When The Monday Before Match Day Is Not A Happy Day

Match: No research, and only a smattering of data, but this article is required reading for faculty counseling graduating MD students from the US with difficulty matching into residency.  A sizable percentage (6.2%) of US seniors did not gain a position during the 2016 primary Match; nearly half of these attained a position during the supplementary program (SOAP) in the days shortly before Match Day.  For those who do not (615 students in the 2016 Match), the authors review a number of options, including delay of graduation, obtaining a position outside of SOAP (fairly high success), re-entering the Match the following year in the same or different specialty (also fairly high success), pursuing interim activities to improve Match success, or pursuing a non-clinical career.  A systemic problem is that there is no centralized clearinghouse of open residency positions, which may occur off-cycle.  The authors also address more specific issues for school administrators such as policies/practices regarding delay of graduation, Dean’s Letter update, leave of absence from rotations following Match failure, and support for students post-graduation. — Laura Willett, MD

Bumsted T, Schneider BN, Deiorio NM. Considerations for Medical Students and Advisors After an Unsuccessful Match. Acad Med. 2017 March

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Don’t Know Much About….Feedback

Feedback: This scoping review which describes what has been published in English regarding feedback to healthcare learners will be of interest mostly to researchers and those looking for a comprehensive view of the field.  The bulk of publications were from English-speaking countries and focused on medical students or residents in those countries.  Of publications with a specialty focus, a majority involved either internal medicine or surgery.  The overall level of the literature seems to be in a nascent stage.  For example, even though a majority of articles described a new approach to feedback, only 7.5% of articles involved randomization of learners.  Likewise, in the large number of articles that evaluated a feedback intervention, 57.7% confined that evaluation to the learners’ reaction to feedback, rather than measuring more important outcomes such as changes in care or behavior.  “High-level, evidence-based educational recommendations for feedback are lacking.” — Laura Willett, MD

Bing-You R, Hayes V, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Acad Med. 2017 Feb 7. Feedback for Learners in Medical Education: What Is Known? A Scoping Review.

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Faculty Development For Community-Based Faculty

Faculty Development: In this survey of North American family medicine clerkship directors, researchers focused on the use of community-based preceptors and how they are developed and rewarded. Sixty-nine percent of schools reported heavy reliance on community-based preceptors for their family medicine clerkship instruction.  Interestingly, 100% of Canadian clerkship directors reported giving direct monetary payments to their community-based preceptors, as opposed to 28% of US directors.  Among schools that paid their preceptors, the average payment was $263 per week.  Schools which paid their preceptors were much more likely to require those preceptors to participate in formal faculty development.  The most common form of formal faculty development was the in-person session, despite the largest barriers to participation being reported as preceptor availability and geographic distribution.  Various forms of distance learning were also utilized.  There was little evidence of rigorous needs assessment or evaluation of effectiveness for most community-based faculty development programs. — Laura Willett, MD

Drowos J, Baker S, Harrison SL, Minor S, Chessman AW, Baker D., Faculty Development for Medical School Community-Based Faculty: A Council of Academic Family Medicine Educational Research Alliance Study Exploring Institutional Requirements and Challenges. Acad Med. 2017 Feb 21.

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Updates From the EPA Pilot Schools

Entrustable Professional Activities: Ten US medical schools were chosen to work on pilot projects related to teaching and assessing the 13 proposed entrustable professional activities (EPAs) for graduation from medical school.  These reports document a lot of thought about how to put these EPAs into practice, but offer no data-driven advice, as expected for early in the process.  The Brown et al paper present a “trustworthiness” assessment framework that they believe underlies all entrustment decisions, which educators may find useful.  The proposed elements are:  “discernment: awareness of the limits of one’s clinical knowledge and skill; conscientiousness: thoroughness and dependability in following through with assigned tasks; and truthfulness: appropriate balance of truth and tact.” — Laura Willett, MD

Lomis, Kimberly MD; Amiel, Jonathan M. MD; Ryan, Michael S. MD, MEHP; Esposito, Karin MD, PhD; Green, Michael MD, ScM; Stagnaro-Green, Alex MD, MHPE; Bull, Janet MA; Mejicano, George C. MD, MS; Implementing an Entrustable Professional Activities Framework in Undergraduate Medical Education: Early Lessons From the AAMC Core Entrustable Professional Activities for Entering Residency Pilot.for the AAMC Core EPAs for Entering Residency Pilot Team, Academic Medicine, January 3, 2017

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Brown, David R. MD; Warren, Jamie B. MD, MPH; Hyderi, Abbas MD, MPH; Drusin, Ronald E. MD; Moeller, Jeremy MD; Rosenfeld, Melvin PhD; Orlander, Philip R. MD; Yingling, Sandra PhD; Call, Stephanie MD; Terhune, Kyla MD; Bull, Janet MA; Englander, Robert MD; Wagner, Dianne P. MD, Finding a path to entrustment in undergraduate medical education: A progress report from the AAMC core entrustable professional activities for entering residency entrustment concept group. Academic Medicine, January 2017

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Are Clerkship Clinical Grades Fair? (or, “I Want That Male Intern To Evaluate Me.”)

Grading: The authors investigated the influence of student and evaluator demographics on the summary clinical grades given to 155 clerkship students at one medical school.  The possible grades were “exceptional”, “above expectations”, “meets expectations”, and “below expectations”.  Newcomers to student evaluation may be startled by the strong “Lake Woebegone” effect:  only 16 of 4,462 evaluations were “below expectations” and only 12-23%, depending on the clerkship, were “meets expectations”.   It is not surprising, but of concern, that variables outside of the students’ control appeared to have a moderate to large effect on the clinical grade assigned.  The authors focus on the gender effects:  Male students were graded lower than female students, but only when being evaluated by female residents or attendings.  Male evaluators , but not female evaluators, became much more stringent graders with increasing age. However, another variable had an even larger effect on grade.  Observation times of >1 day were associated with a much higher rate of “exceptional” ratings.  Gender effects on evaluations, including evaluations by standardized patients, have been seen in the prior studies.  Clerkship directors may need to keep these influences in mind. — Laura Willett, MD

Riese A, Rappaport L, Alverson B, Park S, Rockney RM. Clinical Performance Evaluations of Third-Year Medical Students and Association With Student and Evaluator Gender. Acad Med. 2017 Jan 17.

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Can Residents Be Taught To Teach? 

Resident As Teacher: The authors describe a one-day “residents as teachers” modified team-based learning curriculum utilized for second-year pediatrics residents.  Residents were given time to do brief pre-readings on pertinent topics:  adult learning theory, feedback, skill-teaching, and learner orientation.  The rest of class time was taken up with individual and team quizzes assessing understanding of the readings, and active application of the concepts in discussions and simulations with volunteer final-year medical students.  Outcomes were the results of attitudinal and self-efficacy surveys and objective structure teaching examinations (OSTEs) done at the beginning and end of the day.  All of these outcomes showed substantial improvements.  It would be useful to compare longer-term and more “real world” outcomes, such as student evaluations of resident teaching, for those exposed vs. not exposed to this curriculum. — Laura Willett, MD

Chokshi BD, Schumacher HK, Reese K, Bhansali P, Kern JR, Simmens SJ, Blatt B, Greenberg LW. A “Resident-as-Teacher” Curriculum Using a Flipped Classroom Approach: Can a Model Designed for Efficiency Also Be Effective? Acad Med. 2016 Dec 27.

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Best Time To Get Sick? Never!

Resident Transition: Chances are, many of us have heard of the saying, “Don’t get sick in July,” which refers to the perceived and possibly real association between the start of a new academic year and worse patient outcomes in teaching hospitals. There’s also literature suggesting that weekend admissions are associated with increased mortality. Add to this the findings of a new study published in this month’s JAMA regarding increased risk of mortality associated with resident service changes, and one is left with no “good time” to get sick. But are these findings valid? In this retrospective study, the authors looked at 230,000+ admissions to internal medicine services at 10 US Veterans Health Administration hospitals and associations between in-hospital, 30-day and 90-day mortality and readmission rates with resident care transitions. After adjusting for important comorbidities, resident transition was associated with a statistically significant increase in risk of mortality (OR 1.21, 95% CI 1.12 – 1.31 for 30-day mortality with intern + resident transition). However, in an alternative analysis that compared patients admitted 2 days prior to resident transitions with those admitted on days not associated with service changes, there was no significant association between resident transition and mortality. This suggests that the increased risk of mortality observed in the original analysis may be due to inadequate adjustment for other important confounding variables in this observational study looking at a complex care delivery system where resident transition is just one small piece of the process. Having said that, given what we know about how important information can be missed during handoffs, this study should make us consider strategies to ensure safety of patients regardless of when they are admitted to the hospital. — Sarang Kim, MD

Chief Resident Commentary:  We asked one of our internal medicine chief residents to comment on this article and to consider the idea of minimizing resident transitions, perhaps by making a service rotation longer than the typical 4 weeks:

While on service as a resident, I noticed that there arises the occasion that you kind of feel like your “wheels are spinning” with a certain patient. You and your team are stuck in a rut, and nothing really gets done for the patient. Often times in those situations, I looked forward to my attending changing out, or even the whole resident team changing out just so that the patient got a fresh perspective of their case. Sometimes that’s exactly what a patient needs to advance in their care.

The obvious downside of being on service longer than 4 weeks would be elimination of the coveted “4+1” block schedule (4 weeks inpatient + 1 week outpatient). I think one might also run into serious burnout possibilities with being on service longer than a month. It’s physically and emotionally draining to be on service for that long without a break. We also have residents doing only 2-week blocks and in some rare cases 1-week blocks, which further increase handoffs. But with the constraints of the rotating 4+1 system and giving residents the ability to choose their own vacation weeks, these shorter rotations seem inevitable from a scheduling perspective. Maybe a good solution would be to change out the senior resident and intern in a “staggered” manner, as is done in some other programs. So when the senior resident switches, the intern stays on the team and vice-versa. This way, there’s always someone who has some degree of knowledge (hopefully) about the patient.

Daniel Schaer, MD, MPH
Chief Resident
Department of Medicine
Rutgers-Robert Wood Johnson Medical School

Denson et al. Association between end-of-rotation resident transition in care and mortality among hospitalized patients. JAMA 2016;316(21)2204-2213.

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