Questioning Style and Pimping in Clinical Education: A Quantitative Score Derived from a Survey of Internal Medicine Teaching Faculty.

Construct: Pimping is a controversial pedagogical technique in medicine, and there is a tension between pimping being considered as "value adding" in some circumstances versus always unacceptable. Consequently, faculty differ in their attitudes toward pimping, and such differences may be measurable and used to inform future research regarding the impact of pimping on learner outcomes. BACKGROUND: Despite renewed attention in medical education on creating a supportive learning environment, there is a dearth of prior research on pimping. We sought to characterize faculty who are more aggressive in their questioning style (i.e., those with a "pimper" phenotype) from those who are less threatening. APPROACH: This study was conducted between December 2015 and September 2016 at Johns Hopkins University. We created a 13-item questionnaire assessing faculty perceptions on pimping as a pedagogical technique. We surveyed all medicine faculty (n = 150) who had attended on inpatient teaching services at two university-affiliated hospitals over the prior 2 years. Then, using responses to the faculty survey, we developed a numeric "pimping score" designed to characterize faculty into "pimper" (those with scores in the upper quartile of the range) and "nonpimper" phenotypes. RESULTS: The response rate was 84%. Although almost half of the faculty reported that being pimped helped them in their own learning (45%), fewer reported that pimping was effective in their own teaching practice (20%). The pimping score was normally distributed across a range of 13-42, with a mean of 24 and a 75th percentile cutoff of 28 or greater. Younger faculty, male participants, specialists, and those reporting lower quality of life had higher pimping score values, all p < .05. Faculty who openly endorsed favorable views about the educational value of pimping had sevenfold higher odds of being characterized as "pimpers" using our numeric pimping score (p ≤ .001). CONCLUSIONS: The establishment of a quantitative pimping score may have relevance for training programs concerned about the learning environment in clinical settings and may inform future research on the impact of pimping on learning outcomes.

Team deliberate practice in medicine and related domains: a consideration of the issues.

A better understanding of the factors influencing medical team performance and accounting for expert medical team performance should benefit medical practice. Therefore, the aim here is to highlight key issues with using deliberate practice to improve medical team performance, especially given the success of deliberate practice for developing individual expert performance in medicine and other domains. Highlighting these issues will inform the development of training for medical teams. The authors first describe team coordination and its critical role in medical teams. Presented next are the cognitive mechanisms that allow expert performers to accurately interpret the current situation via the creation of an accurate mental "model" of the current situation, known as a situation model. Following this, the authors propose that effective team performance depends at least in part on team members having similar models of the situation, known as a shared situation model. The authors then propose guiding principles for implementing team deliberate practice in medicine and describe how team deliberate practice can be used in an attempt to reduce barriers inherent in medical teams to the development of shared situation models. The paper concludes with considerations of limitations, and future research directions, concerning the implementation of team deliberate practice within medicine.

The Process of Developing an Assessment Checklist for Simulated Infant Respiratory Distress Using a Modified Delphi Method: A Mixed Methods Study.

Introduction Assessing clinical performance, such as managing respiratory distress, in clinical trainees is challenging yet important. Our objective was to describe and evaluate an integrative and iterative approach to developing a checklist measuring simulated clinical performance for infant respiratory distress. Methods We implemented a five-step modified Delphi process with an embedded qualitative component. An implementation period occurred followed by a second qualitative data collection. Validity evidence was collected throughout the process. Results A 19-item assessment checklist was developed for managing infant respiratory distress by medical student learners in a simulation-based setting. The iterative process provided content validity while the qualitative data provided response process validity. Cohen kappa was 0.82 indicating strong rater agreement. The assessment checklist was found to be easy to use and measure what was intended. Conclusion We developed an accurate and reliable assessment checklist for medical student learners in a simulation-based learning setting with high interrater reliability and validity evidence. Given its ease of use, we encourage medical educators and researchers to utilize this method to develop and implement assessment checklists for their interventions.

The teaching effectiveness of standardized patients.

Teaching nursing students therapeutic communication skills begins in the classroom and extends to the clinical environment. The usual method of instruction consists of random patient encounters observed by faculty and measures of competence that rely on paper-and-pencil tests. Using standardized patients (SPs) offers an alternative approach to the traditional method of teaching. Standardized patients are individuals who have been carefully trained to present an illness or scenario in a standardized, unvarying manner. This pilot study compared use of SPs with the usual method of instruction in a class of undergraduate nursing students. Results indicated that students who participated in the SP method overwhelmingly described the experience as positive, creative, and meaningful. No significant differences were found between the two groups on measures of interpersonal skills, therapeutic communication skills, and knowledge of depression

Tracking development of clinical reasoning ability across five medical schools using a progress test.

PURPOSE: Little is known about the acquisition of clinical reasoning skills in medical school, the development of clinical reasoning over the medical curriculum as a whole, and the impact of various curricular methodologies on these skills. This study investigated (1) whether there are differences in clinical reasoning skills between learners at different years of medical school, and (2) whether there are differences in performance between students at schools with various curricular methodologies. METHOD: Students (n = 2,394) who had completed zero to three years of medical school at five U.S. medical schools participated in a cross-sectional study in 2008. Students took the same diagnostic pattern recognition (DPR) and clinical data interpretation (CDI) tests. Percent correct scores were used to determine performance differences. Data from all schools and students at all levels were aggregated for further analysis. RESULTS: Student performance increased substantially as a result of each year of training. Gains in DPR and CDI performance during the third year of medical school were not as great as in previous years across the five schools. CDI performance and performance gains were lower than DPR performance and gains. Performance gains attributable to training at each of the participating medical schools were more similar than different. CONCLUSIONS: Years of training accounted for most of the variation in DPR and CDI performance. As a rule, students at higher training levels performed better on both tests, though the expected larger gains during the third year of medical school did not materialize.

Use of "standardized examinees" to screen for standardized-patient scoring bias in a clinical skills examination.

BACKGROUND: Clinical skills examinations using standardized patients (SPs) are important in documenting the proficiency of trainees. "Standardized examinees" (SEs) are individuals trained to a specific level of performance; they can be used as internal controls in a high-stakes, clinical skills examination. PURPOSE: The purpose of this study was to determine whether SEs can be trained to portray a specified level of confidence and whether SPs' checklist scoring is affected by the personal manner of the examinee. METHODS: Eight SEs were trained as "students" and trained to achieve a failing score on six cases in an National Board of Medical Examiners (NBME) Prototype Clinical Skills Examination. Four SEs were coached to be confident in manner, and 4 were coached to be insecure. Checklist scores were compared. Seven lay reviewers scored the SEs as confident or insecure on a behavioral assessment form. RESULTS: SEs were not detected as simulations. There was no difference between the checklist scores of confident versus insecure SEs, but their manner was rated as significantly different on all scales in the behavioral assessment. CONCLUSIONS: SEs can be trained to a specified performance level and a desired level of confidence. In this small study, personal manner did not affect SPs' checklist scoring. The use of the SEs provides a mechanism to screen for bias in high-stakes SP examinations.

The physician's role in discussing organ donation with families.

Federal Conditions of Participation from the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) introduced in 1998 require that all families be presented the option of organ and tissue donation when death is imminent. The perception that physicians were being excluded from participating in this process led to a resolution at the American Medical Association House of Delegates meeting in December 1999, calling on the American Medical Association Council on Scientific Affairs to review the Conditions of Participation "to ensure that there is no prohibition of physician involvement in the organ donation process..." The number of organs procured for transplantation in the United States is insufficient to meet needs. Families' hospital experiences significantly affect their decisions to donate organs. Discussing severe brain injury, brain death, and organ donation after brain death with families is a specialized form of end-of-life decision-making and care in the intensive care unit; however, the knowledge, skills, and attitudes necessary for physicians and nurses to promote good end-of-life decision-making are widely variable. The federal Conditions of Participation require that those making requests of families for organ donation receive specific training. They do not prohibit physician involvement in initiating organ donation requests, provided these individuals are properly trained. Physicians have an important role in caring for patients and families in these circumstances, and the care they provide is enhanced through training, attention to the special issues involved, and collaboration with organ procurement organization personnel.