Analysis of narrative assessments of internal medicine resident performance: are there differences associated with gender or race and ethnicity?

BACKGROUND: Equitable assessment is critical in competency-based medical education. This study explores differences in key characteristics of qualitative assessments (i.e., narrative comments or assessment feedback) of internal medicine postgraduate resident performance associated with gender and race and ethnicity. METHODS: Analysis of narrative comments included in faculty assessments of resident performance from six internal medicine residency programs was conducted. Content analysis was used to assess two key characteristics of comments- valence (overall positive or negative orientation) and specificity (detailed nature and actionability of comment) - via a blinded, multi-analyst approach. Differences in comment valence and specificity with gender and race and ethnicity were assessed using multilevel regression, controlling for multiple covariates including quantitative competency ratings. RESULTS: Data included 3,383 evaluations with narrative comments by 597 faculty of 698 residents, including 45% of comments about women residents and 13.2% about residents who identified with race and ethnicities underrepresented in medicine. Most comments were moderately specific and positive. Comments about women residents were more positive (estimate 0.06, p 0.045) but less specific (estimate - 0.07, p 0.002) compared to men. Women residents were more likely to receive non-specific, weakly specific or no comments (adjusted OR 1.29, p 0.012) and less likely to receive highly specific comments (adjusted OR 0.71, p 0.003) or comments with specific examples of things done well or areas for growth (adjusted OR 0.74, p 0.003) than men. Gendered differences in comment specificity and valence were most notable early in training. Comment specificity and valence did not differ with resident race and ethnicity (specificity: estimate 0.03, p 0.32; valence: estimate - 0.05, p 0.26) or faculty gender (specificity: estimate 0.06, p 0.15; valence: estimate 0.02 p 0.54). CONCLUSION: There were significant differences in the specificity and valence of qualitative assessments associated with resident gender with women receiving more praising but less specific and actionable comments. This suggests a lost opportunity for well-rounded assessment feedback to the disadvantage of women.

Complex decision making in an intensive care environment: Perceived practice versus observed reality.

RATIONALE: Advancing our understanding of how decisions are made in cognitively, socially and technologically complex hospital environments may reveal opportunities to improve healthcare delivery, medical education and the experience of patients, families and clinicians. AIMS AND OBJECTIVES: Explore factors impacting clinician decision making in the Boston Children's Hospital Cardiac Intensive Care Unit. METHODS: A convergent mixed methods design was used. Quantitative and qualitative data sources consisted of a faculty survey, direct observations of clinical rounds in a specific patient population identified by a clinical decision support system (CDSS) and semistructured interviews (SSIs). Deductive and inductive coding was used for qualitative data. Qualitative data were translated into images using social network analysis which illustrate the frequency and connectivity of the codes in each data set. RESULTS: A total of 25 observations of eight faculty-led interprofessional teams were performed between 12 February and 31 March 2021. Individual patient characteristics were noted by faculty in SSIs to be the most important factor in their decision making, yet ethnographic observations suggested faculty cognitive traits, team expertise and value-based decisions were more heavily weighted. The development of expertise was impacted by role modeling. Decisions were perceived to be influenced by the system and environment. CONCLUSIONS: Clinician perception of decision making was not congruent with the observed behaviours in a complicated and dynamic system. This study identifies important considerations in clinical curricula as well as the design and implementation of CDSS. Our method of using social network analysis to visualize components of decision making could be adopted to explore other complex environments.

Explicit bias among fourth-year medical students.

The aim of this study was to analyze themes related to explicit bias in patient-doctor relationships among fourth-year medical students. Class cohorts between 2013 and 2016 taking an online elective, "Self and Culture," submitted reflections about explicit bias. Thematic analysis was conducted on 283 student submissions totaling 849 entries until saturation. Themes included explicit bias toward patients with obesity, those who smoked, those from low-socioeconomic conditions, and, to a lesser extent, race/ethnicity. Themes related to the patient-doctor relationship included a negative impact on the relationship itself, trust, treatment of the patient, and patient experience. Themes related to making a positive impact included seeking positive treatment of the patient, understanding patients' circumstances rather than making assumptions, partnering with the patient, and education. Furthermore, researchers noted external versus internal attribution of the bias. Some students used neutral language to explain explicit biases, whereas fewer used internal attribution language. Results demonstrated that this type of reflection promoted personal insight, and faculty members should be trained to ensure successful crucial conversations about the impact of assumptions and biases on patient treatment, care plans, and health disparities. Finally, the curriculum should be intentional, providing experiences with marginalized populations to develop cultural humility and empathy.

Historical Trajectory and Implications of Duty-Hours in Graduate Medical Education.

Duty-hours policies continue to be debated. Most know the pro and con arguments, but many may not be aware of background information preceding and intertwining the development and implementation of these policies. Interestingly, several aspects of law were involved or potentially correlated with policies enacted. This review updates new generations of physicians and scholars on the historical trajectory of duty-hour policies and highlights policy implications and the current state of evidence. In reviewing the historical and legal trajectory of duty-hours, many updates seemed to be a reaction to potential federal entanglement. Additionally, the review of the postimplementation literature revealed minimal empirical evidence. Instead, the majority of the positive findings were perception based. These summaries demonstrate a need for further outcomes evidence to validate policies.

Facilitators and barriers to ad hoc team performance.

Most teams in hospital medicine are ad hoc, meaning that the teams vary in participants. Ad hoc teams can be found in academic teaching hospitals where team members change across shifts and rotations. Due to varying team membership, these teams face significant hurdles, because they lack an opportunity to develop a team identity, shared mental models, and trust. This article discusses facilitators and barriers to effective functioning of ad hoc teams. Communication, conflict management, power, and leadership are areas that either serve as facilitators or barriers to positive team function. In addition to discussing these aspects, solutions and recommendations from practice are shared. Solutions include data about successful teams, communication in those teams, and data about how to improve education and team training. These practical applications can be applied in practice to improve team functioning. Finally, we recommend that additional research be conducted in the area of ad hoc teams, because this type of team is a large part of medicine with a gap in evidence.

Pleural infections: a 9-year review of bacteriology, case characteristics and mortality.

BACKGROUND: Despite advances in medical therapies, pleural infections remain a common disease. The characteristics of this disease seem to change over time, with alterations in patient characteristics and bacteriology. The purpose of this study was to provide a retrospective descriptive analysis of pleural infections during a 9-year period. METHODS: We performed a single-center retrospective review of all culture-positive pleural infections between January 2000 and December 2008. The primary outcome was assessment of long-term survival and associated independent risk factors affecting survival. Length of survival was determined using the Social Security Death Index. Case characteristics and bacteriology were reviewed for descriptive analysis. RESULTS: During a 9-year period, 187 culture-positive pleural infections were identified. Review of bacteriology revealed gram-positive cocci as the predominate organisms, most commonly Streptococcus and Staphylococcus. Anaerobes were found in 9.1% of the cases. Independent risk factors associated with risk of death based on multivariable survival analysis were age older than 65, cirrhosis and past and present malignancy. The hospital mortality was 10.7%, and the 1-year, 3-year and 5-year estimated survival rates were 73.8%, 63.3% and 60.6%, respectively. CONCLUSIONS: Pleural infections continue to remain a major health problem and carry significant morbidly and mortality. The importance of Staphylococcus aureus in this population has yet to be fully examined, and although potentially underestimated in this study, anaerobic infections remain a common pathogen.

Residents' perspectives of the value of a simulation curriculum in a general surgery residency program: a multimethod study of stakeholder feedback.

BACKGROUND: Simulation has altered surgical curricula throughout residency programs. The purpose of this multimethod study was to explore residents' perceptions of simulation within surgical residency as relevant stakeholder feedback and program evaluation of the surgery simulation curriculum. METHODS: Focus groups were held with a sample of surgery residents (n = 25) at a university-affiliated program. Residents participated in focus groups based on level of training and completed questionnaires regarding simulation curricula. Groups were facilitated by nonsurgeon faculty. Residents were asked: "What is the role of simulation in surgical education?" An interdisciplinary team recorded narrative data and performed content analyses. Quantitative data from questionnaires were summarized using descriptive statistics and frequencies. RESULTS: Major themes from the qualitative data included: concerns regarding simulation in surgical education (28%), exposure to situations and technical skills in a low-stress learning environment (24%), pressure by external agencies (19%), an educational tool (17%), and quality assurance for patient care (12%). Laparoscopy and cadaver lab were the most prevalent simulation training during residency, in addition to trauma simulations, central lines/chest tubes/IV access, and stapling lab. In response to the statement: "ACGME should require a simulation curriculum in surgery residency," 52.1% responded favorably and 47.8% responded nonfavorably. CONCLUSION: Residents acknowledge the value of simulation in patient safety, quality, and exposure to procedures before clinical experience, but remain divided on efficacy and requirement of simulation within curricula. The greater challenge to residency programs may be strategic implementation of simulation curricula within the right training context.

Pancoast's syndrome secondary to infectious etiologies: a not so uncommon occurrence.

Pancoast's syndrome includes Horner's syndrome, atrophy of the hand muscles and shoulder, axilla or arm pain. This syndrome is caused by an apical thoracic lesion, most commonly a bronchogenic carcinoma, which invades the brachial plexus roots and the cervicothoracic sympathetic chain. Several nonmalignant causes are documented in the literature with infection being one. After a case of Pancoast syndrome caused by a methicillin-sensitive Staphylococcus aureus empyema, we began a systematic search of the literature to identify case reports/series of Pancoast syndrome secondary to infection. Our search was limited to the English language and performed using MEDLINE. Thirty-one cases of Pancoast's syndrome secondary to infectious causes were found in our review of the literature. The infectious causes identified were bacterial, fungal and parasitic organisms; however, no single organism could be identified as the most prevalent. Our review represents the most complete summation of individual case reports on this subject and highlights clinical characteristics of each presentation and the organisms that were encountered. This number of cases of Pancoast's syndrome secondary to infectious causes indicates that this association may be more common than previously reported.