Making narrative feedback meaningful.

BACKGROUND: Narrative written feedback given to students by faculty often fails to identify areas for improvement and recommended actions to lead to this improvement. When these elements are missing, it is challenging for students to improve and for medical schools to use narrative feedback in promotion decisions, to guide coaching plans and to pass on meaningful information to residency programs. Large-group faculty development has improved narrative written feedback, but less is known about individualised faculty development to supplement large-group sessions. To fill this gap, we built a curriculum with general and individualised faculty development to improve narrative written feedback from Internal Medicine faculty to clerkship students. APPROACH: We used Kern's steps to build a curriculum with general and individualised one-on-one faculty development to improve the problem of inadequate narrative written feedback. We used a novel narrative feedback rubric for pre and post-intervention faculty scores. RESULTS/FINDINGS/EVALUATION: Through general and individualised one-on-one faculty development with peer comparison scores, we were able to improve narrative written feedback from 3.7/6 to 4.6/6, for an increase of 23%. IMPLICATIONS: We found our faculty development program effective in improving feedback and was easy to implement. Our rubric was easy to use, and faculty were receptive to feedback in one-on-one meetings. We plan to extend this work locally to other divisions/departments and into graduate medical education; it should also be easily extended to other medical disciplines or health professions.

Practice Doesn't Make Perfect: Clinical Experience With Procedures Does Not Correlate Well With Competence in Third-Year Medical Students.

OBJECTIVE: There is limited data available about factors which promote competence with procedures in medical students. Specifically, the relationship between procedural clinical experience and performance on an assessment is unclear. We sought to determine whether a correlation exists between the amount and type of clinical experience with a procedure and student performance on a standardized assessment of that procedure. DESIGN: Faculty performed standardized assessments of third-year medical students on ten procedures using simulation. We prospectively surveyed students about 3 types of experience (performed, observed, and simulated) with these procedures during their clerkships. We then analyzed whether a correlation exists between student experience and their competency assessment scores using Pearson's correlation. SETTING/PARTICIPANTS: Third-year medical students at the University of Kentucky College of Medicine. RESULTS: In 2018 to 2019, 131 students were assessed on procedural competency with 10 failures. One hundred and twenty students (91.6%) completed the clinical experience survey. Correlations between types of experience and competency scores were small to moderate, with only 5 of 40 being significant. We found no correlation between experience having performed a procedure and competency score. CONCLUSIONS: Overall, we did not find convincing evidence of a correlation between experience with procedures during clerkships and performance on a competency assessment. This suggests other factors may be contributing to procedural competence, which has implications for how educators should develop procedural competence in students.

Development of a Community Hospital Medicine Affiliated Inpatient Rotation for Family Medicine Residents-A Collaborative Success.

Background: Hospitalists perform key roles as inpatient educators for family medicine residents. For the past decade, Duke University Family Medicine Residency Program had its inpatient family medicine resident rotation at non-Duke facilities. Objective: The authors describe the steps taken in 2020 to develop an inpatient Duke family medicine rotation at a North Carolina community hospital, Duke Regional Hospital, and provide outcomes data. Methods: Duke Family Medicine Residency and Duke Regional Hospital Medicine collaborated in addressing key issues to develop an inpatient rotation for family medicine residents. Performance metrics of patients cared for by both the family medicine inpatient resident team and internal medicine teams were compared. Resident satisfaction survey results were reviewed. Results: Retrospective cohort evaluation comparing the two inpatient services (internal medicine and family medicine) revealed the family medicine resident inpatient service performed comparatively in length of stay and 30-day readmission rates. Resident evaluation surveys of the family medicine inpatient rotation showed overall satisfaction with learning objectives. Conclusions: This new family medicine inpatient rotation has benefitted all parties. Key quality performance metrics such as LOS and readmissions are comparable to internal medicine, hospitalists have more teaching opportunities, and Duke family medicine has its residents training in a Duke-affiliated community hospital for their core inpatient rotation.

Impact of Bedside Rounding on Attending Teaching Evaluations.

OBJECTIVE: To examine associations between bedside rounding (BSR) and other rounding strategies (ORS) with resident evaluations of teaching attendings and self-reported attending characteristics. METHODS: Faculty from three academic medical centers who attended resident teaching services for ≥4 weeks during the 2018-2019 academic year were invited to complete a survey about personal and rounding characteristics. The survey instrument was iteratively developed to assess rounding strategy as well as factors that could affect choosing one rounding strategy over another. Survey results and teaching evaluation scores were linked, then deidentified and analyzed in aggregate. Included evaluation items assessed resident perceptions of autonomy, time management, professionalism, and teaching effectiveness, as well as a composite score (the numeric average of each attending's scores for all of the items at his or her institution). BSR was defined as spending >50% of rounding time in patients' rooms with the team. Hallway rounding and conference room rounding were combined into the ORS category and defined as >50% of rounding time in these settings. All of the scores were normalized to a 10-point scale to allow aggregation across sites. RESULTS: A total of 105 attendings were invited to participate, and 65 (62%) completed the survey. None of the resident evaluation scores significantly differed based on rounding strategy. Composite scores were similar for BSR and ORS (difference of <0.1 on a 10-point scale). Spearman correlation coefficients identified no statistically significant correlation between rounding strategy and evaluation scores. An exploratory analysis of variance model identified no single factor that was significantly associated with composite teaching scores (P > 0.45 for all) or the domains of teaching efficacy, professionalism, or autonomy (P > 0.13 for all). Having a formal educational role was significantly associated with better evaluation scores for time management, and the number of lectures delivered per year approached statistical significance for the same domain. CONCLUSIONS: Conducting BSR did not significantly affect resident evaluations of teaching attendings. Resident perception of teaching effectiveness based on rounding strategy should be neither a motivator nor a barrier to widespread institution of BSR.

Candy Gland: A Diabetes Board Game for Medical Students.

Introduction: Diabetes mellitus can be a challenging topic for medical students. Educational games can engage students, encourage collaboration and peer teaching, and support friendly competition. To enhance student training on diabetes diagnosis and management, we developed a flashcard-style board game to review these concepts and provide a formative assessment. Methods: In this 50-minute session, 102 second-year medical students used a game board and playing cards to compete in small groups. To play, teams took turns answering flashcard-style playing cards and moved forward on the board with correct answers. The first team to reach the end of the board won. Students completed a survey about their confidence in the topic and a multiple-choice test before and after the session to measure the effectiveness of this intervention. Results: Medical knowledge scores improved from 7.3 before the intervention to 8.0 after (10-point scale, p < .001). Students' ratings of their confidence in diabetes pharmacology, diagnosis, and management all improved (ps < .05 for all), with the greatest improvement seen in pharmacology. Student satisfaction ratings and narrative feedback were very positive. Discussion: This educational game effectively improved student knowledge and confidence in diabetes diagnosis, pharmacology, and management in an engaging, unique session. The intervention would be easy for other institutions to implement.

Developing Physical Exam Skills in Residency: Comparing the Perspectives of Residents and Faculty About Values, Barriers, and Teaching Methods.

BACKGROUND: The physical examination (PE) skills of residents are often not improved since medical school. Unfortunately, how residents learn PE is not well understood. There is a paucity of research on the factors involved and the differences between resident and faculty perspectives. The authors sought to determine resident and faculty perceptions about the value of PE, the major barriers to learning PE, and the most effective teaching methods. METHODS: Based on a rigorous process of literature review and semi-structured interviews, the authors developed an online survey which was sent to 406 internal medicine residents and 93 faculty at 3 institutions. Residents and faculty answered questions about both their own opinions and about their perception of the other group's opinions. RESULTS: About 283 residents (70%) and 61 faculty (66%) completed the survey. Both residents and faculty rated the importance of PE similarly. Residents rated being too busy, followed by a lack of feedback, as the most significant barriers to learning PE. Faculty rated a lack of feedback, followed by a lack of resident accountability, as the most significant barriers. Both groups rated the availability of abnormal findings as the least significant barrier. Both groups agreed that faculty demonstration at the bedside was the most effective teaching method. CONCLUSION: This survey can serve as a needs assessment for educational interventions to improve the PE skills of residents by focusing on areas of agreement between residents and faculty, specifically faculty demonstration at the bedside combined with feedback about residents' skills.

Evaluating the effectiveness of undergraduate clinical education programs.

Medical schools should use a variety of measures to evaluate the effectiveness of their clinical curricula. Both outcome measures and process measures should be included, and these can be organized according to the four-level training evaluation model developed by Donald Kirkpatrick. Managing evaluation data requires the institution to employ deliberate strategies to monitor signals in real-time and aggregate data so that informed decisions can be made. Future steps in program evaluation includes increased emphasis on patient outcomes and multi-source feedback, as well as better integration of existing data sources.

Competency-Based Medical Education in the Internal Medicine Clerkship: A Report From the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force.

As medical educators continue to redefine learning and assessment across the continuum, implementation of competency-based medical education in the undergraduate setting has become a focus of many medical schools. While standards of competency have been defined for the graduating student, there is no uniform approach for defining competency expectations for students during their core clerkship year. The authors describe the process by which an Alliance for Academic Internal Medicine task force developed a paradigm for competency-based assessment of students during their inpatient internal medicine (IM) clerkship. Building on work at the resident and fellowship levels, the task force focused on the development of key learning outcomes as defined by entrustable professional activities (EPAs) that were specific to educational experiences on the IM clerkship, as well as identification of high-priority assessment domains. The work was informed by a national survey of clerkship directors.Six key EPAs emerged: generating a differential diagnosis, obtaining a complete and accurate history and physical exam, obtaining focused histories and clinically relevant physical exams, preparing an oral presentation, interpreting the results of basic diagnostic studies, and providing well-organized clinical documentation. A model for assessment was proposed, with descriptors aligned to the scale of supervision and mapped to Accreditation Council for Graduate Medical Education domains of competence. The proposed paradigm offers a standardized template that may be used across IM clerkships, and which would effectively bridge competency evaluation in the clerkship to fourth-year assessment as well as eventual postgraduate training.

Recognizing Patients' Emotions: Teaching Health Care Providers to Interpret Facial Expressions.

PURPOSE: Facial expressions are an important clue to a patient's emotions. The authors developed a 90-minute workshop in May 2011 to teach physicians and physicians-in-training to interpret facial expressions and to use that skill in the context of patient care. METHOD: The workshop included a didactic presentation in which facial expression features were taught using progressively more difficult examples, followed by three interactive exercises. The authors presented the workshop at six separate venues in the United States in 2011 and 2012. To test the effectiveness of this workshop, the authors designed a comprehensive pre- and postworkshop evaluation which assessed participants' skill, knowledge, attitude (toward importance), and confidence. RESULTS: A total of 156 health care providers participated in the workshop and completed pre- and postworkshop evaluations. Participants showed substantial improvement in skill and knowledge (fact- and case-based) scores, as well as modest improvement in importance and confidence ratings. Faculty and medical students demonstrated similar baseline measures of skill, knowledge, and importance, though faculty reported a slightly higher confidence in their skills. No correlation was found between baseline ratings of confidence in abilities and any baseline measure of performance. CONCLUSIONS: Given the similar baseline performance of faculty and medical students, the ability to interpret facial expressions does not appear to be learned through routine clinical practice, highlighting the need for dedicated facial expression training. The authors were able to demonstrate that physicians and physicians-in-training could effectively learn to recognize emotion by interpreting facial expressions through a short workshop.

Prostate cancer screening.

Universal screening for prostate cancer (Pca) using prostate-specific antigen-based testing is not recommended, as the potential harms of screening (overdiagnosis and overtreatment) outweigh potential benefits. The case for Pca screening requires a paradigm shift, which emphasizes the risks of screening over the risks of undetected cancer. Physicians are encouraged to use shared decision making with patients who express an interest in Pca screening, taking into account both the patient's screening preferences and individual risk profile. New models of care informed by the Patient Protection and Affordable Care Act are intended to assist clinicians in providing recommended preventive services.

Achieving vascular access success in the quality outcomes era.

BACKGROUND: In 1997 the National Kidney Foundation put forth guidelines for hemoaccess through its Dialysis Outcomes Quality Initiative (DOQI). Some centers have been able to meet these standards; most have not. METHODS: A retrospective review was made of our database of more than 3,500 hemoaccess procedures from 1986 to 2003. RESULTS: Our approach, increased use of transposed fistulas and preoperative duplex mapping, has led to a fistula incidence (84%) and prevalence (54%) exceeding DOQI criteria. Meeting the DOQI guideline for thrombectomy rate (0.5 per year) is mostly achieved by increased use of fistulas. Additionally, access monitoring, as well as intraoperative angiography, angioplasty, stenting, and surgical revision, can aid in decreasing the frequency of occlusions (0.45 per year). This operative approach has led to a 98% success rate for surgical thrombectomy, exceeding the DOQI guideline of 85%. Earlier referrals from nephrologists have lowered the catheter use prevalence to 9%. CONCLUSIONS: An aggressive approach to placing fistulas, maintaining the access, and receiving prompt referrals can lead to success in meeting DOQI criteria.

Endotension distribution and the role of thrombus following endovascular AAA exclusion.

PURPOSE: To determine the pattern of strain and pressure transmitted to an aortic aneurysm wall before and after endovascular exclusion and to evaluate the role of sac thrombus on the conduction of pressure and wall strain. METHODS: Three canine thoracic aortas were used to create abdominal aortic aneurysms (AAA). The segments were placed on a pulsatile pump system, and 8 strain transducers were positioned in the aneurysm sac. Baseline strain/pressure (S/P) was recorded in 1 animal, then the AAA was excluded with a stent-graft. Thrombin was injected into the sac, and strain/pressure was recorded at 7 systemic pressures (35 to 120 mmHg) over 6 hours. The thrombus was replaced with fibrin glue, and S/P was recorded over 4 hours. Additional trials using whole and 50% diluted unclotted blood were performed prior to sac thrombosis. Computed tomography and angiography were performed before and after aneurysm exclusion. RESULTS: Pressure transmitted to the aneurysm wall decreased following stent-graft placement (p