Are All Teaching Activities Valued the Same? Their Relative Worth Is in the Eye of the Beholder.

OBJECTIVES: The pressures for generating revenue from clinical activities dissuade clinician-educators from teaching; taking the steps to develop an educational value system is a way to recognize and perhaps support education. We compared the perceived educational value of diverse pedagogical activities during clinical training from students, residents, and faculty in medical and surgical specialties. METHODS: Between 2016 and 2017, a survey among medical students, residents, and faculty from medical (internal medicine, pediatrics) or surgical (general surgery, obstetrics and gynecology) departments was conducted at an academic medical center that sponsors 88 training programs. Participants ranked teaching activities relative to their perceived teaching importance. RESULTS: In total, 156 subjects participated (48 core teaching faculty, 68 residents, and 40 medical students). Teaching in the wards was the highest-ranked teaching activity for medical (mean 1.6) and surgical specialties (mean 1.9). For medicine and pediatrics, active teaching activities were ranked higher (mean 2.9, 95% confidence interval [CI] 2.8-3.0) than passive teaching activities (mean 5.3, 95% CI 5.1-5.5, P < 0.001). Similarly, for surgery and obstetrics and gynecology, active teaching activities were ranked higher (mean 3.6, 95% CI 3.3-3.9) than passive teaching activities (mean 5.2, 95% CI 4.8-5.5, P < 0.001). CONCLUSIONS: Medical students, residents, and faculty across specialties have a high degree of agreement regarding the ranking of diverse pedagogical activities; such correlation will facilitate the interpretation of educational value units across specialties.

The Privilege of Being a Physician and the Immutable Values of the Medical Profession.

The medical profession has been, is, and will continue to be under siege by a variety of sources most of which are external to the profession and not under our control. The consequences of this unrelenting pressure are leading to burnout, early retirement, and low career satisfaction. Arguably, these and perhaps other not-well-recognized factors has influenced the well-being of physicians and culminated in a high suicide rate in the profession. However, the pressures that our profession have been under over the last 2,500 years, albeit less pronounced than the current ones, have been successfully navigated by going back to the foundational values of medicine that are both intemporal and immutable. We should stand by these principles and defend the description of the Ideal Internist; these principles should guide how health care is delivered as they are rooted in the fiduciary commitment our profession has made to society since the Hippocratic Oath was written.

Connecting the dots: like watching a movie critically.

Acquisition of expertise in the diagnosis and management of patients requires years of practice; exposure to diverse clinical entities is critical as well as the myriad ways in which the same disease can present in a given patient. However, this repeated exposure has to be accompanied by two critical elements; first, the novice needs the guidance of an expert or master to appreciate the nuances and subtleties in making a diagnosis or taking a course of action. Second, and perhaps most importantly, the physician needs to acquire the habit of reflecting on and in actions during the clinical encounter. Unguided repetition during formative years or lack of critical introspection during practice hinders the progression to expertise. In a way, a complex clinical encounter is akin to watching a complex movie; it takes repeated exposure to the movie to understand the subtleties the director is utilizing to understand the plot in its entirety.

Using cognitive mapping to define key domains for successful attending rounds.

BACKGROUND: Ward attending rounds are an integral part of internal medicine education. Being a good teacher is necessary, but not sufficient for successful rounds. Understanding perceptions of successful attending rounds (AR) may help define key areas of focus for enhancing learning, teaching and patient care. OBJECTIVE: We sought to expand the conceptual framework of 30 previously identified attributes contributing to successful AR by: 1) identifying the most important attributes, 2) grouping similar attributes, and 3) creating a cognitive map to define dimensions and domains contributing to successful rounds. DESIGN: Multi-institutional, cross-sectional study design. PARTICIPANTS: We recruited residents and medical students from a university-based internal medicine residency program and a community-based family medicine residency program. Faculty attending a regional general medicine conference, affiliated with multiple institutions, also participated. MAIN MEASURES: Participants performed an unforced card-sorting exercise, grouping attributes based on perceived similarity, then rated the importance of attributes on a 5-point Likert scale. We translated our data into a cognitive map through multi-dimensional scaling and hierarchical cluster analysis. KEY RESULTS: Thirty-six faculty, 49 residents and 40 students participated. The highest rated attributes (mean rating) were "Teach by example (bedside manner)" (4.50), "Sharing of attending's thought processes" (4.46), "Be approachable-not intimidating" (4.45), "Insist on respect for all team members" (4.43), "Conduct rounds in an organized, efficient & timely fashion" (4.39), and "State expectations for residents/students" (4.37). Attributes were plotted on a two-dimensional cognitive map, and adequate convergence was achieved. We identified five distinct domains of related attributes: 1) Learning Atmosphere, 2) Clinical Teaching, 3) Teaching Style, 4) Communicating Expectations, and 5) Team Management. CONCLUSIONS: We identified five domains of related attributes essential to the success of ward attending rounds.

The activities and responsibilities of the vice chair for education in U.S. and Canadian departments of medicine.

PURPOSE: A profile of the activities and responsibilities of vice chairs for education is notably absent from the medical education literature. The authors sought to determine the demographics, roles and responsibilities, and major priorities and challenges faced by vice chairs for education. METHOD: In 2010, the authors sent a confidential, Web-based survey to all 82 identified department of medicine vice chairs for education in the United States and Canada. The authors inquired about demographics, roles, expectations of and for their position, opinions on the responsibilities outlined for their position, metrics used to evaluate their success, top priorities, and job descriptions. Analysis included creating descriptive statistics and categorizing the qualitative comments. RESULTS: Fifty-nine vice chairs for education (72%) responded. At the time of appointment, only 6 (10%) were given a job description, and only 17 (28%) had a defined job description and metrics used to evaluate their success. Only 20 (33%) had any formal budget management training, and 23 (38%) controlled an education budget. Five themes emerged regarding the responsibilities and goals of the vice chair for education: oversee educational programs; possess educational expertise; promote educational scholarship; serve in leadership activities; and, disturbingly, respondents found expectations to be vague and ill defined. CONCLUSIONS: Vice chairs for education are departmental leaders. The authors' findings and recommendations can serve as a beginning for defining educational directions and resources, building consensus, and designing an appropriate educational infrastructure for departments of medicine.

Use of ecological momentary assessment to determine which structural factors impact perceived teaching quality of attending rounds.

INTRODUCTION: Providing high-quality teaching to residents during attending rounds is challenging. Reasons include structural factors that affect rounds, which are beyond the attending's teaching style and control. OBJECTIVE: To develop a new evaluation tool to identify the structural components of ward rounds that most affect teaching quality in an internal medicine (IM) residency program. METHODS: The authors developed a 10-item Ecological Momentary Assessment (EMA) tool and collected daily evaluations for 18 months from IM residents rotating on inpatient services. Residents ranked the quality of teaching on rounds that day, and questions related to their service (general medicine, medical intensive care unit, and subspecialty services), patient census, absenteeism of team members, call status, and number of teaching methods used by the attending. RESULTS: Residents completed 488 evaluation cards over 18 months. This found no association between perceived teaching quality and training level, team absenteeism, and call status. We observed differences by service (P < .001) and patient census (P  =  .009). After adjusting for type of service, census was no longer significant. Use of a larger variety of teaching methods was associated with higher perceived teaching quality, regardless of service or census (P for trend < .001). CONCLUSIONS: The EMA tool successfully identified that higher patient census was associated with lower perceived teaching quality, but the results were also influenced by the type of teaching service. We found that, regardless of census or teaching service, attendings can improve their teaching by diversifying the number of methods used in daily rounds.

Evidence-based medicine training in a resource-poor country, the importance of leveraging personal and institutional relationships.

RATIONALE, AIMS AND OBJECTIVES: Efforts to implement evidence-based medicine (EBM) training in developing countries are limited. We describe the results of an international effort to improve research capacity in a developing country; we conducted a course aimed at improving basic EBM attitudes and identified challenges. METHOD: Between 2005 and 2009, we conducted an annual 3-day course in Perú consisting of interactive lectures and case-based workshops. We assessed self-reported competence and importance in EBM using a Likert scale (1 = low, 5 = high). RESULTS: Totally 220 clinicians participated. For phase I (2005-2007), self-reported EBM competence increased from a median of 2 to 3 (P < 0.001) and the perceived importance of EBM did not change (median = 5). For phase II (2008-2009), before the course, 8-72% graded their competence very low (score of 1-2). After the course, 67-92% of subjects graded their increase in knowledge very high (score of 4-5). The challenges included limited availability of studies relevant to the local reality written in Spanish, participants' limited time and lack of long-term follow-up on practice change. Informal discussion and written evaluation from participants were universally in agreement that more training in EBM is needed. CONCLUSIONS: In an EBM course in a resource-poor country, the baseline self-reported competence and experience on EBM were low, and the course had measurable improvements of self-reported competence, perceived utility and readiness to incorporate EBM into their practices. Similar to developed countries, translational research and building the research capacity in developing countries is critical for translating best available evidence into practice.

Clinical prediction rule for stratifying risk of pulmonary multidrug-resistant tuberculosis.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB), resistance to at least isoniazid and rifampin, is a worldwide problem. OBJECTIVE: To develop a clinical prediction rule to stratify risk for MDR-TB among patients with pulmonary tuberculosis. METHODS: Derivation and internal validation of the rule among adult patients prospectively recruited from 37 health centers (Perú), either a) presenting with a positive acid-fast bacillus smear, or b) had failed therapy or had a relapse within the first 12 months. RESULTS: Among 964 patients, 82 had MDR-TB (prevalence, 8.5%). Variables included were MDR-TB contact within the family, previous tuberculosis, cavitary radiologic pattern, and abnormal lung exam. The area under the receiver-operating curve (AUROC) was 0.76. Selecting a cut-off score of one or greater resulted in a sensitivity of 72.6%, specificity of 62.8%, likelihood ratio (LR) positive of 1.95, and LR negative of 0.44. Similarly, selecting a cut-off score of two or greater resulted in a sensitivity of 60.8%, specificity of 87.5%, LR positive of 4.85, and LR negative of 0.45. Finally, selecting a cut-off score of three or greater resulted in a sensitivity of 45.1%, specificity of 95.3%, LR positive of 9.56, and LR negative of 0.58. CONCLUSION: A simple clinical prediction rule at presentation can stratify risk for MDR-TB. If further validated, the rule could be used for management decisions in resource-limited areas.

The importance of measuring competency-based outcomes: standard evaluation measures are not surrogates for clinical performance of internal medicine residents.

BACKGROUND: Despite recent emphasis on educational outcomes, program directors still rely on standard evaluation techniques such as tests of knowledge and subjective ratings. PURPOSES: To assess the correlation of standard internal medicine (IM) residency evaluation scores (attending global evaluations, In-Training examination, and Mini-Clinical Examination Exercise) with documented performance of preventive measures for continuity clinic patients. METHODS: Cross-sectional study of 132 IM residents attending an IM teaching clinic, July 2000 to June 2003, comparing standard evaluations with chart audit. RESULTS: Mean resident performance ranged from 53% (SD = 24) through 89% (SD = 20) across the 6 preventive measures abstracted from 1,102 patient charts. We found weak and mostly not significant correlations between standard measures and performance of preventive services. CONCLUSIONS: Standard measures are not adequate surrogates for measuring clinical outcomes. This supports the Accreditation Council for Graduate Medical Education's recommendations to incorporate novel Toolbox measures, like chart audit, into residency evaluations.

Can residents accurately abstract their own charts?

PURPOSE: To assess the accuracy of residents' record review, using trained abstractors as a gold standard comparison. METHOD: In 2005, the authors asked 74 residents to review their own charts (n = 392) after they received brief instruction on both how to locate data on the medical record and how to use a data abstraction form. Trained abstractors then re-reviewed these charts to assess performance of preventive health care measures in medicine (smoking screening, smoking cessation advice, mammography, colon cancer screening, lipid screening, and pneumonia vaccination) and pediatrics (parent smoking screening, parent smoking cessation advice, car seat safety, car restraint use, eye alignment, and immunizations up to date). The authors then quantified agreement between the two record reviews and assessed the sensitivity and specificity of the residents versus the trained abstractors. RESULTS: Overall resident-measured performance was similar (within 5%) to that of the trained abstractor for five of six measures in medicine and four of six in pediatrics. For the various measures, sensitivity of resident-measured performance ranged from 100% to 15% and specificity from 100% to 33% compared with the trained abstractors. Relative to the trained abstractor record review, residents did not overestimate their performance. Most residents' (81%) relative performance rankings did not change when the basis for the ranking was resident measured versus trained abstractor measured. CONCLUSIONS: Residents' self-abstraction can be an alternative to costly trained abstractors. Appropriate use of these data should be carefully considered, acknowledging the limitations.

Scholarship opportunities for trainees and clinician educators: learning outcomes from a case report writing workshop.

INTRODUCTION: Publishing a case report demonstrates scholarly productivity for trainees and clinician-educators. AIM: To assess the learning outcomes from a case report writing workshop. SETTING: Medical students, residents, fellows and clinician-educators attending a workshop. PROGRAM DESCRIPTION: Case report writing workshop conducted nine times at different venues. PROGRAM EVALUATION: Before and after each workshop, participants self-rated their perceived competence to write a case report, likelihood of submitting a case report to a meeting or for publication in the next 6-12 months, and perceived career benefit of writing a case report (on a five-point Likert scale). The 214 participants were from 3 countries and 27 states or provinces; most participants were trainees (64.5 %). Self-rated competence for writing a case report improved from a mean of 2.5 to 3.5 (a 0.99 increase; 95% CI, 0.88-1.12, p < 0.001). The perceived likelihood of submitting a case report, and the perceived career benefit of writing one, also showed statistically significant improvements (p = 0.002, p = 0.001; respectively). Nine of 98 participants published a case report 16-41 months after workshop completion. DISCUSSION: The workshop increased participants' perception that they could present or publish a case report.

Internal medicine training in the 21st century.

Many are calling for changes for internal medicine training, arguing that changes in the practice environment mandate changes in how the internal medicine residency is structured. Residency could be shorter, more conducive to role differentiation among general internists, and more supportive of subspecialization. Training could provide more experience in ambulatory care, multidisciplinary team-based care, chronic disease management, and quality improvement. The authors contend that the claim that internal medicine training ought to mirror internal medicine practice is mistaken. Many changes now proposed would likely damage if not destroy the consultant-generalist ideal of traditional internal medicine training which remains critical to effective medical care in the 21st century. The authors propose a model for training similar in structure but different in spirit from contending models. This model, like others, would involve a core experience in the first two years with tracking in the final year; unlike others, it would provide a conceptually coherent experience based on internal medicine's traditional ideal. Outpatient experience would be subsidiary to a predominantly inpatient experience, and it would be structured in blocks rather than continuity clinics. Twenty-first-century internists will continue to face what has always been the internist's task: the resolution of complex and ill-defined patient problems into proper diagnoses and therapeutic options. Contemporary internal medicine training must fit trainees for that task and must, thus, continue to offer the training experience necessary for the realization of the Oslerian ideal: a substantial apprenticeship taking care of inpatients with a wide range of medical illnesses.

A pilot study using nominal group technique to assess residents' perceptions of successful attending rounds.

BACKGROUND: Ward attending rounds are fundamental for internal medicine residency training. An improved understanding of interns' and residents' perceptions of attending rounds should inform training programs and attending physicians. OBJECTIVES: The aim of this study was to assess residents' perceptions of successful attending rounds. DESIGN: We convened two groups of interns and two groups of residents, to elicit their perceptions on attending rounds. SUBJECTS: Participants were recruited by e-mail and conference announcements from the 49 interns and 80 residents in the internal medicine and medicine-pediatrics residency programs. MEASUREMENTS: The nominal group technique (NGT) uses a structured group process to elicit and prioritize answers to a carefully articulated question. MAIN RESULTS: Seven interns (14%) identified 27 success factors and ranked attending approachability and enthusiasm and high quality teaching as most important. A second group of six (12%) interns identified 40 detractors and ranked having "mean attendings," receiving disrespectful comments, and too long or too short rounds as the most significant detractors. Nine (11%) residents identified 32 success factors and ranked attention to length of rounds, house staff autonomy, and establishing goals/expectations as the most important success factors. A second group of six (8%) residents identified 34 detractors and ranked very long rounds, interruptions and time constraints, and poor rapport between team members as the most significant detractors). CONCLUSIONS: Although there was some overlap in interns' and residents' perceptions of attending rounds, interns identified interpersonal factors as the most important factors; whereas residents viewed structural factors as most important. These findings should assist attending physicians improve the way they conduct rounds targeting both interns and residents needs.

Taking apart the art: the risk of anatomizing clinical competence.

The Accreditation Council for Graduate Medical Education (ACGME) is encouraging medical residency programs to objectively assess their trainees for possession of six general clinical competencies by the completion of residency training. This is the thrust of the ACGME Outcome Project, now in its seventh year. As residency programs seek to integrate the general competencies into clinical training, educators have begun to suggest that objective assessment of clinical competence may be able to guide decisions about length of training and timing of subspecialization. The authors contend that higher-level competence is not amenable to assessment by the objective comparison of resident performance with learning objectives, even if such objectives are derived from general competencies. Present-day attempts at such assessment echo the uses to which medical schools hoped to put curricular learning objectives in the 1970s. Objective assessment may capture knowledge and skills that amount to the "building blocks" of competence, but it cannot elucidate or scrutinize higher-level clinical competence. Higher-level competence involves sensitivity to clinical context and can be validly appraised only in such a context by fully competent clinical appraisers. Such assessment is necessarily subjective, but it need not be unreproducible if raters are trained and if sampling of trainee performance is sufficiently extensive. If the ACGME approach to clinical competency is indeed brought to bear on decisions about training length and subspecialization timing, the present apprenticeship model for clinical training in the United States, a model both remarkably successful and directly descendant from Osler's innovations, will be under threat.

Does residency training improve performance of physical examination skills?

BACKGROUND: Few studies use objective structured clinical examinations (OSCEs) to measure physical examination skills of internal medicine residents. Little is known about performance by year of residency training. PURPOSE: To determine differences between postgraduate year (PGY)-1 and PGY-3 residents on performance and comfort of physical examination skills. METHODS: In a cross-sectional study, we tested 16 PGY-1 (weeks 0 and 4) and 8 PGY-3 internal medicine residents with a five-station OSCE. RESULTS: PGY-3 residents performed better than PGY-1 week 0 residents (P = 0.03) but not PGY-1 week 4 residents (P = 0.42). PGY-1 resident performance improved after 1 month of inpatient wards experience (P < 0.001). PGY-3 residents had higher comfort compared to PGY-1 week 0 residents (P = 0.003) but not PGY-1 week 4 residents (P = 0.10). CONCLUSIONS: Senior residents performed better and were more confident on physical examination skills, but the difference disappeared after 1 month of internship. This calls into question how much further learning occurs with physical examination throughout residency training.

Implementing achievable benchmarks in preventive health: a controlled trial in residency education.

PURPOSE: To evaluate the Preventive Health Achievable Benchmarks Curriculum, a multifaceted improvement intervention that included an objective, practice-based performance evaluation of internal medicine and pediatric residents' delivery of preventive services. METHOD: The authors conducted a nonrandomized experiment of intervention versus control group residents with baseline and follow-up of performance audited for 2001-2004. All 130 internal medicine and 78 pediatric residents at two continuity clinics at the University of Alabama School of Medicine, Birmingham, participated. Performance of preventive care was assessed by structured chart review. The multifaceted feedback curriculum included individualized performance feedback, academic detailing by faculty, and collective didactic sessions. The main outcome was difference in receipt of preventive care for patients seen by intervention and control residents, comparing baseline and follow-up. RESULTS: Charts were reviewed for 3,958 patients. Receipt of preventive care increased for patients of intervention residents, but not for patients of control residents. For the intervention group, significant increases occurred for five of six indicators in internal medicine: smoking screening, quit smoking advice, colon cancer screening, pneumonia vaccine, and lipid screening; and four of six in pediatrics: parental quit smoking advice, car seats, car restraints, and eye alignment (p < .05 for all). For control residents, no consistent improvements were seen. There was greater improvement for intervention than for control residents for four of six indicators in internal medicine, and two of six in pediatrics. CONCLUSIONS: Using a multifaceted feedback curriculum, the authors taught residents about the care they provide and improved documented patient care.