of the departmental educational mission and scholarship. CONCLUSION: Given the variability in expectations observed, the authors suggest the adoption of a unified VCE job description with detailed responsibilities and performance metrics to ensure success in the role. Efforts to improve the diversity of VCEs are encouraged to better match the diversity of learners.

Comparison of the Standardized Video Interview and Interview Assessments of Professionalism and Interpersonal Communication Skills in Emergency Medicine.

OBJECTIVES: The Association of American Medical Colleges Standardized Video Interview (SVI) was recently added as a component of emergency medicine (EM) residency applications to provide additional information about interpersonal communication skills (ICS) and knowledge of professionalism (PROF) behaviors. Our objective was to ascertain the correlation between the SVI and residency interviewer assessments of PROF and ICS. Secondary objectives included examination of 1) inter- and intrainstitutional assessments of ICS and PROF, 2) correlation of SVI scores with rank order list (ROL) positions, and 3) the potential influence of gender on interview day assessments. METHODS: We conducted an observational study using prospectively collected data from seven EM residency programs during 2017 and 2018 using a standardized instrument. Correlations between interview day PROF/ICS scores and the SVI were tested. A one-way analysis of variance was used to analyze the association of SVI and ROL position. Gender differences were assessed with independent-groups t-tests. RESULTS: A total of 1,264 interview-day encounters from 773 unique applicants resulted in 4,854 interviews conducted by 151 interviewers. Both PROF and ICS demonstrated a small positive correlation with the SVI score (r = 0.16 and r = 0.17, respectively). ROL position was associated with SVI score (p < 0.001), with mean SVI scores for top-, middle-, and bottom-third applicants being 20.9, 20.5, and 19.8, respectively. No group differences with gender were identified on assessments of PROF or ICS. CONCLUSIONS: Interview assessments of PROF and ICS have a small, positive correlation with SVI scores. These residency selection tools may be measuring related, but not redundant, applicant characteristics. We did not identify gender differences in interview assessments.

Learning to learn: A qualitative study to uncover strategies used by Master Adaptive Learners in the planning of learning.

Background: The ability to adapt expertise to both routine and uncommon situations, termed adaptive expertise, has been suggested as a necessary skill for physicians. The Master Adaptive Learner (MAL) framework proposes four phases necessary to develop adaptive expertise. The first phase, "planning" for learning, includes three stages: identification of gaps, prioritization of gaps, and identification of learning resources. This study explored key strategies used by MALs in "planning" for learning. Methods: Focus groups were used to identify strategies that successful postgraduate trainees use to plan learning. Researchers analyzed transcripts using constant comparison analysis and grounded theory to guide the generation of themes. Results: 38 participants, representing 14 specialties, participated in 7 focus groups. Six key strategies used in the "planning" phase of learning were found. During gap identification, they used performance-driven gap identification and community-driven gap identification. To prioritize gaps, they used the schema of triage and adequacy. To identify resources they used intentional adaptation and weighted curation. Barriers such as lack of time and inexperience were noted. Conclusions: MALs use six strategies to plan learning, using patients, health-care team roles, and clinical questions to guide them. Understanding these strategies can help educators design learning opportunities and overcome barriers.