The Case for Instructional Teams in the New Era of Online Medical Education.

After a period of "emergency remote teaching" precipitated by COVID-19, academic medical centers are moving into a second, more mature phase in online education. This article offers guidance to institutions planning for this second phase. In it, we advocate a reorientation towards "instructional teams;" outline typical roles and skill sets on instructional teams; discuss the hardware, software, and space required to develop high-quality online courses; and describe common pitfalls experienced by instructional teams along with strategies to avoid them. Our objective is to help institutions hoping to develop high-quality, sustainable online programming to set realistic and informed expectations, allocate resources intelligently, hire appropriately, and work productively.

Best Practices for Survey Use in Medical Education: How to Design, Refine, and Administer High-Quality Surveys.

Surveys are a frequently used method to collect data in medical education research. As such, it behooves medical educators involved in scholarly work to understand the best practices in the selection, development, implementation, and reporting of surveys used when conducting research and curriculum development projects. This review article prepares the reader to name the steps of designing and administering high-quality surveys in medical education research, identify the characteristics of both well-written and poorly written survey questions, and apply the principles of survey design to write and revise surveys for use in their own research.

Grit Does Not Predict Burnout among First-Year Internal Medicine Residents.

OBJECTIVES: Grit, defined as passion and perseverance for long-term goals, has been associated with the avoidance of burnout among residents in a number of specialties. We aimed to evaluate the relationship between grit and burnout among first-year Internal Medicine residents. METHODS: During the 2018-2019 academic year, the authors recruited 75 first-year Internal Medicine residents within a large academic program to complete the Short Grit Scale (Grit-S) and the Maslach Burnout Inventory General Survey (MBI-GS) at baseline and after 6 and 12 months. The primary outcome was the association between baseline Grit-S and MBI-GS scores within the domains of emotional exhaustion (EE) or cynicism (CYN) over time using linear mixed models. Secondary outcomes included the association between grit and high burnout at 6 or 12 months, grit and persistently high burnout, and the association of baseline high burnout with later high scores at 6 and 12 months using logistic regression models and trends in grit over time using repeated-measures analysis of variance. RESULTS: A total of 53 of 75 (71%) first-year residents completed the Grit-S and MBI-GS at baseline and at least one other time point. There was no association between grit and EE (P = 0.44) or CYN (P = 0.61) burnout domain scores. High baseline EE and high baseline CYN significantly increased the odds of later high burnout scores within each domain (EE odds ratio 9.66, 95% confidence interval 1.16-80.83; CYN odds ratio 13.37, 95% confidence interval 1.52-117.75). Grit scores and professional efficacy scores remained stable throughout the year (P = 0.15 and 0.46, respectively), while EE and CYN significantly increased (both P < 0.01). CONCLUSIONS: In this single-center study, grit was not associated with burnout among first-year Internal Medicine residents; however, our findings highlight the value of baseline burnout scores in helping to identify first-year residents who may be at higher risk of later burnout.

A Curriculum Innovation on Writing Simulated Patient Cases for Communication Skills Education.

Introduction: Facilitated communication practice with simulated patients (SPs) is a highly effective form of communication training. Unfortunately, little guidance exists on writing SP cases. Methods: We created a curriculum composed of a case-development workbook and case-writing session with input from national communication educators. In November 2017, we implemented the curriculum in a Teaching Communication Skills course for medical educators. Educators divided into four groups to write cases. Primary outcome was the number of criteria that cases fulfilled. Secondary outcomes were SP evaluation and educator-reported confidence and satisfaction. Results: Seventeen medical educators (including 15 fellows) completed the curriculum. Four new cases were analyzed against 24 criteria and compared to eight cases written by educators following a previous curriculum. An SP evaluated ease of portrayal for all 12 cases on a 5-point Likert scale (1 = poor, 5 = excellent). Educators completed precurriculum and postcurriculum surveys. Compared to the previous curriculum, cases based on the new curriculum incorporated 26% more case criteria (70% or 16.8 criteria/case vs. 96% or 23.0 criteria/case, p < .01). Ease-of-portrayal rating improved but did not differ statistically (mean: 2.8 vs. 4.5, p = .11). A moderate correlation was found between number of included case criteria and Likert-scale rating (rs = .61, p = .03). Pre- and postcurriculum, educators reported significant increases in confidence (mean: 1.9 vs. 4.0, p < .01) and high curricular satisfaction (mean: 4.8). Discussion: A case-development workbook and case-writing session increased the quality of newly developed SP cases as assessed by prespecified case criteria.

Optimizing Synchronous Online Teaching Sessions: A Guide to the "New Normal" in Medical Education.

In response to the COVID-19 pandemic, the medical education community was forced to transition to the virtual space seemingly overnight, with little time to prepare. As such, many medical educators are actively seeking ways to improve delivery of online content and utilize features of different technologies. This View from the APPD, informed by existing literature and author experience, was created to guide medical teachers in their transition to hosting synchronous learning sessions in the virtual space. We hope to empower medical educators with the confidence and skills needed to teach effectively from a distance.

Exploring Mentoring Experiences, Perceptions, and Needs of General Internal Medicine Clinician Educators Navigating Academia: a Mixed-Methods Study.

BACKGROUND: Few studies examined specific mentoring needs and preferences of clinician educators (CEs). Further research on CEs' perceptions of mentoring adequacy, as related to educational development and career advancement, is needed. OBJECTIVE: The study aims were to (1) explore general internal medicine CEs' experiences as mentees within various mentoring models; (2) examine the perceived quality, nature, and impact of mentoring on career development; and (3) determine whether specific models of mentoring impact their attitudes towards mentoring. DESIGN: Sequential mixed methods study design answered the study questions. PARTICIPANTS: Society of General Internal Medicine members identifying themselves as CEs. MAIN MEASURES/APPROACH: Participants completed an anonymous online survey and a subsample participated in two semi-structured focus group discussions. Outcomes of interest were perceptions of mentoring experiences, and perspectives on quality of mentoring as well as mentoring needs specific to clinician educators. KEY RESULTS: One hundred thirty-nine participants completed the survey (37% response rate) with 20 participants in focus group discussions. Among CEs with perceived high-quality mentor relationships (e.g., reporting strongly agree), peer mentorship was viewed as adequate mentorship (45% (n = 17) vs 24% (n = 24), p < 0.05), as beneficial for career development (77% (n = 40) vs 48% (n = 41), p < 0.01) and as being challenged to become a better CE (58% (n = 30) vs 35% (n = 29), p < 0.05), compared to reporting agree or lower. Qualitative analysis generated four themes: (1) A mentoring team promotes career advancement, (2) peer mentors are important at every stage of a CE's career, (3) there is inadequate mentoring specific to CE needs, and (4) mentoring needs protected time and skill development. CONCLUSIONS: The traditional dyadic mentoring relationship may not adequately address all professional needs of CEs. A mentoring team can provide valuable perspectives on career goals. Peer mentoring can be powerful for professional growth. Mentoring needs change at different career stages and training in mentoring skills is essential.

A Nutrition Counseling Curriculum to Address Cardiovascular Risk Reduction for Internal Medicine Residents.

Introduction: Primary care providers play a critical role in reducing patients' risk for cardiovascular disease, including providing dietary counseling. However, few physicians feel adequately trained to provide this counseling, and most internal medicine (IM) residencies do not offer nutrition education. Methods: We created an interactive, case-based activity for IM residents to improve the delivery of nutrition counseling to patients with hypertension, hyperlipidemia, overweight, and obesity. The curriculum was given over two in-person small-group sessions facilitated by physician preceptors. It reviewed evidence for relevant dietary patterns, provided resources for dietary referrals, and allowed residents to practice counseling based on a patient's stage of behavioral change. Results: Residents completed electronic surveys prior to curriculum implementation, immediately after, and 2 months after completion of the curriculum. Aggregate percent correct scores of knowledge questions improved significantly in the immediate postsurvey (n = 24 paired responses, p = .004). We also reviewed electronic health records of patients with body mass index ≥ 25, hypertension, or hyperlipidemia who were seen in our resident clinics 2 months prior (n = 503) and 2 months after (n = 473) curriculum delivery. Residents' documented nutrition counseling increased from 35% to 41% (odds ratio, 1.27; 95% CI, 0.97-1.67; p = .085). Discussion: We demonstrated improved knowledge of nutrition interventions to reduce cardiovascular risk and reported improvement of resident-provided nutrition counseling for appropriate patients. This activity offers IM residents effective initial nutrition training for patients at risk for cardiovascular disease and is practical to implement as part of an ambulatory curriculum.

Clinician-Educator Training and Its Impact on Career Success: a Mixed Methods Study.

BACKGROUND: Clinician-educator (CE) careers in academic medicine are heterogeneous. Expectations for CEs have grown, along with a need to better prepare CEs for these roles. OBJECTIVE: To assess whether advanced education training is associated with productivity and success. DESIGN: We used a sequential mixed methods approach, collecting quantitative survey data and qualitative focus groups data. We developed a three-tiered categorization of advanced training to reflect intensity by program type. PARTICIPANTS: We surveyed CEs in the Society of General Internal Medicine (SGIM) and conducted two focus groups at an SGIM annual meeting. MAIN MEASURES: Primary outcomes were academic productivity (manuscripts, presentations, etc.) and leadership role attainment. Secondary analysis examined the interactive effect of gender and training intensity on these outcomes. KEY RESULTS: A total of 198 completed the survey (response rate 53%). Compared with medium- or low-intensity training, high-intensity training was associated with a greater likelihood of publishing ≥ 3 first- or senior-author manuscripts (adjusted OR 2.6; CI 0.8-8.6; p = 0.002), teaching ≥ 3 lectures/workshops at the regional/national/international level (adjusted OR 5.7; CI 1.5-21.3; p = 0.001), and having ≥ 3 regional/national committee memberships (adjusted OR 3.4; CI 1.0-11.7; p = 0.04). Among participants in the "no training" and "high-intensity training" categories, men were more likely to have ≥ 3 publications (OR 4.87 and 3.17, respectively), while women in the high intensity category had a likelihood similar to men with no training (OR 4.81 vs. OR 4.87). Participants felt the value of advanced training exists not only in content but also in networking opportunities that programs provide. CONCLUSIONS: While opinions were divided as to whether advanced training is necessary to position oneself for education roles, it is associated with greater academic productivity and reduced gender disparity in the publication domain. Institutions should consider providing opportunities for CEs to pursue advanced education training.

A Robust Faculty Development Program for Medical Educators: A Decade of Experience.

OBJECTIVES: Faculty development programs (FDPs) foster learning communities and enhance professional identity formation for medical educators. Competency-based frameworks for faculty development drive skill development across clinical practice, teaching, and scholarship domains. The aims of this study are to outline the context, content, and evolution of a novel FDP; map the individual conferences that make up the FDP to established faculty development competencies; identify steps to implement similar programming; and demonstrate outcomes to date. METHODS: The FDP consists of four, 1-hour-long conferences held weekly on a rotating basis since 2007 at the University of Pittsburgh School of Medicine: Academy of Master Educators, Medical Education Research, Medical Education Journal Club, and Medical Education Research Methods and Innovative Design conference. Authors outline the relation of each of these four conferences to faculty development competencies and describe early outcomes for each conference over four consecutive academic years from 2014 to 2018. Participants include attendees and presenters in four consecutive academic years from 2014 to 2018. RESULTS: The well-attended FDP meets all established competencies for educator faculty. Presenters and attendees were diverse in terms of academic rank and represented a breadth of clinical and basic science specialties. CONCLUSIONS: This integrated FDP fosters a community of medical educators and develops faculty skills across established medical educator competencies.

Does Formal Training in Medical Education and Professional Development Lead to Better Career Outcomes for Clinician Educators?

OBJECTIVES: Medical school and residency training programs rely on skilled clinician-educators to provide high-quality educational experiences. In 2002, the University of Pittsburgh's Institute for Clinical Research Education created a master's-level degree-granting program in medical education, which now has more than a decade of graduates. METHODS: All graduates between 2004 and 2014 were invited to complete an anonymous electronic survey regarding their experiences with the program and their perception of whether the master's program adequately prepared them in domains pertinent to medical educators. Participants also were asked to upload their current curricula vitae (CV) to assess objective measures of academic productivity among program graduates. RESULTS: More than 75% of surveys were completed (47/60) and 75% of CVs were submitted (45/60). Demographics of respondents showed that 66% were woman. The racial demographics of respondents revealed 13% Hispanic/Latino, 28% Asian, and 59% white, respectively. More than 90% of respondents agreed that because they completed the program, they were competent in multiple teaching and learning domains; 94% of respondents believed that they were more effective educators than peers who did not complete this degree. CV abstraction revealed that 98% of respondents currently held academic positions. Number of publications and number of years since program graduation were used to determine the rate of productivity of the graduates. Twenty-six graduates (58%) successfully published at least one peer-reviewed article per year since they graduated. This equated to approximately 3.77 publications per year for these 26 respondents and 2.27 publications per year for the entire cohort. CONCLUSIONS: Program graduates attributed their competence in several key domains that are crucial to excellence as a clinician-educator to their participation in the degree-granting program. The results of this study suggest that receipt of a graduate-level degree in medical education develops and enhances teaching skills and academic productivity among clinician-educators.

Comprehensive Curriculum for Internal Medicine Residents on Primary Care of Patients Identifying as Lesbian, Gay, Bisexual, or Transgender.

Introduction: Significant gaps remain in the training of health professionals regarding the care of individuals who identify as lesbian, gay, bisexual, and transgender (LGBT). Although curricula have been developed at the undergraduate medical education level, few materials address the education of graduate medical trainees. The purpose of this curriculum was to develop case-based modules targeting internal medicine residents to address LGBT primary health care. Methods: We designed and implemented a four-module, case-based, interactive curriculum at one university's internal medicine residency program. The modules contained facilitator and learner guides and addressed four main content areas: understanding gender and sexuality; performing a sensitive history and physical examination; health promotion and disease prevention; and mental health, violence, and reproductive health. Knowledge, perceived importance, and confidence were assessed before and after each module to assess curricular effectiveness and acceptability. General medicine faculty delivered these modules. Results: Perceived importance of LGBT topics was high at baseline and remained high after the curricular intervention. Confidence significantly increased in many areas, including being able to provide resources to patients and to institute gender-affirming practices (p < .05). Knowledge improved significantly on almost all topics (p < .0001). Faculty felt the materials gave enough preparation to teach, and residents perceived that the faculty were knowledgeable. Discussion: This resource provides an effective curriculum for training internal medicine residents to better understand and feel confident addressing LGBT primary health care needs. Despite limitations, this is an easily transferable curriculum that can be adapted in a variety of curricular settings.

Outpatient Exam Room Presentations in Resident Continuity Clinics: a Qualitative Report.

INTRODUCTION: Outpatient exam room presentations (OERPs) in resident continuity clinics could address several current challenges in graduate medical education including increasing patient satisfaction, enhancing patient-centered care, and operationalizing competency-based education through direct observation. The authors' aim of this study was to explore the positive and negative aspects of OERPs as a precepting model in resident continuity clinics and to develop a list of best practices for medical educators to utilize when conducting OERPs. MATERIALS AND METHODS: The authors defined an OERP as a case presentation and subsequent discussion taking place inside the exam room with the attending physician, resident physician, and patient present. Following a 1-month pilot period of conducting OERPs in internal medicine resident continuity clinics, the authors conducted individual phone interviews and focus groups with internal medicine attendings and residents, respectively. The authors analyzed transcripts using thematic analysis and the constant comparative method. Sixteen attendings participated in individual phone interviews and four resident focus groups averaged five participants per group. RESULTS: Four main topics emerged: (1) effect of OERPs on patient care, (2) effect of OERPs on medical education, (3) barriers to OERPs, and (4) OERP best practices. CONCLUSION: Participants noted both positive and negative effects of OERPs on patient care and medical education. Best practices suggested to maximize these benefits and minimize drawbacks included targeting OERPs to certain types of clinical encounters and employing strategies to preserve the resident physician-patient relationship and resident autonomy.

Twelve Tips for Medical Education Leadership to Help Faculty in the Transition to Online Teaching.

This article was migrated. The article was marked as recommended. The COVID-19 pandemic has had innumerable profound impacts, many of which have resulted in irrevocable changes to both the practice of medicine and the teaching of medicine. Medical educators have adapted to the need for social distancing by providing virtual educational opportunities for their learners, often without training or experience in online teaching. Because these educators require both professional development and technical support for their online teaching to be sustainable and effective, departments need to provide immediate help and support. These twelve tips are designed for those in leadership roles who have recognized the need for investment in online education and are interested in strategies to ensure the success of their educational programs.

A Longitudinal Ambulatory Quality Improvement Curriculum That Aligns Resident Education With Patient Outcomes: A 3-Year Experience.

Quality improvement (QI) plays a vital role in practice management, patient care, and reimbursement. The authors implemented a 3-year longitudinal curriculum that combined QI didactics, intervention development, and implementation at university-based, community-based, and Veterans Administration-based practices. Highlights included Plan-Do-Study-Act cycle format, team-based collaboration to brainstorm interventions, interdisciplinary QI council to select and plan interventions, system-wide intervention implementation across entire clinic populations with outcome monitoring, and intervention modifications based on challenges. A pre-post survey assessed residents' confidence in QI skills and interdisciplinary team participation, while quarterly quality data assessed patient outcomes. All 150 internal medicine residents participated. Confidence in QI and interdisciplinary team participation improved significantly (P < .001). Patient outcomes improved for 6 of 9 targeted projects and were sustained at 1 year. This curriculum is a systems-based innovation designed to improve patient care and encourage interdisciplinary teamwork and can be adopted by residencies seeking to improve engagement in QI.

The impact of residents sitting at the bedside on patient satisfaction during team rounds.

OBJECTIVES: Patient satisfaction ratings are a priority for academic medical centers. Sitting during patient encounters has been recommended as a "best practice."1 A prior study showed that hospitalists had higher-rated communication skills when sitting compared to standing at the bedside during rounds.2 It is unclear whether the same is true of resident-led team rounds. METHODS: We performed a cluster-randomized crossover trial assigning 18 internal medicine residents to sit or stand at the bedside during rounds. RESULTS: A total of 347 patients were surveyed to assess physician communication skills. Standing residents received higher ratings than sitting residents on 2 of 5 survey items and rounding duration did not differ. These results differ from prior work that suggests sitting is superior to standing2-6. CONCLUSION: We suspect that one rounding member sitting, while all others stand, is not enough to impact patients' perceptions. These results suggest that initiatives to optimize patient satisfaction on resident-staffed units should be focused elsewhere. PRACTICE IMPLICATIONS: Patients do not have better impressions of physician communication skills when one team member is sitting and the rest are standing.

Implementation of Case Conferences to Improve Interprofessional Collaboration in Resident Continuity Clinic.

OBJECTIVES: Residents must be trained in skills for interprofessional collaboration and team-based care in the outpatient setting, and successful models are needed to achieve this aim. A longitudinal curriculum was developed to enhance residents' knowledge of interprofessional team members' roles, residents' attitudes toward team-based care, and patient referrals to team members. METHODS: Postgraduate year 1 through postgraduate year 3 internal medicine residents with continuity clinic at a large hospital-based practice received the curriculum. Residents with continuity clinic at another site did not receive the curriculum and served as controls. Intervention residents attended five small-group conferences during the course of 1 year, each dedicated to a specific interprofessional discipline: pharmacy, psychology, diabetes/nurse education, social work, and case management. Conferences involved interactive, case-based discussions of patients who benefit from an interprofessional approach. Control and intervention residents were surveyed with pre- and posttests. The rates of patient referrals to interprofessional team members were assessed. RESULTS: Seventy-one residents received the curriculum. Intervention residents' knowledge of team members' names and roles, indications for patient referral, and communication methods improved after curriculum implementation. Attitudes toward team-based care did not change but were positive at baseline. Following curriculum implementation, new patient referrals increased for the pharmacist (0.1-1/100 patient visits, P = 0.015) and psychologist (1.1-2.2/100 patient visits, P = 0.032). CONCLUSIONS: Case-based interprofessional conferences improved residents' knowledge regarding interprofessional care and increased referrals to team members. This curriculum addresses barriers to team-based care experienced by residents in continuity clinic and is adaptable to other clinic settings.

A Program to Support Scholarship During Internal Medicine Residency Training: Impact on Academic Productivity and Resident Experiences.

Problem: Although scholarship during residency training is an important requirement from the Accreditation Council for Graduate Medical Education, efforts to support resident scholarship have demonstrated inconsistent effects and have not comprehensively evaluated resident experiences. Intervention: We developed the Leadership and Discovery Program (LEAD) to facilitate scholarship among all non-research-track categorical internal medicine (IM) residents. This multifaceted program set expectations for all residents to participate in a scholarly project, supported faculty to manage the program, facilitated access to faculty mentors, established a local resident research day to highlight scholarship, and developed a didactic lecture series. Context: We implemented LEAD at a large university training program. We assessed resident scholarship before and after LEAD implementation using objective metrics of academic productivity (i.e., scientific presentations, peer-reviewed publications, and both presentations and publications). We compared these metrics in LEAD participants and a similar historical group of pre-LEAD controls. We also assessed these outcomes over the same two periods in research track residents who participated in research training independent from and predating LEAD (research track controls and pre-LEAD research track controls). We conducted focus groups to qualitatively assess resident experiences with LEAD. Outcome: Compared to 63 pre-LEAD controls, greater proportions of 52 LEAD participants completed scientific presentations (48.1% vs. 28.6%, p = .03) and scientific presentations and peer-reviewed publications (23.1% vs. 9.5%, p = .05). No significant differences existed for any academic productivity metrics among research track controls and pre-LEAD research track controls (p > .23, all comparisons). Perceived facilitators of participation in LEAD included residents' desire for research experiences and opportunities to publish prior to fellowship training; the main barrier to participation was feeling overwhelmed due to the time constraints imposed by clinical training. Suggestions for improvement included establishing clearer programmatic expectations and providing lists of potential mentors and projects. Lessons Learned: Implementation of a multifaceted program to support scholarship during residency was associated with significant increases in academic productivity among IM residents. Residents perceived that programs to support scholarship during residency training should outline clear expectations and identify available mentors and projects for residents who are challenged by the time constraints of clinical training.