How Residents Die

Risk: In this survey of deaths of residents from all ACGME programs, malignancy and suicide were the most common causes of death.  Hearteningly, death rates from all causes and from suicide were substantially lower in residents than in the general population.  This is in distinction from suicide rates in practicing physicians, which are higher than the general population.  The time of highest risk for suicide was the first quarter of internship year.  The report reinforces the need for behavioral health care for our residents; fairly common causes of death included suicide, accidents, deaths of “ill-defined or undetermined intent”, and accidental poisoning. — Laura Willett, MD

Yaghmour NA, Brigham TP, Richter T, Miller RS, Philibert I, Baldwin DC Jr, Nasca TJ.Causes of Death of Residents in ACGME-Accredited Programs 2000 Through 2014: Implications for the Learning Environment.
Acad Med. 2017 May

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Are Written Words A Reliable Way To Assess Residents?

Assessment: It looks like it.  In this insightful study, Canadian researchers sent collections of comments from evaluators of two cohorts of nearly 50 interns in one internal medicine program to faculty in several other programs.  Each faculty person was asked to rank-order 16 interns according to the written comments only; associated numerical grades were hidden from the rankers.  A high degree of reliability was found (G about 0.80) with as few as two independent faculty members viewing only the first 3 written comments for an individual intern, obtained over the intern’s first 4 months of training. Maybe qualitative comments are the “gold standard”? — Laura Willett, MD

Ginsburg S, van der Vleuten CP, Eva KW., The Hidden Value of Narrative Comments for Assessment: A Quantitative Reliability Analysis of Qualitative Data. Acad Med. 2017 Apr.

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When The Monday Before Match Day Is Not A Happy Day

Match: No research, and only a smattering of data, but this article is required reading for faculty counseling graduating MD students from the US with difficulty matching into residency.  A sizable percentage (6.2%) of US seniors did not gain a position during the 2016 primary Match; nearly half of these attained a position during the supplementary program (SOAP) in the days shortly before Match Day.  For those who do not (615 students in the 2016 Match), the authors review a number of options, including delay of graduation, obtaining a position outside of SOAP (fairly high success), re-entering the Match the following year in the same or different specialty (also fairly high success), pursuing interim activities to improve Match success, or pursuing a non-clinical career.  A systemic problem is that there is no centralized clearinghouse of open residency positions, which may occur off-cycle.  The authors also address more specific issues for school administrators such as policies/practices regarding delay of graduation, Dean’s Letter update, leave of absence from rotations following Match failure, and support for students post-graduation. — Laura Willett, MD

Bumsted T, Schneider BN, Deiorio NM. Considerations for Medical Students and Advisors After an Unsuccessful Match. Acad Med. 2017 March

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Don’t Know Much About….Feedback

Feedback: This scoping review which describes what has been published in English regarding feedback to healthcare learners will be of interest mostly to researchers and those looking for a comprehensive view of the field.  The bulk of publications were from English-speaking countries and focused on medical students or residents in those countries.  Of publications with a specialty focus, a majority involved either internal medicine or surgery.  The overall level of the literature seems to be in a nascent stage.  For example, even though a majority of articles described a new approach to feedback, only 7.5% of articles involved randomization of learners.  Likewise, in the large number of articles that evaluated a feedback intervention, 57.7% confined that evaluation to the learners’ reaction to feedback, rather than measuring more important outcomes such as changes in care or behavior.  “High-level, evidence-based educational recommendations for feedback are lacking.” — Laura Willett, MD

Bing-You R, Hayes V, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Acad Med. 2017 Feb 7. Feedback for Learners in Medical Education: What Is Known? A Scoping Review.

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Faculty Development For Community-Based Faculty

Faculty Development: In this survey of North American family medicine clerkship directors, researchers focused on the use of community-based preceptors and how they are developed and rewarded. Sixty-nine percent of schools reported heavy reliance on community-based preceptors for their family medicine clerkship instruction.  Interestingly, 100% of Canadian clerkship directors reported giving direct monetary payments to their community-based preceptors, as opposed to 28% of US directors.  Among schools that paid their preceptors, the average payment was $263 per week.  Schools which paid their preceptors were much more likely to require those preceptors to participate in formal faculty development.  The most common form of formal faculty development was the in-person session, despite the largest barriers to participation being reported as preceptor availability and geographic distribution.  Various forms of distance learning were also utilized.  There was little evidence of rigorous needs assessment or evaluation of effectiveness for most community-based faculty development programs. — Laura Willett, MD

Drowos J, Baker S, Harrison SL, Minor S, Chessman AW, Baker D., Faculty Development for Medical School Community-Based Faculty: A Council of Academic Family Medicine Educational Research Alliance Study Exploring Institutional Requirements and Challenges. Acad Med. 2017 Feb 21.

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Updates From the EPA Pilot Schools

Entrustable Professional Activities: Ten US medical schools were chosen to work on pilot projects related to teaching and assessing the 13 proposed entrustable professional activities (EPAs) for graduation from medical school.  These reports document a lot of thought about how to put these EPAs into practice, but offer no data-driven advice, as expected for early in the process.  The Brown et al paper present a “trustworthiness” assessment framework that they believe underlies all entrustment decisions, which educators may find useful.  The proposed elements are:  “discernment: awareness of the limits of one’s clinical knowledge and skill; conscientiousness: thoroughness and dependability in following through with assigned tasks; and truthfulness: appropriate balance of truth and tact.” — Laura Willett, MD

Lomis, Kimberly MD; Amiel, Jonathan M. MD; Ryan, Michael S. MD, MEHP; Esposito, Karin MD, PhD; Green, Michael MD, ScM; Stagnaro-Green, Alex MD, MHPE; Bull, Janet MA; Mejicano, George C. MD, MS; Implementing an Entrustable Professional Activities Framework in Undergraduate Medical Education: Early Lessons From the AAMC Core Entrustable Professional Activities for Entering Residency Pilot.for the AAMC Core EPAs for Entering Residency Pilot Team, Academic Medicine, January 3, 2017

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Brown, David R. MD; Warren, Jamie B. MD, MPH; Hyderi, Abbas MD, MPH; Drusin, Ronald E. MD; Moeller, Jeremy MD; Rosenfeld, Melvin PhD; Orlander, Philip R. MD; Yingling, Sandra PhD; Call, Stephanie MD; Terhune, Kyla MD; Bull, Janet MA; Englander, Robert MD; Wagner, Dianne P. MD, Finding a path to entrustment in undergraduate medical education: A progress report from the AAMC core entrustable professional activities for entering residency entrustment concept group. Academic Medicine, January 2017

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Are Clerkship Clinical Grades Fair? (or, “I Want That Male Intern To Evaluate Me.”)

Grading: The authors investigated the influence of student and evaluator demographics on the summary clinical grades given to 155 clerkship students at one medical school.  The possible grades were “exceptional”, “above expectations”, “meets expectations”, and “below expectations”.  Newcomers to student evaluation may be startled by the strong “Lake Woebegone” effect:  only 16 of 4,462 evaluations were “below expectations” and only 12-23%, depending on the clerkship, were “meets expectations”.   It is not surprising, but of concern, that variables outside of the students’ control appeared to have a moderate to large effect on the clinical grade assigned.  The authors focus on the gender effects:  Male students were graded lower than female students, but only when being evaluated by female residents or attendings.  Male evaluators , but not female evaluators, became much more stringent graders with increasing age. However, another variable had an even larger effect on grade.  Observation times of >1 day were associated with a much higher rate of “exceptional” ratings.  Gender effects on evaluations, including evaluations by standardized patients, have been seen in the prior studies.  Clerkship directors may need to keep these influences in mind. — Laura Willett, MD

Riese A, Rappaport L, Alverson B, Park S, Rockney RM. Clinical Performance Evaluations of Third-Year Medical Students and Association With Student and Evaluator Gender. Acad Med. 2017 Jan 17.

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