Using Dashboards to Support Continuous Quality Improvement in Undergraduate and Graduate Medical Education.

Like other complex systems, medical education programs require a systematic continuous quality improvement (CQI) approach to drive effective improvement. Accreditation bodies in both undergraduate medical education (UME) and graduate medical education (GME) require programs to have effective CQI processes. Dashboards facilitate visualization and tracking of key metrics that impact medical education programming, thus driving excellence. Keys to developing useful dashboards include using existing program evaluation frameworks to identify desired outputs, determine acceptable evidence, and identify key data sources. In developing dashboards, it is important to consider data management including oversight and appropriate sharing of reports. When effectively developed and delivered to key parties, data dashboards serve as valuable tools to drive improvement of medical education programing. The purpose of this paper is to provide guidance for dashboard implementation and use in medical education, with a focus on UME and GME, based on available literature and experiences in our own institutions.

Time Given to Trainees to Attempt Cannulation During Endoscopic Retrograde Cholangiopancreatography Varies by Training Program and Is Not Associated With Competence.

Advanced endoscopy training programs (AETPs) were developed as a result of the lack of comprehensive endoscopic retrograde cholangiopancreatography (ERCP) training during gastroenterology fellowships. There is no standardized curriculum for AETPs and the influence of program- and trainer-associated factors on trainee competence in ERCP has not been investigated adequately. In prior work, we showed that advanced endoscopy trainees (AETs) achieve ERCP competence at varying rates.1,2 The aims of this study were to measure the variability in time given to AETs to attempt cannulation between AETPs and throughout the 1-year training period, and to determine the association between AET cannulation time and AET competence at the end of training.

Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice.

BACKGROUND & AIMS: It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence. METHODS: We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs. RESULTS: By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate). CONCLUSIONS: In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.

A Guide for Increasing Scholarship for Medical Educators.

Disseminating scholarly work as a clinician educator is critical to furthering new knowledge in medical education, creating an evidence base for new practices, and increasing the likelihood of promotion. Knowing how to initiate scholarship and develop habits to support it, however, may not be clear. This perspective is designed to help readers choose and narrow their focus of scholarly interest, garner mentors, find potential project funding, and identify outside support through involvement with national organizations, collaborators, and faculty development programs. By incorporating these suggestions into their daily work, educators can find ways to connect their clinical and educational interests and make their daily work count toward scholarship.

Development of a neonatal curriculum for medical students in Zimbabwe - a cross sectional survey.

BACKGROUND: Calls have been made to reassess the curricula of medical schools throughout the world to adopt competence-based programs that address the healthcare needs of society. Zimbabwe is a country characterized by a high neonatal mortality rate of 24 per 1000 live births. The current research sought to determine the content and appropriate teaching strategies needed to guide the development of an undergraduate neonatal curriculum map for medical students at the University of Zimbabwe College of Health Sciences. METHODS: We surveyed faculty (n = 8) and non-faculty pediatricians (n = 5), senior resident medical officers (N = 26) using a self-administered questionnaire, and completed one focus group discussion with midwives (n = 11). We asked respondents their expectations regarding knowledge, psychomotor skills, competencies, and teaching strategies in a basic newborn curriculum for medical students. Relevant policy and curricula documents were reviewed to assess newborn health needs and the current training. A group of faculty educationists (n = 11) collated and finalized the findings from the document review, survey, and focus group using descriptive statistics and thematic analysis. RESULTS: The document review revealed three key neonatal health objectives according to the current national maternal and neonatal health road map. These objectives are to be met using a four tier approach comprising (i) family planning (ii) focused antenatal care (iii) clean and safe delivery and (iv) basic and comprehensive emergency obstetric & neonatal care. Existing curriculum has 15 newborn topics taught in lecture style during the pediatric rotations, and five newborn care skills to be learned through observation. The existing curriculum is silent on desired competencies. In the current study 19 cognitive areas, 17 psychomotor skills and six competency domains were identified for an ideal neonatal curriculum for undergraduate students. A combination of teaching strategies including classroom, simulation and a clinical rotation were recommended. CONCLUSION: This study revealed a significant gap between the existing neonatal curriculum and the ideal curriculum as recommended by broad stakeholders in the context of national health care needs. Next steps are to complete the development and implementation of the proposed curriculum map to better align with the ideal state.

The SGIM TEACH Program: A Curriculum for Teachers of Clinical Medicine.

BACKGROUND: Demand for faculty with teaching expertise is increasing as medical education is becoming well established as a career pathway. Junior faculty may be expected to take on teaching responsibilities with minimal training in teaching skills. AIM: To address the faculty development needs of junior clinician-educators with teaching responsibilities and those changing their career focus to include teaching. SETTING: Sessions at two Society of General Internal Medicine (SGIM) annual meetings combined with local coaching and online learning during the intervening year. PARTICIPANTS: Eighty-nine faculty scholars in four consecutive annual cohorts from 2013 to 2016. PROGRAM DESCRIPTION: Scholars participate in a full-day core teaching course as well as selective workshops at the annual meetings. Between meetings they receive direct observation and feedback on their teaching from a local coach and participate in an online discussion group. PROGRAM EVALUATION: Sessions were evaluated using a post-session survey. Overall content rating was 4.48 (out of 5). Eighty-nine percent of participants completed all requirements. Of these, 100% agreed that they had gained valuable knowledge and skills. DISCUSSION: The TEACH certificate program provides inexperienced faculty teachers an opportunity to develop core skills. Satisfaction is high. Future research should focus on the impact that this and similar programs have on teaching skills.

Attending rounds: What do the all-star teachers do?

AIM: To examine differences in the types of teaching activities performed during rounds between the most effective and least effective inpatient teaching attendings. METHODS: Participants included 56 attending physicians supervising 279 trainees. Trained observers accompanied teams during rounds and recorded the frequencies of educational activities that occurred. Students and residents then rated their satisfaction with the teaching on rounds. RESULTS: Attending physicians with the highest learner satisfaction scores performed significantly more teaching activities per patient than attending physicians who were rated as average or less-effective (2.1 vs. 1.4 vs. 1.5; p = .03). There were significant differences in the frequencies of 3 out of the 9 specific teaching activities observed, including answering specific patient-care related questions (77% vs. 66% vs. 47%; p = .003), teaching on learner chosen topics (8% vs. 2% vs. 2%; p = .02), and providing feedback (31% vs. 10% vs. 0.1%; p = .001). CONCLUSIONS: Specific categories of teaching activities-patient-specific teaching, teaching on learner-identified topics, and providing real-time feedback-are performed more frequently by the highest-rated attending physicians, which can guide faculty development.

Methods and outcomes for the remediation of clinical reasoning.

INTRODUCTION: There is no widely accepted structured, evidence based strategy for the remediation of clinical reasoning skills. AIM: To assess the effectiveness of a standardized clinical reasoning remediation plan for medical learners at various stages of training. SETTING: Learners enrolled in the University of Colorado School of Medicine Remediation Program. PROGRAM DESCRIPTION: From 2006 to 2012, the learner remediation program received 151 referrals. Referrals were made by medical student clerkship directors, residency and fellowship program directors, and through self-referrals. Each learner's deficiencies were identified using a standardized assessment process; 53 were noted to have clinical reasoning deficits. The authors developed and implemented a ten-step clinical reasoning remediation plan for each of these individuals, whose subsequent performance was independently assessed by unbiased faculty and senior trainees. Participant demographics, faculty time invested, and learner outcomes were tracked. PROGRAM EVALUATION: Prevalence of clinical reasoning deficits did not differ by level of training of the remediating individual (p = 0.49). Overall, the mean amount of faculty time required for remediation was 29.6 h (SD = 29.3), with a median of 18 h (IQR 5-39) and a range of 2-100 h. Fifty-one of the 53 (96%) passed the post remediation reassessment. Thirty-eight (72%) learners either graduated from their original program or continue to practice in good standing. Four (8%) additional residents who were placed on probation and five (9%) who transferred to another program have since graduated. DISCUSSION: The ten-step remediation plan proved to be successful for the majority of learners struggling with clinical reasoning based on reassessment and limited subsequent educational outcomes. Next steps include implementing the program at other institutions to assess generalizability and tracking long-term outcomes on clinical care.

Failure to fail: the institutional perspective.

PURPOSE: To determine institutional barriers to placing failing students on probation, dismissing students. METHODS: An online survey study was distributed to Student Affairs Deans or the equivalent at allopathic (MD) and osteopathic (DO) medical schools, and physician assistant (PA) and nurse practitioner (NP) schools across the United States. Nineteen (40%) of the 48 schools responded: six MD, four DO, five PA and four NP. The survey contained demographic questions and questions regarding probation and dismissal. Themes were independently coded and combined via consensus based on grounded theory. The survey was distributed until saturation of qualitative responses were achieved. RESULTS: Respondents identified variations in the use of probation and dismissal and a wide range of barriers, with the greatest emphasis on legal concerns. Respondents felt that students were graduating who should not be allowed to graduate, and that the likelihood of a student being placed on probation or being terminated was highly variable. DISCUSSION: Our results suggest that institution culture at heath professions schools across the United States may represent an obstacle in placing failing learners on probation and dismissing learners who should not graduate. Additional studies are needed to prove if these concerns are founded or merely fears.

Feasibility and sustainability of an interactive team-based learning method for medical education during a severe faculty shortage in Zimbabwe.

BACKGROUND: In 2010, in the midst of the human immunodeficiency virus (HIV) epidemic in Zimbabwe, 69% of faculty positions in the Department of Medicine of the University of Zimbabwe College of Health Sciences (UZ-CHS) were vacant. To address the ongoing need to train highly skilled HIV clinicians with only a limited number of faculty, we developed and implemented a course for final-year medical students focused on HIV care using team-based learning (TBL) methods. METHODS: A competency-based HIV curriculum was developed and delivered to final-year medical students in 10 TBL sessions as part of a 12 week clinical medicine attachment. A questionnaire was administered to the students after completion of the course to assess their perception of TBL and self-perceived knowledge gained in HIV care. Two cohorts of students completed the survey in separate academic years, 2011 and 2012. Descriptive analysis of survey results was performed. RESULTS: Ninety-six of 120 students (80%) completed surveys. One hundred percent of respondents agreed that TBL was an effective way to learn about HIV and 66% strongly agreed. The majority of respondents agreed that TBL was more stimulating than a lecture course (94%), fostered enthusiasm for the course material (91%), and improved teamwork (96%). Students perceived improvements in knowledge gained across all of the HIV subjects covered, especially in challenging applied clinical topics, such as management of HIV antiretroviral failure (88% with at least a "large improvement") and HIV-tuberculosis co-infection (80% with at least a "large improvement"). CONCLUSIONS: TBL is feasible as part of medical education in an African setting. TBL is a promising way to teach challenging clinical topics in a stimulating and interactive learning environment in a low-income country setting with a high ratio of students to teachers.

Student and Teacher Perspectives on Equity in Clinical Feedback: A Qualitative Study Using a Critical Race Theory Lens.

PURPOSE: The authors aimed to gain a better understanding of students' and teachers' perspectives about whether clinical clerkship feedback is provided equitably irrespective of a student's race/ethnicity. METHOD: A secondary analysis of existing interview data was conducted, focusing on racial/ethnic disparities in clinical grading. Data had been acquired from 29 students and 30 teachers at 3 U.S. medical schools. The authors performed secondary coding on all 59 transcripts, writing memos focused on statements related to aspects of feedback equity and developing a template for coding students' and teachers' observations and descriptions specific to clinical feedback. Using the template, memos were coded, and thematic categories emerged describing perspectives on clinical feedback. RESULTS: Forty-eight (22 teachers and 26 students) participants' transcripts provided narratives about feedback. Both student and teacher narratives described how students who are racially/ethnically underrepresented in medicine may receive less helpful formative clinical feedback needed for professional development. Thematic analysis of narratives yielded 3 themes related to feedback inequities: 1) teachers' racial/ethnic biases influence the feedback they provide students, 2) teachers have limited skill sets to provide equitable feedback, and 3) racial/ethnic inequities in the clinical learning environment shape clinical and feedback experiences. CONCLUSIONS: Narratives indicated that both students and teachers perceived racial/ethnic inequities in clinical feedback. Teacher- and learning environment-related factors influenced these racial/ethnic inequities. These results can inform medical education's efforts to mitigate biases in the learning environment and provide equitable feedback to ensure every student has what they need to develop into the competent physician they aspire to be.

Understanding and Addressing Bias in Grading: Progress at Washington University School of Medicine.

In 2020, the authors published work examining disparities in clerkship grading and found students who identify as White were more likely to receive honors grades compared with students from races/ethnicities traditionally underrepresented in medicine. Through a quality improvement approach, the authors identified the following 6 areas where improvements could mitigate grading disparities and, therefore, put processes in place to: ensure equitable access to examination preparation resources, change student assessment, develop medical student curriculum interventions, improve the learning environment, change house staff and faculty recruitment and retention practices, and provide ongoing program evaluation and continuous quality improvement processes to monitor for success. While the authors cannot yet be sure that they have achieved their goal of promoting equity in grading, they believe this evidence-based, multipronged intervention is a clear step in the right direction and encourage other schools to consider a similar approach to tackling this critically important problem at their own institutions.

Racial/Ethnic Disparities in Clerkship Grading: Perspectives of Students and Teachers.

PURPOSE: Racial/ethnic disparities exist in clinical clerkship grading, yet little is known about medical student and faculty perspectives on why these disparities occur. This study explored what happens during clerkships that might explain grading disparities. METHOD: Medical students and clerkship teachers at 3 U.S. medical schools completed a demographic survey and semistructured interview. The constant comparative method was used to analyze transcripts by inductively developing codes; grouping codes in categories; and refining codes, descriptions, and group assignments to identify themes. Interpretations of and relationships among themes were iteratively discussed to develop a grounded theory. RESULTS: Fifty-nine participants (29 medical students, 30 teachers [28 clinical faculty, 2 residents]) were interviewed in 2020. The Social Milieu of Medical Education (relationships, fit, opportunities, and judgments in the clinical-learning setting) was the organizing theme, influenced by 5 additional themes: Societal Influence (experiences in society), Students' Characteristics and Background (personal characteristics and experiences outside medical school), Assessment Processes (collection of student performance data and how data inform grades), Learning Environment (resources available and messaging within the clinical setting), and Students' Interactions and Reactions (interactions with and reactions to peers and teachers). The grounded theory highlights complex, multilayered aspects of how the social milieu of medical education is shaped by and shapes students' experiences, relationships, and clerkship assessments and promotes clerkship-grading disparities. CONCLUSIONS: Mitigating clerkship-grading disparities will require intervening on interrelated, contextual factors to provide equitable opportunities for students from diverse backgrounds and with varying styles of engagement in clinical-learning settings, along with attending to modifying assessment processes.

Clinical and occupational risk factors for coronavirus disease 2019 (COVID-19) in healthcare personnel.

Objective: To identify characteristics associated with positive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) polymerase chain reaction (PCR) tests in healthcare personnel. Design: Retrospective cohort study. Setting: A multihospital healthcare system. Participants: Employees who reported SARS-CoV-2 exposures and/or symptoms of coronavirus disease 2019 (COVID-19) between March 30, 2020, and September 20, 2020, and were subsequently referred for SARS-CoV-2 PCR testing. Methods: Data from exposure and/or symptom reports were linked to the corresponding SARS-CoV-2 PCR test result. Employee demographic characteristics, occupational characteristics, SARS-CoV-2 exposure history, and symptoms were evaluated as potential risk factors for having a positive SARS-CoV-2 PCR test. Results: Among 6,289 employees who received SARS-CoV-2 PCR testing, 873 (14%) had a positive test. Independent risk factors for a positive PCR included: working in a patient care area (relative risk [RR], 1.82; 95% confidence interval [CI], 1.37-2.40), having a known SARS-CoV-2 exposure (RR, 1.20; 95% CI, 1.04-1.37), reporting a community versus an occupational exposure (RR, 1.87; 95% CI, 1.49-2.34), and having an infected household contact (RR, 2.47; 95% CI, 2.11-2.89). Nearly all HCP (99%) reported symptoms. Symptoms associated with a positive PCR in a multivariable analysis included loss of sense of smell (RR, 2.60; 95% CI, 2.09-3.24) or taste (RR, 1.75; 95% CI, 1.40-2.20), cough (RR, 1.95; 95% CI, 1.40-2.20), fever, and muscle aches. Conclusions: In this cohort of >6,000 healthcare system and academic medical center employees early in the pandemic, community exposures, and particularly household exposures, were associated with greater risk of SARS-CoV-2 infection than occupational exposures. This work highlights the importance of COVID-19 prevention in the community and in healthcare settings to prevent COVID-19.

Patient, resident physician, and visit factors associated with documentation of sexual history in the outpatient setting.

BACKGROUND: Providers need an accurate sexual history for appropriate screening and counseling, but data on the patient, visit, and physician factors associated with sexual history-taking are limited. OBJECTIVES: To assess patient, resident physician, and visit factors associated with documentation of a sexual history at health care maintenance (HCM) visits. DESIGN: Retrospective cross-sectional chart review. PARTICIPANTS: Review of all HCM clinic notes (n = 360) by 26 internal medicine residents from February to August of 2007 at two university-based outpatient clinics. MEASUREMENTS: Documentation of sexual history and patient, resident, and visit factors were abstracted using structured tools. We employed a generalized estimating equations method to control for correlation between patients within residents. We performed multivariate analysis of the factors significantly associated with the outcome of documentation of at least one component of a sexual history. KEY RESULTS: Among 360 charts reviewed, 25% documented at least one component of a sexual history with a mean percent by resident of 23% (SD = 18%). Factors positively associated with documentation were: concern about sexually transmitted infection (referent: no concern; OR = 4.2 [95% CI = 1.3-13.2]); genitourinary or abdominal complaint (referent: no complaint; OR = 4.3 [2.2-8.5]); performance of other HCM (referent: no HCM performed; OR = 3.2 [1.5-7.0]), and birth control use (referent: no birth control; OR = 3.0 [1.1, 7.8]). Factors negatively associated with documentation were: age groups 46-55, 56-65, and >65 (referent: 18-25; ORs = 0.1, 0.1, and 0.2 [0.0-0.6, 0.0-0.4, and 0.1-0.6]), and no specified marital status (referent: married; OR = 0.5 [0.3-0.8]). CONCLUSIONS: Our findings highlight the need for an emphasis on documentation of a sexual history by internal medicine residents during routine HCM visits, especially in older and asymptomatic patients, to ensure adequate screening and counseling.

C-reactive protein testing does not decrease antibiotic use for acute cough illness when compared to a clinical algorithm.

BACKGROUND: Antibiotics are commonly overused in adults seeking emergency department (ED) care for acute cough illness. OBJECTIVE: To evaluate the effect of a point-of-care C-reactive protein (CRP) blood test on antibiotic treatment of acute cough illness in adults. METHODS: A randomized controlled trial was conducted in a single urban ED in the United States. The participants were adults (age ≥ 18 years) seeking care for acute cough illness (≤ 21 days duration); 139 participants were enrolled, and 131 completed the ED visit. Between November 2005 and March 2006, study participants had attached to their medical charts a clinical algorithm with recommendations for chest X-ray study or antibiotic treatment. For CRP-tested patients, recommendations were based on the same algorithm plus the CRP level. RESULTS: There was no difference in antibiotic use between CRP-tested and control participants (37% [95% confidence interval (CI) 29-45%] vs. 31% [95% CI 23-39%], respectively; p = 0.46) or chest X-ray use (52% [95% CI 43-61%] vs. 48% [95% CI 39-57%], respectively; p = 0.67). Among CRP-tested participants, those with normal CRP levels received antibiotics much less frequently than those with indeterminate CRP levels (20% [95% CI 7-33%] vs. 50% [95% CI 32-68%], respectively; p = 0.01). CONCLUSIONS: Point-of-care CRP testing does not seem to provide any additional value beyond a point-of-care clinical decision support for reducing antibiotic use in adults with acute cough illness.

Educational leadership in the time of a pandemic: Lessons from two institutions.

Over the course of a few weeks in March, COVID-19 upended the daily lives of Americans. Academic Medical Centers became a center-point for the response to the virus. Leaders within academic medical centers faced twin challenges of responding to the needs of the patients we serve while managing radical changes within their own institutions, including the educational mission. In this article, we describe some key themes identified and lessons learned as educational leaders during this time. We draw from the experiences of two institutions- one public and one private. These lessons learned fall into the broad categories of leadership decision-making and communication and included the importance of principled decision-making, a connected leadership team, and effective communication both within leadership and to the broader institutional community. The consequences of these responses resulted in a renewed recognition for us as educational leaders of the interdependence of our tripartide academic fates, the importance of academic medical centers as anchor institutions and advocates for our community, and the resilience and ingenuity of our students. We provide examples of these lessons and themes and make recommendations for how to approach educational decision-making in the "new normal" of living with COVID-19 for the immediate future.