Should Pre-Med Students Be Required To Pay Tuition To Do Useful Work As Medical Scribes?

Medical Scribes — Lin et al presents a compelling program for pre-medical students that serves to both provide students with strong clinical experiences as well as provide physicians with practical assistance in documentation required in the health care setting.  The main focus of the program is having students trained and serve as scribes, yet the program also includes faculty teaching at the bedside, giving feedback on applications, and mentoring on scholarly projects.  The program does charge a tuition and so allows the school to use this resource to hire two program managers that serve as chief scribes and communicators of opportunities.  Data was presented to attest to student satisfaction, production of abstracts, and reflection on personal growth.  Yet, the one in three acceptance to a health professions school does not seem as high as what might be expected with the amount of hands on support students’ obtain.  The data on physician/provider outcomes has been presented in other publications with an additional measure of self-report improved joy of practice presented here.  As admissions becomes more competitive with increased applications, the clamor for access to clinical experience has increased. This program provides one method of serving both the physician and pre-med population.  Whether it provides adequate outcomes for the pre-meds in terms of their goal to be accepted to a health professions school and whether it would meld with different practice structures and faculty needs, are considerations each school needs to consider within their own environment.  — Liesel Copeland, PhD

Lin S, Duong A, Nguyen C, Teng V. Five Years’ Experience With a Medical Scribe Fellowship: Shaping Future Health Professions Students While Addressing Provider Burnout. Acad Med. 2021 May 1;96(5):671-679. doi: 10.1097/ACM.0000000000003757. PMID: 32969839.

Link To Article

Posted in Undergraduate Medical Education | Tagged | Leave a comment

Out Of Sight, But Not Out Of Mind

Depression: Willingness among medical trainees to seek help for a mental health issue gets a boost when faculty members share their own struggles.  At least that is the finding from a limited study of 39 residents who attended a closed conference on the subject given by three self-selected faculty at Mayo Clinic Rochester.  On an anonymous survey given to residents who attended the event, 89.7% stated their knowledge of available mental health resources increased, 84.7% said they were more likely to pursue mental health resources, and 97.4% replied that faculty sharing their challenges de-stigmatizes mental health.  These are impressive stats, but a post-conference afterglow effect might be at play here.  The authors acknowledge as much by emphasizing the need to study whether residents retain their enthusiasm over time, and more importantly, they seek that help they need.  Despite its limitations, this study opens a window on depression among residents which remains too often out of sight, but not out of mind. — The Editorial Team

Brianna E Vaa Stelling, Colin P West, Faculty Disclosure of Personal Mental Health History and Resident Physician Perceptions of Stigma Surrounding Mental Illness, Academic Medicine January 2021. 

Link To Article

Posted in Graduate Medical Education | Tagged , | Leave a comment

A Rich Menu of Options for Integrating Sciences Into The Clinical Years

Basic Science — When it comes to integrating the basic sciences into the clinical years, this meal can be cooked in many ways. Eleven medical school education deans serve a mostly data-free review of their diverse attempts to deliver on the promise of a well-balanced medical education: a firm grounding in the basic sciences with sound clinical skills. Schools attempted integration at the program, clerkship and bedside levels, with the program-level efforts being the least rewarding. Successful efforts share a common ingredient: basic science information delivered when its needed most — in the clinical environment. The kicker is that clinical faculty are often unprepared to answer on the fly. The solution, at some medical schools, is to hand out teaching scripts (crib notes, anyone?). Question banks (either third-party or home grown) for Step 1 prep-work were also a winner among students. The challenges to integrating science into the clinical years are the usual suspects: money, coordination, buy-in. But there is hope. One school reported a 20% favorability rating increase on the “required clinical experiences integrated basic science content” part of the Association of American Medical Colleges’ Graduation Questionnaire. With that kind of response, perusing the menu of options available in this article might be just the ticket. — The Editorial Team

Daniel, Michelle MD, MHPE; Morrison, Gail MD; Hauer, Karen E. MD, PhD; Pock, Arnyce MD, MHPE; Seibert, Christine MD; Amiel, Jonathan MD; Poag, Molly MD; Ismail, Nadia MD, MPH, MEd; Dalrymple, John L. MD; Esposito, Karin MD, PhD; Pettepher, Cathleen PhD; Santen, Sally A. MD, PhD, Strategies From 11 U.S. Medical Schools for Integrating Basic Science Into Core Clerkships, Academic Medicine December 2020.

Link To Article

Posted in Undergraduate Medical Education | Tagged , | Leave a comment

Who Benefits From Learner Handovers?

Learner Handover: Faculty use learner handoffs for their own benefit, a recent study finds.  Learner handovers occur when the supervision of a student is passed from one faculty member to another. Researchers interviewed 23 faculty at two Canadian universities in 2018 and found that faculty formally viewed learner handoffs as a means to improving faculty “efficiency by focusing on teaching and feedback”, but faculty also informally viewed handoffs as serving “social or therapeutic purposes” to openly share frustrations, lessen insecurities around entrustment and assessment of learners, plus to “gossip”, and “vent”. The authors question who learner handovers are for — students or faculty.   The answer is both.  Students get “longitudinal assessment in rotation-based systems” and faculty get a chance to kvetch. — The Editorial Team with David A. Cohen, MD

Humphrey-Murto Susan MD, MEd; Lingard Lorelei PhD; Varpio Lara PhD; Watling Christopher John MD, PhD; Ginsburg Shiphra MD, MEd, PhD; Rauscher Scott; LaDonna Kori PhD, Learner Handover: Who Is It Really For?, Academic Medicine, November 2020

Link to Article

Posted in Graduate Medical Education, Undergraduate Medical Education | Tagged | Leave a comment

Medical Education Research Round-Up

A Peak Into Medical Malpractice Claims Involving Trainees

Malpractice — Medical malpractice claims involving trainees is the focus of this research.   Between 2012 and 2016, researchers looked at 581 malpractice claims(malpractice defined as “written requests for compensation due to injury”) from 32 teaching institutions and 9 states and found direct involvement of a resident in 81% of cases, a fellow in 13% of cases and both residents and fellows in 6% of cases. They further found that the most common diagnosis associated with malpractice claims was laceration during surgery (11%) in specialty fields such as oral surgery/dentistry and ob-gyn.  Inadequate supervision was a contributing factor in 24% of cases.  –DR MERL Editorial Team

Myers, Laura C. MD, MPH; Gartland, Rajshri M. MD, MPH; Skillings, Jillian; Heard, Lisa MSN, RN; Bittner, Edward A. MD, PhD; Einbinder, Jonathan MD, MPH; Metlay, Joshua P. MD, PhD; Mort, Elizabeth MD, MPH, An Examination of Medical Malpractice Claims Involving Physician Trainees, Academic Medicine, August 2020

Link To Article

Diagnostic Accuracy Improves Upon Reflection

Reflection Recognizing that diagnostic error is one of the most common and most harmful patient safety problems, researchers looked at reflection as a tool for improvement.   One hundred and sixty-seven (167) physicians in Bern, Switzerland were asked to reflect on patient cases (1) without instruction, (2) with confirmatory evidence, (3) with contradictory evidence, or (4) both.  Results found reflection in any mode helped improve diagnostic accuracy as measured by the set of cases presented to the physicians for this study.    — DR MERL Editorial Team

Mamede, Sílvia; Hautz, Wolf E.; Berendonk, Christoph; Hautz, Stefanie C.; Sauter, Thomas C.; Rotgans, Jerome; Zwaan, Laura; Schmidt, Henk G, Think Twice: Effects on Diagnostic Accuracy of Returning to the Case to Reflect Upon the Initial Diagnosis, Academic Medicine, August 2020

Link To Article

How Clinical Decision Rules Factor Into the Diagnostic Mix

Decision-Making — Sixteen emergency medicine physicians from 3 teaching hospitals in Canada were interviewed while diagnosing simulated patients with chest pain, breathlessness, or leg discomfort to see how clinical decision rules (CDR, using a given set of clinical predictors to estimate the probability of a diagnosis) factored into their thought process.   Analysis shows that physicians use dynamic and iterative clinical decision-making which contrasts with the static, linear approach found in CDR’s.   In the group studied, CDR’s were applied only after tests were ordered. — DR MERL Editorial Team

Chan, Teresa M.; Mercuri, Mathew; Turcotte, Michelle; Gardiner, Emily; Sherbino, Jonathan; de Wit, Kerstin, Making Decisions in the Era of the Clinical Decision Rule: How Emergency Physicians Use Clinical Decision Rules, Academic Medicine, 2020

Link To Article

Antimicrobial Therapy Under The Microscope

Thought-Process — In this qualitative study, investigators explore clinicians’ thought process involved in prescribing anti-microbials. Sixteen participants described 3 steps, 25 factors, 4 areas and 14 different drug characteristics that the authors developed into a framework which may provide be helpful in the development of education tools across medical disciplines. — DR MERL Editorial Team

Abdoler, Emily A. MD, MAEd; O’Brien, Bridget C. PhD; Schwartz, Brian S. MD, Following the Script: An Exploratory Study of the Therapeutic Reasoning Underlying Physicians’ Choice of Antimicrobial Therapy, Academic Medicine, 2020

Link To Article

Posted in Graduate Medical Education, Undergraduate Medical Education | Tagged , , | Leave a comment

Collaboration Thrives In A Culture of Collaboration 

Interprofessionalism:  It is no surprise that adverse events in patient care are attributed in part to ineffective communication, especially at transitions of care between the inpatient and outpatient settings.  One manner in which to improve this process is to promote the communication via education on intraprofessional collaboration. This study in the Journal of Medical Education shows that medical educators who are interested in building and maintaining intraprofessional collaboration may still benefit from a quick dip into this ethnographic non-participatory observational study from the Netherlands.

Forty-two residents and their supervisors at five hospitals were interviewed about collaboration between primary care physicians and medical specialists.  The results (based 45 hours of taped recordings) suggest that intraprofessional collaboration between these two cohorts is promoted when there is a culture of collaboration, and power dynamics and hierarchy are limited.  Three themes were identified as a means to improve the culture of collaboration: 1)while intraprofessional collaboration is implicitly learned, active learning promotes a culture change, 2)empowering the primary care team members to promote their knowledge and skills mitigates any competing roles between the primary care (PC) team, and medical subspecialty (SC) teams and 3) shared physical space in the clinical work environment allows for equity and collaboration. Furthermore, barriers to collaboration arise when placement goals overlook collaboration and participants are not accustomed to reaching out to each other for assistance.

There are, however, some noteworthy limitations in this study. The data source was  limited to emergency and geriatric departments, but the multi-site approach suggests the findings may be widespread and may be true in other departments as well.   Additionally, while the observations were done in an incognito manner, they occurred in locations without active patient care. This precludes the observation of informal learning that occurs in this space.

One final note: researchers in this study used rapid ethnography — a technique of entering into the arena of study with focused questions and finding results quickly.   We can only wonder then what else researchers might have found if they used the traditional ethnographic approach and took more time. While these limitations exist, this study does highlight the role training, supervision, and the clinical learning environment in the promotion of successful intraprofessional collaboration to mitigate adverse events between primary care and medical subspecialty care teams.  — Payal Parikh, MD (with Editorial Team)

Natasja Looman, Cornelia Fluit, Marielle van Wijngaarden, Esther de Groot, Patrick Dielissen, Dieneke van Asselt, Jacqueline de Graaf, Nynke Scherpbier-de Haan, Chances for learning intraprofessional collaboration between residents in hospitals, Med Educ 2020 Jun 21.

Link To Article


Posted in Graduate Medical Education | Tagged | Leave a comment

Once A Bad Apple, Maybe Always A Bad Apple

Professionalism: This study from Academic Medicine is the first to prospectively support what most of us believe: that students with professionalism issues in medical school may exhibit unprofessionalism and, potentially, prosecutable behavior in clinical practice.

Two groups of medical students from Harvard and Case Western Reserve were identified: 108 former medical students who appeared before their school’s review boards, and a control group of 216 former medical students (matched for gender, underrepresented status in medicine, and year of graduation) who did not.   Four data points were used in this study: before medical school (including demographics, undergraduate college and major, and MCAT score), during medical school (clerkship grades and USMLE scores), during residency (ratings from residency directors), and after residency (state medical board sanctions and malpractice history).

Findings suggest that students who appeared before a review board in medical school were FIVE times more likely to be cited for professionalism issues during residency.   Furthermore, TEN percent of those who appeared before a review board were later sued or sanctioned by their state medical board, compared with five percent who were not brought before their medical school’s review board.  In addition to appearing before the medical school review board, scores on some standardized tests (Step 2 CK score, step 3 score, and MCAT total score) and clerkship grades (neurology, internal medicine, and obstetrics–gynecology) were also predictive of residency disciplinary review and/or future malpractice or sanctioning.

The study is not without limitations: the authors used a small sample size from two highly selective medical schools, relied on resident directors’ recollection (which is sometimes unreliable), and focused on subjects early in their careers.  Importantly, the study did not look at the effectiveness of alternative disciplinary or remediation strategies. Despite these shortcomings, this study is worthwhile reading, if for no other reason than the statistics are eye-catching —   David A. Cohen, MD (with Editorial Staff)

Krupat (et al), Do Professionalism Lapses in Medical School Predict Problems in Residency and Clinical Practice?, Academic Medicine June 2020

Link To Article


Posted in Graduate Medical Education, Undergraduate Medical Education | Tagged | Leave a comment

Medical Education Research Round-Up

Do Professionalism Lapses in Medical School Predict Problems in Residency and Clinical Practice?
Krupat E (et al)

N: 108 (medical school graduates)
Method: review of records
Multi-site: Yes
Location: Harvard Medical School; Case Western Reserve University School of Medicine
Conclusion: “Students with professionalism lapses in medical school are significantly more likely to experience professionalism-related problems during residency and practice, although other factors may also play an important predictive role.”
Journal: Academic Medicine

A Signal Through the Noise: Do Professionalism Concerns Impact the Decision Making of Competence Committees?
Odorizzi S (et al)

N: 25 (emergency medicine program directors and senior faculty)
Method: survey
Multi-site: No
Location: Royal College of Physicians and Surgeons of Canada
Conclusion: “When reviewing a simulated resident portfolio, individual reviewer scores for residents PAE (progressing as expected) were responsive to the addition of professionalism concerns. Considering this, educators using a CC (competence committee) should have a system to report, collect, and document professionalism issues.”
Journal: Academic Medicine

Internal Medicine Resident Professionalism Assessments: Exploring the Association With Patients’ Overall Satisfaction With Their Hospital Stay Ratelle JT (et al)

N: 409 (409 patients assessed 72 PGY-1 residents)
Multi-site: No
Location: Mayo Clinic Hospital-Rochester, Saint Marys Campus
Conclusion: “Hospitalized patients’ assessment scores of in-hospital resident professionalism were strongly correlated with overall patient satisfaction with hospital stay but were not correlated with resident professionalism in other settings. The limitations of patient evaluations should be considered before incorporating these evaluations into programs of assessment.”
Journal: Academic Medicine

Does Empathy Decline in the Clinical Phase of Medical Education? A Nationwide, Multi-Institutional, Cross-Sectional Study of Students at DO-Granting Medical Schools
Hojat M, (et al)

N: 10,751 (medical students)
Multi-site: Yes
Method: Survey
Location: 41 DO granting medical schools in United States
Conclusion: Students in clinical years (M3 and M4) have slightly less empathy than students in preclinical years (M1 and M2) in both MD and DO progams; however, the decline is less pronounced in DO students.
Journal: Academic Medicine

Chances for learning intraprofessional collaboration between residents in hospitals
Looman N, et al

N: 42 (residents and supervisors)
Method: interviews
Multi-site: Yes
Location: three emergency departments and three geriatric departments of five hospitals in the Netherlands
Conclusion: Intraprofessional collaboration (intraPC) between primary care (PC) doctors and medical specialists (MS) is promoted when there is a collaborative culture, hierarchy is limited, there is dedicated time for intraPC and support from the supervisor.
Journal: Medical Education

Posted in Graduate Medical Education, Undergraduate Medical Education | Tagged , | Leave a comment

DR MERL on Twitter

Posted in Graduate Medical Education, Undergraduate Medical Education | Tagged | Leave a comment

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.
Link To Article
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.
Link To Article



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)

Posted in Graduate Medical Education | Tagged , | Comments Off on How Can Residents Learn To Think On Their Own? Qualitative Studies Of Cognitive Autonomy In Residents