Measuring the development of a medical professional identity through medical school.

Purpose: The Professional Identity Essay (PIE) is a theory and evidence-based Medical Professional Identity Formation (MPIF) measure. We describe trajectories of PIE-measured MPIF over a 4-year US medical school curriculum.Methods: Students write PIEs at medical school orientation, clinical clerkships orientation, and post-advanced (near graduation) clerkship. A trained evaluator assigns an overall stage score to narrative responses to nine PIE prompts (inter-rater ICC 0.83, 95% CI [0.57 - 0.96], intra-rater ICC 0.85). Distribution of PIE stage scores across time points were analyzed in the aggregate and individual students were classified as Increase, Stable (no score change) or Decrease based on the trajectories of PIE stage scores over time.Results 202 students completed 592 PIEs from 2018-2023. There was a significant change in the proportion of PIEs in stages over time (X2 84.40, p < 0.001), 47% (n = 95) students were categorized in the Increase trajectory, 45.5% (n = 92) as Stable and 7.4% (n = 15) as Decrease. Older age and time-predicted stage scores change within trajectories (p < 0.05).Conclusions Medical students' PIE stage scores increase over time with three distinctive trajectories. Further study is needed to explore the utility of this method for formative assessment, program evaluation, and MPIF research.

Improving the Quality of Care in Radiation Oncology using Artificial Intelligence.

Radiation therapy is a complex process involving multiple professionals and steps from simulation to treatment planning to delivery, and these procedures are prone to error. Additionally, the imaging and treatment delivery equipment in radiotherapy is highly complex and interconnected and represents another risk point in the quality of care. Numerous quality assurance tasks are carried out to ensure quality and to detect and prevent potential errors in the process of care. Recent developments in artificial intelligence provide potential tools to the radiation oncology community to improve the efficiency and performance of quality assurance efforts. Targets for artificial intelligence enhancement include the quality assurance of treatment plans, target and tissue structure delineation used in the plans, delivery of the plans and the radiotherapy delivery equipment itself. Here we review recent developments of artificial intelligence applications that aim to improve quality assurance processes in radiation therapy and discuss some of the challenges and limitations that require further development work to realise the potential of artificial intelligence for quality assurance.

Effects of Preparatory Coaching and Home Practice for Deep Inspiration Breath Hold on Cardiac Dose for Left Breast Radiation Therapy.

AIMS: Deep inspiration breath hold (DIBH) reduces cardiac radiation exposure by creating cardiac-chest wall separation in breast cancer radiotherapy. DIBH requires sustaining chest wall expansion for up to 40 s and involves complex co-ordination of thoraco-abdominal muscles, which may not be intuitive to patients. We investigated the effect of in-advance preparatory DIBH coaching and home practice on cardiac doses. MATERIALS AND METHODS: Successive patients from 1 February 2015 to 31 December 2016 with left-sided breast cancer who underwent tangential field radiotherapy utilising the DIBH technique were included. The study cohort consisted of patients treated by a physician who routinely provided DIBH coaching and home practice instructions at least 5 days before simulation. The control group included non-coached patients under another physician's care. Minimum, maximum and mean cardiac doses and V5, V10 and V30 from DIBH and free breathing simulation computed tomography scans were obtained from the planning system. DIBH and free breathing cardiac doses and volume exposures were compared between the coached and non-coached groups using the two-sample t-test, Fisher's exact test and the Mann-Whitney U-test. RESULTS: Twenty-seven coached and 42 non-coached patients were identified. The DIBH maximum cardiac dose was lower in coached patients at 13.1 Gy compared with 19.4 Gy without coaching (P = 0.004). The percentage cardiac volume exposure in DIBH was lower in coached patients; the DIBH V10 was 0.5% without coaching and 0.1% with coaching (P = 0.005). There was also a trend towards lower DIBH V5 in the coached group compared with the non-coached group (1.2% versus 1.9%, P = 0.071). No significant differences in patient cardiopulmonary comorbidity factors that might influence cardiac doses were found between the groups. CONCLUSIONS: Our results suggest that cardiac dose sparing can potentially be further improved with a 5 day regimen of preparatory DIBH coaching and in-advance home practice before simulation. These hypothesis-generating findings should be confirmed in a larger study.

Factors influencing medical student attrition and their implications in a large multi-center randomized education trial.

Participant attrition may be a significant threat to the generalizability of the results of educational research studies if participants who do not persist in a study differ from those who do in ways that can affect the experimental outcomes. A multi-center trial of the efficacy of different computer-based instructional strategies gave us the opportunity to observe institutional and student factors linked to attrition from a study and the ways in which they altered the participation profile. The data is from a randomized controlled trial conducted at seven US medical schools investigating the educational impact of different instructional designs for computer-based learning modules for surgical clerks. All students undertaking their surgical clerkships at the participating schools were invited participate and those that consented were asked to complete five study measures during their surgery clerkship. Variations in study attrition rates were explored by institution and by participants' self-regulation, self-efficacy, perception of task value, and mastery goal orientation measured on entry to the study. Of the 1,363 invited participants 995 (73 %) consented to participate and provided baseline data. There was a significant drop in the rate of participation at each of the five study milestones with 902 (94 %) completing at least one of two module post-test, 799 (61 %) both module post-tests, 539 (36 %) the mid-rotation evaluation and 252 (25 %) the final evaluation. Attrition varied between institutions on survival analysis (p < 0.001). Small but statistically significant differences in self-regulation (p = 0.01), self-efficacy (p = 0.02) and task value (p = 0.04) were observed but not in mastery or performance goal orientation measures (p = NS). Study attrition was correlated with lower achievement on the National Board of Medical Examiners subject exam. The results of education trials should be interpreted with the understanding that students who persist may be somewhat more self-regulated, self-efficacious and higher achievers than their peers who drop out and as such do not represent the class as a whole.

Just enough, but not too much interactivity leads to better clinical skills performance after a computer assisted learning module.

BACKGROUND: Well-designed computer-assisted instruction (CAI) can potentially transform medical education. Yet little is known about whether specific design features such as direct manipulation of the content yield meaningful gains in clinical learning. We designed three versions of a multimedia module on the abdominal exam incorporating different types of interactivity. METHODS: As part of their physical diagnosis course, 162 second-year medical students were randomly assigned (1:1:1) to Watch, Click or Drag versions of the abdominal exam module. First, students' prior knowledge, spatial ability, and prior experience with abdominal exams were assessed. After using the module, students took a posttest; demonstrated the abdominal exam on a standardized patient; and wrote structured notes of their findings. RESULTS: Data from 143 students were analyzed. Baseline measures showed no differences among groups regarding prior knowledge, experience, or spatial ability. Overall there was no difference in knowledge across groups. However, physical exam scores were significantly higher for students in the Click group. CONCLUSIONS: A mid-range level of behavioral interactivity was associated with small to moderate improvements in performance of clinical skills. These improvements were likely mediated by enhanced engagement with the material, within the bounds of learners' cognitive capacity. These findings have implications for the design of CAI materials to teach procedural skills.

SU-E-T-239: In Vivo Dosimetry with Surface Diodes during Total Body Irradiation: A Patient Thickness Factor to Correct Midline Dose.

PURPOSE: In vivo dosimetry (IVD) assessment of treatment dose is important when delivering total body irradiation (TBI). One method is to average AP and PA surface diode measurements and compare them to prescribed midline doses. We designed phantom studies to examine the impact of patient thickness on surface IVD measurements under TBI conditions. METHODS: Phantom studies were designed to assess the effects of patient thickness on diode IVD. Sun Nuclear QED diodes with inherent buildup were placed on anterior and posterior surfaces of a solid water phantom. Phantom thickness was varied between 20 and 40 cm. A PTW farmer chamber was inserted in the center of the phantom at 425 SSD to reflect prescribed midline dose, and 50 cGy was delivered to midline with 18 MV photons. Averaged entrance and exit diode doses were then compared to farmer chamber measurements of phantom midline dose. RESULTS: A trend of increased deviation with increasing umbilicus thickness was observed between averaged surface diodes and midline farmer chamber measurements. Averaged surface diode dose ranged from 49.6 cGy (20 cm thickness) to 52.1 cGy (40 cm thickness). Interpolation of diode measurements to midline resulted in linear overestimation of delivered dose relative to farmer chamber measurements at midline, up to 6.8% at 40 cm umbilicus thickness. CONCLUSION: Accurate in vivo dosimetry at time of patient TBI is important to allow individual correction of MU exposure and tissue compensation. Without patient thickness correction, overresponse of surface diodes may lead to unnecessary clinical intervention to treatment MU or compensation and insufficient midline dose. Additionally, SAD setup is preferable to SSD setup to minimize thickness non-linearity. In conclusion, thickness correction factors should be used to generate expected diode readings for patients with thickness greater than 30 cm.

A randomized trial of teaching clinical skills using virtual and live standardized patients.

BACKGROUND: We developed computer-based virtual patient (VP) cases to complement an interactive continuing medical education (CME) course that emphasizes skills practice using standardized patients (SP). Virtual patient simulations have the significant advantages of requiring fewer personnel and resources, being accessible at any time, and being highly standardized. Little is known about the educational effectiveness of these new resources. We conducted a randomized trial to assess the educational effectiveness of VPs and SPs in teaching clinical skills. OBJECTIVE: To determine the effectiveness of VP cases when compared with live SP cases in improving clinical skills and knowledge. DESIGN: Randomized trial. PARTICIPANTS: Fifty-five health care providers (registered nurses 45%, physicians 15%, other provider types 40%) who attended a CME program. INTERVENTIONS: Participants were randomized to receive either 4 live cases (n=32) or 2 live and 2 virtual cases (n=23). Other aspects of the course were identical for both groups. RESULTS: Participants in both groups were equivalent with respect to pre-post workshop improvement in comfort level (P=.66) and preparedness to respond (P=.61), to screen (P=.79), and to care (P=.055) for patients using the skills taught. There was no difference in subjective ratings of effectiveness of the VPs and SPs by participants who experienced both (P=.79). Improvement in diagnostic abilities were equivalent in groups who experienced cases either live or virtually. CONCLUSIONS: Improvements in performance and diagnostic ability were equivalent between the groups and participants rated VP and SP cases equally. Including well-designed VPs has a potentially powerful and efficient place in clinical skills training for practicing health care workers.

Personal growth in medical faculty: a qualitative study.

BACKGROUND: A physician's effectiveness depends on good communication, and cognitive and technical skills used with wisdom, compassion, and integrity. Attaining the last attributes requires growth in awareness and management of one's feelings, attitudes, beliefs, and life experiences. Yet, little empiric research has been done on physicians' personal growth. OBJECTIVE: To use qualitative methods to understand personal growth in a selected group of medical faculty. DESIGN: Case study, using open-ended survey methods to elicit written descriptions of respondents' personal growth experiences. SETTING: United States and Great Britain. PARTICIPANTS: Facilitators, facilitators-in-training, and members of a personal growth interest group of the American Academy on Physician and Patient, chosen because of their interest, knowledge, and experience in the topic area and their accessibility. MEASUREMENTS: Qualitative analysis of submitted stories included initially identifying and sorting themes, placing themes into categories, applying the categories to the database for verification, and verifying findings by independent reviewers. RESULTS: Of 64 subjects, 32 returned questionnaires containing 42 stories. Respondents and nonrespondents were not significantly different in age, sex, or specialty. The analysis revealed 3 major processes that promoted personal growth: powerful experiences, helping relationships, and introspection. Usually personal growth stories began with a powerful experience or a helping relationship (or both), proceeded to introspection, and ended in a personal growth outcome. Personal growth outcomes included changes in values, goals, or direction; healthier behaviors; improved connectedness with others; improved sense of self; and increased productivity, energy, or creativity. CONCLUSIONS: Powerful experiences, helping relationships, and introspection preceded important personal growth. These findings are consistent with theoretic and empiric adult learning literature and could have implications for medical education and practice. They need to be confirmed in other physician populations.

Ambulatory versus inpatient rotations in teaching third-year students internal medicine.

We studied 63 randomly selected third-year students who split their 10-week medicine clerkship between ambulatory and inpatient components. Compared with their inpatient experience, during the ambulatory rotation, the 63 students felt more like doctors, more responsible for patients, and more able to know and help their patients. Students reported that ambulatory attending staff appeared happier and less stressed, and did not embarrass them as frequently. Compared with their 619 "inpatient" classmates, these 63 "ambulatory" students scored as well on the medicine examination, and were as likely to receive honors (44% vs 41%), and to choose internal medicine residencies (35% vs 34%). In conclusion, students experienced better relationships with their patients and teachers during the ambulatory rotation, which was academically comparable to the inpatient experience.

Patients as teachers: an integrated approach to teaching medical students about the ambulatory care of HIV infected patients.

Our experience with medical students in a large inner city hospital left us concerned that students' fears affect their ability to learn about and care for HIV-positive people. Therefore, we decided to create an environment in which the students could feel safe exploring their own attitudes and feelings about HIV. To accomplish the goal, we developed a curriculum in the ambulatory care of HIV-positive people. We recruited and trained patients from an HIV support group at our hospital to work with students in one-on-one sessions to teach interviewing, physical exam, and patient counseling skills. As part of a 4-week ambulatory clerkship for third year students we developed a minicourse which included four sessions with didactic and experiential components. The first week consisted of an orientation and group discussion in which patients told the students about what its like to live with HIV. During each of the following three sessions, students met with a preceptor to learn about HIV in an ambulatory care setting. The didactic session was followed by one-on-one student/patient encounters in which students practised skills discussed that week and patients gave them feedback. At the close of the day, the entire group reconvened to discuss what had happened. As a result of this integrated approach, students are experiencing the relational aspects of providing medical care, often for the first and only time. In the process they are learning to take good social histories and are learning how patients with HIV relate to and sometimes reorganize their family and social support systems. Students have the opportunity to get to know, in depth, a relatively healthy person who is living with a chronic, stigmatizing illness. Both patients and students are talking to each other on a level of intimacy that is rare in the training environment. Patients express a new appreciation of their own role and power in the relationship and a new insight into the struggles of the provider. Faculty experience a renewed commitment to the importance of creating an environment where the students can discover for themselves the joy of the connection between doctor and patient. Students have an opportunity to relate to patients not as pathology, but as people with lives before and beyond the medical system. This model is practical and may be useful in teaching about other chronic diseases in the ambulatory setting.

Interruption in the medical interaction.

OBJECTIVES: To describe patterns of interruption in the physician-patient interaction; specifically, to determine who interrupts, to determine if a shift in control occurs as a result of interruption, and to characterize the information gained when patients interrupt physicians. DESIGN: Observational. SETTING: Community-based primary care practices in North Carolina. SUBJECTS: Internists and family physicians in private practice in North Carolina (six men and two women) and their patients (13 men and 27 women). INTERVENTIONS: None. MAIN OUTCOME MEASURE: The obtainment of control of the interaction, at least momentarily, as a result of interruption. RESULTS: Analysis of 40 audiotaped interactions revealed 833 interruptions (mean +/- SD, 20.8 +/- 12.2 per interaction): Patients initiated 55% of all interruptions. Physicians and patients each gained control of the conversation after 50% of interruptions. Patients gained control after 74% of patient-initiated interruptions, and physicians gained control after 79% of physician-initiated interruptions. Patients were more likely to gain control by interrupting late in the interaction, and 75% of patient-initiated interruptions resulted in new information (solicited and unsolicited) being contributed to the interaction. CONCLUSION: Interruption by patients can be an informative event.

How do physicians talk with their patients about risks?

To describe the communication about risk between community-based physicians and their patients, the authors audiotaped 160 physician-patient encounters in the private practices of 19 physicians. Coding was done using a structured scheme to identify the presence of talk about risk of future illness, and to describe its characteristics. Patient understanding and satisfaction were assessed through an interview. Risk discussion occurred in 26% (95% CI 19%-33%) of the visits, quantitatively in two cases and specifically with respect to outcome in 48% (95% CI 40%-56%) of the visits. The patients initiated only 16% of this discussion but were, in general, satisfied with their care and the information they had received, but they had poor recall of the specifics of the discussion.

Referral patterns of primary care physicians for eye care.

BACKGROUND: There is very little data regarding the referral rates of primary care physicians for eye care. We studied the extent to which primary care physicians follow guidelines and standards that have been set by professional organizations within eye care. METHODS: Forty-eight patients over age 40 years seen during one day in the Primary Care Department of a large, metropolitan hospital were reviewed. RESULTS: Only 12.5 percent of patients seen were referred for eye care. Only 8 percent of those who were diabetic and 13 percent of those with hypertension were referred for eye care, while of each group respectively, 25 percent and 34.8 percent had been seen for eye care in the previous year. Referrals tended to be for acute problems, not for routine monitoring of ocular signs associated with hypertension or diabetes. Only 33.3 percent of the patients had an ocular assessment in the physician's records within the year. In addition, most patients did not have ophthalmoscopy, glaucoma testing, or any other form of vision care during the year. CONCLUSIONS: In this study, referrals for eye care seemed to be driven by acute, symptomatic problems, and to a lesser extent by a known ocular condition. The importance of routine eye care was not reflected in the referral patterns observed in this study.

Diabetic ketoacidosis in prisoners without access to insulin.

OBJECTIVE: To assess the cause and clinical severity of diabetic ketoacidosis in male prisoners hospitalized in New York City. DESIGN: Retrospective chart review. SETTING: A municipal hospital in New York City. PATIENTS: Forty-nine adult male prisoners with a total of 54 hospital admissions for diabetic ketoacidosis between January 1, 1989, and June 30, 1991. MAIN OUTCOME MEASURES: Charts were reviewed for diabetic and medical history, time from arrest until hospitalization, cause of diabetic ketoacidosis, admission laboratory data, and hospital course. RESULTS: Thirty-eight (70%) of the 54 admissions for diabetic ketoacidosis among prisoners occurred because prisoners had not received insulin during the period immediately following arrest (mean number of days from arrest until hospitalization was 2.5). All of these individuals had a history of insulin-dependent diabetes and were reportedly compliant with their insulin regimen at the time of arrest. Admission laboratory data for this group of prisoners included a mean serum glucose level of 27.4 mmol/L (495 mg/dL) and a mean serum bicarbonate level of 14.4 mmol/L. Mean number of days in the hospital was 3.4 including a mean of 1 day in an intensive care unit. CONCLUSIONS: Inadequate access to medication results in serious sequelae for recently arrested prisoners in New York City with insulin-dependent diabetes. Access to health care for recently arrested prisoners needs to be improved.

How well do faculty evaluate the interviewing skills of medical students?

OBJECTIVE: To study the reliability and validity of using medical school faculty in the evaluation of the interviewing skills of medical students. DESIGN: All second-year University of North Carolina medical students (n = 159) were observed interviewing standardized patients for 5 minutes by one of eight experienced clinical faculty. Interview quality was assessed by a faculty checklist covering questioning style, facilitative behaviors, and specific content. Twenty-one randomly chosen students were videotaped and rated: by the original rater as well as four other raters; by two nationally recognized experts; and according to Roter's coding dimensions, which have been found to correlate strongly with patient compliance and satisfaction. SETTING: Medical school at a state university in the southeastern United States. PARTICIPANTS: Faculty members who volunteered to evaluate second-year medical students during an annual Objective Structured Clinical Exam. INTERVENTIONS: Interrater reliability and intrarater reliability were tested using videotapes of medical students interviewing a standardized patient. Validity was tested by comparing the faculty judgment with both an analysis using the Roter Interactional Analysis System and an assessment made by expert interviewers. MEASUREMENTS AND MAIN RESULTS: Faculty mean checklist score was 80% (range 41-100%). Intrarater reliability was poor for assessment of skills and behaviors as compared with that for content obtained. Interrater reliability was also poor as measured by intraclass correlation coefficients ranging from 0.11 to 0.37. When compared with the experts, faculty raters had a sensitivity of 80% but a specificity of 45% in identifying students with adequate skills. The predictive value of faculty assessment was 12%. Analysis using Roter's coding scheme suggests that faculty scored students on the basis of likability rather than specific behavioral skills, limiting their ability to provide behaviorally specific feedback. CONCLUSIONS: To accurately evaluate clinical interviewing skills we must enhance rater consistency, particularly in assessing those skills that both satisfy patients and yield crucial data.