More specific feedback: why "confidence" in feedback is too ambiguous.

High quality feedback should be delivered in a timely manner, based on specific direct observation, and formulated to be actionable on the part of the trainee. Utilizing "confidence" as a point of feedback does not meet these criteria given the ambiguity and lack of actionable steps towards improvement. "Confidence"-based feedback makes a judgment about the trainee's internal state leading to potentially gender or culturally biased feedback. There is a risk of emotional harm for trainees when it is integrated into feedback and it is unclear if there is a role for the use of "confidence" in medical education. We are calling for a moratorium on the utilization of the word "confidence" in feedback in medical education until further studies are performed to assess its potential place. At this time, educators should refrain from "confidence"-based feedback and shift the focus towards more specific, actionable, behavioral-based feedback.

Who Benefits Most? A Multisite Study of Coaching and Resident Well-being.

BACKGROUND: Coaching has been shown to improve resident well-being; however, not all benefit equally. OBJECTIVE: Assess predictors of changes in resident physician well-being and burnout in a multisite implementation of a Professional Development Coaching Program. DESIGN: Pre- and post-implementation surveys administered to participant cohorts at implementation sites in their intern year. Effect size was calculated comparing pre- and post-intervention paired data. PARTICIPANTS: In total, 272 residents in their intern year at five internal medicine residency programs (Boston Medical Center, University Hospitals Cleveland Medical Center, Duke University, Emory University, Massachusetts General Hospital). Analyses included 129 residents with paired data. INTERVENTIONS: Interns were paired with a faculty coach trained in positive psychology and coaching skills and asked to meet quarterly with coaches. MAIN MEASURES: Primary outcomes included Maslach Burnout Inventory depersonalization (DP) and emotional exhaustion (EE) subscales, and the PERMA well-being scale. Key predictors included site, demographics, intolerance of uncertainty, hardiness-resilience, gratitude, and coping. Program moderators included were reflection, goal setting, and feedback. KEY RESULTS: Well-being (PERMA) changed from baseline to follow-up in all participants; females showed a decline and males an increase (-1.41 vs. .83, p = 0.04). Self-reflection was associated with positive change in PERMA (mean positive change 1.93, p = 0.009). Burnout (EE) declined in non-Hispanic white residents vs. Black/Asian/Hispanic/other residents (-1.86, p = 0.021). Burnout improved with increased goal setting. CONCLUSION: Coaching programs should consider tailored approaches to support residents whose well-being is impacted by gender and/or race, and who have higher intolerance of uncertainty and lower resilience at baseline. Coaching skills of goal setting and reflection may positively affect interns and teach coping skills.

Morbid obesity: obscuring the diagnosis of aortic stenosis in a patient with cardiogenic wheezing.

We report the case of a morbidly obese 65-year-old female who presented with repeated hypotensive episodes following dialysis. She was misdiagnosed as suffering from asthma, and eventually was found to have severe aortic stenosis. Obesity has become a common and formidable obstacle to gathering important diagnostic information in patients. Modern diagnostic lab tests and imaging modalities such as transthoracic echocardiography (TTE) can provide spurious data in the morbidly obese population, which can ultimately lead to misdiagnosis. In this clinical vignette, we discuss the relationship between the basic pathophysiologic mechanisms underlying aortic stenosis and patient clinical presentation. We also review the relevant literature and discuss the impact of obesity on the diagnosis of this condition.

Faculty development for the 21st century: lessons from the Society of General Internal Medicine-Hartford Collaborative Centers for the Care of Older Adults.

In this review of a recent set of faculty development initiatives to promote geriatrics teaching by general internists, nontraditional strategies to promote sustained change were identified, included enrolling a limited number of "star" faculty, creating ongoing working relationships between faculty, and developing projects for clinical or education program improvement. External funding, although limited, garnered administration support and was associated with changes in individual career trajectories. Activities to enfranchise top leadership were felt essential to sustain change. Traditional faculty development programs for clinician educators are periodic, seminar-based interventions to enhance teaching and clinical skills. In 2003/04 the Collaborative Centers for Research and Education in the Care of Older Adults were funded by the John A. Hartford Foundation and administered by the Society of General Internal Medicine. Ten academic medical centers received individual grants of $91,000, with required cost sharing, to develop collaborations between general internists and geriatricians to create sustained change in geriatrics clinical teaching and learning. Through written and structured telephone surveys, activities designed to foster sustainability at funded sites were identified, and the activities and perceived effects of funding at the 10 funded sites were compared with those of the 11 highest-ranking unfunded sites. The experience of the Collaborative Centers supports the conclusion that modest, targeted funding can provide the credibility and legitimacy crucial for clinician educators to allocate time and energy in new directions. Key success factors likely include high intensity and duration, integration into career trajectories, integration into clinical programs, and activities to enfranchise institutional leadership.

Use of Web-based library resources by medical students in community and ambulatory settings.

PURPOSE: The purpose was to evaluate the use of Web-based library resources by third-year medical students. SETTING/PARTICIPANTS/RESOURCES: Third-year medical students (147) in a twelve-week multidisciplinary primary care rotation in community and ambulatory settings. METHODOLOGY: Individual user surveys and log file analysis of Website were used. RESULTS/OUTCOMES: Twenty resource topics were compiled into a Website to provide students with access to electronic library resources from any community-based clerkship location. These resource topics, covering subjects such as hypertension and back pain, linked to curriculum training problems, full-text journal articles, MEDLINE searches, electronic book chapters, and relevant Websites. More than half of the students (69%) accessed the Website on a daily or weekly basis. Over 80% thought the Website was a valuable addition to their clerkship. DISCUSSION/CONCLUSION: Web-based information resources can provide curriculum support to students for whom access to the library is difficult and time consuming.