Has Resident Duty Hour Regulation Adversely Affected Medical Student Education? Depends Who You Ask

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dutyhoursRed In the midst of much controversy about resident duty hour regulations, another study adds to the uncertainty about its impact on medical student education. In this study, investigators surveyed medical students and clerkship directors about the quality of teaching, evaluation, and patient care during internal medicine clerkship or sub internship before and after duty hour regulations. Response rates were 48% to 64% for students and 82% for clerkship directors. Although students perceived few adverse effects of the 2011 duty hour regulations on their education, clerkship directors generally had negative perceptions. While it may be somewhat reassuring that students’  perceptions were not worse, the discrepancy between students’ and clerkship directors’ perceptions is interesting, and lends support to the notion that perceptions may not be useful in trying to measure the impact of duty hour regulations.  — Sarang Kim, MD

R Kogan J, Lapin J, Aagaard E, Boscardin C, Aiyer MK, Cayea D, Cifu A, Diemer G, Durning S, Elnicki M, Fazio SB, Khan AR, Lang VJ, Mintz M, Nixon LJ, Paauw D, Torre DM, Hauer KE. The effect of resident duty-hours restrictions on internal medicine clerkship experiences: surveys of medical students and clerkship directors.Teach Learn Med. 2015;27(1):37-50.

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Interprofessional Training For Medical Students

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interprofession  Interdisciplinary teamwork has been shown to lead to improved patient outcomes as well as greater job satisfaction for the healthcare workers involved.  Consequently, there is increased interest in providing interprofessional education (IPE) for medical students.  University of Toronto initiated a “Transition to Clerkship” course for third-year medical students to prepare them for working with other healthcare professionals (HCPs) on the wards.  The intent of this course is to improve interprofessional relationships and facilitate positive attitudinal changes toward HCPs.  The students shadowed a variety of HCPs in the hospital and then provided feedback on their experience.  A large majority of students responded that the experiences improved their understanding of the roles and responsibilities of the professions that they shadowed and that the experience left them better equipped to communicate with the various HCPs.  The students felt that this experience was a valuable component of their education. Lee Ann Schein, Ph.D.

Daniel M. Shafran , Lisa Richardson & Mark Bonta, A Novel Interprofessional Shadowing Initiative for Senior Medical Students, Med Teach. 2015 Jan;37(1):86-9.

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Active Learning Techniques For Medical Educators

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active_learning  Traditionally, lectures are the principle mode of delivering core content in an emergency medicine (EM) curriculum. The authors describe a variety of different active learning approaches that can be incorporated in this curriculum to improve knowledge retention and create a deeper understanding of the material. The active learning approaches are proving to be very effective for understanding evidence-based medicine, communication skills, and self-directed learning, the skills that are well aligned with the goal of EM residency programs. This is a very comprehensive compilation of a variety of active learning methods that can be used by medical educators. The authors have created very structured and concise tables summarizing these approaches, which will allow the educators to choose the most appropriate method based on their goals and available resources. The authors give brief description (objectives, how to use, suggestions for modifications, examples etc) of each of these approaches such as, pause procedures, one-minute paper, the muddiest point, think-pair-share, case-based learning, concept maps, role-play, commitment activities, jigsaw, team-based learning, problem-based learning, and thinking hats. Although the authors have described these approaches for emergency medicine curriculum, these can be used in all years throughout the medical education. -Sangita Phadtare, Ph.D., Cooper Medical School of Rowan University

MARGARET WOLFF, MARY JO WAGNER, STACEY POZNANSKI, JOCELYN SCHILLER, SALLY SANTEN., NOT ANOTHER BORING LECTURE: ENGAGING LEARNERS WITH ACTIVE LEARNING TECHNIQUES., THE JOURNAL OF EMERGENCY MEDICINE 2015 JANUARY VOLUME 48(1), 85–93

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How Can We Measure Medical School Applicant Socioeconomic Status?

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diversity  Medical student diversity is an important aim, with socioeconomic diversity perhaps more difficult to measure and attain than other types of diversity.  The authors suggest an easy-to-administer measure of parental education and occupation (EO) with 5 levels ranging from EO-1 (parent has less than a bachelor’s degree) to EO-5 (parent has doctoral/professional degree and “executive, managerial, professional position”).  There was a strong, graded correlation with other widely used measures of socioeconomic status, such as low family contribution to education.  This reviewer felt that, given that 32.7% of EO-1 candidates had no other measures of disadvantaged status and census data showing that only around 30% of adults have a bachelor’s degree, that there might be some utility to sub-dividing the EO-1 group into more and less disadvantaged subgroups. — Laura Willett, MD

Grbic D, Jones DJ, Case ST. The Role of Socioeconomic Status in Medical School Admissions: Validation of a Socioeconomic Indicator for Use in Medical School Admissions. Acad Med. 2015 Jan 27.

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Can You Observe Me AFTER Him (or Her)?  Prior Observations Affect Graders of High-Stakes Evaluations

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evaluation Replicating the results of experiment, investigators found that examiners’ ratings of candidates in two very different high-stakes behavioral testing situations were affected by the performance of prior candidates.  The first group of scores were from 2,272 takers of a UK 16-station OSCE required for any medical school graduate who has been out of medical school for more than 2 years and who wishes to pursue subspecialty training.  The second were the multiple mini-interview (MMI) scores of 3,016 applicants to the University of Alberta Medical School.  Consistent negative correlations were found between the index score and those of preceding examinees.  That is, a candidate was graded somewhat higher if he or she was preceded by less-ranked candidates, and vice versa.  The effect accounted for 5% to 11% of total score variance.  This appears to be a fairly robust effect.  Now the difficulty will be in deciding how to correct or ameliorate it. — Laura Willett, MD

Yeates P1, Moreau M, Eva K. Are Examiners’ Judgments in OSCE-Style Assessments Influenced by Contrast Effects? Acad Med. 2015 Jan 27.

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Have Your Attending (Not The Trainee) Decide If Intensive Care Is Futile

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intensive_care   In this extensive single-center study, critical care attendings and fellows generated more than 10,000 assessments regarding the futility of care provided to their ICU patients.  Attendings were much less likely than fellows (7% vs. 17%) to deliver an assessment that care was futile.  Six months later, 61.5% of patients assessed by fellows as receiving futile care had died, as opposed to 84.6% of patients so assessed by attendings.  Not only were attendings more accurate, they also took more time (4 days vs. 2 days of patient interaction) to come to this assessment. — Laura Willett, MD

Neville TH, Wiley JF, Holmboe ES, Tseng CH, Vespa P, Kleerup EC, Wenger NS. Differences Between Attendings’ and Fellows’ Perceptions of Futile Treatment in the Intensive Care Unit at One Academic Health Center: Implications for Training. Acad Med. 2014 Dec.

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For Diagnostic Reasoning Accuracy, Experience Helps — Time Pressure & Interruptions Don’t Hurt

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accuracy  Forty-six US and Canadian ER attending physicians and 152 multi-specialty Canadian residents sitting for Part II qualifying exams were given 20 general medical diagnostic cases.  Attendings scored more correct answers (71%) than residents (43%).  Test-takers were randomly exposed to different testing conditions – a “fast” vs. “slow” time condition, and an interruption vs. no-interruption condition.  During the “fast” condition, participants were told to “work as quickly as you can without sacrificing accuracy,” while during the “slow” condition, they were advised to “consider all the data before you arrive at your diagnosis,” and they were given 50% more time.  Half of the questions were non-interrupted, while the other half were interrupted by an audible 4-digit number which had to be transcribed at the end of the case and a visual unrelated multiple-choice question.  Interruptions and the “slow” condition increase the time for physicians to come to a response, but did not change the overall accuracy of the answers. — Laura Willett, MD

Monteiro SD, Sherbino JD, Ilgen JS, Dore KL, Wood TJ, Young ME, Bandiera G, Blouin D, Gaissmaier W, Norman GR, Howey E. Disrupting Diagnostic Reasoning: Do Interruptions, Instructions, and Experience Affect the Diagnostic Accuracy and Response Time of Residents and Emergency Physicians?
Acad Med. 2015 Jan

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Does A Milestone-Based Evaluation Have Better Discriminatory Ability? Yes and No.

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evaluations    Residency programs across the country have recently transitioned to a Milestone-based evaluation form in response to ACGME’s call to measure and report resident performance via education milestones. Prior to this change, many evaluation systems relied on the Dreyfus framework of assessment, which describes a learner as a novice, advanced beginner, competent, proficient, or expert. In this before/after study from a university-based internal medicine residency program, investigators compared scores on resident evaluations between a Dreyfus-based model of evaluation and a new Milestone-based evaluation. Both evaluation systems assessed resident performance in the 6 ACGME competency domains using a 5-point scale: for the Dreyfus model, 1 = beginner, 2 = advanced beginner, 3 = approaching competency, 4 = competent, and 5 = advanced competent; for the Milestone-based model, a 5-point scale was anchored by performance expected at a given level of training, where 1= 0-3 months, 2 = 6 months, 3 = 12 months, 4 = 18-24 months, 5 = 30-36 months. While the study investigators report better discriminatory ability with the Milestone-based evaluation as demonstrated by larger separation in scores among the 3 PGY classes with wider use of the 5-point scale, they did not report discriminatory ability within PGY classes. In fact, standard deviations around mean scores were consistently smaller with the Milestone-based evaluation compared to the Dreyfus-based evaluation. It’s quite plausible that when a scale is anchored by level of training, evaluators may feel “free” to use lower ratings for early PGY-1’s. Similarly, evaluators may have felt compelled to use higher ratings for graduating residents, though this was not addressed by the study. — Sarang Kim, MD

Friedman KA, Balwan S, Cacace F, Katona K, Sunday S, Chaudhry S. Impact on house staff evaluation scores when changing from a Dreyfus- to a Milestone-based evaluation model: one internal medicine residency program’s findings. Med Educ Online. 2014 Nov 24;19:25185.

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Just-in-Time Teaching With Peer Instruction Improves Resident Involvement During Conferences

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JIT  Several techniques for increasing learner engagement as compared to lecture have been described in the general education literature and are starting to replace lectures in didactic conferences for residents.  In a surgical residency program, faculty members were offered faculty development in just-in-time teaching (JiTT) during a one-hour faculty development session, or individually.  Seventy-three percent of the faculty presenting resident conferences volunteered for faculty development.  Residents were assigned readings before the class session and answered several pre-session questions addressing key concepts, as well as a question asking which concepts were most difficult.  Class sessions were structured with mixed-level resident groups.  Faculty members gave brief “mini-lectures” based on the concepts with which the residents demonstrated the most difficulty, followed by several multiple choice questions to be answered by residents individually using an audience response system.  If between 35% and 70% of residents answered the question correctly, the mixed level groups were asked to discuss the answers among themselves, utilizing peer instruction.  If very few residents answered correctly, the faculty member needed to clarify misconceptions; if the vast majority answered correctly, only brief clarification was needed.  Overall, a large majority of both residents and faculty responded positively to JiTT.  A majority of residents found the pre-readings helpful, and 90% of faculty members found the resident pre-session responses useful in their preparation.  Residents particularly enjoyed the peer instruction element.  Sessions were videotaped to objectively measure resident engagement.  Residents were actively engaged 34% of the time during JiTT sessions, vs. 11% of the time during the same faculty members’ lecture sessions.  JiTT appears to be another active-learning technique which can be successfully applied to resident conferences. — Laura Willett, MD

Schuller MC, DaRosa DA, Crandall ML. Using Just-in-Time Teaching and Peer Instruction in a Residency Program’s Core Curriculum: Enhancing Satisfaction, Engagement, and Retention. Acad Med. November 2014

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Medical Education Leaders Don’t Know Much About Medical Education Evidence

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evidence  In this qualitative study, investigators interviewed 15 undergraduate medical education leaders regarding their use of empirical evidence about medical education practices.  They found that “many did not actively seek research evidence to inform their educational practices.”  Three factors were reported to increase these faculty members’ use of evidence re medical education: peer involvement in education research, peer recommendation of resources, and the availability of faculty development.  Several factors decreased faculty use of evidence.  These included:  the perception that the evidence is of poor quality; inadequate time to seek out the education literature; faculty or student resistance to change; and limitations in resources needed for curricular change.  One barrier to the use of empirical evidence in medical education is one that this newsletter aims to ameliorate:  “Participants wanted empirical evidence to be disseminated using approaches that are highly accessible to educators, in part through simple synthesis and brief presentation.” — Laura Willett, MD

Onyura B, Légaré F, Baker L, Reeves S, Rosenfield J, Kitto S, Hodges B, Silver I, Curran V, Armson H, Leslie K. Affordances of Knowledge Translation in Medical Education: A Qualitative Exploration of Empirical Knowledge Use Among Medical Educators. Acad Med. 2014
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