The meaning of excellence.

RATIONALE AND OBJECTIVES: Program directors would like to interview the very best students applying to their programs. The summary paragraph of the dean's letter should provide useful information regarding a student's performance in medical school. One frequently found descriptor is excellent. However, its very frequency suggests the word may be loosely used. The purpose of this investigation is to determine the meaning of excellence. MATERIALS AND METHODS: The descriptor excellent was searched for in the summary paragraph. An effort was made to determine how many medical schools used excellent, how precisely the medical school defined this word, whether numbers were used to define the upper and lower boundaries of excellent, and what other buzzwords were used in the summary paragraphs for students not defined as excellent. RESULTS: Excellent was the most common descriptor, used by 75% of the medical schools. Defined numeric boundaries were used by 47% of schools. Tabulated results showed that within a school the range of excellence varied from as tight as 20 percentile points to so broad that 65% of the students were classified as excellent. The boundaries of excellent, among different schools, varied from as low as the third to as high as the ninety-second percentile. In half the schools, students described as excellent might be in the bottom half of their class. A total of 28% of the schools used excellent, but without any numeric definition. No school used excellent to describe its best students. CONCLUSIONS: Medical student deans often exaggerate the quality of their graduates by using the word excellent at variance with the dictionary definition of exceptionally good. Inaccurate descriptions by deans of their graduating medical students diminish the value of MSPE.

Redesigning training for internal medicine.

The American College of Physicians supports the need for reform throughout the continuum of training in internal medicine. Today's internists must have the necessary knowledge, skills, and attitudes to meet the challenges of an expanding body of medical knowledge and a rapidly evolving system of health care delivery. Suggested priorities for undergraduate medical education include redesigning curricular experiences to afford students earlier and more exposure to career opportunities in internal medicine, improving ambulatory education, exposing students to outstanding faculty role models in internal medicine, and incorporating educational experiences during the fourth year that optimize its value and relevance to the student's future career plans in internal medicine. Internal medicine residency training should remain a 3-year experience, with a component of core education common to all trainees and a component of customized training in the third year targeted toward the resident's career goals. Residency programs should be designed around educational rather than institutional service needs. The ambulatory component of training requires substantial reform in its structure, sites, content, and timing. Team-based models should be used both for patient care and for flexibility in design of residency training. Better faculty models must be developed that build on the concept of a "core faculty," improve the rewards for teaching faculty, and provide appropriate faculty development focusing on a necessary set of educator competencies.

Resident as teacher: the Mount Sinai experience and a review of the literature.

Residents play a pivotal role in the education of medical students and junior house staff but are rarely provided with the tools to help them teach effectively. Residents value their roles as teachers and desire training programs in teaching skills. Teaching skills courses for residents have been shown to improve residents' self-confidence and self-assessed use of effective teaching behaviors. They have also been shown to improve residents' evaluations by students. The Institute for Medical Education at the Mount Sinai School of Medicine has developed a successful, multidisciplinary curriculum to improve the teaching and leadership skills of all of our residents at the Mount Sinai Hospital and its affiliate institutions. The Resident Teaching Development Program (RTDP) has already been implemented in the departments of Medicine, Surgery, Pediatrics, Psychiatry, and Obstetrics and Gynecology. This adaptable, seven-hour curriculum has been well received by residents and faculty. We are currently evaluating the effects of the program on residents' confidence and use of learned skills. And we are working to expand this program to every department and to create innovative means of measuring resident competency in teaching and its ultimate effect on student learning.

Nurse practitioner-led home care curriculum for third-year medical students.

Recent data have shown that medical students do not receive adequate exposure to the practice of home care. The number of homebound people is expected to increase, and health care services for these patients will need to expand. A one-week didactic and clinical curriculum was designed and implemented by four nurse practitioners in the Visiting Doctors Program, to provide home care exposure to medical students. The program stresses the medical, psychosocial and palliative aspects of patient care. The students evaluated both the nurse practitioners and the program favorably, using a five-point Likert scale. Role modeling and professionalism were noted to be of value to the students, and bear further study in the context of medical school curricula for home care.

Investigation of correlation between house-staff work hours and prescribing errors.

PURPOSE: The possible correlation between the frequency and significance of prescribing errors and the number of hours worked during a 24-hour shift by hospital house staff was studied. METHODS: A prospective observational trial was conducted in two internal medicine units at an academic medical center. Orders written by medical house staff covering the study units between January 8 and March 10, 2001, were collected daily and evaluated for obvious prescribing errors, the type and significance of the errors, and the number of hours the resident had worked during a 24-hour shift at the time of the prescribing error. RESULTS: A total of 45,366 orders (including orders for medications, laboratory tests, diagnostic procedures, and nursing care) were entered on the study units during the study period. A total of 498 erroneous prescribing orders were identified. A majority of the erroneous orders (77%) could have resulted in significant morbidity or mortality had they reached the patient. The most common errors involved the wrong dose (18%), the wrong dosage frequency (15%), and duplicate orders (15%). There was no statistically significant correlation between the number of hours worked and the frequency or significance of the errors. CONCLUSION: The number of hours worked by medical house staff during a 24-hour shift did not appear to affect the frequency or significance of their prescribing errors.

Improving geriatrics training in internal medicine residency programs: best practices and sustainable solutions.

National surveys indicate a need for additional training in geriatrics during internal medicine residencies. This paper describes 1) "best practices" for integrating geriatrics education into internal medicine residency programs, 2) barriers to implementation of these practices, and 3) possible ways to improve geriatrics training for internal medicine residents. These best practices were determined by a systematic review of the literature and through interviews with leaders of 26 residency and geriatrics programs concerned with geriatrics training for residents. The most successful programs have clinical experiences with 3 key elements: model geriatric care in 1 or more settings (for example, in the hospital or in ambulatory practice), patient care across sites or transitions of care, and interdisciplinary teamwork. Barriers include attitudes, few faculty, need for relationships with nontraditional training sites, and lack of funding. Local solutions include engaging the internal medicine program director to accomplish a mutual goal--for example, by creating a model geriatrics training experience in which residents demonstrate their skill in a new Accreditation Council of Graduate Medical Education competency (such as systems-based practice). National solutions include reaching consensus on the competencies in geriatrics that should be achieved by board-eligible internists. This may mean increasing the number of questions that test geriatrics competency in the certifying and in-training examinations, increasing numbers of faculty members able to teach and model geriatric care, developing "effective medical resident teaching" courses for nonphysician faculty, and lobbying for improved systems of care.

Teaching evidence-based medicine: a regional dissemination model.

BACKGROUND: Evidence-based medicine (EBM) is a framework for critically appraising medical literature and applying it to the care of individual patients. Lack of faculty skilled in practicing and teaching EBM limits the ability to train residents in this area. DESCRIPTION: A 31/2-day interactive course, called Teaching Evidence-Based Medicine, was given in 1996, 1998, and 1999. The goal of the course was to create a cadre of faculty within New York State's internal medicine residency programs educated in EBM knowledge and skills who could integrate EBM into their training program. Thirty (58.8%) of 51 metropolitan New York internal medicine residency programs and three of 12 upstate programs sent participants. EVALUATION: The postcourse ratings showed increased self-rated knowledge and a willingness to apply the teaching methods at their home institutions. CONCLUSIONS: There is a high demand for the opportunity to learn EBM skills and in turn to implement EBM at home institutions