Facilitating Direct Observation of Medical Trainees: Enter the Minicard

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mini-CEX   Most medical educators are familiar with the mini-CEX, developed by the ABIM and used extensively across US medical schools to facilitate direct observation and feedback of residents and medical students, particularly in internal medicine. In this study by Donato et al, investigators analyze direct observation of internal medicine residents documented with the use of a different tool, the Minicard. The Minicard is similar to the mini-CEX in that observation of multiple domains of patient interaction can be documented, but uses behaviorally anchored scales of “poor” to “excellent” rather than numeral ratings of 1 to 9. In doing so, the Minicard is actually not so “mini,” and not a “card,” but consists of 12 items spanning multiple pages. How does it perform?  Of 3715 Minicards collected over a 6 year period (reflecting 73 residents in inpatient and outpatient settings), the majority of the rating range was used and scores increased over the course of the training. The authors also highlight their findings that the rating of “marginal” was given with relatively high frequency (8% of observations for first year residents and 2% for third year residents) compared to reports from prior studies using the mini-CEX (0 or 0.5% of observations), and that action-oriented feedback was documented in 50% of the encounters compared to 8% reported in a prior study using the mini-CEX.

Should we then all switch to the Minicard? Not so fast. It’s worth noting that there was extensive faculty development plus financial incentives (yes!) involved: the authors report that completion of 1 Minicard per learner per week was 1 of 3 educational metrics used to calculate incentive pay, approximately $4000/year. But a more important issue to keep in mind is that the actual tool used is likely much less important than developing and promoting a culture of high quality feedback that is not just enforced, but embraced, by faculty and trainees. — Sarang Kim, MD

Donato,Park,George,Schwartz,Yudkowsky, Validity and Feasibility of the Minicard Direct Observation Tool in 1 Training Program, Journal of Graduate Medical Education, Vol. 7, No. 2: 225-229

The Fourth Year of US Medical Schools: Curricular Content and Student Perceived Value

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4th_Year  Two articles in this month’s issue of Academic Medicine address the 4th (the final) year of US medical schools: a study by Elnicki et al describing course offerings by 136 US medical schools, and a study by Benson et al reporting the results of a survey of medical students (47% response rate) from 20 US medical schools regarding their attitudes towards 4th year medical education and the residency application process. To place this discussion in context, the reader should be aware that there has been a lot of debate about the value and goals of the forth year of medical school, and that in the early 1970’s, about 25% of US medical schools had eliminated the 4th year. The major issue for debate has been whether the 4th year should be a time to develop career-specific competencies or broad skill sets that may not be related to a student’s chosen specialty.

The article by Elnicki et al describes a wide variability in course offerings, though sub internships were required by 90% of the schools, and many schools required specific rotations such as emergency medicine (45%), ICU rotation (34%), and ambulatory care (35%). Increasing use of capstone courses was also reported (59%), designed to better prepare students for internship by addressing common or serious medical situations, basic science concepts, procedural, communication and team skills. In terms of student perspectives on the 4th year, Benson et al report that students most value the 4th year as a time to prepare for and strengthen their residency application (interviewing at residency programs, doing away electives), while also recognizing its value for broadening their educational experience.  At first glance, course offerings and student perceived values reported in these studies seem aligned. However, student perceptions can vary by intended specialty, and perceptions of educators, and those of recent graduates who have experienced internships, should also be taken into account if a curricular recommendation or guideline regarding what ought to be in a 4th year curriculum is to be developed. — Sarang Kim, MD

A 4th Year Medical Student Perspective:

Some educators have argued that the fourth year of medical school is unnecessary as it increases student debt while not improving the overall readiness of medical students for residency. Medical students, including this reviewer, typically have not agreed with this statement. As reported by the majority of medical students surveyed by Benson et al, the fourth year of medial school provides a valuable opportunity for students to prepare for their next step in the medical field. At most US medical schools, the third-year is heavily arranged with required clerkships,  giving the student little time to explore his/her interests. During the fourth year, many students embrace the opportunity to explore various fields- both as a way to solidify their interests and to expand their breadth of knowledge and skills. Without the fourth year, students may not be prepared to thrive in their field of interest. To me, the idea of starting residency without the knowledge and skills gained through subinternship, capstone courses (aka “bootcamp”), emergency medicine, ICU, and ambulatory care experiences during the fourth year is frightening; I believe doing away with such experiences would be detrimental to the student and overall adequacy of intern readiness. The fourth year also provides a time for students to reflect on the type of physician they want to become and where they might spend the next several years of their lives as they continue to train towards their goal. By providing opportunities to explore, broaden and sharpen knowledge and skills, and time to reflect and prepare for what’s ahead, I believe that the fourth-year truly serves a meaningful purpose. — Heather Belle, Rutgers Robert Wood Johnson Medical School MD Candidate Class of 2016

Benson, Nicole M. MD; Stickle, Timothy R. PhD; Raszka, William V, Jr. Going “Fourth” from Medical School: Fourth-Year Medical Students’ Perspectives on the Fourth Year of Medical School. Academic Medicine, 2015

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Elnicki, D. Michael MD; Gallagher, Susan MD; Willett, Laura MD; Kane, Gregory MD; Muntz, Martin MD; Henry, Daniel MD; Cannarozzi, Maria MD; Stewart, Emily MD; Harrell, Heather MD; Aiyer, Meenakshy MD; Salvit, Cori MD; Chudgar, Saumil MD, MS; Vu, Robert MD; for the Clerkship Directors in Internal Medicine Association of Program Directors in Internal Medicine Committee on Transition to Internship “Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship.”  Academic Medicine, 2015

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e-Modules Increase Practical Skills Preparation

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practicalskillspreparation   This study compares two different teaching modalities for pre-clerkship practical skills training sessions.  In UMC Utrecht Faculty of Medicine, students performed a total of 16 physical examination training sessions over two academic years (2011-12 and 2012-13).  Each of these sessions were tested by end of year comprehensive Observed Structured Clinical Exams (OSCEs).  To prepare for each session, students had mandatory preparation sessions.  Some of the prep sessions were text-based, while others were interactive e-modules.  OSCE test scores were used to benchmark competency in each skill. Scores were compared between skills where the preparation modules were text-based verses e-modules.  The overall results indicate that for OSCE stations with an e-module preparation, students received a higher score than for those with text-based preps (average 3.67 vs 3.58).  In addition, looking at individual students, scores were higher for each student for e-module prep stations than for text-prep stations (3.6 vs 3.5; n=332).  The authors conclude that physical examination skills can improve with introduction of e-module preparation sessions, which are at least as good, and probably more convenient than text-based preparations.– Lee Ann Schein, Ph. D

Kwant KJ, Custers EJ, Jongen-Hermus FJ, Kluijtmans M. Preparation by mandatory E-modules improves learning of practical skills: a quasi-experimental comparison of skill examination results. BMC Med Educ. 2015 Jun 10;15:102.

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Length Of Knowledge Retention. Does TBL Help?

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tbl   The benefits to learning outcomes of active learning have been well-documented in educational literature.  However, all of the data thus far has looked at only short-termed retention of material.  This study looks at both the long- and short-termed acquisition of knowledge.  Two groups of students were given the same pre-clinical pediatric course.   One group had the material only being delivered by lectures (control group).  The other group had the pediatric course containing both lectures and Team-based Learning (TBL) activities.  Both groups had four assessments to evaluate their knowledge base and retention:  pre-course, post-course, pre-pediatric clerkship, and post-clerkship.  The results showed that the only statistically-significant difference between the two groups was at the post-course time point (79% vs. 59%).  Data indicated considerably greater short-termed knowledge in the TBL-containing class than the lecture-only class, but no increased long-term retention.  The authors suggest that this highlights a need to capitalize on the increased knowledge acquisition from active learning modalities with continued practice to maintain the long-termed retention of knowledge.  — Lee Ann Schein, Ph D.

Emke AR, Butler AC, Larsen DP.,Effects of Team-Based Learning on short-term and long-term retention of factual knowledge. Med Teach. 2015 Apr 21:1-6.

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Musings On Professionalism

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professionalism  The interested reader is directed to the May 12, 2015 JAMA issue containing multiple short essays regarding professionalism across the spectrum of education and practice.  Most impressive to this reviewer has been the accumulating evidence of the pernicious effect of money, greed, and income inequality on professionalism.  In the mid-20th century, a primary care physician made 2.75 times the US median household income (which were mostly one-earner households) and specialists made only slightly more.  Now a primary care physician makes 3.40 times the median household income and “some specialists earn 10 and 20 times that level,” with income boosted the more tests and procedures done.  Financial incentives of this magnitude make it nearly impossible for mere humans to behave as true fiduciaries for our stakeholders – patients, learners, peers, other healthcare providers, shareholders in healthcare organizations, and taxpayers.–Laura Willett, MD
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Mind Those Quality Indicators!

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quality_improvement  With strong US licensing body mandates for quality improvement (QI) education, it is more important than ever to ensure that common QI indicators really measure quality.  Hospital length of stay (LOS) is an extremely common quality measure because it is easy to quantify and has a large influence on hospital economics.  Thirty-day mortality has more face validity as a quality measure, but is a fairly uncommon outcome and requires tracking after hospital discharge.   Because shorter LOS is likely correlated with lower severity of illness, a patient-based comparison of LOS vs. mortality would be hopelessly confounded.  In this single-site observational study, researchers tracked the 30-day mortality of inpatients who were arbitrarily (based on routine procedure) assigned to the teaching service of one of 79 internal medicine attendings.  Attendings were categorized into two equal-sized groups by their average LOS, lower or higher than 4.77 days.  Patients discharged by the short-LOS physicians had a higher 30-day mortality than those discharged by the long-LOS physicians (5.5% vs. 4.3%, p=0.007).  These results were maintained after either logistic regression or propensity score matching.  Pending further exploration, these results suggest that LOS, and perhaps other quality measures, may need re-thinking. — Laura Willett, MD

Southern WN, Arnsten JH.  Increased risk of mortality among patients cared for by physicians with short length-of-stay tendencies. JGIM 2015;30:712-8.

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Pay Faculty To Teach And They Will Teach (Well)

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pay Educators in a newly-established medical school describe their successful establishment of a well-received 8-week primary care clerkship utilizing established internal medicine and family medicine physicians in the Ochsner (New Orleans) Health System.  They used a three-pronged approach:  “protected time to teach, dedicated tuition money for reimbursing teaching, and a faculty development program.”  Based on previous data, they estimated that incorporation of a clerkship student into a 4-hour session would require about 40 minutes of time.  Participating faculty had 40 minutes of clinic time blocked out on their precepting days and were credited with 2.5 educational value units (EVUs) which equaled about US $110, so there was no overall change in compensation.  The preceptors’ overall compensation was based on  productivity (clinical plus EVUs), a leadership position component, and a “seniority component to reward longevity”.  The authors also describe a robust faculty development program including monthly discussions with all precepting faculty.  Although this plan describes compensation and development for community-based faculty, medical school administrators might want to apply this paradigm to their full-time faculty as well. — Laura Willett, MD

Denton GD, Griffin R, Cazabon P, Monks SR, Deichmann R. Recruiting Primary Care Physicians to Teach Medical Students in the Ambulatory Setting: A Model of Protected Time, Allocated Money, and Faculty Development. Acad Med. 2015

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Double Check That Citation! Misrepresentation Of Publications By Residency Applicants

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Publication   The investigators of this study examined data from the Canadian Resident Match Service (similar to the US Electronic Residency Application Service, or ERAS) to assess misrepresentation of publications reported among applicants to Canadian otolaryngology residency programs over a 3-year period. Citations were verified using PubMed, Google Scholar and electronic journals, with misrepresentation defined as falsely claiming authorship of an existing article, claimed authorship of a non-existing article, or improper order of authorship. Of a total of 427 peer-reviewed publications reported by 124 of 182 applicants, 385 were verified, and 47 (12%) were misrepresented by 29 (23%) of applicants. Age, gender, prior academic degree, and number of citations per applicant were not associated with likelihood of misrepresentation. This study adds to existing single institution-based studies describing publication misrepresentation in residency applicants. — Sarang Kim, MD.

Sater L, Schwartz JS, Coupland S, Young M, Nguyen LH, Nationwide study of publication misrepresentation in applicants to residency. Med Educ. 2015 Jun;49(6):601-11.

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Role Of Preclinical Classroom Attendance Sharply Divides Faculty and Students

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classroom attendance    In several medical schools, attendance in preclinical years is not mandatory for lectures, recordings of which are usually available to the students. Classroom attendance has diminished in some schools. A single-center cohort study was carried out using internet-based surveys to investigate how students and faculty perceive classroom attendance and how nonattendance influences teachers and the overall learning environment. The study showed that medical students (n = 382) and their teachers (n = 248) have significantly different expectations of the classroom experience, which in part contributes to their different outlooks regarding the importance of classroom attendance and its relationship to professionalism. Compared to students, faculty more significantly perceived a negative impact of poor attendance on lecture (74.7% for faculty vs. 41.6% for students). The authors provide suggestions to overcome this discrepancy including mutual understanding and faculty training in active learning approaches. They note that the study is limited by perceptions at the site of study and the conclusions may not apply to curricula which are predominantly based on small-groups or require attendance for lectures.-Sangita Phadtare, Ph.D., Cooper Medical School of Rowan University

Allyson R. Zazulia and Patricia Goldhoff., Faculty and medical student attitudes about preclinical classroom attendance., Teaching and Learning in Medicine: An International Journal  2014, 26:4, 327-334

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How Do Medical Schools Deal With Students’ Professionalism Lapses?

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professionalism  Researchers interviewed education deans (response rate 61%) regarding their schools’ practices regarding lapses in professionalism.  A majority (80%) had written policies and procedures regarding unprofessional behavior on the part of medical students, but practices were quite variable.  Involvement of student affairs deans, course or clerkship directors, medical education deans, and promotions committees was commonly reported.  Several strategies for remediation were reported by more than 50% of interviewed deans:  mandated mental health evaluation; remediation curriculum or assignment (e.g. reflective writing); mandated professionalism mentor; stress management counseling; and repetition of all or part of the involved course or clerkship.  Many dean expressed concerns regarding feed-forward practices, lack of adequate reporting of professionalism lapses, and unclear criteria for successful remediation.  The authors suggest research to establish best practices in this important area. — Laura Willett, MD

Ziring D, Danoff D, Grosseman S, Langer D, Esposito A, Jan MK, Rosenzweig S, Novack D. How Do Medical Schools Identify and Remediate Professionalism Lapses in Medical Students? A Study of U.S. and Canadian Medical Schools. Acad Med. 2015

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