How The Experts Visualize Professionalism Remediation

Professionalism: In this qualitative study, the authors interviewed experienced educators about their professionalism remediation processes.  These experts visualized a 3-stage process, with all 3 stages not being necessary in every case.  During the first phase, “explore and understand”, the main object was to obtain the student’s viewpoint regarding the professionalism complaint.  Often, the process could end there if there was a clear miscommunication or “one-off” incident.  The second phase was focused on “remediation”, with the faculty member acting as a coach to try to help the student meet professional expectations.  Some concerns were expressed that some students could “game” the system during this phase by expressing socially appropriate comments without changing attitudes.  The third phase, “gather evidence for dismissal”, was entered for a small minority of students identified by professionalism complaints, only after a decision was reached that remediation was unlikely to be effective.  Evidence was gathered to bring before duly constituted committees of the medical school.  This structure will be useful for educators working with students reported for professionalism concerns. — Laura Willett, MD

Mak-van der Vossen, Marianne C., MD; Croix, Anne de la, MA, MEd, PhD; Teherani, Arianne, Ms Ed, PhD; Mook, Walther N.K.A. van, MD, PhD; Croiset, Gerda, MD, PhD; Kusurkar, Rashmi A., MD, PhDA Roadmap for Attending to Medical Students’ Professionalism Lapses Academic Medicine: November 27, 2018

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Is Going To Medical School Depressing?

Depression: Yes, for many of us.  Researchers surveyed more than 3,000 medical students in year 1 and year 4 with surveys including validated scales for depression, stress, coping methods, and social support.  Predictors of depression in year 4 were found via multivariate analysis and a predictive score was developed.  Overall, 31% of year 4 students reported “depression symptoms”.  Multivariable analysis showed independent predictors as measured in year 1:  depression at year 1 (the strongest predictor), age >24, race/ethnicity non-white and non-Hispanic, high stress, high measure of negative coping, low social support, and mid-range medical school tuition (the only school-related variable that was predictive).  A weighted score was developed which could range from 0 to 10.  Students with a score of 0-1 had a 15% prevalence of depressive symptoms in year 4 and those with scores of 6-10 had a prevalence of 64%.  The authors speculate about the potential uses of this predictor. — Laura Willett, MD

Dyrbye LN, Wittlin NM, Hardeman RR, Yeazel M, Herrin J, Dovidio JF, Burke SE, Cunningham B, Phelan SM, Shanafelt TD, van Ryn M. A Prognostic Index to Identify the Risk of Developing Depression Symptoms Among U.S. Medical Students Derived From A National, Four-Year Longitudinal Study. Acad Med. 2018 Sep

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Money Talks, To Residents Too

Debt: This survey of family medicine residents regarding debt burden and future employment plans had predictable but sobering findings. Firstly, 60% of these residents had a debt burden of more than $150,000, and 45% of residents with a DO degree had a debt burden of more than $250,000. High levels of debt burden were associated to a large and statistically significant degree with lower interest in academic employment, government employment, and geriatrics fellowship. — Laura Willett, MD

Phillips J, Peterson LE, Fang B, Kovar-Gough I, Phillips RL Jr.  Debt and The Emerging Physician Workforce: The Relationship Between Educational Debt and Family Medicine Residents’ Practice and Fellowship Intentions. Acad Med. 2018 Sep.

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How Long Should That Clerkship Be?

Clerkship: It looks like we have no idea.  Researchers looked at a “natural experiment” in clerkship length during a curriculum change at the University of Michigan Medical School.  During this transition, all clerkship lengths were decreased by 25%.  For example the surgery clerkship was shortened from 8 weeks to 6 weeks.  Multiple outcomes were measured pre- and post- change for all 7 clerkships; while a few were of statistical significance, none appeared to be important.  These outcomes included scores on standardized and/or faculty-developed examinations in each clerkship , performance on a multi-station objective clinical skills exam after completion of all clerkships, and survey measures of student satisfaction and well-being.  — Laura Willett, MD

Monrad SU, Bibler Zaidi NL, Gruppen LD, Gelb DJ, Grum C, Morgan HK, Daniel M, Mangrulkar RS, Santen SA. Does Reducing Clerkship Lengths by 25% Affect Medical Student Performance and Perceptions? Acad Med. 2018 Jul

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Benefits And Harms Of “Close Supervision” Of Residents

Supervision: This single-center rigorous randomized controlled trial of level of attending supervision on a large inpatient general internal medicine service adds data to the debate about the “right” level of resident supervision.  Twenty-two attending physicians were randomized to standard practice or increased work-rounds supervision over different 2-week rotations, leading to the observation of 44 blocks.  Standard supervision (at Massachusetts General Hospital) consists of bedside presentations to the attending of all new patients and a “card-flip” on established patients following-resident-led work rounds.  In the intervention arm, attendings “joined both new patient presentations and resident work rounds 7 days a week, providing direct supervision during work rounds.”  Multiple outcomes were tracked including medical errors discovered by rigorous investigation, other patient outcomes, time-motion observations of rounds, tracking of orders and consultations, and survey responses of interns, residents, and attendings.  There were slightly but not significantly more errors in the standard supervision arm, but nearly all the errors were mild.  Only two severe errors were discovered, one in each group.  General patient outcomes, e.g. length of stay, mortality, transfer to the ICU, etc. were indistinguishable, as were number of orders and consultations.  Time-motion studies showed that work rounds were 202 minutes (!) under both conditions and that interns spoke about 10 fewer minutes during work rounds which included the attending.  The biggest differences were found in the survey data:  Interns and residents overall preferred standard supervision with large differences in the numbers agreeing that autonomy and supervision were “just right” (e.g. 97% vs. 58%) and many more agreeing that their “comfort in making independent patient care decisions improved”.  Resident and interns felt they provided very good patient care under both levels of supervision.  Attendings felt that that knew their team’s plan of care better with the enhanced supervision of work rounds.  Among attendings evaluating the periods of intensive vs. standard supervision, there were statistically borderline increases in agreement with two statements:  “we provided outstanding quality of care” and “work-life balance was poor”.   For this reviewer, the large improvement in resident autonomy, possibly leading to better care by these doctors in the future, should carry weight in this on-going discussion. — Laura Willett, MD

Finn KM, Metlay JP, Chang Y, Nagarur A, Yang S, Landrigan CP, Iyasere C. Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident Education: A Randomized Clinical Trial. JAMA Intern Med. 2018 Jun.

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Can Doctors Be Taught To Deliver Bad News?

Communication: Yes, is the short answer given in this meta-analysis of 17 studies evaluating interventions to “improve the communication of bad or difficult news”.  Most interventions were fairly brief stand-alone interventions involving simulation or role-play; the SPIKES model was the most commonly used framework for instruction.  The two most commonly assessed outcomes were observer-rated skill during a simulation exercise and physician self-rated confidence.  Both of these measures showed robust short-term improvement following training.  The authors mention the desirability of looking at longer-term outcomes and patient-centered outcomes.  This reviewer would advise some caution on measuring the latter.  Prior work has shown that patients with Stage 4 incurable cancers who did not understand they were terminally ill rated their oncologists’ communication skills better than patients who accurately understood their situation. — Laura Willett, MD

Johnson J, Panagioti M. Interventions to Improve the Breaking of Bad or Difficult News by Physicians, Medical Students, and Interns/Residents: A Systematic Review and Meta-Analysis. Acad Med. 2018 Jun

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Don’t Know Much About…..Measuring Teamwork

Teamwork: Everyone agrees that the ability to work in teams is an important competency, but how do we know that our learners have achieved this?  One observer joined 20 internal medicine housestaff teams for one morning work rounds and evaluated them using 9 different published teamwork observation instruments.  The instruments for the most part included items in the same 5 domains: team structure, leadership, situation monitoring, mutual support, and communication.  All of the tools identified the same low outlier team, but other than that one agreement, there was wide variation in the ranking of the different teams by different instruments.  If ratings of teamwork are to become high-stakes, we would hope for more robust measurement tools. — Laura Willett, MD

Weingart SN, Yaghi O, Wetherell M, Sweeney M. Measuring Medical Housestaff Teamwork Performance Using Multiple Direct Observation Instruments: Comparing Apples and Apples.  Acad Med. 2018 Apr

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