Promotion in Place: A Model for Competency-Based, Time-Variable Graduate Medical Education.

PROBLEM: Competency-based medical education is increasingly regarded as a preferred framework for physician training, but implementation is limited. U.S. residency programs remain largely time based, with variable assessments and limited opportunities for individualization. Gaps in graduates' readiness for unsupervised care have been noted across specialties. Logistical barriers and regulatory requirements constrain movement toward competency-based, time-variable (CBTV) graduate medical education (GME), despite its theoretical benefits. APPROACH: The authors describe a vision for CBTV-GME and an implementation model that can be applied across specialties. Termed "Promotion in Place" (PIP), the model relies on enhanced assessment, clear criteria for advancement, and flexibility to adjust individuals' responsibilities and time in training based on demonstrated competence. PIP allows a resident's graduation to be advanced or delayed accordingly. Residents deemed competent for early graduation can transition to attending physician status within their training institution and benefit from a period of "sheltered independence" until the standard graduation date. Residents who need extended time to achieve competency have graduation delayed to incorporate additional targeted education. OUTCOMES: A proposal to pilot the PIP model of CBTV-GME received funding through the American Medical Association's "Reimagining Residency" initiative in 2019. Ten of 46 residency programs in a multihospital system expressed interest and pursued initial planning. Seven programs withdrew for reasons including program director transitions, uncertainty about resident reactions, and the COVID-19 pandemic. Three programs petitioned their specialty boards for exemptions from time-based training. One program was granted the needed exemption and launched a PIP pilot, now in year 4, demonstrating the feasibility of implementing this model. Implementation tools and templates are described. NEXT STEPS: Larger-scale implementation with longer-term assessment is needed to evaluate the impact and generalizability of this CBTV-GME model.

A two-year experience of an integrated simulation residency curriculum.

BACKGROUND: Human Patient Simulation (HPS) is increasingly used in medical education, but its role in Emergency Medicine (EM) residency education is uncertain. STUDY OBJECTIVES: The objective of this study was to evaluate the perceived effectiveness of HPS when fully integrated into an EM residency didactic curriculum. METHODS: The study design was a cross-sectional survey performed in 2006, 2 years after the implementation of an integrated simulation curriculum. Fifty-four residents (postgraduate year [PGY] 1-4) of a 4-year EM residency were surveyed with demographic and curricular questions on the perceived value of simulation relative to other teaching formats. Survey items were rated on a bipolar linear numeric scale of 1 (strongly disagree) to 9 (strongly agree), with 5 being neutral. Data were analyzed using Student t-tests. RESULTS: Forty residents responded to the survey (74% response rate). The perceived effectiveness of HPS was higher for junior residents than senior residents (8.0 vs. 6.2, respectively, p<0.001). There were no differences in perceived effectiveness of lectures (7.8 vs. 7.9, respectively, p=0.1), morbidity and mortality conference (8.5 vs. 8.7, respectively, p=0.3), and trauma conference (8.4 vs. 8.8, respectively, p=0.2) between junior and senior residents. Scores for perceptions of improvement in residency training (knowledge acquisition and clinical decision-making) after the integration of HPS into the curriculum were positive for all residents. CONCLUSION: Residents' perceptions of HPS integration into an EM residency curriculum are positive for both improving knowledge acquisition and learning clinical decision-making. HPS was rated as more effective during junior years than senior years, while the perceived efficacy of more traditional educational modalities remained constant throughout residency training.

Plagiarism in residency application essays.

BACKGROUND: Anecdotal reports suggest that some residency application essays contain plagiarized content. OBJECTIVE: To determine the prevalence of plagiarism in a large cohort of residency application essays. DESIGN: Retrospective cohort study. SETTING: 4975 application essays submitted to residency programs at a single large academic medical center between 1 September 2005 and 22 March 2007. MEASUREMENTS: Specialized software was used to compare residency application essays with a database of Internet pages, published works, and previously submitted essays and the percentage of the submission matching another source was calculated. A match of more than 10% to an existing work was defined as evidence of plagiarism. RESULTS: Evidence of plagiarism was found in 5.2% (95% CI, 4.6% to 5.9%) of essays. The essays of non-U.S. citizens were more likely to demonstrate evidence of plagiarism. Other characteristics associated with the prevalence of plagiarism included medical school location outside the United States and Canada; previous residency or fellowship; lack of research experience, volunteer experience, or publications; a low United States Medical Licensing Examination Step 1 score; and non-membership in the Alpha Omega Alpha Honor Medical Society. LIMITATIONS: The software database is probably incomplete, the 10%-match threshold for defining plagiarism has not been statistically validated, and the study was confined to applicants to 1 institution. Evidence of matching content in an essay cannot be used to infer the applicant's intent and is not sensitive to variations in the cultural context of copying in some societies. CONCLUSION: Evidence of plagiarism in residency application essays is more common in international applicants but was found in those by applicants to all specialty programs, from all medical school types, and even among applicants with significant academic honors. PRIMARY FUNDING SOURCE: No external funding.

Back to the bedside: the 8-year evolution of a resident-as-teacher rotation.

BACKGROUND: Teaching our residents to teach is a vital responsibility of Emergency Medicine (EM) residency programs. As emergency department (ED) overcrowding may limit the ability of attending physicians to provide bedside instruction, senior residents are increasingly asked to assume this role for more junior trainees. Unfortunately, a recent survey suggests that only 55% of all residencies provide instruction in effective teaching methods. Without modeling from attending physicians, many residents struggle with this responsibility. OBJECTIVES: We introduced a "Resident-as-Teacher" curriculum in 2002 as a means to address a decline in bedside instruction and provide our senior residents with a background in effective teaching methods. DISCUSSION: Here, we describe the evolution of this resident-as-teacher rotation, outline its current structure, cite potential pitfalls and solutions, and discuss the unique addition of a teach-the-teacher curriculum. CONCLUSION: A resident-as-teacher rotation has evolved into a meaningful addition to our senior residents' training, fostering their growth as educators and addressing our need for bedside instruction.

Doctors in acute and longitudinal care specialties emphasise different professional attributes: implications for training programmes.

OBJECTIVES: Organised medicine mandates that professionalism be taught during specialty training. This study's primary objective was to determine the relative importance that doctors in different specialties place on different attributes of a medical professional. METHODS: Attending staff and resident doctors in acute care (anaesthesia, emergency medicine, surgery) and longitudinal care (internal medicine, psychiatry) specialties at a large academic hospital completed an anonymous, web-based survey. The forced-choice format required respondents to narrow down 25 professional attributes to three. The main outcome measure was the number of doctors in the two specialty groups who chose one or more attributes in each of six underlying categories. RESULTS: Almost two-thirds of respondents in both groups chose Moral and Ethical attributes. Significantly more longitudinal than acute care doctors chose Relationships with Patients attributes (76% versus 58%) and Communication Skills attributes (28% versus 18%), whereas significantly more acute care doctors chose Clinical Competence attributes (44% versus 29%). Specialty group was more important in choice of professional attributes than gender or position as a resident or attending staff doctor. CONCLUSIONS: Most respondents chose attributes that the literature and organised medicine define as core elements of medical professionalism. The differences between specialty groups suggest that attributes in the Relationships with Patients and Communication Skills categories be emphasised for trainees in acute care specialties, and attributes in the Clinical Competence category be emphasised for trainees in longitudinal care specialties.

Anonymity Decreases the Punitive Nature of a Departmental Morbidity and Mortality Conference.

OBJECTIVES: We sought to analyze the effect of an anonymous morbidity and mortality (M&M) conference on participants' attitudes toward the educational and punitive nature of the conference. We theorized that an anonymous conference might be more educational, less punitive, and would shift analysis of cases toward systems-based analysis and away from individual cognitive errors. METHODS: We implemented an anonymous M&M conference at an academic emergency medicine program. Using a pre-post design, we assessed attitudes toward the educational and punitive nature of the conference as well as the perceived focus on systems versus individual errors analyzed during the conference. Means and standard deviations were compared using a paired t test. RESULTS: Fifteen conferences were held during the study period and 53 cases were presented. Sixty percent of eligible participants (n = 38) completed both the pretest and posttest assessments. There was no difference in the perceived educational value of the conference (4.42 versus 4.37, P = 0.661), but the conference was perceived to be less punitive (2.08 versus 1.76, P = 0.017). There was no difference between the perceived focus of the conference on systems (2.76 versus 2.76, P = 1.00) versus individual (4.21 versus 4.16, P = 0.644) errors. Most participants (59.5%) preferred that the conference remain anonymous. CONCLUSIONS: We assessed the effect of anonymity in our departmental M&M conference for a 7-month period and found no difference in the perceived effect of M&M on the educational nature of the conference but found a small improvement in the punitive nature of the conference.

A comprehensive medical simulation education curriculum for emergency medicine residents.

Medical simulation allows trainees to experience realistic patient situations without exposing patients to the risks inherent in trainee learning and is adaptable to situations involving widely varying clinical content. Although medical simulation is becoming more widely used in medical education, it is typically used as a complement to existing educational strategies. Our approach, which involved a complete curriculum redesign to create a fully integrated medical simulation model with an "all at once" implementation, represents a significant departure from conventional graduate medical education models. We applied adult learning principles, medical simulation learning theory, and standardized national curriculum requirements to create an innovative set of simulation-based modules for integration into our emergency medicine residency curriculum. Here we describe the development of our simulation modules using various simulation technologies, their implementation, and our experiences during the first year of integration.

A National Cross-Sectional Study of Surgery Residents Who Underreport Duty Hours.

OBJECTIVE: Previous work demonstrates that many surgery residents underreport duty hours. The purpose of this study was to identify characteristics of these residents and better understand why they exceed duty hours. DESIGN: During the winter of 2015 we conducted an anonymous cross-sectional survey of Accreditation Council for Graduate Medical Education accredited general surgery programs. SETTING: A total of 101 general surgery residency programs across the United States. PARTICIPANTS: A total of 1003 general surgery residents across the United States. Respondents' mean age was 29.9 ± 3.0 years; 53% were male. RESULTS: Study response rate was 31.9%. Residents age <30 were more likely to exceed duty hours to complete charting/documentation (68% vs. 54%, p < 0.001). Females more often cited guilt about leaving the hospital (32% vs. 24%, p = 0.014) as to why they exceed duty hours. Programs with >40 residents had the highest rates of underreporting (82% vs. 67% in other groups p < 0.001) and residents who worked >90 hours on an average week more frequently cited external pressure (p = 0.0001), guilt (p = 0.006), and feeling it was expected of them (p < 0.0001) as reasons why they underreport compared to those who worked fewer hours. CONCLUSIONS: Underreporting and duty-hour violations are a complex issue influenced by many variables including age, sex, and internal and external pressures.

A novel mentorship programme for residents integrating academic development, clinical teaching and graduate medical education assessment.

INTRODUCTION: Mentorship fosters career development and growth. During residency training, mentorship should support clinical development along with intellectual and academic interests. Reported resident mentoring programmes do not typically include clinical components. We designed a programme that combines academic development with clinical feedback and assessment in a four-year emergency medicine residency programme. METHODS: Incoming interns were assigned an advisor. At the conclusion of the intern year, residents actively participated in selecting a mentor for the duration of residency. The programme consisted of quarterly meetings, direct clinical observation and specific competency assessment, assistance with lecture preparation, real-time feedback on presentations, simulation coaching sessions, and discussions related to career development. Faculty participation was recognized as a valuable component of the annual review process. Residents were surveyed about the overall programme and individual components. RESULTS: Over 88 % of the respondents said that the programme was valuable and should be continued. Senior residents most valued the quarterly meetings and presentation help and feedback. Junior residents strongly valued the clinical observation and simulation sessions. CONCLUSIONS: A comprehensive mentorship programme integrating clinical, professional and academic development provides residents individualized feedback and coaching and is valued by trainees. Individualized assessment of clinical competencies can be conducted through such a programme.