Showing papers in "Academic Medicine in 2007"

Viewpoint: Competency-Based Postgraduate Training: Can We Bridge the Gap between Theory and Clinical Practice?

Abstract: The introduction of competency-based postgraduate medical training, as recently stimulated by national governing bodies in Canada, the United States, the United Kingdom, The Netherlands, and other countries, is a major advancement, but at the same time it evokes critical issues of curricular implementation. A source of concern is the translation of general competencies into the practice of clinical teaching. The authors observe confusion around the term competency, which may have adverse effects when a teaching and assessment program is to be designed. This article aims to clarify the competency terminology. To connect the ideas behind a competency framework with the work environment of patient care, the authors propose to analyze the critical activities of professional practice and relate these to predetermined competencies. The use of entrustable professional activities (EPAs) and statements of awarded responsibility (STARs) may bridge a potential gap between the theory of competency-based education and clinical practice. EPAs reflect those activities that together constitute the profession. Carrying out most of these EPAs requires the possession of several competencies. The authors propose not to go to great lengths to assess competencies as such, in the way they are abstractly defined in competency frameworks but, instead, to focus on the observation of concrete critical clinical activities and to infer the presence of multiple competencies from several observed activities. Residents may then be awarded responsibility for EPAs. This can serve to move toward competencybased training, in which a flexible length of training is possible and the outcome of training becomes more important than its length.

Global health in medical education: a call for more training and opportunities.

Abstract: Worldwide increases in global migration and trade have been making communicable diseases a concern throughout the world and have highlighted the connections in health and medicine among and between continents. Physicians in developed countries are now expected to have a broader knowledge of tropical disease and newly emerging infections, while being culturally sensitive to the increasing number of international travelers and ethnic minority populations. Exposing medical students to these global health issues encourages students to enter primary care medicine, obtain public health degrees, and practice medicine among the poor and ethnic minorities. In addition, medical students who have completed an international clinical rotation often report a greater ability to recognize disease presentations, more comprehensive physical exam skills with less reliance on expensive imaging, and greater cultural sensitivity. American medical students have become increasingly more interested and active in global health, but medical schools have been slow to respond. The authors review the evidence supporting the benefits of promoting more global health teaching and opportunities among medical students. Finally, the authors suggest several steps that medical schools can take to meet the growing global health interest of medical students, which will make them better physicians and strengthen our medical system.

Comparing problem-based learning with case-based learning: effects of a major curricular shift at two institutions.

Abstract: PurposeProblem-based learning (PBL) is now used at many medical schools to promote lifelong learning, open inquiry, teamwork, and critical thinking. PBL has not been compared with other forms of discussion-based small-group learning. Case-based learning (CBL) uses a guided inquiry method and

Measures of Cultural Competence: Examining Hidden Assumptions

Abstract: Purpose The authors critically examined the quantitative measures of cultural competence most commonly used in medicine and in the health professions, to identify underlying assumptions about what constitutes competent practice across social and cultural diversity. Method A systematic review of approximately 20 years of literature listed in PubMed, the Cumulative Index of Nursing and Allied Health Literature, Social Services Abstracts, and the Educational Resources Information Center identified the most frequently used cultural competence measures, which were then thematically analyzed following a structured analytic guide. Results Fifty-four instruments were identified; the 10 most widely used were analyzed closely, identifying six prominent assumptions embedded in the measures. In general, these instruments equate culture with ethnicity and race and conceptualize culture as an attribute possessed by the ethnic or racialized Other. Cultural incompetence is presumed to arise from a lack of exposure to and knowledge of the Other, and also from individual biases, prejudices, and acts of discrimination. Many instruments assume that practitioners are white and Western and that greater confidence and comfort among practitioners signify increased cultural competence. Conclusions Existing measures embed highly problematic assumptions about what constitutes cultural competence. They ignore the power relations of social inequality and assume that individual knowledge and self-confidence are sufficient for change. Developing measures that assess cultural humility and/or assess actual practice are needed if educators in the health professions and health professionals are to move forward in efforts to understand, teach, practice, and evaluate cultural competence. Acad Med. 2007; 82:548-557.

Responding to the HIV pandemic: the power of an academic medical partnership.

Abstract: Partnerships between academic medical center (AMCs) in North America and the developing world are uniquely capable of fulfilling the tripartite needs of care, training, and research required to address health care crises in the developing world Moreover, the institutional resources and credibility of AMCs can provide the foundation to build systems of care with long-term sustainability, even in resource-poor settings

The predictive validity of the MCAT for medical school performance and medical board licensing examinations: a meta-analysis of the published research.

Abstract: PurposeTo conduct a meta-analysis of published studies to determine the predictive validity of the MCAT on medical school performance and medical board licensing examinations.MethodThe authors included all peer-reviewed published studies reporting empirical data on the relationship between M

Slowing down when you should: a new model of expert judgment.

Abstract: The study of expertise in medical education has tended to follow a tradition of trying to describe the analytic processes and/or nonanalytic resources that experts acquire with experience. However, the authors argue that a critical function of expertise is the judgment required to coordinate these resources, using efficient nonanalytic processes for many tasks, but transitioning to more effortful analytic processing when necessary. Attempts to appreciate the nature of this transition, when it happens, and how it happens, can be informed by the evaluation of other literatures that are addressing these and related problems. The authors review the literatures on educational expertise, attention and effort, situational awareness, and human factors to examine the conceptual frameworks of expertise arising from these domains and the research methodologies that inform their practice. The authors propose a new model of expert judgment that we describe as a process of slowing down when you should.

A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors.

Abstract: Vanderbilt University School of Medicine (VUSM) employs several strategies for teaching professionalism. This article, however, reviews VUSM’s alternative, complementary approach: identifying, measuring, and addressing unprofessional behaviors. The key to this alternative approach is a supportive infrastructure that includes VUSM leadership’s commitment to addressing unprofessional/disruptive behaviors, a model to guide intervention, supportive institutional policies, surveillance tools for capturing patients’ and staff members’ allegations, review processes, multilevel training, and resources for addressing disruptive behavior. Our model for addressing disruptive behavior focuses on four graduated interventions: informal conversations for single incidents, nonpunitive “awareness” interventions when data reveal patterns, leader-developed action plans if patterns persist, and imposition of disciplinary processes if the plans fail. Every physician needs skills for conducting informal interventions with peers; therefore, these are taught throughout VUSM’s curriculum. Physician leaders receive skills training for conducting higher-level interventions. No single strategy fits every situation, so we teach a balance beam approach to understanding and weighing the pros and cons of alternative interventionrelated communications. Understanding common excuses, rationalizations, denials, and barriers to change prepares physicians to appropriately, consistently, and professionally address the real issues. Failing to address unprofessional behavior simply promotes more of it. Besides being the right thing to do, addressing unprofessional behavior can yield improved staff satisfaction and retention, enhanced reputation, professionals who model the curriculum as taught, improved patient safety and risk-management experience, and better, more productive work environments. Acad Med. 2007; 82:1040–1048.

The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education.

Abstract: The Harvard Medical School-Cambridge Integrated Clerkship (HMS-CIC) is a redesign of the principal clinical year to foster students' learning from close and continuous contact with cohorts of patients in the disciplines of internal medicine, neurology, obstetrics-gynecology, pediatrics, and psychiatry. With year-long mentoring, students follow their patients through major venues of care. Surgery and radiology also are taught longitudinally, grounded in the clinical experiences of a cohort of patients and in a brief immersion experience working directly with an attending surgeon. Students participate in weekly, case-based tutorials integrating instruction in the basic sciences with training to address the common and important issues in medicine, as identified by national organizations. In addition, they participate in a social science curriculum that focuses on self-reflection, communication skills, ethics, population sciences, and cultural competence. In the pilot year (July 2004 to July 2005), HMS-CIC students performed at least as well as traditional students in tests of content knowledge and skills, as measured by National Board of Medical Examiners (NBME) Subject Exams and the fourth-year Objective Structured Clinical Exam, and they scored higher on a year-end comprehensive clinical skills self-assessment examination, suggesting that they retained content knowledge better. From surveys, HMS-CIC students were much more likely to see patients before diagnosis and after discharge and to receive feedback and mentoring from experienced faculty than were their traditionally educated peers. HMS-CIC students expressed more satisfaction with their curriculum and felt better prepared to cope with the professional challenges of patient care, such as being truly caring, involving patients in decision making, and understanding how the social context affects their patients.

What do mentoring and training in the responsible conduct of research have to do with scientists' misbehavior? Findings from a National Survey of NIH-funded scientists.

Abstract: Purpose The authors examine training in the responsible conduct of research and mentoring in relation to behaviors that may compromise the integrity of science. Method The analysis is based on data from the authors’ 2002 national survey of 4,160 early-career and 3,600 midcareer biomedical and social science researchers who received research support from the U.S. National Institutes of Health. The authors used logistic regression analysis to examine associations between receipt of separate or integrated training in research ethics, mentoring related to ethics and in general, and eight categories of ethically problematic behavior. Analyses controlled for gender, type of doctoral degree, international degree, and disciplinary field. Results Responses were received from 1,479 early-career and 1,768 midcareer scientists, yielding adjusted response rates of 43% and 52%, respectively. Results for early-career researchers: Training in research ethics was positively associated with problematic behavior in the data category. Mentoring related to ethics and research, as well as personal mentoring, decreased the odds of researchers’ engaging in problematic behaviors, but mentoring on financial issues and professional survival increased these odds. Results for midcareer researchers: Combined separate and integrated training in research ethics was associated with decreased odds of problematic behavior in the categories of policy, use of funds, and cutting corners. Ethics mentoring was associated with lowered odds of problematic behavior in the policy category. Conclusions The effectiveness of training in obviating problematic behavior is called into question. Mentoring has the potential to influence behavior in ways that both increase and decrease the likelihood of problematic behaviors. Acad Med. 2007; 82:853–860.

Viewpoint: learning professionalism: a view from the trenches.

Abstract: The authors, medical students immersed in learning professionalism, observe that most of the professionalism literature misses the mark. Their views on professionalism education, although not the result of qualitative research, were gained from four years of conversations with students from a dozen medical schools, plus online student discussions, focus groups, and meetings with supervisors from five schools. The authors propose that the chief barrier to medical professionalism education is unprofessional conduct by medical educators, which is protected by an established hierarchy of academic authority. Students feel no such protection, and the current structure of professionalism education and evaluation does more to harm students’ virtue, confidence, and ethics than is generally acknowledged. The authors maintain that deficiencies in the learning environment, combined with the subjective nature of professionalism evaluation, can leave students feeling persecuted, unfairly judged, and genuinely and tragically confused. They recommend that administrators, medical educators, residents, and students alike must show a personal commitment to the explicit professionalism curriculum and address the hidden curriculum openly and proactively. Educators must assure transparency in the academic process, treat students respectfully, and demonstrate their own professional and ethical behavior. Students overwhelmingly desire to become professional, proficient, and caring physicians. They seek professional instruction, good role models, and fair evaluation. Students struggle profoundly to understand the disconnect between the explicit professional values they are taught and the implicit values of the hidden curriculum. Evaluation of professionalism, when practiced in an often unprofessional learning environment, invites conflict and compromise by students that would otherwise tend naturally toward avowed professional virtues. Acad Med. 2007; 82:1010–1014.

Virtual Patient Simulation at U.S. and Canadian Medical Schools

Abstract: Purpose “Virtual patients” are computer-based simulations designed to complement clinical training. These applications possess numerous educational benefits but are costly to develop. Few medical schools can afford to create them. The purpose of this inventory was to gather information regarding in-house virtual patient development at U.S. and Canadian medical schools to promote the sharing of existing cases and future collaboration. Method From February to September 2005, the authors contacted 142 U.S. and Canadian medical schools and requested that they report on virtual patient simulation activities at their respective institutions. The inventory elicited information regarding the pedagogic and technical characteristics of each virtual patient application. The schools were also asked to report on their willingness to share virtual patients. Results

Academic health center management of chronic diseases through knowledge networks: Project ECHO.

Abstract: The authors describe an innovative academic health center (AHC)-led program of health care delivery and clinical education for the management of complex, common, and chronic diseases in underserved areas, using hepatitis C virus (HCV) as a model. The program, based at the University of New Mexico School of Medicine, represents a paradigm shift in thinking and funding for the threefold mission of AHCs, moving from traditional fee-for-service models to public health funding of knowledge networks. This program, Project Extension for Community Health care Outcomes (ECHO), involves a partnership of academic medicine, public health offices, corrections departments, and rural community clinics dedicated to providing best practices and protocol-driven health care in rural areas. Telemedicine and Internet connections enable specialists in the program to comanage patients with complex diseases, using case-based knowledge networks and learning loops. Project ECHO partners (nurse practitioners, primary care physicians, physician assistants, and pharmacists) present HCV-positive patients during weekly two-hour telemedicine clinics using a standardized, case-based format that includes discussion of history, physical examination, test results, treatment complications, and psychiatric, medical, and substance abuse issues. In these case-based learning clinics, partners rapidly gain deep domain expertise in HCV as they collaborate with university specialists in hepatology, infectious disease, psychiatry, and substance abuse in comanaging their patients. Systematic monitoring of treatment outcomes is an integral aspect of the project. The authors believe this methodology will be generalizable to other complex and chronic conditions in a wide variety of underserved areas to improve disease outcomes, and it offers an opportunity for AHCs to enhance and expand their traditional mission of teaching, patient care, and research.

Difficult conversations in health care: cultivating relational learning to address the hidden curriculum.

Abstract: The authors describe the philosophy and pedagogical approach of an innovative educational program, grounded in principles of relational learning and designed to improve the preparedness of health care professionals for engaging in challenging conversations with patients and families The Program to Enhance Relational and Communication Skills (PERCS) is a project of The Institute for Professionalism and Ethical Practice at Children's Hospital Boston, developed in collaboration with Education Development Center, Inc The one-day workshop is interdisciplinary in its structure, includes practitioners with varying levels of professional experience, uses trained actors to portray patients and family members, and involves learners in improvised case scenarios The program responds to several developments in contemporary health care: medical education reform, changing definitions of professional competence, and calls for greater attention to qualities of compassion, trust, and respect in practitioners' relationships with patients and families The program's pedagogy responds to these developments by creating a safe climate for relational learning, by enacting emotionally challenging and ethically salient case scenarios, and by integrating patient and family perspectives in novel and substantive ways By creating a curriculum and learning environment that explicitly embraces the moral experience of learners, the program's developers aim to exert a countercultural influence on the dehumanizing effects of the hidden curriculum

PBL in the undergraduate MD program at McMaster University: three iterations in three decades.

Abstract: When the undergraduate MD program of McMaster University admitted its first cohort of 20 students in 1969, it heralded a major change in medical school pedagogy that has influenced the education of medical students around the world. The three-year PBL curriculum, which emphasized small-group tutorials, self-directed learning, a minimal number of didactic presentations, and student evaluation that was based almost entirely on performance in the tutorial, represented a radical departure from traditional curricula. Since the inception of the original curriculum in 1969, there have been two major curriculum revisions, the most recent of which was in 2005. The original curriculum attempted to integrate both basic science and clinical science into the biomedical problems. The second iteration of the curriculum focused on priority health problems and centered on a list of common medical problems as the foundation for curriculum organization, on the basis that an understanding of the management of common conditions included areas of knowledge that would be essential for clinical competence. Under the third, current curriculum, the COMPASS (concept-oriented, multidisciplinary, problem-based, practice for transfer, simulations in clerkship, streaming) model was adopted. Under this concept-based system, emphasis is placed on underscoring the underlying concepts in the curriculum with a logical sequencing of both the concepts and the body systems. This article briefly reviews the history of the development of the undergraduate MD program at McMaster and the three curricula that have been developed during the past three decades.

The Portfolio Approach to Competency-Based Assessment at the Cleveland Clinic Lerner College of Medicine

Abstract: Despite the rapid expansion of interest in competency-based assessment, few descriptions of assessment systems specifically designed for a competency-based curriculum have been reported. The purpose of this article is to describe the design of a portfolio approach to a comprehensive, competency-based assessment system that is fully integrated with the curriculum to foster an educational environment focused on learning. The educational design goal of the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University was to create an integrated educational program-curriculum and instructional methods, student assessment processes, and learning environment-to prepare medical students for success in careers as physician investigators. The first class in the five-year program matriculated in 2004. To graduate, a student must demonstrate mastery of nine competencies: research, medical knowledge, communication, professionalism, clinical skills, clinical reasoning, health care systems, personal development, and reflective practice. The portfolio provides a tool for collecting and managing multiple types of assessment evidence from multiple contexts and sources within the curriculum to document competence and promote reflective practice skills. This article describes how the portfolio was developed to provide both formative and summative assessment of student achievement in relation to the program's nine competencies.

Perceptions and attributions of third-year student struggles in clerkships: do students and clerkship directors agree?

Abstract: Purpose To explore the congruence between students’ and clerkship directors’ perceptions and attributions of students’ struggles during the transition to clerkships. Method Focus groups and interviews were conducted with third- and fourth-year medical students and clerkship directors at 10 U.S. medical schools in 2005 and 2006. Schools were selected to represent diverse locations, sizes, and missions. Interviews and focus groups were recorded, transcribed, and analyzed thematically. Results Students’ struggles included understanding roles and responsibilities, adjusting to clinical cultures, performing clinical skills, learning the logistics of clinical settings, and encountering frequent changes in staff, settings, and content. Clerkship directors recognized students’ struggles with roles and responsibilities, performing clinical skills, and adjusting to clinical cultures, but they also focused on students’ difficulties applying knowledge to clinical reasoning and engaging in selfdirected learning. Conclusions

Burnout in residents of otolaryngology-head and neck surgery: a national inquiry into the health of residency training.

Abstract: PURPOSE To characterize resident burnout on a national scale with a large sample size and to identify associated modifiable factors to minimize burnout and improve the quality of residency education. METHOD A survey was mailed to all 1,364 U.S. residents of otolaryngology-head and neck surgery in September 2005. The main outcome measures were the Maslach Burnout Inventory-Human Services Study, demographic information, and potential burnout predictors, including stressors, satisfaction, self-efficacy, and support systems. RESULTS The response rate was 50% (684/1,364). Current second-year through fifth-year residents were included for further analysis (514). Burnout was extremely common among otolaryngology residents. High burnout was seen in 10% of residents (51), moderate burnout in 76% (391), and low burnout in 14% (72). The strongest associated demographic factor was work hours (P < .001). Hours worked was predictive of emotional exhaustion, with exhaustion scores rising by 0.19 for each hour worked (P < .001). Furthermore, there was an 8% (41 resident) reported violation rate of the Accreditation Council for Graduate Medical Education (ACGME) 80-hour-workweek limitation. Satisfaction with the balance between personal and professional life, relationship stability, and satisfaction with career choice were negatively associated with burnout (all P < .001). CONCLUSIONS Burnout is widely prevalent among U.S. otolaryngology residents and is present at greater levels than those seen in chairs or faculty of the same specialty. Work hours predict emotional exhaustion, and adherence to the ACGME 80-hour workweek may help protect against burnout and its deleterious consequences in residents of all specialties.

Musculoskeletal medicine: an assessment of the attitudes and knowledge of medical students at Harvard Medical School.

Abstract: Purpose To assess medical students’ knowledge and clinical confidence in musculoskeletal medicine as well as their attitudes toward the education they receive in this specialty. Method A cross-sectional survey of students in all four years of Harvard Medical School was conducted during the 2005–2006 academic year. Participants were asked to fill out a 30-question survey and a nationally validated basic competency exam in musculoskeletal medicine.

Knowing when to look it up: a new conception of self-assessment ability.

Abstract: Background Although self-assessment is widely acknowledged as a vital skill for members of self-regulating professions, a ubiquitous finding in the research literature is that self-ratings are quite poor when compared with externally generated measures of ability. Many researchers have identified this as a serious problem for the concept of selfregulation in the professions. However, we question the sufficiency of the operational definitions of self-assessment on which the previous research is based. This study examines the validity of a new conceptualization of self-assessment in practice and evaluates a series of measures for capturing self-assessment ability as defined by this new conceptualization. Method

Exploring Obstacles to and Opportunities for Professional Success Among Ethnic Minority Medical Students

Abstract: Purpose To explore the barriers and facilitators experienced by ethnic minority medical students in achieving personal and professional success. Method In 2002 and 2003, 43 minority medical students participated in one of six two-hour focus groups located in Philadelphia, Pa; Kansas City, Mo; Baltimore, Md; Miami, Fl; New York, NY; and Los Angeles, Calif. Focus groups consisted of an average of seven (range 5-10) individuals. Eighty-eight percent were of black/African descent, 10% were Hispanic, and 2% were Asian/Pacific Islanders. Students discussed their views of personal and professional success, including opportunities and obstacles, and completed a brief demographic survey. Discussions were audiotaped, transcribed verbatim, and reviewed for thematic content in a three-stage independent review/adjudication process. Results All 748 comments were grouped into themes relating to definitions of success (35%) and to perceived facilitators (25%) or inhibitors (40%) of success. Participants strove to achieve professional/academic status, financial security, and quality of life. In so doing, participants identified facilitators of success, including support systems, professional exposure, financial aid, and personal characteristics. Lack of financial and social support, challenges with standardized tests, experiences with racial stereotyping and discrimination, and self-imposed barriers were among inhibitors to success. Conclusions The opportunities for and barriers to academic success identified by minority students should be heeded by educators and administrators who develop programs and policies to recruit minority medical students and to ensure their professional development. To enhance the institutional climate for diversity, programs that improve cultural awareness and reduce biases among all students, faculty, staff, and administrators are needed.

Three domains of competency in global health education: recommendations for all medical students.

Abstract: In the setting of world population growth and migration, global health issues have an increasing impact on domestic conditions and our medical practitioners. The authors ask: What exactly constitutes global health, and how much do U.S. and Canadian medical students or practitioners need to know about it? To address this topic, the authors convened an American Society for Tropical Medicine and Hygiene Committee on Medical Education, sought input from the Global Health Education Consortium, and surveyed members of the American Committee on Clinical Tropical Medicine and Travelers' Health for educational priorities within the tropical medicine field. The information gained from these sources has been distilled into three domains of global health competency that the authors propose each medical school curriculum should try to achieve for all students: global burden of disease, traveler's medicine, and immigrant health. The authors present here the rationale for altering curricula to include these three topics as a starting point for discussion among medical educators.

Redesigning residency training in internal medicine: the consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force.

Abstract: Because of numerous criticisms of the content and structure of residency training, redesigning graduate medical education (GME) has become a high priority for the internal medicine community. From 2005 to 2007, the leadership of the internal medicine community, working under the auspices of the Alliance for Academic Internal Medicine Education Redesign Task Force, developed six recommendations it will pursue to improve residency education: (1) focus education around a “core” of internal medicine, which provides the framework for both the structure and content of residents’ educational experiences, (2) fully adopt competencybased evaluation and advancement, which will enhance training by focusing on individual learners’ needs, (3) allow for increased, resident-centered education beyond the internal medicine core, because different types of practice require customized knowledge and skills, (4) improve ambulatory training by providing patient-centered longitudinal care that addresses the conflict between inpatient and outpatient responsibilities, (5) use new faculty models that emphasize the creation of a core faculty, and (6) align institutional and programmatic resources with the goals of redesign, balancing the clinical mission of the institution with the educational goals of residency training. Adoption of these recommendations will require significant efforts, including pilot projects, faculty development, changes in accreditation requirements, and modifications of GME funding systems. Opportunities are ample for individual programs to develop creative approaches based on the framework for educational redesign outlined in this article, and for these educational and clinical redesign initiatives to work hand-in-hand for the benefit of patients, faculty, trainees, and institutions.

Viewpoint: linking professionalism to humanism: what it means, why it matters.

Abstract: The terms professionalism and humanism are sometimes confused as being synonymous; even more confusing, each is sometimes regarded as a component feature of the other. The author argues that, in the context of medicine, the two terms describe distinctly different, albeit intimately linked attributes of the good doctor. Professionalism denotes a way of behaving in accordance with certain normative values, whereas humanism denotes an intrinsic set of deep-seated convictions about one's obligations toward others. Viewed in this way, humanism is seen as the passion that animates professionalism. Nurturing the humanistic predispositions of entering medical students is key to ensuring that future physicians manifest the attributes of professionalism. Medical educators are encouraged to recognize the role of humanism in professional development and to incorporate into their curricula and learning environments explicit means to reinforce whatever inclinations their students have to be caring human beings. Chief among those means are respected role models who unfailingly provide humanistic care, ceremonies that celebrate the attributes of humanism, awards that honor exemplars of the caring physician, and serious engagement with the medical humanities to provide vivid insights into what a humanistic professional is.

Viewpoint: Reflections on a Well-Traveled Path: Self-Awareness, Mindful Practice, and Relationship-Centered Care as Foundations for Medical Education

Abstract: Medical students enter medical school hoping to have good relationships with their patients. Along with residents, however, they are exposed to a hidden curriculum that places the acquisition of biomedical knowledge above and at times at odds with development of the awareness and relationship skills important to the patient-physician relationship. Seasoned clinicians often enjoy the capacity for rich, healing relationships that are marked by reciprocal influence between them and their patients. The author argues that it is not necessary to relegate this recapturing of the human side of medicine to a midcareer epiphany, and the author calls for educational measures to encourage development of the communication and relationship-building skills throughout the medical education process. This will require a paradigm shift to a culture where teachers and learners are willing to consciously attend to their relationships and to work on self-awareness and mindfulness while they also master the biomedical knowledge required of the profession. Medical educators can facilitate and support continuous development of these skills throughout medical school and residency. Within the curriculum, there are many opportunities to teach how to reflect and to guide those reflections in ways that enhance our students' and residents' understanding of themselves as individuals and in the relationships they form with their patients. Using examples from narratives gathered in workshops and on work rounds with students and residents at the University of Washington School of Medicine, the author explores the concepts of relationship-centered care, self-awareness, and mindfulness as proposed cornerstones of a new foundation for medical education.

Organizational factors associated with high performance in quality and safety in academic medical centers

Abstract: Purpose Leaders of academic medical centers (AMCs) are challenged to ensure consistent high performance in quality and safety across all clinical services. The authors sought to identify organizational factors associated with AMCs that stood out from their peers in a composite scoring system for quality and safety derived from patient-level data. Method A scoring method using measures of safety, mortality, clinical effectiveness, and equity of care was applied to discharge abstract data from 79 AMCs for 2003–2004. Six institutions (three top and three average performers) were selected for site visits; the performance status of the six institutions was withheld from the site visit team. Through interviews and document review, the team sought to identify factors that were associated with the performance status of the institution. Results The scoring system discriminated performance among the 79 AMCs in a clinically meaningful way. For example, the transition of a typical 500-bed hospital from average to top levels of performance could result in 150 fewer deaths per year. Abstraction of key findings from the interview notes revealed distinctive themes in the top versus average performers. Common qualities shared by top performers included a shared sense of purpose, a hands-on leadership style, accountability systems for quality and safety, a focus on results, and a culture of collaboration. Conclusions Distinctive leadership behaviors and organizational practices are associated with measurable differences in patientlevel measures of quality and safety. Acad Med. 2007; 82:1178–1186. Pockets of clinical excellence may be found in most academic medical centers (AMCs), but the leaders of these institutions face the challenge of trying to achieve consistently high performance institution-wide, that is, across a wide variety of clinical services. The sciences of quality improvement and patient safety have focused largely on isolated clinical units or microsystems, demonstrating the

Faculty development as an instrument of change: a case study on teaching professionalism.

Abstract: Faculty development includes those activities that are designed to renew or assist faculty in their different roles. As such, it encompasses a wide variety of interventions to help individual faculty members improve their skills. However, it can also be used as a tool to engage faculty in the process of institutional change. The Faculty of Medicine at McGill University determined that such a change was necessary to effectively teach and evaluate professionalism at the undergraduate level, and a faculty development program on professionalism helped to bring about the desired curricular change. The authors describe that program to illustrate how faculty development can serve as a useful instrument in the process of change. The ongoing program, established in 1997, consists of medical education rounds and "think tanks" to promote faculty consensus and buy-in, and diverse faculty-wide and departmental workshops to convey core content, examine teaching and evaluation strategies, and promote reflection and self-awareness. To analyze the approach used and the results achieved, the authors applied a well-known model by J.P. Kotter for implementing change that consists of the following phases: establishing a sense of urgency, forming a powerful guiding coalition, creating a vision, communicating the vision, empowering others to act on the vision, generating short-term wins, consolidating gains and producing more change, and anchoring new approaches in the culture. The authors hope that their school's experience will be useful to others who seek institutional change via faculty development.

National efforts to reform residency education in surgery.

Abstract: Major changes in surgical practice and myriad external mandates have affected residency education in surgery. The traditional surgery residency education and training model has come under scrutiny, and calls for major reform of this model have been made by a variety of stakeholders. The Amer

The history, purpose, and future of instruction in the responsible conduct of research.

Abstract: This article discusses the key decisions and steps that have partially formalized instruction in the responsible conduct of research (RCR) in U.S. research institutions, the different purposes for offering and/or requiring such instruction, and suggestions for what needs to be done to enhance the professional development of researchers in the future. RCR education has developed during three distinct eras: the 1980s, when policy makers were most concerned with defining and investigating research misconduct; the 1990s, when there was significant but highly decentralized growth in RCR instruction; and the years since 2000, when there have been a series of reforms and educational developments. There is still a need for scientists, universities, and professional societies to develop consensus on best ethical practices in many areas of scientific research. More also needs to be learned about assessing the quality of RCR instruction and the effects of training on researchers' behavior. To help set the course for RCR instruction in the future, more effort and funding need to be directed to studying actual research behavior and the factors that influence it; RCR educators and administrators must develop a common vocabulary and framework for developing and evaluating the impact of RCR instruction; and research institutions and funding agencies alike need to take a more active role in promoting and supporting RCR instruction.

Viewpoint: Cultural competence and the African American experience with health care: The case for specific content in cross-cultural education.

Abstract: Achieving cultural competence in the care of a patient who is a member of an ethnic or racial minority is a multifaceted project involving specific cultural knowledge as well as more general skills and attitude adjustments to advance cross-cultural communication in the clinical encounter. Using the important example of the African American patient, the authors examine relevant historical and cultural information as it relates to providing culturally competent health care. The authors identify key influences, including the legacy of slavery, Jim Crow discrimination, the Tuskegee syphilis study, religion's interaction with health care, the use of home remedies, distrust, racial concordance and discordance, and health literacy. The authors propose that the awareness of specific information pertaining to ethnicity and race enhances cross-cultural communication and ways to improve the cultural competence of physicians and other health care providers by providing a historical and social context for illness in another culture. Cultural education, modular in nature, can be geared to the specific populations served by groups of physicians and provider organizations. Educational methods should include both information about relevant social group history as well as some experiential component to emotively communicate particular cultural needs. The authors describe particular techniques that help bridge the cross-cultural clinical communication gaps that are created by patients' mistrust, lack of cultural understanding, differing paradigms for illness, and health illiteracy.