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.
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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.
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Commentary:

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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Internal Medicine Residency Program Directors Respond To Application Inflation

Application Inflation: Housetaff recruitment is an area of critical focus at every training program. At an estimated cost of $14,162 per filled position, managing recent trends in a growing applicant pool poses an added challenge.

In this survey based study of IM program directors (PDs) in 2017 with wide representation from university and community programs, inclusion and exclusion criteria for interview granting, USMLE cutoff scores, process changes related to recent trends in application inflation, and the ability to conduct “holistic’ interviews were analyzed. To no surprise, USMLE Step scores (step 2 followed by Step 1) were cited as Single Most Important (SMI) factors for the decision to interview, followed by the candidates’ ranking in the chair’s departmental letter and MSPE ranking. Exclusion criteria for interviews focused on “hints of unprofessional behavior in the MSPE or recommendation letter” followed by Step 2 CK failure, negative comments in the MSPE, failure on the Step 2 CS and Step 1 failure, in descending order.  The survey also inquired about the USMLE scores programs used for interview cutoffs and found the mean Step 1/2 cut offs for IMG’s were 224/ 228 and 211/216 for USG’s in 2017.  These cutoffs were lower for internal medicine than for programs in dermatology, orthopedic surgery, plastic surgery and radiation oncology (~245).

With an increase in applicants over the past 3 years, 54% of IM PD’s responded by raising the bar for granting interview invitations.  Others invited more applicants, added more interview days, or turned away applicants without ties to the program.  Due to this increase in applicants, 46% of programs reported they are less likely to perform a “holistic” review of applicants.  In the setting of increasing numbers of applicants, this survey based study demonstrates the persistent reliance on USMLE scores for evaluating candidates and a diminished ability to conduct a thorough review of applicants — Payal Dave MD & Ranita Sharma MD.

Angus, Steven V. MD; Williams, Christopher M. MPH; Stewart, Emily A. MD; Sweet, Michelle MD; Kisielewski, Michael MA; Willett, Lisa L. MD, MACM, Internal Medicine Residency Program Directors’ Screening Practices and Perceptions About Recruitment Challenges, Academic Medicine, November 12 2019

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US Medical Education By The Numbers (LCME and ACGME Divisions)

Medical Education: JAMA again presents a deep dive into the numbers and characteristics of learners in MD-granting US medical schools and in US residency programs accredited by the ACGME, which is now encompassing most of the programs previously accredited by the Association of American Colleges of Osteopathic Medicine (AACOM).

Regarding MD-granting medical schools:  The number of medical students per 100,000 state residents is quite variable among the states which have medical schools, from a low of 11.6/100,000 in Arizona to 75.6/100,000 in Vermont.  After many years of stable total enrollment of about 70,000 until 2008, the total enrollment has risen to about 86,000 in the most recent data, with close to even numbers of women and men.  Fifty-eight percent of schools noted “increased difficulty finding and retaining inpatient clinical placements” for their clerkships, primarily due to competition for sites from other medical or health-professions schools.

Regarding ACGME-accredited residency and fellowship programs:  From 2013-14 to 2018-19, the number of trainees in these programs expanded from about 117,000 to about 136,000.  This included increases of about 1,000 international medical graduates (IMGs), about 8,000 US MD graduates, and about 10,000 US osteopathic graduates.  This reviewer assumes that much of the latter increase is due to the incorporation of many programs previously certified by AACOM.  Learners in these residency programs come primarily from US MD-granting schools (62.7%), DO-granting schools (14.2%), and international medical schools (23.0%).  These learner types are not evenly spread among the specialties.  IMGs are disproportionately represented in neurology, pathology, and internal medicine and its specialties.  DO recipients are disproportionately represented in emergency medicine, family medicine, and physical medicine/rehabilitation.  Among IMGs, 26% are native US citizens, 12% are naturalized US citizens, and 15% are permanent residents.  The majority of the remainder are visa holders.  The racial and ethnic composition of resident physicians is compared below to the composition of the US population (2010 census data per Wikipedia).  From least to most represented proportionately, they are:  American Indian/Alaskan native 0.11, Black 0.43, Hispanic 0.49, Pacific islander/native Hawaiian 0.50, White 0.78, Multiracial/other/unknown 1.2, and Asian 5.5.  Estimates of proportions for American Indian/Alaskan native and Pacific islander/native Hawaiian are based on low numbers and likely less reliable. — Laura Willett, MD

Barzansky B, Etzel SI, Medical Schools in the United States, 2018-2019.
JAMA, 2019 Sep 10;322(10):986-995.
Link To Article 

Brotherton SE, Etzel SI, Graduate Medical Education, 2018-2019
JAMA. 2019 Sep 10;322(10):996-1016.
Link To Article

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Mid-Level MCAT Scorers Increase Diversity in Medical Schools

Diversity: Medical schools seeking greater diversity in their classes may want to look at data from the 2017 medical school applicants who scored in the middle third of the MCAT range.   Compared to students who scored in the upper-third on the exam, students with mid-third scores show a greater tendency to be the first in their family to graduate from college, to have parents working in the service industry, to have grown up in rural or medically-under served parts of the country, to be non-native English speakers and to be underrepresented based on race/ethnicity.  The authors note that ​in a companion piece in Academic Medicine, success in  medical school can be achieved by students scoring along a range of MCAT scores.  Applicants who score in the mid range of the MCAT score range advance to the second year of medical school nearly as frequently as upper-tier students (95% vs. 98%).    Given the ​importance of meeting the needs of an increasingly diverse US population, the authors suggest medical schools continue​ to use holistic review practices and to look beyond accepting only students with high MCAT scores.  — DR MERL Editors 

Terregino, CA, Saguil A, Price-Johnson T, Anachebe NF, Goodell K. The Diversity and Success of Medical School Applicants with Scores in the Middle Third of the MCAT Score Scale . published ahead of print August 13, 2019]. Acad Med. doi: 10.1097/ACM.0000000000002941.

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Author Interview
The editors of DR MERL spoke with Carol Terregino, MD about her recent publication in Academic Medicine.

What got you interested in the topic of MCAT scores and diversity? 

Terregino: “I have been working in medical school admissions for over 20 years.  Robert Wood Johnson Medical School has been in the business of recruiting and supporting students from diverse groups well before terms such as holistic admissions and student retention became part of the vocabulary of medical student selection.  I have had some of my most meaningful professional experiences in collaboration with staff and faculty from across the nation by participation in research groups at the Association of American Medical Colleges. I was part of the Innovation Lab Working Group of the MR5 Committee (development of MCAT 2015) and H. Liesel Copeland PhD, assistant dean for admissions and medical education and I are currently a part of the MCAT Validity Working Group, made of 16 medical schools representing all regions of the nation, public and private institutions, with missions ranging from research intensive to community based.  We meet semiannually for this multiyear study and have the opportunity to debate important ideas in the world of medical school admissions and diversity with colleagues of similar values.

The current paper is a collaborative work by academic medicine faculty from USUHS, Morehouse School of Medicine, Boston University, Arizona College of Medicine Tucson.  We were committed to the following ideas:

      • The evidence that MCAT scores predict academic performance in medical school and on licensing examinations is strong.
      • In every class we admit, we see variability in the academic performance of students with similar MCAT scores.
      • Students with more modest MCAT scores can and do outperform their classmates with higher MCAT scores.
      • Success depends upon the academics, attributes, and experiences these applicants bring.
      • Success also depends upon our ability to provide a learning environment in which students from different backgrounds and academic trajectories could thrive.

We all need to look beyond the numbers to diversify our classes and meet needs of our populace.”

 

Were you surprised by your findings?  

Terregino: “Given our history meeting the needs of medical students across a range of MCAT scores, I was not surprised with the success rate across the score range, but I must say I was very gratified to see that the new MCAT performed in this way.  I am surprised that there has been no public comment regarding the relative indictment of methodology of medical school rankings and schools reporting pressure to accept only applicants with high scores.”

 

What changes would you like to see come from your article?

Terregino: “I am hoping that as each school defines who comprises their underrepresented in medicine groups, they search for these applicants and review each application thoughtfully, acknowledging how life experiences and personal attributes add context to a given MCAT score-knowing that success can be obtained with scores beneath the highest ones.  There are absolute gems  in this cohort who should not be overlooked.”

 

What’s next for you in terms of medical education research?

Terregino: “My focus in medical education is ensuring that when any patient looks into the eyes of one of our graduates, they find a doctor adept in communicating and developing a therapeutic alliance, well-versed in all realms of professional communication and teamwork, and one with outstanding clinical reasoning and critical thinking skills. My research projects range from admissions, to developing a new communication rating scale to teaching and measuring teamwork skills.”

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