Exploring Competency-Based Medical Education Through the Lens of the UME-GME Transition: A Qualitative Study.

PURPOSE: Competency-based medical education (CBME) represents a shift to a paradigm with shared definitions, explicit outcomes, and assessments of competence. The groundwork has been laid to ensure all learners achieve the desired outcomes along the medical education continuum using the principles of CBME. However, this continuum spans the major transition from undergraduate medical education (UME) to graduate medical education (GME) that is also evolving. This study explores the experiences of medical educators working to use CBME assessments in the context of the UME-GME transition and their perspectives on the existing challenges. METHOD: This study used a constructivist-oriented qualitative methodology. In-depth, semistructured interviews of UME and GME leaders in CBME were performed between February 2019 and January 2020 via Zoom. When possible, each interviewee was interviewed by 2 team members, one with UME and one with GME experience, which allowed follow-up questions to be pursued that reflected the perspectives of both UME and GME educators more fully. A multistep iterative process of thematic analysis was used to analyze the transcripts and identify patterns across interviews. RESULTS: The 9 interviewees represented a broad swath of UME and GME leadership positions, though most had an internal medicine training background. Analysis identified 4 overarching themes: mistrust (a trust chasm exists between UME and GME); misaligned goals (the residency selection process is antithetical to CBME); inadequate communication (communication regarding competence is infrequent, often unidirectional, and lacks a shared language); and inflexible timeframes (current training timeframes do not account for individual learners' competency trajectories). CONCLUSIONS: Despite the mutual desire and commitment to move to CBME across the continuum, mistrust, misaligned goals, inadequate communication, and inflexible timeframes confound such efforts of individual schools and programs. If current efforts to improve the UME-GME transition address the themes identified, educators may be more successful implementing CBME along the continuum.

Using Self-Regulated Learning Microanalysis to Examine Regulatory Processes in Clerkship Students Engaged in Practice Questions.

Introduction: Self-regulated learning is a cyclical process of forethought, performance, and self-reflection that has been used as an assessment tool in medical education. No prior studies have evaluated SRL processes for answering multiple-choice questions (MCQs) and most evaluated one or two iterations of a non-MCQ task. SRL assessment during MCQs may elucidate reasons why learners are successful or not on these questions that are encountered repeatedly during medical education. Methods: Internal medicine clerkship students at three institutions participated in a SRL microanalytic protocol that targeted strategic planning, metacognitive monitoring, causal attributions, and adaptive inferences across seven MCQs. Responses were transcribed and coded according to previously published methods for microanalytic protocols. Results: Forty-four students participated. In the forethought phase, students commonly endorsed prioritizing relevant features as their diagnostic strategy (n = 20, 45%) but few mentioned higher-order diagnostic reasoning processes such as integrating clinical information (n = 5, 11%) or comparing/contrasting diagnoses (n = 0, 0%). However, in the performance phase, students' metacognitive processes included high frequencies of integration (n = 38, 86%) and comparing/contrasting (n = 24, 55%). In the self-reflection phase, 93% (n = 41) of students faulted their management reasoning and 84% (n = 37) made negative references to their abilities. Less than 10% (n = 4) of students indicated that they would adapt their diagnostic reasoning process for these questions. Discussion: This study describes in detail student self-regulatory processes during MCQs. We found that students engaged in higher-order diagnostic reasoning processes but were not explicit about it and seldom reflected critically on these processes after selecting an incorrect answer. Self-reflections focused almost exclusively on management reasoning and negative references to abilities which may decrease self-efficacy. Encouraging students to identify and evaluate diagnostic reasoning processes and make attributions to controllable factors may improve performance.

Evaluation of an Individualized Learning Plan Template for the Transition to Residency.

Background Specialty-specific individualized learning plans (ILPs) have been promoted to improve the undergraduate to graduate medical education transition, yet few pilots have been described. Objective To create and report on the feasibility and acceptability of a pilot internal medicine (IM) ILP template. Methods The ILP was created by a group of diverse IM expert stakeholders and contained questions to stimulate self-reflection and collect self-reported readiness data from incoming interns. US IM residency programs were invited to pilot the ILP with interns in spring 2022. Data was used at the programs' discretion. The pilot was evaluated by a post-pilot survey of programs to elicit perceptions of the impact and value of the ILP and analyze anonymous ILP data from 3 institutions. Results Fifty-two IM residency programs agreed to participate with a survey response rate of 87% (45 of 52). Of responding programs, 89% (40 of 45) collected ILPs, thus we report on data from these 40 programs. A total of 995 interns enrolled with 782 completing ILPs (79%). One hundred eleven ILPs were analyzed (14%). Most programs found the ILP valuable to understand incoming interns' competencies (26 of 40, 65%) and areas for improvement (24 of 40, 60%) and thought it should continue (29 of 40, 73%). Programs estimated the ILP took interns 29.2±14.9 minutes and 21.6±10.3 minutes for faculty mentors to complete. The most common barrier was faculty mentor participation. Conclusions An ILP based on interns' self-reported data was feasible and valuable to IM residency programs in understanding interns' competencies and areas for improvement.

Online Virtual Patient Cases vs. Weekly Classroom Lectures in an Internal Medicine Clerkship: Effects on Military Learner Outcomes.

INTRODUCTION: Virtual patient cases (VPCs), a type of simulated, interactive electronic learning, are a potentially important tool for military health care providers in austere or pandemic settings to maintain skills but need more validation. Our military internal medicine clerkship is spread across military treatment facilities around the country and has 15 weekly live student lectures, but students randomly miss the first, second, or third 5 weeks due to their psychiatry clerkship. We hypothesized that VPCs would be an adequate replacement for lost lectures. MATERIALS AND METHODS: We compared live lectures to a web-based VPC and analyzed the academic outcomes of 734 students from 2015 to 2022. RESULTS: Using our end-of-clerkship Script Concordance Test (SCT) as the primary outcome, there was no significant difference in performance between the 2 learning methods (VPC, 63.9% correct; lectures 63.2%, P = .27). After controlling for gender, baseline knowledge, and the total number of VPCs completed, there was still not a statistically significant difference between teaching methods (F(1,728) = 0.52, P = .47). There was also no significant differences in all other clerkship outcomes including National Board of Medical Examiner and Objective Structured Clinical Examination scores. CONCLUSION: VPCs appear noninferior at teaching clinical reasoning as measured by SCT. VPCs might be substituted for traditional, live lectures in clerkships when time or other resources are limited, in austere environments such as military deployments, or during conditions limiting interpersonal contact such as pandemics but are not a complete substitution for in-person learning.

Reflective Essays During Clerkship Following a Pre-clerkship Leadership Curriculum.

Introduction: Leadership curricula in medical student education require assessment - to determine if leadership skills can be taught to medical students and applied during clinical and medical team interactions to aid in medical student leadership development. Objectives: To examine whether medical students applied principles of their pre-clerkship leadership curriculum (character, competence, context, and communication elements across four levels: personal, interpersonal, team, and organizational) during an internal medicine clerkship. Methods: Using art as a prompt, Uniformed Services University (USU) internal medicine clerkship students completed a structured reflection on a critical incident. Medical student essays written during a 10-week internal medicine clerkship at USU in 2019 were collected. 158 medical student submissions were de-identified and analyzed. Results: Sixty-four submissions (40.5%) focused on leadership or leadership and professionalism. Students identified as male (n = 34, 53%), female (21, 33%), or not reported (9, 14%). Most, 48 (75%), did not describe PITO explicitly in their essay. They instead focused on personal and interpersonal aspects (17, 27%) of leadership, the attending physicians they worked with (33, 52%), and effective leadership strategies (46, 72%). The most common themes written about were responsibility (30, 47%), teamwork (18, 28%), competence (17, 27%), and character/integrity (15, 23%). Conclusion: Although the students' explicit use of the PITO model was limited, student essays centered on themes that reflected leadership concepts taught in pre-clerkship years, such as character, competence, and responsibility. This study demonstrates that an internal medicine clerkship rotation can feasibly implement a leadership reflection.

ACGME Milestones in the Real World: A Qualitative Study Exploring Response Process Evidence.

Background: Since the Accreditation Council for Graduate Medical Education (ACGME) introduced the Milestones in 2013, the body of validity evidence supporting their use has grown, but there is a gap with regard to response process. Objective: The purpose of this study is to qualitatively explore validity evidence pertaining to the response process of individual Clinical Competency Committee (CCC) members when assigning Milestone ratings to a resident. Methods: Using a constructivist paradigm, we conducted a thematic analysis of semi-structured interviews with 8 Transitional Year (TY) CCC members from 4 programs immediately following a CCC meeting between November and December 2020. Participants were queried about their response process in their application of Milestone assessment. Analysis was iterative, including coding, constant comparison, and theming. Results: Participant interviews identified an absence of formal training and a perception that Milestones are a tool for resident assessment without recognizing their role in program evaluation. In describing their thought process, participants reported comparing averaged assessment data to peers and time in training to generate Milestone ratings. Meaningful narrative comments, when available, differentiated resident performance from peers. When assessment data were absent, participants assumed an average performance. Conclusions: Our study found that the response process used by TY CCC members was not always consistent with the dual purpose of the Milestones to improve educational outcomes at the levels of residents and the program.

Extending growth curves: a trajectory monitoring approach to identification and interventions in struggling medical student learners.

Given gaps in both identifying and providing targeted interventions to struggling learners, the purpose of this study is to both improve rapid identification and to improve individualized academic advising for learners using this visual representation of performance. Across three graduating classes, individual growth curves were calculated for each student on National Board of Medical Examiners customized assessments during the pre-clerkship period using their deviation from the class average at each assessment point. These deviation scores were cumulatively summed over time and were regressed onto the sequence of exams. We analyzed the difference between the regression slopes of those students placed on Academic Probation (AP) versus not, as well as differences in slopes based on the timing of when a struggling learner was placed on AP to explore learner trajectory after identification. Students on AP had an average growth slope of - 6.06 compared to + 0.89 for those not on AP. Findings also suggested that students who were placed on AP early during pre-clerkship showed significant improvement (positive changes in trajectory) compared to students identified later in the curriculum. Our findings suggest that earlier academic probation and intervention with struggling learners may have a positive effect on academic trajectory. Future research can better explore how academic trajectory monitoring and performance review can be regularly used in advising sessions with students.

Medical School to Residency: How Can We Trust the Process?

Background To say that the transition from undergraduate medical education (UME) to graduate medical education (GME) is under scrutiny would be an understatement. Findings from a panel discussion at the 2018 Association of American Medical Colleges Annual meeting entitled, "Pass-Fail in Medical School and the Residency Application Process and Graduate Medical Education Transition" addressed what and when information should be shared with residency programs, and how and when that information should be shared. Materials and Methods Over 250 participants representing UME and GME (e.g. leadership, faculty, medical students) completed worksheets addressing these questions. During report-back times, verbal comments were transcribed in real time, and written comments on worksheets were later transcribed. All comments were anonymous. Thematic analysis was conducted manually by the research team to analyze the worksheet responses and report back comments. Results Themes based on suggestions of what information should be shared included the following: 1) developmental/assessment benchmarks such as demonstrating the ability/competencies to do clinical work; 2) performance on examinations; 3) grades and class ranking; 4) 360 evaluations; 5) narrative evaluations; 6) failures/remediation/gaps in training; 7) professionalism lapses; 8) characteristics of students such as resiliency/reliability; and 9) service/leadership/participation. In terms of how this information should be shared, the participants suggested enhancements to the current process of transmitting documents rather than alternative methods (e.g., video, telephonic, face-to-face discussions) and information sharing at both the time of the match and again near/at graduation to include information about post-match rotations. Discussion Considerations to address concerns with the transition from medical school to residency include further enhancements to the Medical Student Performance Evaluation, viewing departmental letters as ones of evaluation and not recommendation, a more meaningful educational handoff, and limits on the number of residency applications allowed for each student. The current medical education environment is ready for meaningful change in the UME to GME transition.

Gathering Validity Evidence on an Internal Medicine Clerkship Multistep Exam to Assess Medical Student Analytic Ability.

Construct: The definition of clinical reasoning may vary among health profession educators. However, for the purpose of this paper, clinical reasoning is defined as the cognitive processes that are involved in the steps of information gathering, problem representation, generating a differential diagnosis, providing a diagnostic justification to arrive at a leading diagnosis, and formulating diagnostic and management plans. Background: Expert performance in clinical reasoning is essential for success as a physician, and has been difficult for clerkship directors to observe and quantify in a way that fosters the instruction and assessment of clinical reasoning. The purpose of this study was to gather validity evidence for the Multistep exam (MSX) format used by our medicine clerkship to assess analytical clinical reasoning abilities; we did this by examining the relationship between scores on the MSX and other external measures of clinical reasoning abilities. This analysis used dual process theory as the main theoretical framework of clinical reasoning, as well as aspects of Kane's validity framework to guide the selection of validity evidence for the investigation. We hypothesized that there would be an association between the MSX (a three-step clinical reasoning tool developed locally), and the USMLE Step 2 CS, as they share similar concepts in assessing the clinical reasoning of students. We examined the relationship between overall scores on the MSX and the Step 2 CS Integrated Clinical Encounter (ICE) score, in which the student articulates their reasoning for simulated patient cases, while controlling for examinee's internal medicine clerkship performance measures such as the NBME subject exam score and the Medicine clerkship OSCE score. Approach: A total 477 of 487 (97.9%) medical students, representing the graduating classes of 2015, 2016, 2017, who took the MSX at the end of each medicine clerkship (2012-2016), and Step 2 CS (2013-2017) were included in this study. Correlation analysis and multiple linear regression analysis were used to examine the impact of the primary explanatory variables of interest (MSX) onto the outcome variable (ICE score) when controlling for baseline variables (Medicine OSCE and NBME Medicine subject exam). Findings: The overall MSX score had a significant, positive correlation with the Step 2 CS ICE score (r = .26, P < .01). The overall MSX score was a significant predictor of Step 2 CS ICE score (ß = .19, P < .001), explaining an additional 4% of the variance of ICE beyond the NBME Medicine subject score and the Medicine OSCE score (Adjusted R2 = 13%). Conclusion: The stepwise format of the MSX provides a tool to observe clinical reasoning performance, which can be used in an assessment system to provide feedback to students on their analytical clinical reasoning. Future studies should focus on gaining additional validity evidence across different learners and multiple medical schools.

Understanding context specificity: the effect of contextual factors on clinical reasoning.

Background Situated cognition theory argues that thinking is inextricably situated in a context. In clinical reasoning, this can lead to context specificity: a physician arriving at two different diagnoses for two patients with the same symptoms, findings, and diagnosis but different contextual factors (something beyond case content potentially influencing reasoning). This paper experimentally investigates the presence of and mechanisms behind context specificity by measuring differences in clinical reasoning performance in cases with and without contextual factors. Methods An experimental study was conducted in 2018-2019 with 39 resident and attending physicians in internal medicine. Participants viewed two outpatient clinic video cases (unstable angina and diabetes mellitus), one with distracting contextual factors and one without. After viewing each case, participants responded to six open-ended diagnostic items (e.g. problem list, leading diagnosis) and rated their cognitive load. Results Multivariate analysis of covariance (MANCOVA) results revealed significant differences in angina case performance with and without contextual factors [Pillai's trace = 0.72, F = 12.4, df =(6, 29), p < 0.001, η p 2 = 0.72 $\eta _{\rm p}^2 = 0.72$ ], with follow-up univariate analyses indicating that participants performed statistically significantly worse in cases with contextual factors on five of six items. There were no significant differences in diabetes cases between conditions. There was no statistically significant difference in cognitive load between conditions. Conclusions Using typical presentations of common diagnoses, and contextual factors typical for clinical practice, we provide ecologically valid evidence for the theoretically predicted negative effects of context specificity (i.e. for the angina case), with large effect sizes, offering insight into the persistence of diagnostic error.

Exploring the Predictors of Post-Clerkship USMLE Step 1 Scores.

Theory: We used two theoretical frameworks for this study: a) experiential learning, whereby learners construct new knowledge based on prior experience, and learning grows out of a continuous process of reconstructing experience, and b) deliberate practice, whereby the use of testing (test-enhanced learning) promotes learning and produces better long-term retention. Hypothesis: We hypothesized that moving the USMLE Step 1 exam to follow the clerkship year would provide students with a context for basic science learning that may enhance exam performance. We also hypothesized that examination performance variables, specifically National Board of Medical Examiners (NBME) Customized Basic Science Examinations and NBME subject examinations in clinical disciplines would account for a moderate to large amount of the variance in Step 1 scores. Thus we examined predictors of USMLE Step 1 scores when taken after the core clerkship year. Method: In 2011, we revised our medical school curriculum and moved the timing of Step 1 to follow the clerkship year. We performed descriptive statistics, an ANCOVA to compare Step 1 mean scores for three graduating classes of medical students before and after the curriculum changes, and stepwise linear regression to investigate the association between independent variables and the primary outcome measure after curriculum changes. Results: 993 students took the Step 1 exam, which included graduating classes before (2012-2014, N = 491) and after (2015-2017, N = 502) the curriculum change. Step 1 scores increased significantly following curricular revision (mean 218, SD 18.2, vs. 228, SD 16.7, p < 0.01) after controlling for MCAT and undergraduate GPA. Overall, 66.4% of the variance in Step 1 scores after the clerkship year was explained by: the mean score on fourteen pre-clerkship customized NBME exams (p < 0.01, 57.0% R2); performance on the surgery NBME subject exam (p < 0.01, 3.0% R2); the pediatrics NBME subject exam (p < 0.01, 2.0% R2); the Comprehensive Basic Science Self-Assessment (p < .01, 2.0% R2) ; the internal medicine NBME subject exam (p < 0.01, 0.03% R2), pre-clerkship Integrated Clinical Skills score (p < 0.01, 0.05% R2), and the pre-matriculation MCAT (p < 0.01, 0.01% R2). Conclusion: In our institution, nearly two-thirds of the variance in performance on Step 1 taken after the clerkship year was explained mainly by pre-clerkship variables, with a smaller contribution emanating from clerkship measures. Further study is needed to uncover the specific aspects of the clerkship experience that might contribute to success on high stakes licensing exam performance.

It's a matter of trust: exploring the basis of program directors' decisions about whether to trust a resident to care for a loved one.

There has been increased attention to and emphasis on competency-based medical education and the transformation from highly supervised medical students towards independent, entrustable physicians. We explored how program directors (PDs) justify decisions about whether they would trust finishing Post Graduate Year 1 (PGY1) residents to care for the PD or a loved one. Using an end of year survey with validity evidence, we assessed PDs' responses (Yes, No, Not Sure) and written comments about this entrustment decision for USUHS medical students from graduating classes of 2013-2015 (PGY1). We performed a qualitative inductive content analysis to identify themes in how PDs justified their decisions as well as descriptive statistics and a contingency table analysis to examine associations between trust decisions and election to membership in Alpha Omega Alpha (AOA), or conversely, referral to the Student Promotions Committee (SPC) for remediation. Qualitative analyses revealed five themes related to this trust decision about medical residents: personal, interpersonal, knowledge, competence, and developmental. Neither AOA status, nor SPC referral status was significantly associated with the trust measure, overall, but positive trust decisions were significantly higher among those elected to AOA than in those who were not. Positive trust decisions were significantly associated with AOA status but negative trust decisions were not significantly associated with referral to the SPC. This study offers insights into what attributes may underpin trust decisions by PDs. Our findings suggest that PDs' frequent use of personal and interpersonal characteristics to justify trust decisions contrasts with the use of clinical and knowledge based assessments during undergraduate medical education (UME), and emphasize the importance of critical intrinsic abilities.

The Clinical Reasoning Mapping Exercise (CResME): a new tool for exploring clinical reasoning.

INTRODUCTION: National organizations have identified a need for the creation of novel approaches to teach clinical reasoning throughout medical education. The aim of this project was to develop, implement and evaluate a novel clinical reasoning mapping exercise (CResME). METHODS: Participants included a convenience sample of first and second year medical students at two US medical schools: University of Central Florida (UCF) and Uniformed Services University of Health Sciences (USUHS). The authors describe the creation and implementation of the CResME. The CResME uses clinical information for multiple disease entities as nodes in different domains (history, physical exam, imaging, laboratory results, etc.), requiring learners to connect these nodes of information in an accurate and meaningful way to develop diagnostic and/or management plans in the process. RESULTS: The majority of medical students at both institutions felt that the CResME promoted their understanding of the differential diagnosis and was a valuable tool to compare and contrast elements of a differential diagnosis. Students at both institutions recommended using the CResME for future sessions. DISCUSSION: The CResME is a promising tool to foster students' clinical reasoning early in medical school. Research is needed on the implementation of the CResME as an instructional and assessment strategy for clinical reasoning throughout medical school training.

Specialty Choices, Practice Characteristics, and Long-term Outcomes of Two Cohorts of USUHS Medical School Graduates Compared with National Data.

Introduction: The education of health professionals and the assessment of their long-term goals are essential. Additionally, in the military health system (MHS), such programs also have the goals of improving readiness, providing high-quality care and meeting the needs and challenges of the MHS. The Uniformed Services University F. Edward Hebert School of Medicine (USUHS) has existed for over 40 years and the assessment of the longer term outcomes of its medical school graduates is an important endeavor. The purpose of this study is to describe the relationship of USUHS on the care in the MHS by reporting specialty choices, practice characteristics and locations of two consecutive cohorts of USUHS graduates and to compare these cohort findings with national data. Two cohorts were chosen as the first cohort has reached retirement and we sought to describe the impact of our graduates following their military service commitment. Materials and Methods: We performed a retrospective analysis of our graduates (1980-2009) using data obtained from the American Medical Association Physician Masterfile in two 15-year cohorts. USU graduate data are described and compared with national allopathic medical school data in order to explore USUHS graduates' practice characteristics and how these contrast with national data. Results: Family medicine was the most commonly identified primary care specialty across both USUHS cohorts. Other primary care specialties such as Internal Medicine and Pediatrics became more popular among USUHS graduates over time. There were a lower percentage of inactive USUHS graduates from the 1980-1994 cohorts than the U.S. national sample (3.23% vs. 3.98%). The proportion of USUHS graduates working in an office-based practice increased from 34.8% (1980-1994) to 43.6% (1995-2009) yet still was lower than U.S. national data (1980-1994: 73.5%; 1995-2009: 73.8%). The type of practice in which the majority of USUHS and national graduates were involved was direct patient care (over 70% of the population). Practice locations for medical school graduates included all 50 states. Furthermore, though several states such as Mississippi, Nevada, South Carolina, and Utah were among the top 20 practice locations among USUHS graduates, they did not appear among the top 20 practicing states for U.S. graduates. Conclusions: USUHS can play a major role by training health care professionals needed to meet the large health care strategic goals of a transforming military health system. A high percentage of USUHS graduates had significant changes in practice characteristics over time, are staying in practice for longer time compared with U.S. graduates, and practice in all 50 states including those that are underserved.