The Variables That Lead to Severe Action Decisions by the Liaison Committee on Medical Education.

PURPOSE: To identify the variables associated with severe action decisions (SADs) (unspecified accreditation term, warning status, probation status) by the Liaison Committee on Medical Education (LCME) regarding the accreditation status of established MD-granting medical education programs in the United States and Canada. METHOD: The authors reviewed all LCME decisions made on full survey reports between October 2004 and June 2012 to test whether SADs were associated with an insufficient response in the data collection instrument/self-study, chronic noncompliance with one or more accreditation standards, noncompliance with specific standards, and noncompliance with a large number of standards. RESULTS: The LCME issued 103 nonsevere action decisions and 40 SADs. SADs were significantly associated with an insufficient response in the data collection instrument/self-study (odds ratio [OR] = 7.30; 95% confidence interval [CI] = 2.38-22.46); chronic noncompliance with one or more standards (OR = 12.18; 95% CI = 1.91-77.55); noncompliance with standards related to the educational program for the MD degree (ED): ED-8 (OR = 6.73; 95% CI = 2.32-19.47) and ED-33 (OR = 5.40; 95% CI = 1.98-14.76); and noncompliance with a large number of standards (rpb = 0.62; P < .001). CONCLUSIONS: These findings provide insight into the LCME's pattern of decision making. Noncompliance with two standards was strongly associated with SADs: lack of evidence of comparability across instructional sites (ED-8) and the absence of strong central management of the curriculum (ED-33). These results can help medical school staff as they prepare for an LCME full survey visit.

Application essays and future performance in medical school: are they related?

BACKGROUND: There is a paucity of research on whether application essays are a valid indicator of medical students' future performance. PURPOSE: The goal is to score medical school application essays systematically and examine the correlations between these essay scores and several indicators of student performance during medical school and internship. METHODS: A journalist created a scoring rubric based on the journalism literature and scored 2 required essays of students admitted to our university in 1 year (N = 145). We picked 7 indicators of medical school and internship performance and correlated these measures with overall essay scores: preclinical medical school grade point average (GPA), clinical medical school GPA, cumulative medical school GPA, U.S. Medical Licensing Exam (USMLE) Step 1 and 2 scores, and scores on a program director's evaluation measuring intern professionalism and expertise. We then examined the Pearson and Spearman correlations between essay scores and the outcomes. RESULTS: Essay scores did not vary widely. American Medical College Application Service essay scores ranged from 3.3 to 4.5 (M = 4.11, SD = 0.15), and Uniformed Services University of the Health Sciences essay scores ranged from 2.9 to 4.5 (M = 4.09, SD = 0.17). None of the medical school or internship performance indicators was significantly correlated with the essay scores. CONCLUSIONS: These findings raise questions about the utility of matriculation essays, a resource-intensive admission requirement.

Alternate list matriculants: outcome data from those medical students admitted from the alternate list.

BACKGROUND: Medical schools are increasing class size to meet future health care needs for our nation. This may lead to more students being accepted from an alternate list (vs. primary acceptances). Given these trends, performance outcomes were compared for alternate list matriculants and primary acceptances. Our hypothesis was that those students accepted from an alternate list would perform equally to the primary acceptances on these outcomes. METHOD: We compared medical school performance of students who received a primary recommendation of "accept" and compared them to those who received a recommendation of "alternate" over a 10-year period. Given the small sample size of this alternate list group (N = 23), descriptive statistics are reported. RESULTS: No consistent differences between alternate and primary acceptance matriculants in terms of cumulative medical school grade point average, United States Medical Licensing Examination (USMLE) Step 1 scores and USMLE Step 2 Clinical Knowledge scores were found. Only three alternates (13.0%) were presented to student promotion committee compared to 17.2% for matriculants who were primary acceptances. Three alternates were required to repeat a year (average percentage of 8.7%) compared to 5.6% of matriculants who were primary acceptances. CONCLUSIONS: This observational study provides some reassurance that as long as the qualifications of the applicant pool remain adequate, admissions policies that provide for alternate list acceptances may not produce poorer performing students, at least by our current outcome measures.

Exploring the relationship between self-reported research experience and performance in medical school and internship.

PURPOSE: To investigate the relationship between self-reported research experience and medical students' performance in medical school and internship. METHODS: We collected data from seven year-groups (1993-1999; N = 1,112) and examined 7 performance outcomes: medical school preclinical grade point average (GPA), medical school clinical GPA, cumulative medical school GPA, U.S. Medical Licensing Examination Step 1 and 2 scores, and scores on a previously validated program director's survey of intern professionalism and expertise. We then conducted a series of multiple linear regressions to determine the relations between self-reported research experience and our seven outcomes. RESULTS: When compared to those who reported no prior research experience, students who reported research experience performed significantly better on U.S. Medical Licensing Examination Step 1 and had a higher medical school preclinical GPA. However, these same students scored significantly lower on intern professionalism and expertise ratings. Self-reported research experience did not show statistically significant correlations with the other outcome variables. CONCLUSIONS: The results from our large, multiyear, cohort study suggest that prior research experience may account for some variance in outcomes in the early stages of medical school education, but that variance explained diminishes considerably as trainees progress into the more senior phases of education. On the other hand, prior research experience may be negatively related to students' performance in internship. In all cases, however, effect sizes are small.

40 years of military medical education: an overview of the Long-Term Career Outcome Study (LTCOS).

In 2005, the Long-Term Career Outcome Study (LTCOS) was established by the Dean, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences (USU). The original charge to the LTCOS team was to establish an electronic database of current and past students at USU. Since its inception, however, the LTCOS team has broadened its mission and started collecting and analyzing data on a continuous basis for the purposes of program evaluation and, in some cases, research. The purpose of this commentary is to review the history of the LTCOS, including details about USU, a brief review of prior LTCOS work, and progress made since our last essay on LTCOS efforts. This commentary also provides an introduction to the special issue, which is arranged as a series of articles that span the medical education continuum (i.e., before, during, and after medical school). The relative balance of articles in each phase of training represents the LTCOS team's efforts to address the entire continuum of medical education.

Identifying themes within a medical school admission committee's reviews of applicants.

BACKGROUND: Admissions committees attempt to select the most qualified applicants based on many cognitive and "noncognitive" factors. PURPOSE: Identify common themes cited in the admissions committee member summaries of medical school matriculants and determine the relative frequency and importance of these themes. METHODS: After reviewing a convenience sample of 150 reviewer comments, 14 qualitative themes were identified. Utterances (thematic word strings) from each of the three reviewer comments for each matriculant for 7 academic years (1989-1996) were then categorized and coded as being positive, negative, or neutral. Intra-rater and inter-rater reliabilities were calculated. RESULTS: Utterances (n = 9299) about 981 matriculants were categorized by theme and sorted as being positive, neutral, or negative. Intra-rater reliabilities were excellent (mean K = 0.98, range 0.90-1.00). Similarly, inter-rater reliabilities were also excellent (mean K = 0.94, range 0.55-1.00 and mean K = 0.90, range 0.08-1.00). Four themes (overall summarizing comments, academic, test scores, and motivation) accounted for more than half (56%) of the utterances. CONCLUSIONS: We were able to qualitatively identify themes and provide information about how one committee weighs both cognitive and "noncognitive" factors. Admission committees should consider reexamining their process and potentially expanding, eliminating, or modifying application components.

Relationship between admissions committee review and student performance in medical school and internship.

PURPOSE: To investigate the association between tertiary reviewer (admissions committee member) comments and medical students' performance during medical school and into internship. METHODS: We collected data from seven year-groups (1993-1999) and coded tertiary reviewer comments into 14 themes. We then conducted an exploratory factor analysis to reduce the dimensions of the themes (excluding the Overall impression theme). Subsequently, we performed Pearson correlation analyses and multiple linear regression analysis to examine the relationship between the factors and seven outcome measures: medical school preclinical grade point average (GPA), medical school clinical GPA, cumulative medical school GPA, U.S. Medical Licensing Examination Step 1 and 2 scores, and scores on a program director's evaluation measuring intern professionalism and expertise. RESULTS: We extracted seven factors from the 13 themes and found small-to-moderate, significant correlations between the factors, the Overall impression theme, and the outcome measures. In particular, positive comments on Test and Maturity were associated with higher U.S. Medical Licensing Examination Step 1 and 2 scores. Negative comments on Interview and Recommendations were associated with lower ratings of professionalism during internship. Comments on Overall impression were significantly associated with all the outcome measures. CONCLUSIONS: Tertiary reviewer comments were weakly associated with performance in medical school and internship. Compared with positive comments, negative comments had stronger associations with medical school and internship performance measures.

Development and initial validation of a survey to assess students' self-efficacy in medical school.

Self-efficacy is a personal belief in one's capability to successfully execute the behaviors necessary to attain designated types of performances. Sometimes described as task-specific self-confidence, self-efficacy is a key component in many contemporary theories of motivation and learning. The purpose of this study was to develop a survey for measuring students' medical skills self-efficacy and to collect reliability and validity evidence for the instrument. A secondary purpose was to explore differences in students' self-efficacy from year 1 of medical school to year 4. We created 19 survey items based on the 6 core competencies of the Accreditation Council for Graduate Medical Education, and we collected data from 304 medical students. Results from an exploratory factor analysis suggested three interpretable factors: patient care self-efficacy (eight items, Cronbach's alpha = 0.92), interpersonal skills self-efficacy (three items, Cronbach's alpha = 0.76), and evidence-based medicine self-efficacy (three items, Cronbach's alpha = 0.79). We then compared students' self-efficacy at different stages of training using a one-way multivariate analysis of variance. Consistent with our expectations, we found several statistically significant differences, suggesting students' self-efficacy increased considerably from year 1 of medical school to year 4, F(9, 725) = 30.58, p < 0.001, Wilks' lambda = 0.46. Using this survey, medical educators and researchers have a psychometrically sound tool for measuring students' medical skills self-efficacy during undergraduate medical education. Practical implications and future directions are discussed.

Relationship between OSCE scores and other typical medical school performance indicators: a 5-year cohort study.

BACKGROUND: Objective Structured Clinical Examinations (OSCEs) are used at the majority of U.S. medical schools. Given the high resource demands with constructing and administering OSCEs, understanding how OSCEs relate to typical performance measures in medical school could help educators more effectively design curricula and evaluation to optimize student instruction and assessment. PURPOSE: To investigate the correlation between second-year and third-year OSCE scores, as well as the associations between OSCE scores and several other typical measures of students' medical school performance. METHODS: We tracked the performance of a 5-year cohort (classes of 2007-2011). We studied the univariate correlations among OSCE scores, U.S. Medical Licensing Examination (USMLE) scores, and medical school grade point average. We also examined whether OSCE scores explained additional variance in the USMLE Step 2 Clinical Knowledge score beyond that explained by the Step 1 score. RESULTS: The second- and third-year OSCE scores were weakly correlated. Neither second- nor third-year OSCE score was strongly correlated with USMLE scores or medical school grade point average. CONCLUSION: Our findings suggest that OSCEs capture a viewpoint that is different from typical assessment measures that largely reflect multiple choice questions; these results also support tenets of situated cognition theory.

Leadership success and the Uniformed Services University: perspectives of flag officer alumni.

UNLABELLED: The Uniformed Services University of the Health Sciences (USU) houses the nation's only federal medical school, the F. Edward Hébert School of Medicine. A key aspect of the curriculum at USU is leadership education as graduates go on to serve the Department of Defense through a variety of senior positions in the military. We surveyed a specific group of USU graduates who have achieved the rank of General or Admiral ("flag officers") to enhance our understanding of successful leadership for military physicians and to gain an understanding of how USU might shape its curriculum in the future. METHODS: We sent an Internet-based survey to 13 flag officer graduates. The first section of the survey contained items from the multifactor leadership questionnaire-6S, a questionnaire with evidence of reliability and validity for evaluating leadership styles. The second section of the survey contained open-ended questions addressing key characteristics of an effective leader in the Military Health System, experiences that prepared them for leadership, USU's role in leadership positions, and advice for USU for better educating future leaders. The second section of the survey was coded using the constant comparative method. RESULTS: Eight flag officers (63%) responded to the survey. They all scored highly on transformational leadership style. Qualitative themes reached saturation for each open-ended question. The flag officers identified characteristics consistent with published literature from other fields regarding effective leadership. They endorsed USU's role in achieving their leadership positions and suggested areas for improvement. CONCLUSIONS: Characteristics of effective leadership (transformational leadership style) identified by the flag officers surveyed in this study are consistent with the literature from other fields. These finding have important implications for leadership education at USU and potentially other institutions. The results also provide additional data to support the notion that USU is meeting its societal obligation to educate future leaders in military medicine.

Where are they now? USU School of Medicine graduates after their military obligation is complete.

The Uniformed Services University's (USU) F. Edward Hébert School of Medicine was chartered in 1972, with the goal of providing high-quality physicians for the Uniformed Services. In exchange for their education, USU graduates incur an active duty service obligation, after which they may choose to stay on active duty or transition to civilian practice. The purpose of this study is to describe the practice characteristics of USU graduates after this obligation has been completed in order to determine the societal benefits during this phase of their careers. To accomplish this purpose, we performed a retrospective cohort study of the first 20 years of USU graduates (1980-1999). We used the American Medical Association Physician Masterfile to determine the graduates' current practice location and characteristics, as well as their board certification status. Of these 2,760 graduates, nearly all (91%) were involved in active clinical practice in over 100 self-declared specialties, the vast majority (89%) practiced in locations other than the immediate vicinity of the medical school (i.e., Maryland and the District of Columbia), and most still worked for the federal government (71%). Finally, USU graduates in full-time clinical practice had a board certification rate of 93%, which was better than the average of all other graduates of U.S. Medical Schools (88%) in the same time period. Thus, it seems USU is attaining its goal of producing high-quality physicians who continue to benefit the nation after their service obligation has been completed, with many still in federal service.

The Long-Term Career Outcome Study (LTCOS): what have we learned from 40 years of military medical education and where should we go?

The work of the Long-Term Career Outcome Study (LTCOS), F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences (USU) has been a multidisciplinary effort spanning more than 5 years. Borrowing from the established program evaluation and quality assurance literature, the LTCOS team has organized its evaluation and research efforts into three phases: before medical school, during medical school, and after medical school. The purpose of this commentary is to summarize the research articles presented in this special issue and to answer two fundamental questions: (1) what has been learned from LTCOS research conducted to date, and (2) where should the LTCOS team take its evaluation and research efforts in the future? Answers to these questions are relevant to USU, and they also can inform other medical education institutions and policy makers. What is more, answers to these questions will help to ensure USU meets its societal obligation to provide the highest quality health care to military members, their families, and society at large.

Achievement goal structures and self-regulated learning: relationships and changes in medical school.

PURPOSE: Practicing physicians have a societal obligation to maintain their competence. Unfortunately, the self-regulated learning skills likely required for lifelong learning are not explicitly addressed in most medical schools. The authors examined how medical students' perceptions of the learning environment relate to their self-regulated learning behaviors. They also explored how students' perceptions and behaviors correlate with performance and change across medical school. METHOD: The authors collected survey data from 304 students at different phases of medical school training. The survey items assessed students' perceptions of the learning environment, as well as their metacognition, procrastination, and avoidance-of-help-seeking behaviors. The authors operationalized achievement as cumulative medical school grade point average (GPA) and, for third- and fourth-year students, collected clerkship outcomes. RESULTS: Students' perceptions of the learning environment were associated with their metacognition, procrastination, and help-avoidance behaviors. These behaviors were also related to academic outcomes. Specifically, avoidance of help seeking was negatively correlated with cumulative medical school GPA (r=-0.23, P<.01) as well as exam (r=-0.22, P<.05) and clinical performance (r=-0.34, P<.01) in the internal medical clerkship; these help-avoidance behaviors were also positively correlated with students' presentation at a grade adjudication committee (r=0.20, P<.05). Additionally, students' perceptions of the learning environment varied as a function of their phase of training. CONCLUSIONS: Medical students' perceptions of the learning environment are related, in predictable ways, to their use of self-regulated learning behaviors; these perceptions seem to change across medical school.

Does self-reported clinical experience predict performance in medical school and internship?

CONTEXT: Medical school admissions committees attempt to select the most qualified applicants. In addition to traditional performance measures, committees often look favourably upon applicants who report previous clinical experience. OBJECTIVES: This study aimed to determine if self-reported clinical experience is a valid indicator of future performance in medical school and internship. METHODS: We collected data for seven year groups (1993-1999; n = 1112) and operationalised trainee performance in terms of five outcomes: cumulative medical school grade point average (GPA); US Medical Licensing Examination (USMLE) Step 1 and 2 scores, and scores on a validated programme director's evaluation measuring intern expertise and professionalism. We then conducted a series of analyses of covariance to compare outcomes in applicants who self-reported previous clinical experience with outcomes in those who did not. In these analyses, the independent variable was self-reported clinical experience (yes/no), the covariate was undergraduate GPA, and the dependent variables were the five performance outcomes. RESULTS: In four of five analyses, we found no differences in the performance of the two groups (clinical experience versus no clinical experience). However, on the cumulative medical school GPA outcome, applicants who reported previous clinical experience had statistically significantly lower cumulative GPAs upon graduation than those who did not report such experience (F(1,940) = 9.35, p = 0.002, partial η(2) = 0.01 [small effect size]). CONCLUSIONS: Our results suggest that applicants who self-report previous clinical experience may not be better candidates. In fact, on some measures of performance, these applicants may actually perform worse than those who report no clinical experience.