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On the DR MERL blog, we have added a new type of post:  commentaries on medical education research.  To further engage our readers further and build our online community, we are allowing readers to comment on individual posts.  We hope this will turn the DR MERL blog into a place where we can keep the conversation going about medical education research.  

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The DR MERL Editorial Team

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Medical Education Research Round-Up

A Peak Into Medical Malpractice Claims Involving Trainees

Malpractice — Medical malpractice claims involving trainees is the focus of this research.   Between 2012 and 2016, researchers looked at 581 malpractice claims(malpractice defined as “written requests for compensation due to injury”) from 32 teaching institutions and 9 states and found direct involvement of a resident in 81% of cases, a fellow in 13% of cases and both residents and fellows in 6% of cases. They further found that the most common diagnosis associated with malpractice claims was laceration during surgery (11%) in specialty fields such as oral surgery/dentistry and ob-gyn.  Inadequate supervision was a contributing factor in 24% of cases.  –DR MERL Editorial Team

Myers, Laura C. MD, MPH; Gartland, Rajshri M. MD, MPH; Skillings, Jillian; Heard, Lisa MSN, RN; Bittner, Edward A. MD, PhD; Einbinder, Jonathan MD, MPH; Metlay, Joshua P. MD, PhD; Mort, Elizabeth MD, MPH, An Examination of Medical Malpractice Claims Involving Physician Trainees, Academic Medicine, August 2020

Link To Article

Diagnostic Accuracy Improves Upon Reflection

Reflection Recognizing that diagnostic error is one of the most common and most harmful patient safety problems, researchers looked at reflection as a tool for improvement.   One hundred and sixty-seven (167) physicians in Bern, Switzerland were asked to reflect on patient cases (1) without instruction, (2) with confirmatory evidence, (3) with contradictory evidence, or (4) both.  Results found reflection in any mode helped improve diagnostic accuracy as measured by the set of cases presented to the physicians for this study.    — DR MERL Editorial Team

Mamede, Sílvia; Hautz, Wolf E.; Berendonk, Christoph; Hautz, Stefanie C.; Sauter, Thomas C.; Rotgans, Jerome; Zwaan, Laura; Schmidt, Henk G, Think Twice: Effects on Diagnostic Accuracy of Returning to the Case to Reflect Upon the Initial Diagnosis, Academic Medicine, August 2020

Link To Article

How Clinical Decision Rules Factor Into the Diagnostic Mix

Decision-Making — Sixteen emergency medicine physicians from 3 teaching hospitals in Canada were interviewed while diagnosing simulated patients with chest pain, breathlessness, or leg discomfort to see how clinical decision rules (CDR, using a given set of clinical predictors to estimate the probability of a diagnosis) factored into their thought process.   Analysis shows that physicians use dynamic and iterative clinical decision-making which contrasts with the static, linear approach found in CDR’s.   In the group studied, CDR’s were applied only after tests were ordered. — DR MERL Editorial Team

Chan, Teresa M.; Mercuri, Mathew; Turcotte, Michelle; Gardiner, Emily; Sherbino, Jonathan; de Wit, Kerstin, Making Decisions in the Era of the Clinical Decision Rule: How Emergency Physicians Use Clinical Decision Rules, Academic Medicine, 2020

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Antimicrobial Therapy Under The Microscope

Thought-Process — In this qualitative study, investigators explore clinicians’ thought process involved in prescribing anti-microbials. Sixteen participants described 3 steps, 25 factors, 4 areas and 14 different drug characteristics that the authors developed into a framework which may provide be helpful in the development of education tools across medical disciplines. — DR MERL Editorial Team

Abdoler, Emily A. MD, MAEd; O’Brien, Bridget C. PhD; Schwartz, Brian S. MD, Following the Script: An Exploratory Study of the Therapeutic Reasoning Underlying Physicians’ Choice of Antimicrobial Therapy, Academic Medicine, 2020

Link To Article

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Collaboration Thrives In A Culture of Collaboration 

Interprofessionalism:  It is no surprise that adverse events in patient care are attributed in part to ineffective communication, especially at transitions of care between the inpatient and outpatient settings.  One manner in which to improve this process is to promote the communication via education on intraprofessional collaboration. This study in the Journal of Medical Education shows that medical educators who are interested in building and maintaining intraprofessional collaboration may still benefit from a quick dip into this ethnographic non-participatory observational study from the Netherlands.

Forty-two residents and their supervisors at five hospitals were interviewed about collaboration between primary care physicians and medical specialists.  The results (based 45 hours of taped recordings) suggest that intraprofessional collaboration between these two cohorts is promoted when there is a culture of collaboration, and power dynamics and hierarchy are limited.  Three themes were identified as a means to improve the culture of collaboration: 1)while intraprofessional collaboration is implicitly learned, active learning promotes a culture change, 2)empowering the primary care team members to promote their knowledge and skills mitigates any competing roles between the primary care (PC) team, and medical subspecialty (SC) teams and 3) shared physical space in the clinical work environment allows for equity and collaboration. Furthermore, barriers to collaboration arise when placement goals overlook collaboration and participants are not accustomed to reaching out to each other for assistance.

There are, however, some noteworthy limitations in this study. The data source was  limited to emergency and geriatric departments, but the multi-site approach suggests the findings may be widespread and may be true in other departments as well.   Additionally, while the observations were done in an incognito manner, they occurred in locations without active patient care. This precludes the observation of informal learning that occurs in this space.

One final note: researchers in this study used rapid ethnography — a technique of entering into the arena of study with focused questions and finding results quickly.   We can only wonder then what else researchers might have found if they used the traditional ethnographic approach and took more time. While these limitations exist, this study does highlight the role training, supervision, and the clinical learning environment in the promotion of successful intraprofessional collaboration to mitigate adverse events between primary care and medical subspecialty care teams.  — Payal Parikh, MD (with Editorial Team)

Natasja Looman, Cornelia Fluit, Marielle van Wijngaarden, Esther de Groot, Patrick Dielissen, Dieneke van Asselt, Jacqueline de Graaf, Nynke Scherpbier-de Haan, Chances for learning intraprofessional collaboration between residents in hospitals, Med Educ 2020 Jun 21.

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Once A Bad Apple, Maybe Always A Bad Apple

Professionalism: This study from Academic Medicine is the first to prospectively support what most of us believe: that students with professionalism issues in medical school may exhibit unprofessionalism and, potentially, prosecutable behavior in clinical practice.

Two groups of medical students from Harvard and Case Western Reserve were identified: 108 former medical students who appeared before their school’s review boards, and a control group of 216 former medical students (matched for gender, underrepresented status in medicine, and year of graduation) who did not.   Four data points were used in this study: before medical school (including demographics, undergraduate college and major, and MCAT score), during medical school (clerkship grades and USMLE scores), during residency (ratings from residency directors), and after residency (state medical board sanctions and malpractice history).

Findings suggest that students who appeared before a review board in medical school were FIVE times more likely to be cited for professionalism issues during residency.   Furthermore, TEN percent of those who appeared before a review board were later sued or sanctioned by their state medical board, compared with five percent who were not brought before their medical school’s review board.  In addition to appearing before the medical school review board, scores on some standardized tests (Step 2 CK score, step 3 score, and MCAT total score) and clerkship grades (neurology, internal medicine, and obstetrics–gynecology) were also predictive of residency disciplinary review and/or future malpractice or sanctioning.

The study is not without limitations: the authors used a small sample size from two highly selective medical schools, relied on resident directors’ recollection (which is sometimes unreliable), and focused on subjects early in their careers.  Importantly, the study did not look at the effectiveness of alternative disciplinary or remediation strategies. Despite these shortcomings, this study is worthwhile reading, if for no other reason than the statistics are eye-catching —   David A. Cohen, MD (with Editorial Staff)

Krupat (et al), Do Professionalism Lapses in Medical School Predict Problems in Residency and Clinical Practice?, Academic Medicine June 2020

Link To Article


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Medical Education Research Round-Up

Do Professionalism Lapses in Medical School Predict Problems in Residency and Clinical Practice?
Krupat E (et al)

N: 108 (medical school graduates)
Method: review of records
Multi-site: Yes
Location: Harvard Medical School; Case Western Reserve University School of Medicine
Conclusion: “Students with professionalism lapses in medical school are significantly more likely to experience professionalism-related problems during residency and practice, although other factors may also play an important predictive role.”
Journal: Academic Medicine

A Signal Through the Noise: Do Professionalism Concerns Impact the Decision Making of Competence Committees?
Odorizzi S (et al)

N: 25 (emergency medicine program directors and senior faculty)
Method: survey
Multi-site: No
Location: Royal College of Physicians and Surgeons of Canada
Conclusion: “When reviewing a simulated resident portfolio, individual reviewer scores for residents PAE (progressing as expected) were responsive to the addition of professionalism concerns. Considering this, educators using a CC (competence committee) should have a system to report, collect, and document professionalism issues.”
Journal: Academic Medicine

Internal Medicine Resident Professionalism Assessments: Exploring the Association With Patients’ Overall Satisfaction With Their Hospital Stay Ratelle JT (et al)

N: 409 (409 patients assessed 72 PGY-1 residents)
Multi-site: No
Location: Mayo Clinic Hospital-Rochester, Saint Marys Campus
Conclusion: “Hospitalized patients’ assessment scores of in-hospital resident professionalism were strongly correlated with overall patient satisfaction with hospital stay but were not correlated with resident professionalism in other settings. The limitations of patient evaluations should be considered before incorporating these evaluations into programs of assessment.”
Journal: Academic Medicine

Does Empathy Decline in the Clinical Phase of Medical Education? A Nationwide, Multi-Institutional, Cross-Sectional Study of Students at DO-Granting Medical Schools
Hojat M, (et al)

N: 10,751 (medical students)
Multi-site: Yes
Method: Survey
Location: 41 DO granting medical schools in United States
Conclusion: Students in clinical years (M3 and M4) have slightly less empathy than students in preclinical years (M1 and M2) in both MD and DO progams; however, the decline is less pronounced in DO students.
Journal: Academic Medicine

Chances for learning intraprofessional collaboration between residents in hospitals
Looman N, et al

N: 42 (residents and supervisors)
Method: interviews
Multi-site: Yes
Location: three emergency departments and three geriatric departments of five hospitals in the Netherlands
Conclusion: Intraprofessional collaboration (intraPC) between primary care (PC) doctors and medical specialists (MS) is promoted when there is a collaborative culture, hierarchy is limited, there is dedicated time for intraPC and support from the supervisor.
Journal: Medical Education

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How Can Residents Learn To Think On Their Own? Qualitative Studies Of Cognitive Autonomy In Residents

Autonomy: Everyone agrees that resident autonomy is important but, in contrast to resident procedural autonomy, there are no validated measures of resident cognitive autonomy. Two recent qualitative studies shed some light on the issue. Crockett et al conducted focus groups and open-ended surveys with residents in 6 mostly-cognitive specialties, asking them to define autonomy and to specify what attending physician actions promote or undermine autonomy. Santen et al conducted focus groups with both residents and attendings in emergency medicine, getting their perspectives on entrustment and autonomy. In this latter study, four factors were felt to materially influence the level of autonomy granted to a resident by the attending physician: patient factors (medical acuity and social complexity), resident factors (level of training and perception of resident quality), systems factors (busyness and the local culture of resident autonomy), and faculty factors. The authors report a strong influence of “faculty personality and approach”, with attendings ranging from “micromanagers” to “ghosts”. In the multi-specialty study, residents said they recognized receipt of autonomy when: they made independent decisions, they took a visible role as team leader with patients and others, and they received more trust over time. Residents in these specialties had very similar ideas about attending behaviors that promoted or impaired autonomy. The authors summarize: “Challenging residents to support their care plan while remaining supportive of their thought process is critical, as is basing any changes from the resident plan on evidence rather than style. Being available at a distance as a ‘safety net’ is important for the comfort level of resident physicians, but allowing time to work in the absence of the attending physician is also important for autonomous activity.” Maybe the micro-managers and ghosts among us can try harder to display these behaviors. — Laura Willett, MD

Crockett C, Joshi C, Rosenbaum M, Suneja M. Learning to drive: resident physicians’ perceptions of how attending physicians promote and undermine autonomy. BMC Med Educ. 2019 Jul 31;19(1):293.
Link To Article
Santen SA Wolff MS, Saxon K, Juneja N, Bassin B. Factors Affecting Entrustment and Autonomy in Emergency Medicine: “How much rope do I give them?”, West J Emerg Med. 2019 Jan;20(1):58-63.
Link To Article



Autonomy is a complicated concept to residents; it tends to be highly desired, yet simultaneously feared. A fresh July intern initially fears autonomy due to lack of experience, but as they grow into autonomy-craving residents, a residual fear of complete independence remains. Thus, these two recent qualitative studies did not yield surprising results. Crockett et al, in which focus groups and surveys were used to determine behaviors of attending physicians that support or undermine autonomy, found that residents reported autonomy to be critical to their development as independent physicians. This desired sense of autonomy was supported by attendings who allowed residents to take the lead with an appropriate level of supervision. This essentially describes the “perfect” attending. Every resident fears the extremes: the attending who hovers all hours of the day, commenting on everything from choosing enalapril over lisinopril to improper comma use in a progress note, versus the attending who leaves the hospital at noon and seemingly never has cell phone service. The highly desired attending falls right in the middle, allowing the resident to independently interview, assess, plan, and manage the patient with minimal intervention unless care of the patient is compromised, while maintaining a level of support and accessibility. Similarly, Santen et al used resident and faculty focus groups to discuss entrustment of residents and found that multiple factors affected entrustment including patient factors (acuity, socioeconomic issues), environmental factors (patient volume, systems), resident factors (year of training, previous experience with resident), and faculty factors (confidence level, education interest, fear of risk). These findings again highlight an important point; certainly residents need to be driven and competent enough to seek out their own autonomy, but the attending behind them must possess the confidence and experience to allow the resident to independently make their own assessments and decisions, assuming these decisions will not have a negative impact on patient care. From the perspective of a senior resident, having a supportive attending is comforting, but the attending must remember we will soon be “in the wild” without supervision.  — Lauren Pioppo, MD (PGY 3)

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Mistreatment And Distress Among Residents

Mistreatment: This survey study is required reading for residency program directors.  The authors utilized the US in-training examination to survey 7409 surgical residents (>99% of those eligible) regarding various types of mistreatment, burnout, and suicidal thoughts.  The most common types of mistreatment reported as occurring at least “a few times a year” were gender discrimination (65% of women), racial discrimination (17% of the cohort, not broken out by race), verbal or emotional abuse (30% of the cohort), and sexual harassment (20% of women).  Patients, families, and attendings were the most common sources of mistreatment, with co-residents and nurses responsible for much of the remainder. Thirty-nine percent of residents reported at least one 80-hour duty hours violation in the previous 6 months.  Burnout and suicidal thoughts were highly associated (OR > 2) with reports of any mistreatment at least a few times a year and with >2 duty-hour violations in the prior 6 months.  The only other strong predictor of suicidal thoughts was divorced or widowed marital status.  Although surgical residents are likely a high-risk group, similar results might be found among residents in other specialties.  Program directors and chief residents should continue to assess the environment in which their residents practice. — Laura Willett, MD

Hu YY, Ellis RJ, Hewitt DB, Yang AD, Cheung EO, Moskowitz JT, Potts JR 3rd, Buyske J, Hoyt DB, Nasca TJ, Bilimoria KY. Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training. N Engl J Med. 2019 Oct 31

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Malpractice and the Trainee Physician

Malpractice In this interesting case-control study of closed malpractice claims, investigators evaluated five years of data from 32 teaching hospitals.  Cases (n = 581) were claims made regarding a harm event in which a resident or fellow was directly involved.  Controls (n = 2,610) were claims made from the same facilities in which a trainee was not directly involved in the harm event, although they may have been involved in the patient’s care.  A majority of claims among both cases (71%) and controls (58%) were related to procedures, with a statistically significant higher percentage among the cases as compared with the controls.  Tellingly, “inadequate supervision” was listed as a contributing factor in 24% of the cases and only 1% of controls.  Other contributing factors more commonly cited in the cases than in the controls were failure to reconcile relevant information and poor communication among providers.  Interestingly, after multivariable analysis, cases and controls did not differ by July admission status or weekend admission status.   The specialties of obstetrics-gynecology and oral surgery/dental medicine were over-represented among the cases.  Based on this data, program directors may want to pay particular attention to assuring adequate supervision during trainee procedures. — Laura Willett, MD

Myers LC, Gartland RM, Skillings J, Heard L, Bittner EA, Einbinder J, Metlay JP, Mort E., An Examination of Medical Malpractice Claims Involving Physician Trainees. Acad Med. 2019

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Do Professionalism Lapses In Medical School Predict The Future? 

Professionalism — Probably to some extent, according to the 20+ year case-control study of graduated medical students from Harvard and Case Western medical schools.  Case were 108 students appearing before a review board for professionalism concerns; these were compared to 215 controls matched for gender, under-represented minority status, and year of graduation.  Comparisons were made at several time points based on information available to the researchers:  academic and demographic items at matriculation; academic achievements during medical school; professionalism surveys completed retrospectively by residency program directors; and state board information about board sanctions and malpractice suits.  Cases and controls looked very similar at matriculation, with similar undergraduate institutions, college majors, MCAT scores, and family educational attainment (50% of the students’ fathers had doctorate degrees).  During medical school the academic performance of case students coming to professionalism review was substantially worse than that of their peers as measured by licensing exam scores (Step 1 and Step 2 CK) and clerkship grades. which is interesting given the very similar MCAT scores.  Despite a 50% survey response rate from residency program directors, unsurprising given the passage of time, case students were rated far lower than their peers (with p <0.05) for a wide variety of behaviors during residency: treating colleagues with respect; incorporating feedback; honesty; team functioning; taking responsibility for shortcomings; and trustworthiness.  They were much more likely to “require remediation or counseling” (35% vs. 9%) and the residency director was much less likely to feel “strongly enthusiastic” about the resident possibly applying to be a faculty member (29% vs. 56%).  After residency, there was a small, non-significant trend for increased sanctions by state boards in the cases, 4% vs. 1%, and increased malpractice claims, but these were small trends and not corrected for specialty.  These data suggest that the rare student coming to a review board for professionalism reasons is much more likely to have academic difficulty and to display continuing professionalism misbehaviors during residency than their peers.  The post-residency outcomes measured here are probably somewhat  insensitive for professionalism difficulties, with a small number of outcomes impairing the ability of this study to find a difference (which have been found in some other studies). — Laura Willett, MD

Krupat E, Dienstag JL, Padrino SL, Mayer JE Jr, Shore MF, Young A, Chaudhry HJ, Pelletier SR, Reis BY Do Professionalism Lapses in Medical School Predict Problems in Residency and Clinical Practice? Acad Med. 2019
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