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Showing papers in "Academic Medicine in 2008"


Journal ArticleDOI
TL;DR: The findings suggest that undergraduate medical education may be a major determinant differentially affecting the vicarious empathy of students on the basis of gender and/or specialty choice.
Abstract: PurposeTo determine whether vicarious empathy (i.e., to have a visceral empathic response, versus role-playing empathy) decreases, and whether students choosing specialties with greater patient contact maintain vicarious empathy better than do students choosing specialties with less patient

479 citations


Journal ArticleDOI
TL;DR: Excellent clinical teaching, although multifactorial, transcends ordinary teaching and is characterized by inspiring, supporting, actively involving, and communicating with students.
Abstract: PurposeThe authors perform a review of the literature pertinent to the question, “What makes a good clinical teacher in medicine?”MethodAfter framing the question, based on discussions of their own experiences with clinical teachers, the authors performed a search of the literature pertinent

376 citations


Journal ArticleDOI
TL;DR: The authors seek to integrate generally accepted knowledge and beliefs about how one learns to practice clinical medicine into a coherent developmental framework using the Dreysfus and Dreyfus model of skill acquisition.
Abstract: The Accreditation Council for Graduate Medical Education Outcome Project has shifted the focus of residents' education to competency-based outcomes of learning The challenge of meaningful assessment of learner competence has stimulated interest in the Dreyfus and Dreyfus Model, a framework for assessing skill acquisition that describes developmental stages beginning with novice and progressing through advanced beginner, competent, proficient, expert, and master Many educators have adopted this model, but no consensus about its adaptation to clinical medicine has been documented In this article, the authors seek to integrate generally accepted knowledge and beliefs about how one learns to practice clinical medicine into a coherent developmental framework using the Dreyfus and Dreyfus model of skill acquisition Using the general domain of patient care, the characteristics and skills of learners at each stage of development are translated into typical behaviors A tangible picture of this model in real-world practice is provided through snapshots of typical learner performance at discrete moments in time along the developmental continuum The Dreyfus and Dreyfus model is discussed in the context of other developmental models of assessment of learner competence The limitations of the model, in particular the controversy around the behaviors of "experts," are discussed in light of other interpretations of expertise in the literature Support for descriptive developmental models of assessment is presented in the context of a discussion of the deconstructing versus reconstructing of competencies

275 citations


Journal ArticleDOI
TL;DR: All identified comprehensive medical school rural programs have produced a multifold increase in the rural physician supply, and widespread replication of these models could have a major impact on access to health care in thousands of rural communities.
Abstract: Purpose To systematically review the outcomes of comprehensive medical school programs designed to increase the rural physician supply, and to develop a model to estimate the impact of their widespread replication. Method Relevant databases were searched, from the earliest available date to October 2006, to identify comprehensive programs (with available rural outcomes), that is, those that had (1) a primary goal of increasing the rural physician supply, (2) a defined cohort of students, and (3) either a focused rural admissions process or an extended rural clinical curriculum. Descriptive methodology, definitions, and outcomes were extracted. A model of the impact of replicating this type of program at 125 allopathic medical schools was then developed. Results

240 citations


Journal ArticleDOI
TL;DR: The author describes a grounding of this approach in theories of empathy and moral development and clarifies the educational value that narratives bring to medical education.
Abstract: The use of narratives, including physicians' and patients' stories, literature, and film, is increasingly popular in medical education. There is, however, a need for an overarching conceptual framework to guide these efforts, which are often dismissed as "soft" and placed at the margins of medical school curricula. The purpose of this article is to describe the conceptual basis for an approach to patient-centered medical education and narrative medicine initiated at the University of Michigan Medical School in the fall of 2003. This approach, the Family Centered Experience, involves home visits and conversations between beginning medical students and patient volunteers and their families and is aimed at fostering humanism in medicine. The program incorporates developmental and learning theory, longitudinal interactions with individuals with chronic illness, reflective learning, and small-group discussions to explore the experience of illness and its care. The author describes a grounding of this approach in theories of empathy and moral development and clarifies the educational value that narratives bring to medical education. Specific pedagogical considerations, including use of activities to create "cognitive disequilibrium" and the concept of transformative learning, are also discussed and may be applied to narrative medicine, professionalism, multicultural education, medical ethics, and other subject areas in medical education that address individuals and their health care needs in society.

212 citations


Journal ArticleDOI
TL;DR: The authors propose that consultation communication can be guided by an overarching goal, which is achieved through the use of a set of predetermined strategies, and proposed Comskil Model for CST seeks to make them explicit in these contexts.
Abstract: Current research in communication in physician–patient consultations is multidisciplinary and multimethodological. As this research has progressed, a considerable body of evidence on the best practices in physician–patient communication has been amassed. This evidence provides a foundation f

186 citations


Journal ArticleDOI
TL;DR: Largely because of negative experiences with chemistry classes, URM students and women show a disproportionate decline in interest in continuing in premedical studies, with the result that fewer apply to medical school.
Abstract: PurposeTo determine the causes among underrepresented racial and ethnic minority groups (URM) of a decline in interest during the undergraduate years in pursuing a career in medicine.MethodFrom fall 2002 through 2007, the authors conducted a longitudinal study of 362 incoming Stanford freshm

183 citations


Journal ArticleDOI
TL;DR: Although educators may be uncomfortable with the fundamental change in the learning process represented by video-recorded lecture use, students’ responses indicate that their decisions to attend lectures or view recorded lectures are motivated primarily by a desire to satisfy their professional goals.
Abstract: Purpose In light of educators' concerns that lecture attendance in medical school has declined, the authors sought to assess students' perceptions, evaluations, and motivations concerning live lectures compared with accelerated, video-recorded lectures viewed online. Method The authors performed a cross-sectional survey study of all first- and second-year students at Harvard Medical School. Respondents answered questions regarding their lecture attendance; use of class and personal time; use of accelerated, video-recorded lectures; and reasons for viewing video-recorded and live lectures. Other questions asked students to compare how well live and video-recorded lectures satisfied learning goals. Results Of the 353 students who received questionnaires, 204 (58%) returned responses. Collectively, students indicated watching 57.2% of lectures live, 29.4% recorded, and 3.8% using both methods. All students have watched recorded lectures, and most (88.5%) have used video-accelerating technologies. When using accelerated, video-recorded lecture as opposed to attending lecture, students felt they were more likely to increase their speed of knowledge acquisition (79.3% of students), look up additional information (67.7%), stay focused (64.8%), and learn more (63.7%). Conclusions Live attendance remains the predominant method for viewing lectures. However, students find accelerated, video-recorded lectures equally or more valuable. Although educators may be uncomfortable with the fundamental change in the learning process represented by video-recorded lecture use, students' responses indicate that their decisions to attend lectures or view recorded lectures are motivated primarily by a desire to satisfy their professional goals. A challenge remains for educators to incorporate technologies students find useful while creating an interactive learning culture.

181 citations


Journal ArticleDOI
TL;DR: This study provides an initial exploration of context-specific competence assessments, which affect both patient safety and education, and provides a novel framework for study of the links between language use and competence.
Abstract: Background Clinical supervisors make frequent assessments of medical trainees’ competence so they can provide appropriate opportunities for trainees to experience clinical independence. This study explored context-specific assessments of trainees’ competence for independent clinical work. Method In Phase One, 88 teaching team members from internal and emergency medicine were observed during clinical activities (216 hours), and 65 participants completed brief interviews. In Phase Two, 36 in-depth interviews were conducted using video vignettes. Data collection and analysis employed grounded theory methodology. Results Supervisors’ assessments of trainee trustworthiness for independent clinical work involved consideration of four dimensions: knowledge/skill, discernment of limitations, truthfulness, and conscientiousness. Supervisors’ reliance on language cues as a source of trustworthiness data was revealed. Conclusions

178 citations


Journal ArticleDOI
TL;DR: Bedside teaching is valuable but underutilized, and including the patient, collaborating with learners, faculty development, and promoting a supportive institutional culture can redress several barriers to bedside teaching.
Abstract: PurposeLiterature reviews indicate that the proportion of clinical educational time devoted to bedside teaching ranges from 8% to 19%. Previous studies regarding this paucity have not adequately examined the perspectives of learners. The authors explored learners’ attitudes toward bedside teaching,

153 citations


Journal ArticleDOI
TL;DR: Although many trainees had disclosed errors to patients, only a minority had been formally prepared to do so, and formal disclosure curricula are necessary to prepare trainees to independently disclose errors to Patients by the end of their training.
Abstract: PurposeTo measure trainees’ attitudes andexperiences regarding medical error anderror disclosure.MethodIn 2003, the authors carried out a cross-sectional survey of 629 medical students(320 in their second year, 309 in theirfourth year), 226 interns (159 inmedicine, 67 in surgery), and 283residents (211 in medicine, 72 insurgery), a total 1,138 trainees at twoU.S. academic health centers.ResultsThe response rate was 78% (889/1,138).Most trainees (74%; 652/881) agreedthat medical error is among the mostserious health care problems. Nearly all(99%; 875/884) agreed serious errorsshould be disclosed to patients, but 87%(774/889) acknowledged at least onepossible barrier, including thinking thatthe patient would not understand thedisclosure (59%; 525/889), the patientwould not want to know about theerror (42%; 376/889), and the patientmight sue (33%; 297/889). Personalinvolvement with medical errors wascommon among the fourth-year students(78%; 164/209) and the residents (98%;182/185). Among residents, 45% (83/185) reported involvement in a seriouserror, 34% (62/183) reported experiencedisclosing a serious error, and 63% (115/183) had disclosed a minor error.Whereas only 33% (289/880) of traineeshad received training in error disclosure,92% (808/881) expressed interest insuch training, particularly at the time ofdisclosure.ConclusionsAlthough many trainees had disclosederrors to patients, only a minority hadbeen formally prepared to do so. Formaldisclosure curricula, coupled withsupervised practice, are necessary toprepare trainees to independentlydisclose errors to patients by the end oftheir training.

Journal ArticleDOI
TL;DR: What is needed for institutions to entrench IPE into core education at three levels is recommended, including micro (what individuals in the faculty can do); meso (what a faculty can promote); and macro (how academic institutions can exert its influence in the health education and practice system).
Abstract: Faculties (i.e., schools) of medicine along with their sister health discipline faculties can be important organizational vehicles to promote, cultivate, and direct interprofessional education (IPE). The authors present information they gathered in 2007 about five Canadian IPE programs to identify key factors facilitating transformational change within institutional settings toward successful IPE, including (1) how successful programs start, (2) the ways successful programs influence academia to bias toward change, and (3) the ways academia supports and perpetuates the success of programs. Initially, they examine evidence regarding key factors that facilitate IPE implementation, which include (1) common vision, values, and goal sharing, (2) opportunities for collaborative work in practice and learning, (3) professional development of faculty members, (4) individuals who are champions of IPE in practice and in organizational leadership, and (5) attention to sustainability. Subsequently, they review literature-based insights regarding barriers and challenges in IPE that must be addressed for success, including barriers and challenges (1) between professional practices, (2) between academia and the professions, and (3) between individuals and faculty members; they also discuss the social context of the participants and institutions. The authors conclude by recommending what is needed for institutions to entrench IPE into core education at three levels: micro (what individuals in the faculty can do); meso (what a faculty can promote); and macro (how academic institutions can exert its influence in the health education and practice system).

Journal ArticleDOI
TL;DR: The authors hope to advance the national discussion about the need to more fully integrate basic science teaching throughout all four years of the medical student curriculum by placing a curricular innovation in the context of similar efforts by other U.S. and Canadian medical schools.
Abstract: Abraham Flexner persuaded the medical establishment of his time that teaching the sciences, from basic to clinical, should be a critical component of the medical student curriculum, thus giving rise to the "preclinical curriculum." However, students' retention of basic science material after the preclinical years is generally poor. The authors believe that revisiting the basic sciences in the fourth year can enhance understanding of clinical medicine and further students' understanding of how the two fields integrate. With this in mind, a return to the basic sciences during the fourth year of medical school may be highly beneficial. The purpose of this article is to (1) discuss efforts to integrate basic science into the clinical years of medical student education throughout the United States and Canada, and (2) describe the highly developed fourth-year basic science integration program at the University of Pittsburgh School of Medicine. In their critical review of medical school curricula of 126 U.S. and 17 Canadian medical schools, the authors found that only 19% of U.S. medical schools and 24% of Canadian medical schools require basic science courses or experiences during the clinical years, a minor increase compared with 1985. Curricular methods ranged from simple lectures to integrated case studies with hands-on laboratory experience. The authors hope to advance the national discussion about the need to more fully integrate basic science teaching throughout all four years of the medical student curriculum by placing a curricular innovation in the context of similar efforts by other U.S. and Canadian medical schools.

Journal ArticleDOI
TL;DR: Despite both the strong, growing demand from medical students and the changing societal forces that call for better global health training, Canadian medical school curricula are not well positioned to address these needs.
Abstract: Purpose Globalization is altering health and health care At the same time, prospective and current medical students are increasingly requesting global health training and creating opportunities when these are not provided by medical schools To understand the type and amount of global health activities provided in Canadian medical schools, the authors undertook a survey of global health educational opportunities available at all 17 medical schools during the 2005-2006 academic year Method Using a structured questionnaire, information was collected from deans' offices, institutional representatives, faculty, students, and medical school Web sites Results All 17 medical schools participated Canadian medical schools vary widely in their approach to global health education, ranging from neither required nor elective courses in global health to well-developed, two-year electives that include didactic and overseas training There is no consensus on the educational content covered, the year in which global health issues are taught, whether materials should be elective or required, or how much training is needed Of the 16 Canadian medical schools that allow students to participate in international electives, 44% allow these electives to occur without clear faculty oversight or input Conclusions Despite both the strong, growing demand from medical students and the changing societal forces that call for better global health training, Canadian medical school curricula are not well positioned to address these needs Improving global health opportunities in Canadian medical school curricula will likely require national leadership from governing academic bodies

Journal ArticleDOI
TL;DR: Being able to communicate, understand the plan, and participate with the team in decision making about their child's care were the most frequently cited outcomes of importance to parents.
Abstract: PurposeIn pediatric teaching hospitals, medical decisions are traditionally made by the attending and resident physicians during rounds that do not include parents. This structure limits the ability of the medical team to provide “family-centered care” and the attending physician to model communicat

Journal ArticleDOI
TL;DR: The professional culture of medicine is proposed as a framework to cultural competence education that explores the customs, languages, and beliefs systems that are shared by physicians, thus defining medicine as a culture.
Abstract: The need for physicians who are well equipped to treat patients of diverse social and cultural backgrounds is evident. To this end, cultural competence education programs in medical schools have proliferated. Although these programs differ in duration, setting, and content, their intentions are the same: to bolster knowledge, promote positive attitudes, and teach appropriate skills in cultural competence. However, to advance the current state of cultural competence curricula, a number of challenges have to be addressed. One challenge is overcoming learner resistance, a problem that is encountered when attempting to convey the importance of cultural competence to students who view it as a "soft science." There is also the challenge of avoiding the perpetuation of stereotypes and labeling groups as "others" in the process of teaching cultural competence. An additional challenge is that few cultural competence curricula are specifically designed to foster an awareness of the student's own cultural background. The authors propose the professional culture of medicine as a framework to cultural competence education that may help mitigate these challenges. Rather than focusing on patients as the "other" group, this framework explores the customs, languages, and beliefs systems that are shared by physicians, thus defining medicine as a culture. Focusing on the physician's culture may help to broaden students' concept of culture and may sensitize them to the importance of cultural competence. The authors conclude with suggestions on how students can explore the professional culture of medicine through the exploration of films, role-playing, and the use of written narratives.

Journal ArticleDOI
TL;DR: It is proposed that research into interprofessional communication and medical error can develop better understandings of how and why medical errors are generated and how andwhy gaps in team defenses occur.
Abstract: Progress toward understanding the links between interprofessional communication and issues of medical error has been slow. Recent research proposes that this delay may result from overlooking the complexities involved in interprofessional care. Medical education initiatives in this domain tend to simplify the complexities of team membership fluidity, rotation, and use of communication tools. A new theoretically informed research approach is required to take into account these complexities. To generate such an approach, we review two theories from the social sciences: Activity Theory and Knotworking. Using these perspectives, we propose that research into interprofessional communication and medical error can develop better understandings of (1) how and why medical errors are generated and (2) how and why gaps in team defenses occur. Such complexities will have to be investigated if students and practicing clinicians are to be adequately prepared to work safely in interprofessional teams.

Journal ArticleDOI
TL;DR: Minority faculty are an excellent resource for identifying strategies to improve diversity in academic medicine and have direct application to future institutional policies in recruitment and retention of underrepresented minority faculty.
Abstract: As racial and ethnic diversity in the general population of the United States increases, research continues to show that diversity in the physician workforce improves health care quality and access to care for ethnic minorities.1–3 In 2004, three ethnic minority groups, African Americans, Latino Americans, and American Indians, represented more than 25% of the U.S. population but only 6% of the nation’s physicians.4 Several reports, including those of the Institute of Medicine and the Sullivan Commission, have called for measures to increase the diversity of the medical workforce.1,4,5 Recruitment and retention of racial and ethnic minority faculty at medical schools have been identified as key factors in increasing the pipeline of minority medical students. Minority faculty provide support for minority students in the form of role models, educators, and mentors.6,7 Unfortunately, minority faculty continue to be alarmingly underrepresented, comprising only 4.2% of medical school faculty nationwide in 2005.8 In that same year, approximately 20% of minority faculty were located at three historically black medical schools and three Puerto Rican medical schools accredited by the Liaison Committee on Medical Education.9 Minority academic medicine faculty are less likely to hold senior rank, are promoted at lower rates,10–12 and report more discrimination than white faculty.13 In addition, high rates of discrimination and harassment during medical education and training14,15 might explain differences in the level of physicians’ professional satisfaction according to race and ethnicity.16 A recent study of physicians of African descent found that race-related experiences can create “racial fatigue” and result in personal and professional costs for physicians.17 Diversity in the student body at medical schools has been shown to enhance the educational experience for all students.18 In addition to addressing health disparities in academic medicine and improving the education and training of all medical students, increasing the number of minority faculty may improve care by increasing the numbers of physicians working with underserved populations19 and by multiplying options for minority patients who prefer racially concordant physicians.20–22 The far-reaching effects of anti-affirmative-action policies, such as Proposition 209 in California, have negatively affected minority student enrollment and recruitment. Proposition 209, a constitutional measure passed in 1996, outlawed race- and gender-based admissions and hiring policies at California public institutions. As of 2008, the University of California–San Francisco (UCSF) School of Medicine faculty includes 2.1% African American and 2.6% Latino faculty. UCSF is working on a variety of strategies to increase diversity through initiatives such as the Underrepresented in Medicine Mentorship Program, the School of Medicine Task Force on Underrepresented Minorities, the Chancellor’s Advisory Committee on Diversity, and a new position for a director of academic diversity. In our study, we bring the voice of minority faculty to current diversity efforts by examining the effects of anti-affirmative-action policies on the diversity climate and by making specific recommendations for academic institutions seeking to increase diversity. Previous studies have focused on junior faculty or students,23,24 whereas our study explores both the junior and senior faculty experience. To explore the diversity climate at UCSF, we designed a qualitative study to examine the perceptions of minority faculty with regard to diversity and discrimination on campus. Our objectives were to (1) elicit and explore the perspectives of minority faculty regarding racial and ethnic diversity in academic medicine, and (2) generate collective recommendations on ways to increase diversity in academic medicine at our institution and nationwide.

Journal ArticleDOI
TL;DR: A framework is provided that leaders of institutions and/or departments can adapt for use as a tool to document and monitor policies for guiding the mentorship process, the programs/activities through which these policies are implemented, and the structures that are responsible for maintaining policies and implementing programs.
Abstract: The purpose of this article is to assist institutions in advancing their efforts to support research mentorship. The authors begin by describing how institutions can shape the key domains of research mentorship: (1) the criteria for selecting mentors, (2) incentives for motivating faculty to serve effectively as mentors, (3) factors that facilitate the mentor–mentee relationship, (4) factors that strengthen a mentee’s ability to conduct research responsibly, and (5) factors that contribute to the professional development of both mentees and mentors. On the basis of a conceptual analysis of these domains as currently documented in the literature, as well as their collective experience examining mentoring programs at a range of academic medicine institutions and departments, the authors provide a framework that leaders of institutions and/or departments can adapt for use as a tool to document and monitor policies for guiding the mentorship process, the programs/activities through which these policies are implemented, and the structures that are responsible for maintaining policies and implementing programs. The authors provide an example of how one hypothetical institution might use the self-assessment tool to track its policies, programs, and structures across the key domains of research mentorship and, on the basis of this information, identify a range of potential actions to strengthen its research mentoring efforts. The authors conclude with a brief discussion of the limitations of the self-assessment tool, the potential drawbacks and benefits of the overall approach, and proposed next steps for research in this area.

Journal ArticleDOI
TL;DR: Findings support the hypothesis that the ELAM program has a beneficial impact on ELAM fellows in terms of leadership behaviors and career progression.
Abstract: Purpose The Hedwig van Ameringen Executive Leadership in Academic Medicine (ELAM) program provides an external yearlong development program for senior women faculty in U.S. and Canadian medical schools. This study aims to determine the extent to which program participants, compared with women from two comparison groups, aspire to leadership, demonstrate mastery of leadership competencies, and attain leadership positions. Method A pre-/posttest methodology and longitudinal structure were used to evaluate the impact of ELAM participation. Participants from two ELAM cohorts were compared with women who applied but were not accepted into the ELAM program (NON) and women from the Association of American Medical Colleges (AAMC) Faculty Roster. The AAMC group was a baseline for midcareer faculty; the NON group allowed comparison for leadership aspiration. Baseline data were collected in 2002, with follow-up data collected in 2006. Sixteen leadership indicators were considered: administrative leadership attainment (four indicators), full professor academic rank (one), leadership competencies and readiness (eight), and leadership aspirations and education (three). Results For 15 of the indicators, ELAM participants scored higher than AAMC and NON groups, and for one indicator they scored higher than only the AAMC group (aspiration to leadership outside academic health centers). The differences were statistically significant for 12 indicators and were distributed across the categories. These included seven of the leadership competencies, three of the administrative leadership attainment indicators, and two of the leadership aspirations and education indicators. Conclusions These findings support the hypothesis that the ELAM program has a beneficial impact on ELAM fellows in terms of leadership behaviors and career progression.

Journal ArticleDOI
TL;DR: Shifts in examinee performance in this study were similar to those observed in previous research, although the magnitude of the overall decline was somewhat larger.
Abstract: Yu Ling, David B. Swanson, Kathy Holtzman, and S. Deniz BucakAbstractBackgroundStudies of retention of basic scienceinformation have commonlydemonstrated a knowledge decline asstudents progress through medicaleducation. This study examined itemcharacteristics influencing patterns ofretention.MethodA large content and statisticallyrepresentative sample of basic scienceitems from 2004–2005 forms of UnitedStates Medical Licensing Examination(USMLE) Step 1 was included in unscoredsections of 2004–2005 USMLE Step 2Clinical Knowledge (CK) test forms, andthe performance of 15,000 first-timeexaminees from U.S. and Canadianschools was analyzed to identify itemcharacteristics affecting retention.ResultsAcross the 502 study items, the meanitem difficulty on Step 1 was 76.1%; onStep 2 CK, this value declined to 69.7%.Performance declines were largest inBiochemistry (17.5%) and Microbiology(12.6%). Improvement was onlyobserved for Behavioral Sciences items(8.7%).ConclusionsShifts in examinee performance in thisstudy were similar to those observed inprevious research, although themagnitude of the overall decline wassomewhat larger.

Journal ArticleDOI
TL;DR: The authors argue that service learning, especially efforts that include gaining detailed knowledge of a particular person or persons, coupled with critical reflection, presents a very promising direction toward achieving these goals.
Abstract: There is currently little knowledge or understanding of medical students' knowledge and attitudes toward the poor. Teaching hospitals bring students face-to-face with poor and uninsured patients on a regular basis. However, an overview of the research available suggests that this contact does not result in students' greater understanding and empathy for the plight of the poor and may, in fact, lead to an erosion of positive attitudes toward the poor. A basic understanding of justice suggests that as the poor are disproportionately the subjects of medical training, this population should enjoy a proportionate benefit for this service. Furthermore, medicine's social contract with the public is often thought to include an ideal of service to the underserved and a duty to help educate the general public regarding the health needs of our nation. In their discussion, the authors situate medical students' attitudes toward the poor within larger cultural perspectives, including attitudes toward the poor and attributions for poverty. They provide three suggestions for improving trainees' knowledge of and attitudes toward the poor-namely, increasing the socioeconomic diversity of students, promoting empathy through curricular efforts, and focusing more directly on role modeling. The authors argue that service learning, especially efforts that include gaining detailed knowledge of a particular person or persons, coupled with critical reflection, presents a very promising direction toward achieving these goals. Finally, they posit an agenda for future educational research that might contribute to the increased efficacy of medical education in this important formative domain.

Journal ArticleDOI
TL;DR: It is concluded that implementation of a longitudinal third-year curriculum, with only modest alterations in existing clinical training frameworks, is feasible and effective in meeting its stated goals.
Abstract: A longitudinal clerkship was designed at Harvard Medical School (HMS) in 2004-2005 to emphasize continuity, empathy, learner-centeredness, and patient-centered care. In 2005-2006, the curriculum was piloted with eight students who voluntarily enrolled in the third-year curriculum, which focused on longitudinal mentorship and feedback, interdisciplinary care, integration of clinical and basic science, and humanism in patient care. Eighteen traditional curriculum (TC) students at HMS who were comparable at baseline served as a comparison group. SHELF exams and OSCE performance, monthly and end-of-year surveys, and focus groups provided comparisons between pilot and TC students on their performance, perceptions, attitudes, and satisfaction. Pilot students performed as well as or better than their peers in standardized measures of clinical aptitude. They demonstrated statistically significant greater preservation of patient-centered attitudes compared with declining values for TC students. Pilot students rated the atmosphere of learning, effective integration of basic and clinical sciences, mentorship, feedback, clerkship satisfaction, and end-of-year patient-care preparedness significantly higher than TC students. The authors conclude that implementation of a longitudinal third-year curriculum, with only modest alterations in existing clinical training frameworks, is feasible and effective in meeting its stated goals. "Exposing" the hidden curriculum through specific longitudinal activities may prevent degradation of student attitudes about patient-centered care. Minimizing the disjointed nature of clinical training during a critical time in students' training by providing a cohesive longitudinal curriculum in parallel to clinical clerkships, led by faculty with consistent contact with students, can have positive effects on both professional performance and satisfaction.

Journal ArticleDOI
TL;DR: Policy of medical schools regarding struggling medical students: those at risk of receiving a grade of less than pass because of problems with knowledge, clinical skills, professionalism, or a combination of these items is characterized.
Abstract: PurposeTo characterize policies of medical schools regarding struggling medical students: those at risk of receiving a grade of less than pass because of problems with knowledge, clinical skills, professionalism, or a combination of these items.MethodThe annual 2006 Clerkship Directors in Internal M

Journal ArticleDOI
TL;DR: This two-year curriculum teaches the critical concepts and skills of patient safety and QI: systems thinking and human factors analysis, root cause analysis (RCA), and process mapping for internal medicine residents at the University of Virginia.
Abstract: Improving patient safety and quality in health care is one of medicine's most pressing challenges. Residency training programs have a unique opportunity to meet this challenge by training physicians in the science and methods of patient safety and quality improvement (QI).With support from the Health Resources and Services Administration, the authors developed an innovative, longitudinal, experiential curriculum in patient safety and QI for internal medicine residents at the University of Virginia. This two-year curriculum teaches the critical concepts and skills of patient safety and QI: systems thinking and human factors analysis, root cause analysis (RCA), and process mapping. Residents apply these skills in a series of QI and patient safety projects. The constructivist educational model creates a learning environment that actively engages residents in improving the quality and safety of their medical practice.Between 2003 and 2005, 38 residents completed RCAs of adverse events. The RCAs identified causes and proposed useful interventions that have produced important care improvements. Qualitative analysis demonstrates that the curriculum shifted residents' thinking about patient safety to a systems-based approach. Residents completed 237 outcome assessments during three years. Results indicate that seminars met predefined learning objectives and were interactive and enjoyable. Residents strongly believe they gained important skills in all domains.The challenge to improve quality and safety in health care requires physicians to learn new knowledge and skills. Graduate medical education can equip new physicians with the skills necessary to lead the movement to safer and better quality of care for all patients.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Journal ArticleDOI
TL;DR: The international experiences available to students and residents at U.S. allopathic medical schools are described to increase students’ and residents’ interest in public health, their likelihood of choosing a career in primary care, and their commitment to serving the underserved.
Abstract: Danette W. McKinley, Shirley R. Williams, John J. Norcini, and M. Brownell AndersonAbstractBackgroundInternational health experiences have beenshown to increase students’ and residents’interest in public health, their likelihood ofchoosing a career in primary care, and theircommitment to serving the underserved.The purpose of the current study is todescribe the international experiencesavailable to students and residents at U.S.allopathic medical schools.MethodAn online survey was conducted tocollect information about the types ofinternational opportunities in medicaleducation provided to faculty, students,and residents at U.S. allopathic medicalschools.ResultsReponses from 103 representatives of96 U.S. allopathic medical schools wereincluded in the analysis. A varietyof opportunities for students andresidents was reported, with 59% ofthe respondents reporting electiverotations for residents, 11% reportinga global health track for students, and45% reporting opportunities toperform preclinical research abroad.ConclusionsDespite associated costs and risks,U.S. medical schools are developingand refining international healthexperiences for medical students andresidents.

Journal ArticleDOI
TL;DR: The study OSCE was well suited to assess SBP and PBLI, providing an opportunity to systematically sample the different subdomains of Quality Improvement and for the demonstration of skills rather than the testing of knowledge alone.
Abstract: Purpose To determine the psychometric properties and validity of an OSCE to assess the competencies of Practice-Based Learning and Improvement (PBLI) and Systems-Based Practice (SBP) in graduate medical education. Method An eight-station OSCE was piloted at the end of a three-week Quality Improvement elective for nine preventive medicine and endocrinology fellows at Mayo Clinic. The stations assessed performance in quality measurement, root cause analysis, evidence-based medicine, insurance systems, team collaboration, prescription errors, Nolan's model, and negotiation. Fellows' performance in each of the stations was assessed by three faculty experts using checklists and a five-point global competency scale. A modified Angoff procedure was used to set standards. Evidence for the OSCE's validity, feasibility, and acceptability was gathered. Results Evidence for content and response process validity was judged as excellent by institutional content experts. Interrater reliability of scores ranged from 0.85 to 1 for most stations. Interstation correlation coefficients ranged from -0.62 to 0.99, reflecting case specificity. Implementation cost was approximately $255 per fellow. All faculty members agreed that the OSCE was realistic and capable of providing accurate assessments. Conclusions The OSCE provides an opportunity to systematically sample the different subdomains of Quality Improvement. Furthermore, the OSCE provides an opportunity for the demonstration of skills rather than the testing of knowledge alone, thus making it a potentially powerful assessment tool for SBP and PBLI. The study OSCE was well suited to assess SBP and PBLI. The evidence gathered through this study lays the foundation for future validation work.

Journal ArticleDOI
TL;DR: A majority of fourth-year medical students still have never performed important procedures, and a substantial minority have not performed basic procedures.
Abstract: BackgroundRecent data do not exist on medical students’ performance of and attitudes toward procedural and interpretive skills deemed important by medical educators.MethodA total of 171 medical students at seven medical schools were surveyed regarding frequency of performance, self-confidenc

Journal ArticleDOI
TL;DR: Current proposals continue the trend of increasing ambulatory exposure through providing more clinical hours in the outpatient setting as a pedagogic strategy to improve residents' practical skills in providing quality care in outpatient settings.
Abstract: In the past 25 years, academic leaders and accreditation bodies in internal medicine and pediatrics have made multiple efforts to increase residents' exposure to ambulatory primary care medicine, to bring hospital-based residency training more in line with the career paths of graduates. Current proposals continue the trend of increasing ambulatory exposure through providing more clinical hours in the outpatient setting as a pedagogic strategy to improve residents' practical skills in providing quality care in outpatient settings. Resident clinics, however, are often understaffed and dysfunctional. Under these circumstances, the work environment encourages some residents to learn only that providing high-quality primary care is a frustrating and unrewarding form of labor. Leaders in medicine have used innovative organizational strategies to improve residents' outpatient experiences. Model primary care residency programs and clinics have been created. The diffusion of model primary care clinical practices and structures is, however, limited by the strain of generating sufficient clinical revenue to run an academic medical center efficiently and reliably in the current environment. Increased outpatient exposure, without attention to the quality of practice settings, is potentially counterproductive, generating an unintended consequence that is the opposite of the goals of policy: it may reinforce residents' interest in subspecialty practice.

Journal ArticleDOI
TL;DR: The authors explored residents’ experiences and perceptions of the ITER process to gain insight into why the process succeeds or fails, and articulation of external and internal influences on engagement provides a starting point for targeted interventions.
Abstract: Background In-training evaluation reports (ITERs) often fall short of their goals of promoting resident learning and development. Efforts to address this problem through faculty development and assessment-instrument modification have been disappointing. The authors explored residents' experiences and perceptions of the ITER process to gain insight into why the process succeeds or fails. Method Using a grounded theory approach, semistructured interviews were conducted with 20 residents. Constant comparative analysis for emergent themes was conducted. Results All residents identified aspects of "engagement" in the ITER process as the dominant influence on the success of ITERs. Both external (evaluator-driven, such as evaluator credibility) and internal (resident-driven, such as self-assessment) influences on engagement were elaborated. When engagement was lacking, residents viewed the ITER process as inauthentic. Conclusions Engagement is a critical factor to consider when seeking to improve ITER use. Our articulation of external and internal influences on engagement provides a starting point for targeted interventions.