We Don’t Know Much About Teaching Medical Ethics

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MEDICAL_ETHICS  This Romanell report, an update from a 1985 landmark article, shows that we still know very little about the optimal goals, outcomes, teaching methods, or assessment methods of medical ethics education.  A much longer (compared to 1985) list of proposed objectives and topics is included, which will be of major interest to those involved in curricular planning.  The report also brings up some issues of faculty management:  “Achieving success requires financial support, recognition, and reward for faculty educators….  In some medical school settings, participation in medical education is implicitly devalued by the fact that teaching is a voluntary, nonremunerated activity.” — Laura Willett, MD.

Carrese JA, Malek J, Watson K, Lehmann LS, Green MJ, McCullough LB, Geller G, Braddock CH 3rd, Doukas DJ. The Essential Role of Medical Ethics Education in Achieving Professionalism: The Romanell Report. Acad Med. 2015 Apr

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Attendings Vary In Their Supervisory Role – A Lot

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ATTENDINGS  This will not be news for our trainees.  Twenty-four internal medicine inpatient teaching service attendings were given a sample student presentation and interviewed regarding their supervisory style.  Different styles were characterized by “the relative prioritization of three competing activities – patient care, trainee supervision, and teaching.”  Two styles were at ends of the spectrum: the direct care style and the minimalist style.  In the direct care style, attendings provided direct patient care either in parallel with the trainee efforts (“I just do everything on my own”) or during many hours of rounding together.  In the minimalist style, attendings “relied heavily on the senior medical resident’s ability to run the team and provide teaching” (“I have been burned before”).  More attendings described an empowerment style or a mixed practice style, both of which involved greater trainee teaching and oversight.  Attendings “largely maintained their style affinity regardless of trainee ability and patient load,” and few had discussed their styles with trainees or other attendings — Laura Willett, MD.

Goldszmidt M Faden L, Dornan T, van Merriënboer J, Bordage G, Lingard L. Attending Physician Variability: A Model of Four Supervisory Styles. Acad Med. 2015 Apr.

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Throw Out The Checklists (To Determine OSCE Failure)!  A Global Competent/Not Competent Rating Is Better

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osce  Forty-seven residents were video-taped performing procedures on simulators during an observed structured clinical examination (OSCE).  Trained raters filled out traditional checklists as well global ratings including one for “overall ability to perform procedure”.  Any “not competent” rating generated a written comment.  There was near perfect inter-rater reliability for overall competence decisions.  A high score on the checklist did not rule out incompetence; written comments on “not competent” performances with high checklist scores included notations such as “significant breaches of sterility”, “laceration or damage of important structures”, and “unsuccessful or too many attempts” — Laura Willett, MD.

Walzak A, Bacchus M, Schaefer JP, Zarnke K, Glow J, Brass C, McLaughlin K, Ma IW. Diagnosing Technical Competence in Six Bedside Procedures: Comparing Checklists and a Global Rating Scale in the Assessment of Resident Performance. Acad Med. 2015 Apr 15.

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Are Connectivist Massive Open Online Courses (cMOOCs) The Solution For Faculty Development In Medical Education?

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facultydevelopment Academic Life in Emergency Medicine is an open access medical education web site aimed at emergency medicine practitioners.  The authors describe their experience with their first six monthly on-line scenarios that raise “nonclinical educational dilemmas”.  Each case, before posting, is reviewed by medical education experts for responses citing relevant literature.  After the case is posted on the site, readers post comments which are then analyzed and shaped into a curated community commentary by associate editors.  This commentary, along with the case and expert commentary, forms the final product.  Pageviews in the first week after a scenario was posted ranged from 493 (mentor-mentee relationships) to 1,124 (job negotiations).  Given difficulties with achieving attendance to in-person faculty development sessions by clinically busy faculty, an interactive web-based platform may be part of the solution — Laura Willett, MD.

Chan TM, Thoma B, Lin M. Creating, Curating, and Sharing Online Faculty Development Resources: The Medical Education in Cases Series Experience. Acad Med. 2015

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We Think The Learning Environment Is Important. Can We Measure It?

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learningEnvironment  Johns Hopkins students filled out a survey including Likert-scale learning environment questions with an 81% completion rate. Investigators created a learning environment measure utilizing 28 questions which loaded into 7 general factors.  The score correlated with the students’ overall perception of the learning environment.  Out of a possible maximum score of 140, students who felt the overall learning environment was “exceptional” gave a mean score of 121, while those who felt it was “poor” or “terrible” gave a mean score of 76.  The “community of peers” factor explained by far the highest percentage of variance in the overall score. — Laura Willett, MD.

Shochet RB, Colbert-Getz JM, Wright SM. The Johns Hopkins Learning Environment Scale: Measuring Medical Students’ Perceptions of the Processes Supporting Professional Formation. Acad Med. 2015

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Give Educators (a little) Money, And They Will Innovate

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grants The authors describe the UCSF (University of California San Francisco) experience with giving intramural grants of about $20,000 each, the bulk of which was used to provide faculty with up to 10% protected time for educational innovation and research.  In addition, applicants were encouraged to seek feedback and guidance at a weekly intramural Educational Scholarship Conference attended by experts in curriculum development, learner assessment, and program evaluation.  Sixty-eight principal investigator (PI) faculty who received the grants (an 88% response) reported back to the funding organization.  From the school’s perspective, 79% of the projects led to permanent changes in curricula, teaching methods, or materials.  Forty-one percent led to peer-reviewed publications and 86% to presentations.  Individual PIs described the importance of grant-supported protected time to their status within their departments, their professional identity as educators, their attainment of promotion, and their ability to promote the careers of other faculty members.  Fifty-seven percent “stated that receiving this grant led to additional grants.”  It seems that investing a fairly small amount in intramural education grants can have a large institutional and faculty payoff. — Laura Willett, MD.

Adler SR, Chang A, Loeser H, Cooke M, Wang J, Teherani A. The Impact of Intramural Grants on Educators’ Careers and on Medical Education Innovation. Acad Med. 2015

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TBL Application Exercises: To Grade Or Not To Grade?

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Team Based Learning  Team-based learning (TBL) is a widely used instructional strategy used in medical schools and involves advance preparation, read­iness assurance (IRATs/GRATs) and application of knowledge to problem-solving exercises termed Group Application (GApp) exercises. While graded IRATs and GRATs promote in-depth preparation, the foundation of TBL is the GApp exercise. Using a 22-item survey, the current study in­vestigated how the preferences and perceptions of students are influenced by graded versus ungraded GApp exercises. The data indi­cated that the perceived effectiveness of GApp exercises does not depend on grade weight. Also, the IRAT grades which reflect advance preparation by the students did not differ significantly with ungraded GApp exercises. A majority of students preferred ungraded GApp exercises and mentioned that this creates a better learning environment with reduced stress and anxiety and improves group discussion. -Sangita Phadtare, Ph.D., Cooper Medical School of Rowan University

Adam S. Deardorff, Jeremy A. Moore, Colleen McCormick, Paul G. Koles, Nicole J. Borges., Incentive structure in team-based learning: graded versus ungraded Group Application exercises., Journal of Educational Evaluation for Health Professions 2014, April, 11:6

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If You Can’t Say Something Nice, Don’t Say Nothing At All: Thumper’s Rule And How Faculty Interpret Narrative Comments On Resident Evaluations

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evaluations  In this qualitative study using constructivist grounded theory analysis, investigators describe how faculty interpret narrative comments on residents’ in-training evaluation. De-identified narrative comments of 126 residents were distributed to 24 faculty who were each asked to review 15-16 documents and sort them into four categories ranging from A for outstanding to D for unacceptable, and then rank-order the residents within each category. Semi-structured interviews were conducted to assess how faculty decided to categorize and rank-order residents. Results show that all faculty read between the lines to understand narrative comments. “Excellent” was often interpreted as “middle of the road,” and “good” was considered to actually mean “below level, needs work.” Faculty reported scanning for “red flags” to identify the most relevant cues among all the comments- examples of positive red flags included “chief resident material, future colleague, superstar,” and examples of negative red flags included “solid, good, improving, functioning at expected level.” While faculty also considered consistency and specificity of comments to categorize residents, it’s interesting to note that faculty assume what is written is often not what is meant, and instictively and actively search for hidden meaning. So why do we not just say what we mean? Maybe our feelings about politeness may have something to do with it. The saying “if you can’t say something nice, don’t say nothing at all,” (also known as Thumper’s rule from the Disney movie Bambie), may impede our ability to describe and interpret trainee performance accurately. — Sarang Kim, MD

Medical Student’s Perspective: This article is valuable in exploring how faculty interpret narrative comments on resident evaluations. I was not surprised by the need for illustrative examples to make residents stand out nor by many evaluations blending together. Scanning for positive and negative red flags in such letters seems a natural method for differentiation. I was surprised, however, to see generalized skepticism towards many commonly used descriptive words. It was also surprising that personality trait praises were the most common commentaries but also some of the most disregarded. The most concerning idea revealed was the differing opinions on the purpose of resident evaluations and the resulting variation in commentary content. Some believed they were for resident feedback while others felt their purpose was for program directors to use in generating recommendation letters for fellowship or job applications. Since these goals can seem misaligned, I believe the best standardized approach would be a separate forum of honest feedback documented during rotations along with a summative commentary to highlight exemplary qualities or concerns. This way, the program director stays better abreast of resident development and can evaluate residents based on fuller commentary. — Victoria Behrend, MD Candidate 2015 Rutgers Robert Wood Johnson Medical School

Resident’s Perspective: As one progresses through medical training, less emphasis is placed on objectively based knowledge assessments and shifted towards largely narrative-based assessments of clinical performance.  Although these narrative-based assessments serve many purposes, one core objective is to provide residents constructive feedback to promote professional growth. Faculty physicians face a troubling dilemma when attempting to provide this feedback effectively. They must provide honest and constructive criticism relating to areas where individual residents can improve. However, they must do this in a way that preserves a working teacher-student relationship, protects the psyche of the resident, and not compromise future fellowship/job opportunities for the resident.  The “hidden code” referred to by the authors of this study allows faculty physicians to address many of these issues. Unfortunately though, resident physicians have little experience deciphering the “hidden code”.  The residents may believe they are meeting expectations and get a false sense of security when in fact the faculty might perceive them as struggling. This raises the question of whether the current use of narrative-based assessments, embedded with hidden codes, is ultimately doing residents- and possibly even their patients- a disservice. I would argue, yes. — James Penn, MD (PGY 3) Rutgers Robert Wood Johnson Medical School, Internal Medicine Residency Program

Ginsburg S, Regehr G, Lingard L, Eva KW. Reading between the lines: faculty interpretations of narrative evaluation comments. Med Educ 2015;49:296-306

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Can Clinical Reasoning Deficits Be Remediated?

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clinical_reasoning  Yes, is the resounding answer from Dr. Guerrasio, who literally wrote the book on medical learner remediation.  The authors describe their institution’s experience remediating learners identified as having deficiency in clinical reasoning, most with co-existing deficits in other domains as well.  Of 53 such learners, 96% passed a blinded reassessment and 91% continued successfully in their programs.  They describe a time-intensive program in which learners create extensive tables for “all the main presentations for that specialty”, including illness scripts with semantic qualifiers, diagnostic testing, and treatment algorithms.  The median number of faculty hours expended per learner was 18, with a range up to 100 hours, excluding time for “planning, assessment, or preparation.” — Laura Willett, MD


Guerrasio J, Aagaard EM., Methods and outcomes for the remediation of clinical reasoning. J Gen Intern Med. 2014 Dec;29(12):1607-14.

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Addressing Moderate Lapses in Professionalism

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professionalism  Baylor College of Medicine created a novel process to identify and evaluate professional behaviors of their undergraduate medical students and to implement policies to address breaches in professionalism.  A committee of five faculty members experienced in ethics and or behavioral sciences was formed to evaluate alleged professionalism occurrences.  An on-line, confidential reporting system was employed alerting the committee of potential breaches.  The committee then rates the alleged offense as mild, moderate, or major.  A record is kept of mild acts and, unless a second report is received, no further action is taken.  Major transgressions are reported directly to the Dean of Student Affairs.  Breaches which are considered moderate result in a face to face meeting between the committee and the student, giving the student a chance to explain the alleged infraction.  The committee also discusses action plans with the student to prevent reoccurrences.  The meetings are intervention sessions using guided reflection, as opposed to disciplinary sessions.  From 2008–2013, the committee received 79 reported concerns and conducted 20 student interviews for moderate offenses.  Only one of these students incurred additional professionalism reports.  This novel approach to professionalism breaches received positive feedback from both the students and administration at Baylor. — Lee Ann Schein, Ph.D

Gill AC, Nelson EA, Mian AI, Raphael JL, Rowley DR, Mcguire AL.Med Teach. Responding to moderate breaches in professionalism: An intervention for medical students.2015 Feb;37(2):136-9.

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