Showing papers in "Academic Medicine in 2011"

Does Simulation-Based Medical Education With Deliberate Practice Yield Better Results Than Traditional Clinical Education? A Meta-Analytic Comparative Review of the Evidence

Abstract: Purpose This article presents a comparison of the effectiveness of traditional clinical education toward skill acquisition goals versus simulation-based medical education (SBME) with deliberate practice (DP). Method This is a quantitative meta-analysis that spans 20 years, 1990 to 2010. A search strategy involving three literature databases, 12 search terms, and four inclusion criteria was used. Four authors independently retrieved and reviewed articles. Main outcome measures were extracted to calculate effect sizes.

Empathy decline and its reasons: a systematic review of studies with medical students and residents.

Abstract: Purpose Empathy is a key element of patient– physician communication; it is relevant to and positively influences patients’ health. The authors systematically reviewed the literature to investigate changes in trainee empathy and reasons for those changes during medical school and residency. Method The authors conducted a systematic search of studies concerning trainee empathy published from January 1990 to January 2010, using manual methods and the PubMed, EMBASE, and PsycINFO databases. They independently reviewed and selected quantitative and qualitative studies for inclusion. Intervention studies, those that evaluated psychometric properties of self-assessment tools, and those with a sample size 30 were excluded. Results Eighteen studies met the inclusion criteria: 11 on medical students and 7 on residents. Three longitudinal and six cross-sectional studies of medical students demonstrated a significant decrease in empathy during medical school; one cross-sectional study found a tendency toward a decrease, and another suggested stable scores. The five longitudinal and two cross-sectional studies of residents showed a decrease in empathy during residency. The studies pointed to the clinical practice phase of training and the distress produced by aspects of the “hidden,” “formal,” and “informal” curricula as main reasons for empathy decline.

Physicians' Empathy and Clinical Outcomes for Diabetic Patients

Abstract: Purpose To test the hypothesis that physicians’ empathy is associated with positive clinical outcomes for diabetic patients. Method A correlational study design was used in a university-affiliated outpatient setting. Participants were 891 diabetic patients, treated between July 2006 and June 2009, by 29 family physicians. Results of the most recent hemoglobin A1c and LDL-C tests were extracted from the patients’ electronic records. The results of hemoglobin A1c tests were categorized into good control (7.0%) and poor control (9.0%). Similarly, the results of the LDL-C tests were grouped into good control (100) and poor control (130). The physicians, who completed the Jefferson Scale of Empathy in 2009, were grouped into high, moderate, and low empathy scorers. Associations between physicians’ level of empathy scores and patient outcomes were examined. Results Patients of physicians with high empathy scores were significantly more likely to have good control of hemoglobin A1c (56%) than were patients of physicians with low empathy scores (40%, P .001). Similarly, the proportion of patients with good LDL-C control was significantly higher for physicians with high empathy scores (59%) than physicians with low scores (44%, P .001). Logistic regression analyses indicated that physicians’ empathy had a unique contribution to the prediction of optimal clinical outcomes after controlling for physicians’ and patients’ gender and age, and patients’ health insurance. Conclusions The hypothesis of a positive relationship between physicians’ empathy and patients’ clinical outcomes was confirmed, suggesting that physicians’ empathy is an important factor associated with clinical competence and patient outcomes. Empathy, an essential component of the physician–patient relationship, may be linked to positive patient outcomes. Although this notion is consistent with the conceptual view of physician–patient relationships, 1–3 empirical data supporting the association between physicians’ empathy and tangible clinical outcomes are difficult to find. Several studies generally support the notion that the quality of the physician–patient relationship (as a proxy for empathic engagement in patient care) has a positive influence on patient

Checklists to reduce diagnostic errors.

Abstract: Diagnostic errors are common and can often be traced to physicians' cognitive biases and failed heuristics (mental shortcuts). A great deal is known about how these faulty thinking processes lead to error, but little is known about how to prevent them. Faulty thinking plagues other high-risk, high-reliability professions, such as airline pilots and nuclear plant operators, but these professions have reduced errors by using checklists. Recently, checklists have gained acceptance in medical settings, such as operating rooms and intensive care units. This article extends the checklist concept to diagnosis and describes three types of checklists: (1) a general checklist that prompts physicians to optimize their cognitive approach, (2) a differential diagnosis checklist to help physicians avoid the most common cause of diagnostic error--failure to consider the correct diagnosis as a possibility, and (3) a checklist of common pitfalls and cognitive forcing functions to improve evaluation of selected diseases. These checklists were developed informally and have not been subjected to rigorous evaluation. The purpose of this article is to argue for the further investigation and revision of these initial attempts to apply checklists to the diagnostic process. The basic idea behind checklists is to provide an alternative to reliance on intuition and memory in clinical problem solving. This kind of solution is demanded by the complexity of diagnostic reasoning, which often involves sense-making under conditions of great uncertainty and limited time.

"Teaching as a Competency": Competencies for Medical Educators

Abstract: Most medical faculty receive little or no training about how to be effective teachers, even when they assume major educational leadership roles. To identify the competencies required of an effective teacher in medical education, the authors developed a comprehensive conceptual model. After conducting a literature search, the authors met at a two-day conference (2006) with 16 medical and nonmedical educators from 10 different U.S. and Canadian organizations and developed an initial draft of the “Teaching as a Competency” conceptual model. Conference participants used the physician competencies (from the Accreditation Council for Graduate Medical Education [ACGME]) and the roles (from the Royal College’s Canadian Medical Education Directives for Specialists [CanMEDS]) to define critical skills for medical educators. The authors then refined this initial framework through national/regional conference presentations (2007, 2008), an additional literature review, and expert input. Four core values grounded this framework: learner engagement, learnercenteredness, adaptability, and selfreflection. The authors identified six core competencies, based on the ACGME competencies framework: medical (or content) knowledge; learnercenteredness; interpersonal and communication skills; professionalism and role modeling; practice-based reflection; and systems-based practice. They also included four specialized competencies for educators with additional programmatic roles: program design/implementation, evaluation/scholarship, leadership, and mentorship. The authors then crossreferenced the competencies with educator roles, drawing from CanMEDS, to recognize role-specific skills. The authors have explored their framework’s strengths, limitations, and applications, which include targeted faculty development, evaluation, and resource allocation. The Teaching as a Competency framework promotes a culture of effective teaching and learning.

Core competencies for interprofessional collaborative practice: reforming health care by transforming health professionals' education.

Abstract: Concerns about the quality and safety of health care delivery continue to mount, and the deficiencies cannot be addressed by any health profession alone.1 Despite numerous reports citing the need for team-based education in health professions schools,2 meaningful preparation for collaborative practi

Faculty development in assessment: the missing link in competency-based medical education.

Abstract: As the medical education community celebrates the 100th anniversary of the seminal Flexner Report, medical education is once again experiencing significant pressure to transform. Multiple reports from many of medicine's specialties and external stakeholders highlight the inadequacies of current training models to prepare a physician workforce to meet the needs of an increasingly diverse and aging population. This transformation, driven by competency-based medical education (CBME) principles that emphasize the outcomes, will require more effective evaluation and feedback by faculty.Substantial evidence suggests, however, that current faculty are insufficiently prepared for this task across both the traditional competencies of medical knowledge, clinical skills, and professionalism and the newer competencies of evidence-based practice, quality improvement, interdisciplinary teamwork, and systems. The implication of these observations is that the medical education enterprise urgently needs an international initiative of faculty development around CBME and assessment. In this article, the authors outline the current challenges and provide suggestions on where faculty development efforts should be focused and how such an initiative might be accomplished. The public, patients, and trainees need the medical education enterprise to improve training and outcomes now.

Gender differences in academic productivity and leadership appointments of physicians throughout academic careers

Abstract: PURPOSE Because those selected for leadership in academic medicine often have a record of academic productivity, publication disparities may help explain the gender imbalance in leadership roles. The authors aimed to compare the publication records, academic promotions, and leadership appointments of women and men physicians longitudinally throughout academic careers. METHOD In 2007, the authors conducted a retrospective, longitudinal cohort study of all 25 women physicians then employed at Mayo Clinic with ≥20 years of service at Mayo and of 50 male physician controls, matched 2:1 by appointment date and career category, to women. The authors recorded peer-reviewed publications, timing of promotion, and leadership appointments throughout their careers. RESULTS Women published fewer articles throughout their careers than men (mean [standard deviation] 29.5 [28.8] versus 75.8 [60.3], P = .001). However, after 27 years, women produced a mean of 1.57 more publications annually than men (P < .001). Thirty-three men (66%) achieved an academic rank of professor compared with seven women (28%) (P = .01). Throughout their careers, women held fewer leadership roles than men (P < .001). Nearly half (no. = 11; 44%) of women attained no leadership position, compared with 15 men (30%). CONCLUSIONS Women's publication rates increase and actually exceed those of men in the latter stages of careers, yet women hold fewer leadership positions than men overall, suggesting that academic productivity assessed midcareer may not be an appropriate measure of leadership skills and that factors other than publication record and academic rank should be considered in selecting leaders.

Reframing research on faculty development.

Abstract: Research on faculty development has focused primarily on individual participants and has produced relatively little generalizable knowledge that can guide faculty development programs. In this article, the authors examine how current research on faculty development in medical education can be enriched by research in related fields such as teacher education, quality improvement, continuing medical education, and workplace learning. As a result of this analysis, the authors revise the old model for conceptualizing faculty development (preferably called professional development). This expanded model calls for research on educational process and outcomes focused on two communities of practice: the community created among participants in faculty development programs and the communities of teaching practice in the workplace (classroom or clinic) where teaching actually occurs. For the faculty development community, the key components are the participants, program, content, facilitator, and context in which the program occurs and in which the faculty teach. For the workplace community, associated components include relationships and networks of association in that environment, the organization and culture of the setting, the teaching tasks and activities, and the mentoring available to the members of that academic and/or clinical community of teaching practice. This expanded model of faculty development generates a new set of research questions, which are described along with six recommendations for enhancing research, including establishment of a national center for research in health professions education.

Relationship of pass/fail grading and curriculum structure with well-being among preclinical medical students: a multi-institutional study.

Abstract: Purpose Psychological distress is common among medical students. Curriculum structure and grading scales are modifiable learning environment factors that may influence student well-being. The authors sought to examine relationships among curriculum structures, grading scales, and student well-being. Method The authors surveyed 2,056 first- and second-year medical students at seven U.S. medical schools in 2007. They used the Perceived Stress Scale, Maslach Burnout Inventory, and Medical Outcomes Study Short Form (SF-8) to measure stress, burnout, and quality of life, respectively. They measured curriculum structure using hours spent in didactic, clinical, and testing experiences. Grading scales were categorized as two categories (pass/ fail) versus three or more categories (e.g., honors/pass/fail). Results Of the 2,056 students, 1,192 (58%) responded. In multivariate analyses, students in schools using grading scales with three or more categories had higher levels of stress (beta 2.65; 95% CI 1.54– 3.76, P .0001), emotional exhaustion (beta 5.35; 95% CI 3.34–7.37, P .0001), and depersonalization (beta 1.36; 95% CI 0.53–2.19, P .001) and were more likely to have burnout (OR 2.17; 95% CI 1.41–3.35, P .0005) and to have seriously considered dropping out of school (OR 2.24; 95% CI 1.54–3.27, P .0001) compared with students in schools using pass/fail grading. There were no relationships between time spent in didactic and clinical experiences and well-being.

Sex Differences in Application, Success, and Funding Rates for NIH Extramural Programs

Abstract: Purpose The authors provide an analysis of sex differences in National Institutes of Health (NIH) award programs to inform potential initiatives for promoting diversity in the research workforce. Method In 2010, the authors retrieved data for NIH extramural grants in the electronic Research Administration Information for Management, Planning, and Coordination II database and used statistical analysis to determine any sex differences in securing NIH funding, as well as subsequent success of researchers who had already received independent NIH support. Results Success and funding rates for men and women were not significantly different in most award programs. Furthermore, in programs where participation was lower for women than men, the disparity was primarily related to a lower percentage of women applicants compared with men, rather than decreased success rates or funding rates. However, for subsequent grants, both application and funding rates were generally higher for men than for women. Conclusions Cross-sectional analysis showed that women and men were generally equally successful at all career stages, but longitudinal analysis showed that men with previous experience as NIH grantees had higher application and funding rates than women at similar career points. On average, although women received larger R01 awards than men, men had more R01 awards than women at all points in their careers. Therefore, while greater participation of women in NIH programs is under way, further action will be required to eradicate remaining sex differences.

Are United States Medical Licensing Exam Step 1 and 2 scores valid measures for postgraduate medical residency selection decisions

Abstract: PurposeUnited States Medical Licensing Examination (USMLE) scores are frequently used by residency program directors when evaluating applicants. The objectives of this report are to study the chain of reasoning and evidence that underlies the use of USMLE Step 1 and 2 scores for postgraduate

Rater-based assessments as social judgments: rethinking the etiology of rater errors.

Abstract: BackgroundMeasurement errors are a limitation of using rater-based assessments that are commonly attributed to rater errors. Solutions targeting rater subjectivity have been largely unsuccessful.MethodThis critical review examines investigations of rater idiosyncrasy from impression formatio

Decoding the learning environment of medical education: a hidden curriculum perspective for faculty development.

Abstract: Medical student literature has broadly established the importance of differentiating between formal-explicit and hidden-tacit dimensions of the physician education process. The hidden curriculum refers to cultural mores that are transmitted, but not openly acknowledged, through formal and informal educational endeavors. The authors extend the concept of the hidden curriculum from students to faculty, and in so doing, they frame the acquisition by faculty of knowledge, skills, and values as a more global process of identity formation. This process includes a subset of formal, formative activities labeled “faculty development programs” that target specific faculty skills such as teaching effectiveness or leadership; however, it also includes informal, tacit messages that faculty absorb. As faculty members are socialized into faculty life, they often encounter conflicting messages about their role. In this article, the authors examine how faculty development programs have functioned as a source of conflict, and they ask how these programs might be retooled to assist faculty in understanding the tacit institutional culture shaping effective socialization and in managing the inconsistencies that so often dominate faculty life.

Tensions in informed self-assessment: how the desire for feedback and reticence to collect and use it can conflict.

Abstract: PURPOSE: Informed self-assessment describes the set of processes through which individuals use external and internal data to generate an appraisal of their own abilities. The purpose of this project was to explore the tensions described by learners and professionals when informing their self-assessments of clinical performance. METHOD: This 2008 qualitative study was guided by principles of grounded theory. Eight programs in five countries across undergraduate, postgraduate, and continuing medical education were purposively sampled. Seventeen focus groups were held (134 participants). Detailed analyses were conducted iteratively to understand themes and relationships. RESULTS: Participants experienced multiple tensions in informed self-assessment. Three categories of tensions emerged: within people (e.g., wanting feedback, yet fearing disconfirming feedback), between people (e.g., providing genuine feedback yet wanting to preserve relationships), and in the learning/practice environment (e.g., engaging in authentic self-assessment activities versus "playing the evaluation game"). Tensions were ongoing, contextual, and dynamic; they prevailed across participant groups, infusing all components of informed self-assessment. They also were present in varied contexts and at all levels of learners and practicing physicians. CONCLUSIONS: Multiple tensions, requiring ongoing negotiation and renegotiation, are inherent in informed self-assessment. Tensions are both intraindividual and interindividual and they are culturally situated, reflecting both professional and institutional influences. Social learning theories (social cognitive theory) and sociocultural theories of learning (situated learning and communities of practice) may inform our understanding and interpretation of the study findings. The findings suggest that educational interventions should be directed at individual, collective, and institutional cultural levels. Implications for practice are presented.

Understanding the goals of service learning and community-based medical education: a systematic review.

Abstract: PurposeTo understand the educational goals of projects described as “service learning” or “community-based medical education” and to learn how relationships between medical schools and community members are discussed in these projects.MethodIn 2008, the authors performed a systematic qualita

The physician as health advocate: translating the quest for social responsibility into medical education and practice.

Abstract: There is a growing demand for educating future physicians to be socially responsible. It is not clear, however, how social responsibility is understood and acted on in medical education and practice, particularly within the context of a growing desire to improve health care through an equitable and sustainable delivery system. The authors conduct a concept analysis, exploring the practical philosophical understanding of social responsibility and its implications for medical education and practice. The aim is to inform curricular development, professional practice, and further research on social responsibility. The particular ways in which social responsibility is interpreted can either enhance or establish limits on how it will appear across the continuum of medical education and practice. A physician's place in society is closely tied to a moral sense of responsibility related to the agreed-on professional characteristics of physicianhood in society, the capacity to carry out that role, and the circumstances under which such professionals are called to account for failing to act appropriately according to that role. The requirement for social responsibility is a moral commitment and duty developed over centuries within societies that advanced the notion of a "profession" and the attendant social contract with society. A curriculum focused on developing social responsibility in future physicians will require pedagogical approaches that are innovative, collaborative, participatory, and transformative.

Stories From Early-Career Women Physicians Who Have Left Academic Medicine: A Qualitative Study at a Single Institution

Abstract: Purpose The number of women in academic medicine has steadily increased, although gender parity still does not exist and women leave academics at somewhat higher rates than men. The authors investigated the reasons why women leave careers in academic medicine. Method Semistructured, one-on-one interviews were conducted in 2007–2008 with 20 women physicians who had left a single academic institution to explore their reasons for opting out of academic careers. Data analysis was iterative, and an editing analysis style was used to derive themes. Results A lack of role models for combining career and family responsibilities, frustrations with research (funding difficulties, poor mentorship, competition), work–life balance, and the institutional environment (described as noncollaborative and biased in favor of male faculty) emerged as key factors associated with a decision to leave academic medicine for respondents. Faced with these challenges, respondents reevaluated their priorities and concluded that a discrepancy existed between their own and institutional priorities. Many respondents expressed divergent views with the institutional norms on how to measure success and, as a consequence, felt that they were undervalued at work. Conclusions Participants report a disconnection between their own priorities and those of the dominant culture in academic medicine. Efforts to retain women faculty in academic medicine may include exploring the aspects of an academic career that they value most and providing support and recognition accordingly.

Commentary: Diversity 3.0: A Necessary Systems Upgrade

Abstract: This is a defining moment for health and health care in the United States, and medical schools and teaching hospitals have a critical role to play. The combined forces of health care reform, demographic shifts, continued economic woes, and the projected worsening of physician shortages portend major challenges for the health care enterprise in the near future. In this commentary, the author employs a diversity framework implemented by IBM and argues that this framework should be adapted to an academic medicine setting to meet the challenges to the health care enterprise. Using IBM’s diversity framework, the author explores three distinct phases in the evolution of diversity thinking within the academic medicine community. The first phase included isolated efforts aimed at removing social and legal barriers to access and equality, with institutional excellence and diversity as competing ends. The second phase kept diversity on the periphery but raised awareness about how increasing diversity benefits everyone, allowing excellence and diversity to exist as parallel ends. In the third phase, which is emerging today and reflects a growing understanding of diversity’s broader relevance to institutions and systems, diversity and inclusion are integrated into the core workings of the institution and framed as integral for achieving excellence. The Association of American Medical Colleges, a leading voice and advocate for increased student and faculty diversity, is set to play a more active role in building the capacity of the nation’s medical schools and teaching hospitals to move diversity from a periphery to a core strategy. This is a defining moment for health and health care in the United States, and our medical schools and teaching hospitals have a critical role to play. The combined forces of health care reform, demographic shifts, continued economic woes, and the projected worsening of physician shortages portend major challenges for the health care enterprise in the near future.

Medical education featuring mastery learning with deliberate practice can lead to better health for individuals and populations.

Abstract: Medical education can lead to better health for individuals and populations when it has effective, evidence-based features and is delivered under the right conditions. Effective, evidence-based features include mastery learning (ML), deliberate practice (DP), and rigorous outcome measurement (ML and

Perspective: Does medical education promote professional alexithymia? A call for attending to the emotions of patients and self in medical training

Abstract: Emotions--one's own and others'--play a large role in the lives of medical students. Students must deal with their emotional reactions to intellectual and physical stress, the demanding clinical situations to which they are witness, as well as patients' and patients' family members' often intense feelings. Yet, currently few components in formal medical training--in either direct curricular instruction or physician role modeling--focus on the emotional lives of students. In this article, the author examines patients', medical students', and physician role models' emotions in the clinical context, highlighting challenges in all three of these arenas. Next, the author asserts that the preponderance of medical education continues to address the emotional realm through ignoring, detaching from, and distancing from emotions. Finally, she presents not only possible theoretical and conceptual models for developing ways of understanding, attending to, and ultimately "working with" emotions in medical education but also examples of innovative curricular efforts to incorporate emotional awareness into medical student training. The author concludes with the hope that medical educators will consider making a concerted effort to acknowledge emotions and their importance in medicine and medical training.

What can medical education learn from the neurobiology of learning

Abstract: The last several decades have seen a large increase in knowledge of the underlying biological mechanisms that serve learning and memory. The insights gleaned from neurobiological and cognitive neuroscientific experimentation in humans and in animal models have identified many of the processes at the molecular, cellular, and systems levels that occur during learning and the formation, storage, and recall of memories. Moreover, with the advent of noninvasive technologies to monitor patterns of neural activity during various forms of human cognition, the efficacy of different strategies for effective teaching can be compared. Considerable insight has also been developed as to how to most effectively engage these processes to facilitate learning, retention, recall, and effective use and application of the learned information. However, this knowledge has not systematically found its way into the medical education process. Thus, there are considerable opportunities for the integration of current knowledge about the biology of learning with educational

Use of Simulation-Based Education to Improve Outcomes of Central Venous Catheterization: A Systematic Review and Meta-Analysis

Abstract: PurposeCentral venous catheterization (CVC) is increasingly taught by simulation. The authors reviewed the literature on the effects of simulation training in CVC on learner and clinical outcomes.MethodThe authors searched computerized databases (1950 to May 2010), reference lists, and consi

Humanism at heart: preserving empathy in third-year medical students.

Abstract: Purpose Research suggests that medical student empathy erodes during undergraduate medical education. The authors evaluated the Jefferson Scale of Physician Empathy Medical Student Version (JSPE-MS) scores of two consecutive medical school classes to assess the impact of an educational intervention on the preservation of empathy. Method The authors conducted a before-andafter study of 209 Robert Wood Johnson Medical School (RWJMS) students enrolled in the classes of 2009 and 2010. Students’ clerkships included a mandatory, longitudinal “Humanism and Professionalism” (H&P) component, which included blogging about clerkship experiences, debriefing after significant events, and discussing journal articles, fiction, and film. Students completed the JSPE-MS during their first and last clerkships. Results The results showed that (1) contrary to previous studies’ findings, third-year students did not show significant decline in empathy as measured by the JSPE-MS (these students, from two consecutive RWJMS classes, experienced the H&P intervention), (2) students selected for the Gold Humanism Honor Society (GHHS) were significantly different from their peers in empathy scores as measured by JSPE-MS, and (3) knowledge of selection for the GHHS seems to positively influence students’ JSPE-MS scores.

Lost in transition: the experience and impact of frequent changes in the inpatient learning environment.

Abstract: Purpose The traditional "rotating" model of inpatient training remains the gold standard of residency, moving residents through different systems every two to four weeks. The authors studied the experience and impact of frequent transitions on residents. Method This was a qualitative study. Ninety-seven individuals participated in 12 focus groups at three academic medical centers purposefully chosen to represent a range of geographic locations and structural characteristics. Four groups were held at each site: residents only, faculty only, nurses and ancillary staff only, and a mixed group. Grounded theory was used to analyze data. Results Perceived benefits of transitions included the ability to adapt to new environments and practice styles, improved organization and triage skills, increased comfort with stressful situations, and flexibility. Residents primarily relied on each other to cope with and prepare for transitions, with little support from the program or faculty level. Several potentially problematic workarounds were described within the context of transitions, including shortened progress notes, avoiding pages, hiding information, and sidestepping critical situations. Nearly all residents acknowledged that frequent transitions contributed to a lack of ownership and other potentially harmful effects for patient care. Conclusions These findings challenge the value of the traditional "rotating" model in residency. As residents adapt to frequent transitioning, they implicitly learn to value flexibility and efficiency over relationship building and deep system knowledge. These findings raise significant implications for professional development and patient care and highlight an important element of the hidden curriculum embedded within the current training model.

Commentary: ambiguity and uncertainty: neglected elements of medical education curricula?

Abstract: Despite significant advances in scientific knowledge and technology, ambiguity and uncertainty are still intrinsic aspects of contemporary medicine. To practice confidently and competently, a physician must learn rational approaches to complex and ambiguous clinical scenarios and must possess a certain degree of tolerance of ambiguity. In this commentary, the authors discuss the role that ambiguity and uncertainty play in medicine and emphasize why openly addressing these topics in the formal medical education curriculum is critical. They discuss key points from original research by Wayne and colleagues and their implications for medical education. Finally, the authors offer recommendations for increasing medical student tolerance of ambiguity and uncertainty, including dedicating time to attend candidly to ambiguity and uncertainty as a formal part of every medical school curriculum.

Training the Next Generation of Physician–Executives: An Innovative Residency Pathway in Management and Leadership

Abstract: The rapidly changing field of medicine demands that future physician-leaders excel not only in clinical medicine but also in the management of complex health care enterprises. However, many physicians have become leaders "by accident," and the active cultivation of future leaders is required. Addressing this need will require multiple approaches, targeting trainees at various stages of their careers, such as degree-granting programs, residency and fellowship training, and career and leadership development programs. Here, the authors describe a first-of-its-kind graduate medical education pathway at Duke Medicine, the Management and Leadership Pathway for Residents (MLPR). This program was developed for residents with both a medical degree and management training. Created in 2009, with its first cohort enrolled in the summer of 2010, the MLPR is intended to help catalyze the emergence of a new generation of physician-leaders. The program will provide physicians-in-training with rigorous clinical exposure along with mentorship and rotational opportunities in management to accelerate the development of critical leadership and management skills in all facets of medicine, including care delivery, research, and education. To achieve this, the MLPR includes 15 to 18 months of project-based rotations under the guidance of senior leaders in many disciplines including finance, patient safety, health system operations, strategy, and others. Developing both clinical and management skill sets during graduate medical education holds the promise of engaging future leaders of health care at an early career stage, keeping more MD-MBA graduates within health care, and creating a bench of talented future physician-executives.

Art Rounds: teaching interprofessional students visual thinking strategies at one school.

Abstract: PurposeThe Art Rounds program uses visual thinking strategies (VTS) to teach visual observation skills to medical and nursing students at the University of Texas Health Science Center San Antonio. This study's goal was to evaluate whether students' exposure to VTS would improve their physica

The impact of rural training experiences on medical students: a critical review.

Abstract: PurposeTo address the growing shortage of rural physicians, several medical schools have developed rural training experiences for their students. However, little is known about the educational impact of these experiences. Thus, the authors conducted a critical review of North American studie

The Incidence and Predictors of Job Burnout in First-Year Internal Medicine Residents: A Five-Institution Study

Abstract: PurposeJob burnout is prevalent among U.S. internal medicine (IM) residents and may lead to depression, suboptimal patient care, and medical errors. This study sought to identify factors predicting new burnout to better identify at-risk residents.MethodThe authors administered surveys to fir