Hooray For The New CMS Rules On Student Notes!

Electronic Medical Records: This is not a study, but definitely required reading for anyone in the US who deals with medical students or electronic medical records.  The prior US billing regulations “inadvertently hampered medical education and increased the administrative and regulatory burden on the teaching physician”.  In the new regulations, physicians are not required to re-document anything adequately documented by the student, but must attest to their physical presence and involvement in the history, exam, and medical decision-making.  The authors urge all health systems with medical students to “evolve their internal policies” to improve medical student learning and to “reward rather than punish the act of precepting” by improving preceptors’ documentation efficiency.  A simple and efficient way to comply with the new regulations is for the physician to listen to the student’s history presentation in the presence of the patient (who can correct the student), followed by examination and medical decision-making done by the physician and shared with the student. — Laura Willett, MD

Power DV, Byerley JS, Steiner B. Policy Change from the Centers for Medicare and Medicaid Services Provides an Opportunity to Improve Medical Student Education and Recruit Community Preceptors. Acad Med. 2018 Apr

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Feedback About Feedback

Feedback: In this qualitative study, investigators held focus groups and individual interviews with residents and faculty in the internal medicine department at Brigham and Women’s Hospital (Boston), looking into the “culture” of feedback.  Reviewers looked at transcripts and identified three major themes:  “normalizing constructive feedback to promote a culture of growth, overcoming the mental block to feedback seeking, and hierarchical culture impeding bidirectional feedback.”  Many barriers to honest constructive feedback were mentioned:  fear of damaging the relationship, fear of damaging the team dynamic, lack of comfort with giving feedback to a superior, fear of retaliation from the institution for giving negative feedback, fear of threatening the recipient’s self-esteem, and fear of threatening the reputation of the institution.  Lots of facilitators of useful feedback were also mentioned: normalizing weakness (e.g. superiors admitting their own limitations), attention to the language and tone of constructive feedback, and training in feedback delivery and feedback seeking.  Many physicians felt that longitudinal relationships made giving feedback easier, and that direct observation facilitated feedback, although some residents “saw the presence of a faculty observer as intrusive and a potential threat to autonomy.” — Laura Willett, MD

Ramani S, Könings KD, Mann KV, Pisarski EE, van der Vleuten CPM. About Politeness, Face, and Feedback: Exploring Resident and Faculty Perceptions of How Institutional Feedback Culture Influences Feedback Practices. Acad Med. 2018 Mar

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How To Help Residents Publish

Publishing: This single-site study is required reading for residency program directors and research directors.  The investigators identified all internal medicine resident projects from 2006-2013 by using departmental files and institutional review board (IRB) applications; 55% of these identified projects had resulted in a publication.  In a multivariate model, use of the (free to the user) biostatistics core was the strongest statistically significant predictor of a research project resulting in publication.  The authors mention that the biostatistics core support included help with study design, statistical analysis, writing sections of the manuscript, and addressing reviewer comments.  Projects of residents who were US (vs. international) medical graduates and who had prior publications were somewhat more likely to be published.  The residents with a research mentor having more than 5 publications were much more likely to publish, but this association  just missed statistical significance.  Residents identified as being involved in a research project were surveyed after graduation.  Only 38% responded; 69% of the respondents had published their research, suggesting possible response bias.  In survey responses, unpublished residents were more likely to cite an “uninvolved mentor” as a major barrier.  Published residents were more likely to agree that their mentors were “easily available” and “set expectations”.  “Lack of time” was a barrier cited equally by published and unpublished residents. — Laura Willett, MD

Atreya AR, Stefan M, Friderici JL, Kleppel R, Fitzgerald J, Rothberg MB Characteristics of Successful Internal Medicine Resident Research Projects: Predictors of Journal Publication Versus Abstract Presentation. Acad Med. 2018 Feb

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The “Hidden Curriculum” Strikes Again

Hidden Curriculum: Authors of this small but concerning qualitative study interviewed 15 surgical residents at one program in Canada regarding “impression management” – how individuals strive to actively manage their external image.  These trainees “described being immersed in an environment where they felt pressures to perform a set a strongly normative – but tacit – expectations to be ‘all-knowing’, ‘quick’, ‘decisive’, and ‘confident’.”  They described trying to give “an impression of competence to improve evaluations and afford learning opportunities” as well as to avoid getting a potentially irreversible negative reputation in their program.  There were some positive benefits of impression management such as “building confidence in oneself and building patients’ trust,” but there were many reported negative consequences.  These included:  inaccurate reporting (e.g. that a lab was normal when it was not checked); avoiding asking questions when uncertain; avoiding asking for help; worsened  psychological strain on the resident; and a focus on image or shame as opposed to learning.  Several reported vignettes included behaviors that could impair patient safety and/or resident learning.  The authors urge the creation of “a culture that truly encourages residents to admit knowledge gaps and ask for help when needed.” — Laura Willett, MD

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Patel P, Martimianakis MA, Zilbert NR, Mui C, Mobilio MH, Kitto S, Moulton CA., Fake It ‘Til You Make It: Pressures to Measure Up in Surgical Training. Acad Med. 2017 Dec.
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Trainee Physicians Demonstrate Similar Rates Of Disrespectful Behavior As Faculty In The Same Specialty

Behavior: Authors analyzed 359 validated complaints of disrespectful behavior by physicians at one academic medical center over a 4-year time period.  The most common locations for disrespectful behavior events were the operating room (for faculty) and inpatient units (for trainees).  Independent predictors of events were male gender and procedural specialty.  Rates of such behavior by faculty and trainee within the same specialty were highly correlated (Spearman’s rho 0.90).  Specific specialties with the highest rates of events were orthopedics, cardiothoracic surgery, otolaryngology, surgery, and neurosurgery.  However, absolute rates were quite low in all specialties and most cited physicians were reported for only one event. — Laura Willett, MD

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Hopkins J, Hedlin H, Weinacker A, Desai M., Patterns of Disrespectful Physician Behavior at an Academic Medical Center: Implications for Training, Prevention, and Remediation, Acad Med. 2018 Jan 9.
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Be Wary Even Of Validated Surveys

Surveys: This is required reading for faculty planning to engage in survey research or to use a published survey.  The authors analyzed publications in three major health education journals which described 37 separate self-administered surveys.  The vast majority (94.6%) of surveys contained at least one violation of best practices in survey design.  Even more concerning, the papers seldom reported a survey’s validity (35.1%) or reliability (21.6%).  The authors point out that, if educators are using a published survey, they should re-establish the survey’s validity and reliability in their own setting. — Laura Willett, MD

Artino AR Jr, Phillips AW, Utrankar A, Ta AQ, Durning SJ,”The Questions Shape the Answers”: Assessing the Quality of Published Survey Instruments in Health Professions Education Research.
Acad Med. 2017 Oct
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Financially Disadvantaged Students May Be Further Disadvantaged For Medical School Admission By Multiple Mini-Interviews (MMIs)

Admissions: Five California public medical schools collaborated in this observational comparison of medical school admissions interview structure.  Three of the schools utilized traditional interviews (TIs) of about 30 minutes each and two utilized MMIs.  For both types of interviews, older age and female gender were associated with higher interview scores, while ethnicity and MCAT score had no association with interview scores. Self-identified student financial disadvantage was associated with higher TI scores and lower MMI scores, both influences being statistically significant.  Also interestingly, higher GPA had a negative association with MMI scores but no significant association with TI scores.  Perhaps the traditional interviewers were more likely to be aware of the student’s disadvantaged status and academic rating, whereas the brevity and structure of the MMI would likely preclude this.  Yet more data for admissions officers to figure into their models! — Laura Willett, MD

Henderson MC, Kelly CJ, Griffin E, Hall TR, Jerant A, Peterson EM, Rainwater JA, Sousa FJ, Wofsy D, Franks P. Medical School Applicant Characteristics Associated With Performance in Multiple Mini-Interviews Versus Traditional Interviews: A Multi-Institutional Study. Acad Med. 2017 Oct.
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