How To Keep Community Preceptors

Preceptorship: This qualitative study is required reading for educators running courses, clerkships, residencies, or fellowships which depend on the contributions of volunteer community preceptors.  Researchers interviewed 27 volunteer faculty who were pediatricians practicing in the community and who had recently decided to stop or decrease their teaching of pediatric clerkship students.  Statements from the interviews were grouped into several themes about the difficulties leading to their decision to stop or cut back their involvement with teaching, as well as factors that would be viewed as positive inducements to teaching.

The evolution of healthcare delivery was commonly noted as a barrier, including increased documentation requirements, increased pressure for clinical productivity/RVU generation, and decreased efficiency with use of the electronic medical record (EMR).  These time pressures made the additional time needed for teaching more onerous, and eroded more into personal time needed by the physicians.  Student and educational system factors were also frequently identified as barriers:  disinterested students; decreased connection to or recognition by the academic institution; burdensome or unrealistic clerkship expectations; and decreased student interaction time.  Physicians also identified possible positive factors which would encourage their participation, including:  adequate monetary compensation or other recognition/benefit; a personal connection and improved communication with academic faculty; faculty development to improve teaching and efficiency; and involved students who could contribute something to efficiency.  The recent change in the Center for Medicare/Medicaid Services allowing for student documentation to “count” for billing with proper supervision may help with the last item.  As with most studies of this sort, there are concerns about the representativeness of those who agreed to be interviewed, but the themes identified are consistent with previous work on the topic of community preceptors. –Laura Willett, MD

Paul, Caroline R. MD; Vercio, Chad MD; Tenney-Soeiro, Rebecca MD, MSEd; Peltier, Chris MD; Ryan, Michael S. MD, MEHP; Van Opstal, Elizabeth R. MD; Alerte, Anton MD; Christy, Cynthia MD; Kantor, Julie L.; Mills, William A. Jr. MD, MPH; Patterson, Patricia B. MD; Petershack, Jean MD; Wai, Andrew MD, MPH; Beck Dallaghan, Gary L. PhD, The Decline in Community Preceptor Teaching Activity
Exploring the Perspectives of Pediatricians Who No Longer Teach Medical Students Academic Medicine: August 13, 2019 – Volume Publish Ahead of Print

 

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Who Should Get Honors?

Evaluation: This large survey study of medicine and pediatric inpatient clerkship faculty had a respectable 62% response rate.  Attendings were asked to describe their impressions of the evaluation/honors system and rank a total of 24 student characteristics in terms of their importance to giving an honors grade.  Even though 81% reported receiving no training on which students should receive honors, 86% felt that they could readily identify the high-performing student.  Eighty-three percent thought that fewer than 25% of their students should receive an honors designation.  Of the 24 student characteristics, 21 fell into three domains: professional behaviors (Factor 1), teamwork and communication skills (Factor 2), and systems-based behaviors such as evidence-based medicine practice and patient safety skills (Factor 3).  The five top-rated student characteristics were taking ownership of patients, clinical reasoning, curiosity, dependability, and high ethical standards.  All of these except clinical reasoning fell into Factor 1, the professional behavior domain.    Students who want honors, be aware that these are the characteristics your attendings are looking for! — Laura Willett, MD

Student Perspective: Clerkship grading and evaluations are a major source of stress for medical students. Students are acutely aware of the impact clinical grades have on their MSPE and their overall residency application.  There is sometimes significant variability between clinical sites and evaluator grading even within clerkships, which can add to students’ stress.  A single evaluator with a poor understanding of the rubric can sometimes be the difference between grade levels.  I think most students would be disheartened to read about the degree of variability not only of grading systems, but also of MSPE summative performance evaluations across medical schools.  You can see why residency programs place so much emphasis on an objective measurement like USMLE Step 1 score.  It is unrealistic for medical schools to have the same clerkship grading system.  However, there should be a requirement that schools disclose the percentages of students receiving each grade per clerkship to increase transparency.  Perhaps there should also be some standardization for the summative evaluation including a standard group of adjectives and/or reporting the student’s rank in terms of quartile.  These are important discussions to have, especially as the role of Step 1 is being reconsidered. — Rebecca Krakora (4th Year Medical Student)

Herrera LN, Khodadadi R, Schmit E, Willig J, Hoellein A, Knudson C, Law K, Mingioni N, Walsh K, Estrada C, Williams W. Which Student Characteristics Are Most Important in Determining Clinical Honors in Clerkships? A Teaching Ward Attending Perspective. Acad Med. 2019

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Do Reduced Residency Work Hours Create Worse Doctors?

Duty Hours: While controversy surrounding the 2003 ACGME work hour reforms has quieted significantly, questions remain about whether residents can obtain adequate clinical experience despite working fewer hours.  This interesting retrospective observational study reviewed 30-day mortality, 30-day readmissions, and inpatient spending data from a random 20% sampling of Medicare patients admitted to acute care hospitals from 2000-2012.  The authors compared 1^st year general internists who graduated before and after the ACGME mandate to a control group of 10^th year practitioners in a difference-in-difference analysis.

The two groups performed similarly.  No statistically significant differences were found in 30-day mortality, readmission, or Medicare part B spending.  Mortality rate trends across both cohorts suggest the influence of systemic improvements in hospital care.  The authors surmised that clinical experiences lost to reduced work hours and greater shift work were offset by “greater consolidation of clinical knowledge mediated by reduction in resident fatigue and increased teaching by residency programs.”  While this article primarily focused on inpatient internists, assessments of other aspects of physician quality and in other specialties like surgery also warrant study.

In a commentary on Harvard Business Review, the author suggests considering further trimming of residency work hours in an effort to address physician burnout.  Indeed, it would take a dramatic 40% reduction to bring the current 80-hour workweek in line with the 1998 European Working Time Directive limit of 48 hours a week for all public employees, including physicians in training.  — Catherine Chen, MD

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Jena AB Farid M, Blumenthal D, Bhattacharya J. Association of residency work hour reform with long term quality and costs of care of US physicians: observational study. BMJ. 2019 Jul 10;366:l4134. doi: 10.1136/bmj.l4134

 

Is Attractive As Important As Smart?

Admissions: Unfortunately yes, suggests this study which should be required reading for admissions and recruitment committee members.  Regular faculty reviewers of residency applications rated fictitious applications with variable demographic and academic data and application photos which were pre-adjudicated for obesity and attractiveness.  The raters were asked to generated a rating between 1 and 5 regarding their interest in interviewing the candidate.  Unattractiveness had a negative impact on this rating similar in magnitude to the positive impact of a higher Step 1 examination score, under-represented minority status, class rank, or clerkship grades.  Obesity had a less robust but still significant effect.  This reviewer is sure that this prejudice is not confined to the radiology faculty who were the subjects of this study, but is widespread within society and the medical community. — Laura Willett, MD

Maxfield CM, Thorpe MP, Desser TS, Heitkamp DE, Hull NC, Johnson KS, Koontz NA, Mlady GW, Welch TJ, Grimm LJ. Bias in Radiology Resident Selection: Do We Discriminate Against the Obese and Unattractive? Acad Med. 2019 May

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Entrustable Professional Activities Through Mastery Learning

Entrustable Professional Activities: Assessment of competency-based education is an ongoing challenge as medical schools are tasked with instilling the AAMC’s EPAs in their graduates.  Capstones, bootcamps, and other transition to residency courses have been developed to decrease variability in readiness for residency.  This study by Northwestern University evaluated students on 3 EPAs (getting informed consent, developing a differential diagnosis, and writing prescriptions) during their 2 week long 4^th year capstone course.  Students underwent a baseline skills assessment followed by faculty supervised educational sessions with deliberate practice, actionable feedback, and a post-intervention skills assessment.  Demonstration of mastery was required.  Students received additional deliberate practice and feedback until a minimum passing score on the post-test was achieved.  In this way, the authors concluded that they were able to verify medical student achievement of the 3 core EPAs in a “low-stakes formative assessment” as suggested by the AAMC.  The authors discuss future implementation of capstone and longitudinal EPA-based mastery learning curricula. — Catherine Chen, MD & Beth Goodman, MD

Salzman DH, McGaghie WC, Caprio TW, Hufmeyer KK, Issa N, Cohen ER, Wayne DB,  A mastery learning capstone course to teach and assess components of three entrustable professional activities to graduating medical students.  Teach Learn Med 2019;31:186

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Failure To Thrive: Predicting Interruption In Academic Progress Using A Growth Chart Metaphor

At Risk Students:  Early identification of students who may be at risk for interrupted academic progress (i.e., having to repeat a course, an entire academic year or facing dismissal) is essential for professors, learning specialists, and those in academic affairs. In this innovative article, a visual approach for graphing accumulated exam points (using 11 summative multiple-choice question exams) over the course of the first and second year of medical school is described.  The authors liken plotting student exam scores to the plotting of height and weight on growth charts used in pediatric well visits.  In their metaphor, performing at the class average or gaining points above the class average would be “healthy” growth, while performing below average and increasingly moving away from the class mean would indicate significant risk.  The model allows for easy data analysis using minimal software and has great promise in providing a simplified way to identify at-risk students as early as the fifth summative exam (they were able to predict students at risk with 85% accuracy and are in process of extending the research to other institutions).    Much like a pediatrician would recommend adequate nutrition for a child not meeting growth markers, educators can plot student exam scores and recommend alternate study strategies and retention practices to ensure adequate academic growth. — Kristen M. Coppola, Ph.D.

Cendán J, Joledo O, Soborowicz M, Marchand L, Selim B. Using Assessment Point Accumulation as a Guide to Identify Students at Risk for Interrupted Academic Progress. Academic Medicine. 2018;93(11):1663-1667.

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US News And World Report Rankings Remain Deeply Flawed And Far Too Influential

Rankings: In this thoughtful commentary, the author describes the US News and World Report formula used to rank medical schools and quotes dean Robert Alpen of Yale that “there’s nothing really in (the) formula that is really evaluating the quality of medical education.  That would be so much more valuable to the applicants, to the students.  And it would incentivize us to do a better job in education.”  The author also posits that the student descriptor inputs to the formula may reinforce “a flawed system that values test-taking abilities above all other attributes even before medical school begins.”  The author suggests other, much more meaningful metrics:  preparation for residency; career trajectory; quality of clinical care 10-20 years after graduation; career satisfaction; research impact of the school; community benefit from school, faculty, and graduates. Obviously, these are much more difficult to measure than the metrics currently in the formula. The author ends with an acknowledgement that the pernicious effect of these rankings are not confined to medical schools but extend to many types of educational institutions.  He quotes law professor Jeffrey Evans Stake:

“US News has set up a game.  The players are the schools being ranked and the faculty members at those schools.  Most faculty members and administrators seek to increase their school’s rank by various strategic moves.  These moves are costly, in terms of money and other resources, but do little or nothing to improve legal education for students.  Indeed, it is worse than that.  Many of the strategies run contrary to the interests of students and society.”

It is important to note that the US News and World Report ranking for “primary care” is not discussed in this commentary, but shares similar fatal flaws:  a plurality of the ranking is based on a dean-level reputational survey with an extremely low response rate; the student descriptors are similarly flawed; and there is no measure of long-term entry into primary care by a school’s graduates. — Laura Willet, MD

McGaghie WC, America’s Best Medical Schools: A Renewed Critique of the U.S. News & World Report Rankings. Acad Med. 2019 Apr

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