Showing papers in "Academic Medicine in 2004"

Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains.

Abstract: The factors that cause large individual differences in professional achievement are only partially understood. Nobody becomes an outstanding professional without experience, but extensive experience does not invariably lead people to become experts. When individuals are first introduced to a professional domain after completing their education, they are often overwhelmed and rely on help from others to accomplish their responsibilities. After months or years of experience, they attain an acceptable level of proficiency and are able to work independently. Although everyone in a given domain tends to improve with experience initially, some develop faster than others and continue to improve during ensuing years. These individuals are eventually recognized as experts and masters. In contrast, most professionals reach a stable, average level of performance within a relatively short time frame and maintain this mediocre status for the rest of their careers. The nature of the individual differences that cause the large variability in attained performance is still debated. The most common explanation is that achievement in a given domain is limited by innate factors that cannot be changed through experience and training; hence, limits of attainable performance are determined by one’s basic endowments, such as abilities, mental capacities, and innate talents. Educators with this widely held view of professional development have focused on identifying and selecting students who possess the necessary innate talents that would allow them to reach expert levels with adequate experience. Therefore, the best schools and professional organizations nearly always rely on extensive testing and interviews to find the most talented applicants. This general view also explains age-related declines in professional achievement in terms of the inevitable reductions in general abilities and capacities believed to result from aging. In this article, I propose an alternative framework to account for individual differences in attained professional development, as well as many aspects of age-related decline. This framework is based on the assumption that acquisition of expert performance requires engagement in deliberate practice and that continued deliberate practice is necessary for maintenance of many types of professional performance. In order to contrast this alternative framework with the traditional view, I first describe the account based on innate talent. I then provide a brief review of the evidence on deliberate practice in the acquisition of expert performance in several performance domains, including music, chess, and sports. Finally, I review evidence from the acquisition and maintenance of expert performance in medicine and examine the role of deliberate practice in this domain.

Communication failures: an insidious contributor to medical mishaps.

Abstract: Purpose To describe how communication failures contribute to many medical mishaps. Method In late 1999, a sample of 26 residents stratified by medical specialty, year of residency, and gender was randomly selected from a population of 85 residents at a 600-bed U.S. teaching hospital. The study design involved semistructured face-to-face interviews with the residents about their routine work environments and activities, the medical mishaps in which they recently had been involved, and a description of both the individual and organizational contributory factors. The themes reported here emerged from inductive analyses of the data. Results Residents reported a total of 70 mishap incidents. Aspects of "communication" and "patient management" were the two most commonly cited contributing factors. Residents described themselves as embedded in a complex network of relationships, playing a pivotal role in patient management vis-a-vis other medical staff and health care providers from within the hospital and from the community. Recurring patterns of communication difficulties occur within these relationships and appear to be associated with the occurrence of medical mishaps. Conclusion The occurrence of everyday medical mishaps in this study is associated with faulty communication; but, poor communication is not simply the result of poor transmission or exchange of information. Communication failures are far more complex and relate to hierarchical differences, concerns with upward influence, conflicting roles and role ambiguity, and interpersonal power and conflict. A clearer understanding of these dynamics highlights possibilities for appropriate interventions in medical education and in health care organizations aimed at improving patient safety.

Assessing competence in communication and interpersonal skills: the Kalamazoo II report.

Abstract: Accreditation of residency programs and certification of physicians requires assessment of competence in communication and interpersonal skills. Residency and continuing medical education program directors seek ways to teach and evaluate these competencies. This report summarizes the methods and tools used by educators, evaluators, and researchers in the field of physician-patient communication as determined by the participants in the "Kalamazoo II" conference held in April 2002. Communication and interpersonal skills form an integrated competence with two distinct parts. Communication skills are the performance of specific tasks and behaviors such as obtaining a medical history, explaining a diagnosis and prognosis, giving therapeutic instructions, and counseling. Interpersonal skills are inherently relational and process oriented; they are the effect communication has on another person such as relieving anxiety or establishing a trusting relationship. This report reviews three methods for assessment of communication and interpersonal skills: (1) checklists of observed behaviors during interactions with real or simulated patients; (2) surveys of patients' experience in clinical interactions; and (3) examinations using oral, essay, or multiple-choice response questions. These methods are incorporated into educational programs to assess learning needs, create learning opportunities, or guide feedback for learning. The same assessment tools, when administered in a standardized way, rated by an evaluator other than the teacher, and using a predetermined passing score, become a summative evaluation. The report summarizes the experience of using these methods in a variety of educational and evaluation programs and presents an extensive bibliography of literature on the topic. Professional conversation between patients and doctors shapes diagnosis, initiates therapy, and establishes a caring relationship. The degree to which these activities are successful depends, in large part, on the communication and interpersonal skills of the physician. This report focuses on how the physician's competence in professional conversation with patients might be measured. Valid, reliable, and practical measures can guide professional formation, determine readiness for independent practice, and deepen understanding of the communication itself.

Unprofessional behavior in Medical school is associated with subsequent disciplinary action by a state medical board

Abstract: Purpose. To determine if medical students who demonstrate unprofessional behavior in medical school are more likely to have subsequent state board disciplinary action. Method. A case– control study was conducted of all University of California, San Francisco, School of Medicine graduates disciplined by the Medical Board of California from 1990 –2000 (68). Control graduates (196) were matched by medical school graduation year and specialty choice. Predictor variables were male gender, undergraduate grade point average, Medical College Admission Test scores, medical school grades, National Board of Medical Examiner Part 1 scores, and negative excerpts describing unprofessional behavior from course evaluation forms, dean’s letter of recommendation for residencies, and administrative correspondence. Negative excerpts were scored for severity (Good/Trace versus Concern/Problem/Extreme). The outcome variable was state board disciplinary action. Results. The alumni graduated between 1943 and 1989. Ninety-five percent of the disciplinary actions were for deficiencies in professionalism. The prevalence of Concern/ Problem/Extreme excerpts in the cases was 38% and 19% in controls. Logistic regression analysis showed that disciplined physicians were more likely to have Concern/Problem/Extreme excerpts in their medical school file (odds ratio, 2.15; 95% confidence interval, 1.15– 4.02; p .02). The remaining variables were not associated with disciplinary action. Conclusion. Problematic behavior in medical school is associated with subsequent disciplinary action by a state medical board. Professionalism is an essential competency that must be demonstrated for a student to graduate from medical school. Acad Med. 2004;79:244 –249.

Personal illness narratives: using reflective writing to teach empathy.

Abstract: Reflective writing is one established method for teaching medical students empathetic interactions with patients. Most such exercises rely on students' reflecting upon clinical experiences. To effectively elicit, interpret, and translate the patient's story, however, a reflective practitioner must also be self-aware, personally and professionally. Race, gender, and other embodied sources of identity of practitioners and patients have been shown to influence the nature of clinical communication. Yet, although medical practice is dedicated to examining, diagnosing, and treating bodies, the relationship of physicians to their own physicality is vexed. Medical training creates a dichotomy whereby patients are identified by their bodies while physicians' bodies are secondary to physicians' minds. As a result, little opportunity is afforded to physicians to deal with personal illness experiences, be they their own or those of loved ones. This article describes a reflective writing exercise conducted in a second-year medical student humanities seminar. The "personal illness narrative" exercise created a medium for students to elicit, interpret, and translate their personal illness experiences while witnessing their colleagues' stories. Qualitative analysis of students' evaluation comments indicated that the exercise, although emotionally challenging, was well received and highly recommended for other students and residents. The reflective writing exercise may be incorporated into medical curricula aimed at increasing trainees' empathy. Affording students and residents an opportunity to describe and share their illness experiences may counteract the traditional distancing of physicians' minds from their bodies and lead to more empathic and self-aware practice.

Faculty and the observation of trainees' clinical skills: problems and opportunities.

Abstract: The clinical skills of medical interviewing, physical examination, and counseling remain vital to the effective care of patients, yet research continues to document serious deficiencies in clinical skills among students and residents. The most important method of evaluation is the direct observation of trainees performing these clinical skills. Standardized patients and other simulation technologies are important and reliable tools for teaching clinical skills and evaluating competence and will be incorporated in the near future as part of the United States Medical Licensing Examination. Standardized patients and simulation, however, cannot and should not replace the direct observation by faculty of trainees' clinical skills with actual patients. Faculty are in the best position to document improvement over time and to certify trainees have attained sophisticated levels of skill in medical interviewing, physical examination, and counseling. Unfortunately, current evidence suggests significant deficiencies in faculty direct observation evaluation skills. The author outlines the nature of the problems in clinical skills and their evaluation by faculty and ends with recommendations to improve the current state of faculty skills in evaluation.

Health Disparities Based on Socioeconomic Inequities: Implications for Urban Health Care

Abstract: Health is unevenly distributed across socioeconomic status. Persons of lower income, education, or occupational status experience worse health and die earlier than do their better-off counterparts. This article discusses these disparities in the context of urban medical practice. The article begins with a discussion of the complex relationship among socioeconomic status, race, and health in the United States. It highlights the effects of institutional, individual, and internalized racism on the health of African Americans, including the insidious consequences of residential segregation and concentrated poverty. Next, the article reviews health disparities based on socioeconomic status across the life cycle, beginning in fetal health and ending with disparities among the elderly. Potential explanations for these socioeconomic-based disparities are addressed, including reverse causality (e.g., being poor causes lower socioeconomic status) and confounding by genetic factors. The article underscores social causation as the primary explanation for health disparities and highlights the cumulative effects of social disadvantage across stages of the life cycle and across environments (e.g., fetal, family, educational, occupational, and neighborhood). The article concludes with a discussion of the implications of health disparities for the practice of urban medicine, including the role that concentration of disadvantage plays among patients and practice sites and the need for quality improvement to mitigate these disparities.

Physicians’ Weight Loss Counseling in Two Public Hospital Primary Care Clinics

Abstract: PurposePrimary care physicians are an important source of information on weight management. Nevertheless, weight loss counseling by these physicians remains inadequate. This study sought to determine physicians’ barriers to providing weight loss counseling in a public hospital, patients’ recall of p

The effects of sleep loss and fatigue on resident-physicians: a multi-institutional, mixed-method study.

Abstract: Purpose.To identify and model the effects of sleep loss and fatigue on resident–physicians’ professional lives and personal well-being.Method.In 2001–02, 149 residents at five U.S. academic health centers and from six specialties (obstetrics–gynecology, emergency medicine, family medicine, i

Teaching medical students and residents skills for delivering bad news: a review of strategies.

Abstract: Although delivering bad news is something that occurs daily in most medical practices, the majority of clinicians have not received formal training in this essential and important communication task. A variety of models are currently being used in medical education to teach skills for delivering bad news. The goals of this article are (1) to describe these available models, including their advantages and disadvantages and evaluations of their effectiveness; and (2) to serve as a guide to medical educators who are initiating or refining curriculum for medical students and residents. Based on a review of the literature and the authors' own experiences, they conclude that curricular efforts to teach these skills should include multiple sessions and opportunities for demonstration, reflection, discussion, practice, and feedback.

The ability of the multiple mini-interview to predict preclerkship performance in medical school.

Abstract: Problem Statement and Background.One of the greatest challenges continuing to face medical educators is the development of an admissions protocol that provides valid information pertaining to the noncognitive qualities candidates possess. An innovative protocol, the Multiple Mini-Interview,

Core Competencies in Integrative Medicine for Medical School Curricula: A Proposal

Abstract: The authors present a set of curriculum guidelines in integrative medicine for medical schools developed during 2002 and 2003 by the Education Working Group of the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) and endorsed by the CAHCIM Steering Committee in May 2003. CAHCIM is a consortium of 23 academic health centers working together to help transform health care through rigorous scientific studies, new models of clinical care, and innovative educational programs that integrate biomedicine, the complexity of human beings, the intrinsic nature of healing, and the rich diversity of therapeutic systems. Integrative medicine can be defined as an approach to the practice of medicine that makes use of the bestavailable evidence taking into account the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of both conventional and complementary/alternative approaches. The competencies described in this article delineate the values, knowledge, attitudes, and skills that CAHCIM believes are fundamental to the field of integrative medicine. Many of these competencies reaffirm humanistic values inherent to the practice of all medical specialties, while others are more specifically relevant to the delivery of the integrative approach to medical care, including the most commonly used complementary/alternative medicine modalities, and the legal, ethical, regulatory, and political influences on the practice of integrative medicine. The authors also discuss the specific challenges likely to face medical educators in implementing and evaluating these competencies, and provide specific examples of implementation and evaluation strategies that have been found to be successful at a variety of CAHCIM schools. Acad Med. 2004;79:521‐531.

A call for outcomes research in medical education.

Abstract: The primary goal of medical education is to produce physicians who deliver high-quality health care. Recent calls for greater accountability in medical education and the development of outcomes research methodologies should encourage a new research effort to examine the effects of medical training upon clinical outcomes. The authors offer a research agenda that links medical education and quality of health care and give specific examples of potential research projects that would begin to examine that relationship. A proposed model of patient outcomes research in medical education recognizes the contributory effects of health care system-level factors as well as the continuum of medical education, process measures, and individual training and preparedness to deliver high-quality care. There exists an opportunity to create a research agenda in medical education outcomes research that is multidisciplinary, broad based, and focused on patient-centered outcomes.

Orienting Teaching Toward the Learning Process

Abstract: Based on developments in educational psychology from the late 1980s, the authors present a model of an approach to teaching. Students’ learning processes were analyzed to determine teacher functions. The learning-oriented teaching (LOT) model aims at following and guiding the learning process. The main characteristics of the model are (1) the components of learning: cognition (what to learn), affect (why learn), and metacognition (how to learn); and (2) the amount of guidance students need. If education aims at fostering one’s ability to function independently in society, an important general objective should be that one learns how to fully and independently regulate his or her own learning; i.e., the ability to pursue one’s professional life independently. This implies a transition from external guidance (from the teacher) through shared guidance (by the student together with the teacher) to internal guidance (by the student alone). This transition pertains not only to the cognitive component of learning (content) but also to the affective component (motives) and the metacognitive component (learning strategies). This model reflects a philosophy of internalization of the teacher’s functions in a way that allows optimal independent learning after graduation. The model can be shown as a two-dimensional chart of learning components versus levels of guidance. It is further elaborated from learners’ and teachers’ perspectives. Examples of curriculum structure and teachers’ activities are given to illustrate the model. Implications for curriculum development, course development, individual teaching moments, and educational research are discussed. Acad Med. 2004;79:219 –228.

Women in academic general surgery.

Abstract: PURPOSE To portray the professional experiences of men and women in academic general surgery with specific attention to factors associated with differing academic productivity and with leaving academia. METHOD A 131-question survey was mailed to all female (1,076) and a random 2:1 sample of male (2,152) members of the American College of Surgeons in three mailings between September 1998 and March 1999. Detailed questions regarding academic rank, career aspirations, publication rate, grant funding, workload, harassment, income, marriage and parenthood were asked. A five-point Likert scale measured influences on career satisfaction. Responses from strictly academic and tenure-track surgeons were analyzed and interpreted by gender, age, and rank. RESULTS Overall, 317 surgeons in academic practice (168 men, 149 women) responded, of which 150 were in tenure-track positions (86 men, 64 women). Men and women differed in academic rank, tenure status, career aspirations, and income. Women surgeons had published a median of ten articles compared with 25 articles for men (p <.001). Marriage or parenthood did not influence numbers of publications for women. Overall career satisfaction was high, but women reported feeling career advancement opportunities were not equally available to them as to their male colleagues and feeling isolation from surgical peers. Ten percent to 20% of surgeons considered leaving academia, with women assistant professors (29%) contemplating this most commonly. CONCLUSION Addressing the differences between men and women academic general surgeons is critical in fostering career development and in recruiting competitive candidates of both sexes to general surgery.

What is empathy, and how can it be promoted during clinical clerkships?

Abstract: The ability of medical students to empathize often declines as they progress through the curriculum. This suggests that there is a need to promote empathy toward patients during the clinical clerkships. In this article, the authors attempt to identify the patient interviewing style that facilitates empathy and some practice habits that interfere with it. The authors maintain that (1) empathy is a multistep process whereby the doctor's awareness of the patient's concerns produces a sequence of emotional engagement, compassion, and an urge to help the patient; and (2) the first step in this process--the detection of the patient's concerns--is a teachable skill. The authors suggest that this step is facilitated by (1) conducting a "patient-centered" interview, thereby creating an atmosphere that encourages patients to share their concerns, (2) enquiring further into these concerns, and (3) recording them in the section traditionally reserved for the patient's "chief complaint." Some practice habits may discourage patients from sharing their concerns, such as (1) writing up the history during patient interviewing, (2) focusing too early on the chief complaint, and (3) performing a complete system review. The authors conclude that sustaining empathy and promoting medical professionalism among medical students may necessitate a change in the prevailing interviewing style in all clinical teaching settings, and a relocation of a larger proportion of clinical clerkships from the hospital setting to primary care clinics and chronic care, home care, and hospice facilities, where students can establish a continuing relationship with patients.

Facilitating faculty success: outcomes and cost benefit of the UCSD National Center of Leadership in Academic Medicine.

Abstract: Problem and Background.In 1998, the University of California San Diego (UCSD) was selected as one of four National Centers of Leadership in Academic Medicine (NCLAM) to develop a structured mentoring program for junior faculty.Method.Participants were surveyed at the beginning and end of the

A survey of medical ethics education at U.S. and Canadian medical schools.

Abstract: Purpose.To assess the format, content, method, and placement of medical ethics education in medical schools; the faculty and curricular resources and institutional structure and support of medical ethics; and the perceptions of ethics education among deans of medical education and medical et

Bringing Good Teaching Cases “To Life”: A Simulator-Based Medical Education Service

Abstract: Realistic medical simulation has expanded worldwide over the last decade. Such technology is playing an increasing role in medical education not merely because simulator sessions are enjoyable, but because they can provide an enhanced environment for experiential learning and reflective thought. High-fidelity patient simulators allow students of all levels to "practice" medicine without risk, providing a natural framework for the integration of basic and clinical science in a safe environment. Often described as "flight simulation for doctors," the rationale, utility, and range of medical simulations have been described elsewhere, yet the challenges of integrating this technology into the medical school curriculum have received little attention. The authors report how Harvard Medical School established an on-campus simulator program for students in 2001, building on the work of the Center for Medical Simulation in Boston. As an overarching structure for the process, faculty and residents developed a simulator-based "medical education service"-like any other medical teaching service, but designed exclusively to help students learn on the simulator alongside a clinician-mentor, on demand. Initial evaluations among both preclinical and clinical students suggest that simulation is highly accepted and increasingly demanded. For some learners, simulation may allow complex information to be understood and retained more efficiently than can occur with traditional methods. Moreover, the process outlined here suggests that simulation can be integrated into existing curricula of almost any medical school or teaching hospital in an efficient and cost-effective manner.

Assessing the role of influential mentors in the research development of primary care fellows.

Abstract: Purpose.To assess the association between mentorship and both subsequent research productivity and career development among primary care research fellows.Method.In 1998, using a self-administered questionnaire, the authors surveyed 215 fellows who graduated from 25 National Research Service

More training needed in chronic care: A survey of U.S. physicians

Abstract: Purpose.Although more than 125 million North Americans have one or more chronic conditions, medical training may not adequately prepare physicians to care for them. The authors evaluated physicians’ perceptions of the adequacy of their chronic illness care training to and the effects of trai

Results of an Academic Promotion and Career Path Survey of Faculty at the Johns Hopkins University School of Medicine

Abstract: PurposeClinician–educator faculty are increasing in numbers in academic medical centers, but their academic advancement is slower than that of research faculty. The authors sought to quantify the magnitude of this difference in career advancement and to explore the characteristics of faculty

Effectiveness of the one-minute preceptor model for diagnosing the patient and the learner: proof of concept.

Abstract: PurposeTo compare the One-Minute Preceptor (OMP) and traditional models of ambulatory teaching in terms of the preceptors’ (1) ability to correctly diagnose patients’ medical problems, (2) ability to rate students’ skills and confidence in doing so, and (3) satisfaction with both models.MethodA with

Using simulation to instruct emergency medicine residents in cognitive forcing strategies.

Abstract: Purpose.Recent literature defines certain cognitive errors that emergency physicians will likely encounter. The authors have utilized simulation and debriefing to teach the concepts of metacognition and error avoidance.Method.The authors conducted a qualitative study of an educational interv

Creating a learning environment to produce competent residents: the roles of culture and context.

Abstract: Six core competencies have been developed for use by residency programs in assessing individual resident training outcomes. The authors propose that it is important to consider the role of residency culture and work context in helping residents achieve the required competencies. Specifically, the development of a learning-oriented culture and favorable work conditions that facilitate the presence of that culture should be a high priority for residency programs and the organizations (e.g., hospitals) in which they are housed. This places formal accountability at the doorstep of these programs and organizations in helping to create a "competent" resident. Using ideas from management theory, the authors identify specific attitudes, behaviors, and interactions that define a learning culture and show their usefulness when applied to residents' achievement of the competencies. They assert that current features of everyday resident work life decrease the chances that such attitudes, behaviors, and interactions will occur. Identifying and prioritizing the components of desired work environments for promoting a learning-oriented culture, in addition to assessing the presence or absence of both the components and learning best practices within residency programs, should become normal activities that complement the process of assessing competencies.

Patient complaints about physician behaviors: a qualitative study.

Abstract: Purpose. Health care institutions are required to routinely collect and address formal patient complaints. Despite the availability of this feedback, no published efforts explore such data to improve physician behavior. The authors sought to determine the usefulness of patient complaints by establishing meaningful categories and exploring their epidemiology. Method. A register of formal, unsolicited patient complaints collected routinely at the Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina was used to categorize complaints using qualitative research strategies. After eliminating complaints unrelated to physician behavior, complaints from March 1999 were analyzed (60) to identify complaint categories that were then validated using complaints from January 2000 (122). Subsequently, all 1,746 complaints for the year 2000 were examined. Those unrelated to physician behavior (1,342) and with inadequate detail (182) were excluded, leaving 222 complaints for further analysis. Results. Complaints were most commonly lodged by a patient (111), followed by a patient’s spouse (33), child (52), parent (50), relative/friend (15), or health care professional (2). The most commonly identified category was disrespect (36%), followed by disagreement about expectations of care (23%), inadequate information (20%), distrust (18%), perceived unavailability (15%), interdisciplinary miscommunication (4%), and misinformation (4%). Multiple categories were identified in 42 (19%) complaints. Examples from each category provide adequate detail to develop instructional modules. Conclusion. The seven complaint categories of physician behaviors should be useful in developing curricula related to professionalism, communication skills, and practice-based learning. Acad Med. 2004;79:134 –138.

Direct observation of students during clerkship rotations: a multiyear descriptive study.

Abstract: PurposeTo determine how often students report that they are observed while performing physical examinations and taking histories during clerkship rotations.MethodFrom 1999–2001, 397 students at the University of Virginia School of Medicine were asked at the end of their third year to report

Teaching communication in clinical clerkships: models from the macy initiative in health communications.

Abstract: Medical educators have a responsibility to teach students to communicate effectively, yet ways to accomplish this are not well-defined. Sixty-five percent of medical schools teach communication skills, usually in the preclinical years; however, communication skills learned in the preclinical years may decline by graduation. To address these problems the New York University School of Medicine, Case Western Reserve University School of Medicine, and the University of Massachusetts Medical School collaborated to develop, establish, and evaluate a comprehensive communication skills curriculum. This work was funded by the Josiah P. Macy, Jr. Foundation and is therefore referred to as the Macy Initiative in Health Communication. The three schools use a variety of methods to teach third-year students in each school a set of effective clinical communication skills. In a controlled trial this cross-institutional curriculum project proved effective in improving communication skills of third-year students as measured by a comprehensive, multistation, objective structured clinical examination. In this paper the authors describe the development of this unique, collaborative initiative. Grounded in a three-school consensus on the core skills and critical components of a communication skills curriculum, this article illustrates how each school tailored the curriculum to its own needs. In addition, the authors discuss the lessons learned from conducting this collaborative project, which may provide guidance to others seeking to establish effective cross-disciplinary skills curricula.

Basing the evaluation of professionalism on observable behaviors: a cautionary tale.

Abstract: PROBLEM STATEMENT AND BACKGROUND The evaluation of professionalism often relies on the observation and interpretation of students' behaviors; however, little research is available regarding faculty's interpretations of these behaviors. METHOD Interviews were conducted with 30 faculty, who were asked to respond to five videotaped scenarios in which students are placed in professionally challenging situations. Behaviors were catalogued by person and by scenario. RESULTS There was little agreement between faculty about what students should and should not do in each scenario. Abstracted principles (e.g., honesty, altruism) were defined and applied inconsistently, both between and within individual faculty. There was no apparent "shared standard" that faculty held for professional behavior in students, and similar behaviors (e.g., lying) could be interpreted as either professional or unprofessional. CONCLUSIONS Future efforts at evaluation need to look beyond the behaviors, and should incorporate the reasoning and motivations behind students' actions in challenging professional situations.

Assessing residents' competencies at baseline: Identifying the gaps

Abstract: PURPOSE Entering residents have variable medical school experiences and differing knowledge and skill levels. To structure curricula, enhance patient safety, and begin to meet accreditation requirements, baseline assessment of individual resident's knowledge and skills is needed. To this end, in 2001 the University of Michigan Health System created the Postgraduate Orientation Assessment (POA), an eight-station, objective structured clinical examination for incoming residents. METHOD The POA, administered at orientation, included items addressing critical laboratory values, cross-cultural communication, evidence-based medicine, radio-graphic image interpretation, informed consent, pain assessment and management, aseptic technique, and system compliance such as fire safety. The POA assessed many of the skills needed by interns in their initial months of training when supervision by senior physicians might not be present. RESULTS In 2002, 132 interns from 14 different specialties and 59 different schools participated in the POA. The mean score was 74.8% (SD = 5.8). When scores were controlled for U.S. Medical Licensing Examination scores, there were no significant differences in performance across specialties. There were differences between University of Michigan Medical School graduates and those from other institutions (p <.001). Eighty-one percent of the residents would recommend the POA. CONCLUSIONS The POA provides a feasible format to measure initial knowledge and skills and identify learning needs. Orientation is an effective time to identify important gaps in learning between medical school and residency. This is the first step in a continuing evaluation of the Accreditation Council for Graduate Medical Education's general competencies.