Showing papers in "Academic Medicine in 2012"

The Relationship Between Physician Empathy and Disease Complications: An Empirical Study of Primary Care Physicians and Their Diabetic Patients in Parma, Italy

Abstract: Purpose To test the hypothesis that scores of a validated measure of physician empathy are associated with clinical outcomes for patients with diabetes mellitus. Method This retrospective correlational study included 20,961 patients with type 1 or type 2 diabetes mellitus from a population of 284,298 adult patients in the Local Health Authority, Parma, Italy, enrolled with one of 242 primary care physicians for the entire year of 2009. Participating physicians’ Jefferson Scale of Empathy scores were compared with occurrence of acute metabolic complications (hyperosmolar state, diabetic ketoacidosis, coma) in diabetes patients hospitalized in 2009. Results Patients of physicians with high empathy scores, compared with patients of physicians with moderate and low empathy scores, had a significantly lower rate of acute metabolic complications (4.0, 7.1, and 6.5 per 1,000 patients, respectively, P < .05). Logistic regression analysis showed physicians’ empathy scores were associated with acute metabolic complications: odds ratio (OR) = 0.59 (95% confidence interval [CI], 0.37–0.95, contrasting physicians with high and low empathy scores). Patients’ age (≥69 years) also contributed to the prediction of acute metabolic complications: OR = 1.7 (95% CI, 1.2–1.4). Physicians’ gender and age, patients’ gender, type of practice (solo, association), geographical location of practice (mountain, hills, plain), and length of time the patient had been enrolled with the physician were not associated with acute metabolic complications. Conclusions These results suggest that physician empathy is significantly associated with clinical outcome for patients with diabetes mellitus and should be considered an important component of clinical competence.

Competency is not enough: integrating identity formation into the medical education discourse.

Abstract: Despite the widespread implementation of competency-based medical education, there are growing concerns that generally focus on the translation of physician roles into "measurable competencies." By breaking medical training into small, discrete, measurable tasks, it is argued, the medical education community may have emphasized too heavily questions of assessment, thereby missing the underlying meaning and interconnectedness of how physician roles shape future physicians. To address these concerns, the authors argue that an expanded approach be taken that includes a focus on professional identity development. The authors provide a conceptual analysis of the issues and language related to a broader focus on understanding the relationship between the development of competency and the formation of identities during medical training. Including identity alongside competency allows a reframing of approaches to medical education away from an exclusive focus on "doing the work of a physician" toward a broader focus that also includes "being a physician." The authors consider the salient literature on identity that can inform this expanded perspective about medical education and training.

Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians.

Abstract: A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect. The authors identify a broad range of disrespectful conduct, suggesting six categories for classifying disrespectful behavior in the health care setting: disruptive behavior; humiliating, demeaning treatment of nurses, residents, and students; passive-aggressive behavior; passive disrespect; dismissive treatment of patients; and systemic disrespect.At one end of the spectrum, a single disruptive physician can poison the atmosphere of an entire unit. More common are everyday humiliations of nurses and physicians in training, as well as passive resistance to collaboration and change. Even more common are lesser degrees of disrespectful conduct toward patients that are taken for granted and not recognized by health workers as disrespectful.Disrespect is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices. Nurses and students are particularly at risk, but disrespectful treatment is also devastating for patients. Disrespect underlies the tensions and dissatisfactions that diminish joy and fulfillment in work for all health care workers and contributes to turnover of highly qualified staff. Disrespectful behavior is rooted, in part, in characteristics of the individual, such as insecurity or aggressiveness, but it is also learned, tolerated, and reinforced in the hierarchical hospital culture. A major contributor to disrespectful behavior is the stressful health care environment, particularly the presence of "production pressure," such as the requirement to see a high volume of patients.

Fostering and evaluating reflective capacity in medical education: developing the REFLECT rubric for assessing reflective writing

Abstract: Purpose Reflective writing (RW) curriculum initiatives to promote reflective capacity are proliferating within medical education. The authors developed a new evaluative tool that can be effectively applied to assess students’ reflective levels and assist with the process of providing individualized written feedback to guide reflective capacity promotion. Method Following a comprehensive search and analysis of the literature, the authors developed an analytic rubric through repeated iterative cycles of development, including empiric testing and determination of interrater reliability, reevaluation and refinement, and redesign. Rubric iterations were applied in successive development phases to Warren Alpert Medical School of Brown University students’ 2009 and 2010 RW narratives with determination of intraclass correlations (ICCs). Results The final rubric, the Reflection Evaluation for Learners’ Enhanced Competencies Tool (REFLECT), consisted of four reflective capacity levels ranging from habitual action to critical reflection, with focused criteria for each level. The rubric also evaluated RW for transformative reflection and learning and confirmatory learning. ICC ranged from 0.376 to 0.748 for datasets and rater combinations and was 0.632 for the final REFLECT iteration analysis. Conclusions The REFLECT is a rigorously developed, theory-informed analytic rubric, demonstrating adequate interrater reliability, face validity, feasibility, and acceptability. The REFLECT rubric is a reflective analysis innovation supporting development of a reflective clinician via formative assessment and enhanced crafting of faculty feedback to reflective narratives.

Addressing the leadership gap in medicine: residents' need for systematic leadership development training.

Abstract: All clinicians take on leadership responsibilities when delivering care. Evidence suggests that effective clinical leadership yields superior clinical outcomes. However, few residency programs systematically teach all residents how to lead, and many clinicians are inadequately prepared to meet their

The Ottawa Surgical Competency Operating Room Evaluation (O-SCORE): a tool to assess surgical competence.

Abstract: PurposeMost assessment of surgical trainees is based on measures of knowledge, with limited evaluation of their competence to actually perform various surgical procedures. In this study, the authors evaluated a tool they designed to assess a trainee’s competence to perform an entire surgical procedu

Perspective: Guidelines for reporting team-based learning activities in the medical and health sciences education literature.

Abstract: Medical and health sciences educators are increasingly employing team-based learning (TBL) in their teaching activities. TBL is a comprehensive strategy for developing and using self-managed learning teams that has created a fertile area for medical education scholarship. However, because this method can be implemented in a variety of ways, published reports about TBL may be difficult to understand, critique, replicate, or compare unless authors fully describe their interventions.The authors of this article offer a conceptual model and propose a set of guidelines for standardizing the way that the results of TBL implementations are reported and critiqued. They identify and articulate the seven core design elements that underlie the TBL method and relate them to educational principles that maximize student engagement and learning within teams. The guidelines underscore important principles relevant to many forms of small-group learning. The authors suggest that following these guidelines when writing articles about TBL implementations should help standardize descriptive information in the medical and health sciences education literature about the essential aspects of TBL activities and allow authors and reviewers to successfully replicate TBL implementations and draw meaningful conclusions about observed outcomes.

The impact of a program in mindful communication on primary care physicians.

Abstract: Purpose In addition to structural transformations, deeper changes are needed to enhance physicians' sense of meaning and satisfaction with their work and their ability to respond creatively to a dynamically changing practice environment. The purpose of this research was to understand what aspects of a successful continuing education program in mindful communication contributed to physicians' well-being and the care they provide. Method In 2008, the authors conducted in-depth, semistructured interviews with primary care physicians who had recently completed a 52-hour mindful communication program demonstrated to reduce psychological distress and burnout while improving empathy. Interviews with a random sample of 20 of the 46 physicians in the Rochester, New York, area who attended at least four of eight weekly sessions and four of eight monthly sessions were audio-recorded, transcribed, and analyzed qualitatively. The authors identified salient themes from the interviews. Results Participants reported three main themes: (1) sharing personal experiences from medical practice with colleagues reduced professional isolation, (2) mindfulness skills improved the participants' ability to be attentive and listen deeply to patients' concerns, respond to patients more effectively, and develop adaptive reserve, and (3) developing greater self-awareness was positive and transformative, yet participants struggled to give themselves permission to attend to their own personal growth. Conclusions Interventions to improve the quality of primary care practice and practitioner well-being should promote a sense of community, specific mindfulness skills, and permission and time devoted to personal growth.

ResearchMatch: A National Registry to Recruit Volunteers for Clinical Research

Abstract: The authors designed ResearchMatch, a disease-neutral, Web-based recruitment registry to help match individuals who wish to participate in clinical research studies with researchers actively searching for volunteers throughout the United States. In this article, they describe ResearchMatch's stakeholders, workflow model, technical infrastructure, and, for the registry's first 19 months of operation, utilization metrics. Having launched volunteer registration tools in November 2009 and researcher registration tools in March 2010, ResearchMatch had, as of June 2011, registered 15,871 volunteer participants from all 50 states. The registry was created as a collaborative project for institutions in the Clinical and Translational Science Awards (CTSA) consortium. Also as of June 2011, a total of 751 researchers from 61 participating CTSA institutions had registered to use the tool to recruit participants into 540 active studies and trials. ResearchMatch has proven successful in connecting volunteers with researchers, and the authors are currently evaluating regulatory and workflow options to open access to researchers at non-CTSA institutions.

Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representative U.S. medical schools.

Abstract: PurposeVital, productive faculty are critical to academic medicine, yet studies indicate high dissatisfaction and attrition. The authors sought to identify key personal and cultural factors associated with intentions to leave one’s institution and/or academic medicine.MethodFrom 2007 through early 2

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements

Abstract: With changes in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements related to transitions in care effective July 1, 2011, sponsoring institutions and training programs must develop a common structure for transitions in care as well as comprehensive curricula to teach and evaluate patient handoffs. In response to these changes, within the Duke University Health System, the resident-led Graduate Medical Education Patient Safety and Quality Council performed a focused review of the handoffs literature and developed a plan for comprehensive handoff education and evaluation for residents and fellows at Duke. The authors present the results of their focused review, concentrating on the three areas of new ACGME expectations--structure, education, and evaluation--and describe how their findings informed the broader initiative to comprehensively address transitions in care managed by residents and fellows. The process of developing both institution-level and program-level initiatives is reviewed, including the development of an interdisciplinary minimal data set for handoff core content, training and education programs, and an evaluation strategy. The authors believe the final plan fully addresses both Duke's internal goals and the revised ACGME Common Program Requirements and may serve as a model for other institutions to comprehensively address transitions in care and to incorporate resident and fellow leadership into a broad, health-system-level quality improvement initiative.

Educational outcomes of the Harvard Medical School-Cambridge integrated clerkship: a way forward for medical education.

Abstract: The authors report data from the Harvard Medical School-Cambridge Integrated Clerkship (CIC), a model of medical education in which students' entire third year consists of a longitudinal, integrated curriculum. The authors compare the knowledge, skills, and attitudes of students completing the CIC with those of students completing traditional third-year clerkships.

A systematic review: The effect of clinical supervision on patient and residency education outcomes

Abstract: PurposeTo summarize the literature regarding the effect of clinical supervision on patient and educational outcomes, especially in light of the recent (2010) Accreditation Council for Graduate Medical Education report that recommends augmented supervision to improve resident education and patient sa

Perspective: A Culture of Respect, Part 2 Creating a Culture of Respect

Abstract: Creating a culture of respect is the essential first step in a health care organization’s journey to becoming a safe, high-reliability organization that provides a supportive and nurturing environment and a workplace that enables staff to engage wholeheartedly in their work. A culture of respect requires that the institution develop effective methods for responding to episodes of disrespectful behavior while also initiating the cultural changes needed to prevent such episodes from occurring. Both responding to and preventing disrespect are major challenges for the organization’s leader, who must create the preconditions for change, lead in establishing and enforcing policies, enable frontline worker engagement, and facilitate the creation of a safe learning environment. When disrespectful behavior occurs, it must be addressed consistently and transparently. Central to an effective response is a code of conduct that establishes unequivocally the expectation that everyone is entitled to be treated with courtesy, honesty, respect, and dignity. The code must be enforced fairly through a clear and explicit process and applied consistently regardless of rank or station. Creating a culture of respect requires action on many fronts: modeling respectful conduct; educating students, physicians, and nonphysicians on appropriate behavior; conducting performance evaluations to identify those in need of help; providing counseling and training when needed; and supporting frontline changes that increase the sense of fairness, transparency, collaboration, and individual responsibility.

Aligning the Goals of Community-Engaged Research: Why and How Academic Health Centers Can Successfully Engage With Communities to Improve Health

Abstract: Community engagement (CE) and community-engaged research (CEnR) are increasingly viewed as the keystone to translational medicine and improving the health of the nation. In this article, the authors seek to assist academic health centers (AHCs) in learning how to better engage with their communities and build a CEnR agenda by suggesting five steps: defining community and identifying partners, learning the etiquette of CE, building a sustainable network of CEnR researchers, recognizing that CEnR will require the development of new methodologies, and improving translation and dissemination plans. Health disparities that lead to uneven access to and quality of care as well as high costs will persist without a CEnR agenda that finds answers to both medical and public health questions. One of the biggest barriers toward a national CEnR agenda, however, are the historical structures and processes of an AHC-including the complexities of how institutional review boards operate, accounting practices and indirect funding policies, and tenure and promotion paths. Changing institutional culture starts with the leadership and commitment of top decision makers in an institution. By aligning the motivations and goals of their researchers, clinicians, and community members into a vision of a healthier population, AHC leadership will not just improve their own institutions but also improve the health of the nation-starting with improving the health of their local communities, one community at a time.

Does stereotype threat affect women in academic medicine

Abstract: In a classic social psychology experiment, male and female undergraduates at a top university, all of whom saw themselves as strong math students, took a test made up of difficult questions from the math section of the Graduate Record Examinations. Half of these students were told that the questions showed gender differences; the other half were told that the questions showed no gender differences. Remarkably, female students performed worse than their male counterparts when the test was described as showing gender differences but performed equally well when the test was described as showing no gender differences.1 This and related studies illustrate the phenomenon now known as stereotype threat, in which individuals who are members of a group characterized by negative stereotypes in a particular domain perform below their actual abilities in that domain when group membership is made salient.2-4 Over 300 experiments have now shown that stereotype threat leads to stress,5 negative mood (i.e. anxiety, frustration, disappointment, and sadness),6,7 increased monitoring of one’s behavior, greater emotional regulation, a reduction in mental capacity, and a decrease in motivation--all of which impair performance.8,9 In other words, under the threat of confirming a group stereotype, talented and competent individuals may become “deskilled” and perform below their abilities.3,4 In addition, stereotype threat may decrease individual motivation and engagement in a particular domain. For example, in one experiment, women under stereotype threat had lower leadership aspirations than women who did not experience that threat.10 Individuals may be conscious of stress and anxiety under these circumstances but often are not aware of its etiology, so are likely to attribute their anxiety to their own deficits rather than to the situation.11 A large achievement gap exists between men and women at the highest levels of leadership in academic medicine.12,13 As recently as 2009, only 19% of full professors, 13% of department chairs, and 13% of deans were women.14 In this article, we consider the contribution of stereotype threat to this achievement gap and suggest strategies for closing it.

The role of emotion in the learning and transfer of clinical skills and knowledge.

Abstract: Purpose Medical school and residency are emotional experiences for trainees. Most research examining emotion in medicine has focused on negative moods associated with physician burnout and poor quality of life. However, positive emotional states also may have important influences on student learning and performance. The authors present a review of the literature on the influence of emotion on cognition, specifically how individuals learn complex skills and knowledge and how they transfer that information to new scenarios. Method From September 2011 to February 2012, the authors searched Medline, PsycInfo, GoogleScholar, ERIC, and Web of Science, as well as the reference lists of relevant articles, for research on the interaction between emotion, learning, and knowledge transfer. They extracted representative themes and noted particularly relevant empirical findings. Results The authors found articles that show that emotion influences various cognitive processes that are involved in the acquisition and transfer of knowledge and skills. More specifically, emotion influences how individuals identify and perceive information, how they interpret it, and how they act on the information available in learning and practice situations. Conclusions There are many ways in which emotions may influence medical education. Researchers must further explore the implications of these findings to ensure that learning is not treated simply as a rational, mechanistic process but that trainees are effectively prepared to perform under a wide range of emotional conditions.

Have motivation theories guided the development and reform of medical education curricula? A review of the literature.

Abstract: PurposeEducational psychology indicates that learning processes can be mapped on three dimensions: cognitive (what to learn), affective or motivational (why learn), and metacognitive regulation (how to learn). In a truly student-centered medical curriculum, all three dimensions should guide curricul

The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine.

Abstract: To address physician depression and suicide at one U.S. medical school, a faculty committee launched a Suicide Prevention and Depression Awareness Program in 2009 whose focus is medical students’, residents’, and faculty physicians’ mental health. The program consists of a two-pronged approach: (1) screening, assessment, and referral and (2) education. The screening process is anonymous, confidential, and Web based, using customized software created by the American Foundation for Suicide Prevention. The educational component consists of a medical-schoolwide campaign including Grand Rounds on physician burnout, depression, and suicide as well as similar sessions geared toward trainees. The authors document the process of developing and implementing the program, including the program’s origins and goals, their critical decision-making processes, and successes and challenges of the program’s first year. Of the 2,860 medical students, housestaff, and faculty who received the e-mail invitation in the first year, 374 individuals (13%) completed screens, 101/374 (27%) met criteria for significant risk for depression or suicide, and 48/374 (13%) received referrals for mental health evaluation and treatment. The program provided 29 Grand Rounds and other presentations during the first year. This may be the first program that aims to increase awareness of depression and to destigmatize help-seeking in order to prevent suicide and whose target population includes the full panoply of medical school constituents: students, residents, and faculty physicians. The program was well received in its first year, and while demonstrating the prevention of suicides is difficult, the authors are encouraged by the program’s results thus far.

Contemporary performance of U.S. teaching and nonteaching hospitals.

Abstract: PurposeTo compare the performance of U.S. teaching and nonteaching hospitals using a portfolio of contemporary, publicly reported metrics.MethodThe authors classified acute care general hospitals filing a Medicare Institutional Cost Report according to teaching intensity: nonteaching, teaching, or C

Eradicating Medical Student Mistreatment: A Longitudinal Study of One Institution’s Efforts

Abstract: Purpose Since 1995, the David Geffen School of Medicine at UCLA (DGSOM) has created policies to prevent medical student mistreatment, instituted safe mechanisms for reporting mistreatment, provided resources for discussion and resolution, and educated faculty and residents. In this study, the authors examined the incidence, severity, and sources of perceived mistreatment over the 13-year period during which these measures were implemented. Method From 1996 to 2008, medical students at DGSOM completed an anonymous survey after their third-year clerkships and reported how often they experienced physical, verbal, sexual harassment, ethnic, and power mistreatment, and who committed it. The authors analyzed these data using descriptive statistics and the students’ descriptions of these incidents qualitatively, categorizing them as “mild,” “moderate,” or “severe.” They compared the data across four periods, delineated by milestone institutional measures to eradicate mistreatment. Results

Perspective: Transforming Science Into Medicine: How Clinician-Scientists Can Build Bridges Across Research's "Valley of Death"

Abstract: Significant increases in National Institutes of Health (NIH) spending on medical research have not produced corresponding increases in new treatments and cures. Instead, laboratory discoveries remain in what has been termed the “valley of death,” the gap between bench research and clinical application. Recently, there has been considerable discussion in the literature and scientific community about the causes of this phenomenon and how to bridge the abyss. In this article, the authors examine one possible explanation: Clinician–scientists’ declining role in the medical research enterprise has had a dilatory effect on the successful translation of laboratory breakthroughs into new clinical applications. In recent decades, the percentage of MDs receiving NIH funding has drastically decreased compared with PhDs. The growing gap between the research and clinical enterprises has resulted in fewer scientists with a true understanding of clinical problems as well as scientists who are unable to or uninterested in gleaning new basic research hypotheses from failed clinical trials. The NIH and many U.S. medical schools have recognized the decline of the clinician–scientist as a major problem and adopted innovative programs to reverse the trend. However, more radical action may be required, including major changes to the NIH peer-review process, greater funding for translational research, and significantly more resources for the training, debt relief, and early career support of potential clinician–scientists. Such improvements are required for clinician–scientists to conduct translational research that bridges the valley of death and transforms biomedical research discoveries into tangible clinical treatments and technologies. In this age of ever-expanding scientific discoveries and unprecedented U.S. government funding of public research, the dramatic drop in the number of new drugs and treatments being introduced for patient use should be cause for concern. The National Institutes of Health (NIH), one of the main drivers of biomedical research in the United States, invested approximately $31 billion in medical research in 2010, roughly four times the amount spent just 20 years

Conflicting messages: examining the dynamics of leadership on interprofessional teams.

Abstract: Purpose Despite the importance of leadership in interprofessional health care teams, little is understood about how it is enacted. The literature emphasizes a collaborative approach of shared leadership, but this may be challenging for clinicians working within the traditionally hierarchical health care system. Method Using case study methodology, the authors collected observation and interview data from five interprofessional health care teams working at teaching hospitals in urban Ontario, Canada. They interviewed 46 health care providers and conducted 139 hours of observation from January 2008 through June 2009. Results Although the members of the interprofessional teams agreed about the importance of collaborative leadership and discussed ways in which their teams tried to achieve it, evidence indicated that the actual enactment of collaborative leadership was a challenge. The participating physicians indicated a belief that their teams functioned nonhierarchically, but reports from the nonphysician clinicians and the authors' observation data revealed that hierarchical behaviors persisted, even from those who most vehemently denied the presence of hierarchies on their teams. Conclusions A collaborative approach to leadership may be challenging for interprofessional teams embedded in traditional health care, education, and medical-legal systems that reinforce the idea that physicians sit at the top of the hierarchy. By openly recognizing and discussing the tensions between traditional and interprofessional discourses of collaborative leadership, it may be possible to help interprofessional teams, physicians and clinicians alike, work together more effectively.

A multi-institutional study exploring the impact of positive mental health on medical students' professionalism in an era of high burnout.

Abstract: PurposeAlthough burnout is associated with erosion of professionalism and serious personal consequences, whether positive mental health can enhance professionalism and how it shapes personal experience remain poorly understood. The study simultaneously explores the relationship between positive ment

Theory and practice in the design and conduct of graduate medical education.

Abstract: Medical education practice is more often the result of tradition, ritual, culture, and history than of any easily expressed theoretical or conceptual framework. The authors explain the importance and nature of the role of theory in the design and conduct of graduate medical education. They outline three groups of theories relevant to graduate medical education: bioscience theories, learning theories, and sociocultural theories. Bioscience theories are familiar to many medical educators but are often misperceived as truths rather than theories. Theories from such disciplines as neuroscience, kinesiology, and cognitive psychology offer insights into areas such as memory formation, motor skills acquisition, diagnostic decision making, and instructional design. Learning theories, primarily emerging from psychology and education, are also popular within medical education. Although widely employed, not all learning theories have robust evidence bases. Nonetheless, many important notions within medical education are derived from learning theories, including self-monitoring, legitimate peripheral participation, and simulation design enabling sustained deliberate practice. Sociocultural theories, which are common in the wider education literature but have been largely overlooked within medical education, are inherently concerned with contexts and systems and provide lenses that selectively highlight different aspects of medical education. They challenge educators to reconceptualize the goals of medical education, to illuminate maladaptive processes, and to untangle problems such as career choice, interprofessional communication, and the hidden curriculum.Theories make visible existing problems and enable educators to ask new and important questions. The authors encourage medical educators to gain greater understanding of theories that guide their educational practices.

The Relationship Between Response Time and Diagnostic Accuracy

Abstract: Purpose Psychologists theorize that cognitive reasoning involves two distinct processes: System 1, which is rapid, unconscious, and contextual, and System 2, which is slow, logical, and rational. According to the literature, diagnostic errors arise primarily from System 1 reasoning, and therefore they are associated with rapid diagnosis. This study tested whether accuracy is associated with shorter or longer times to diagnosis. Method Immediately after the 2010 administration of the Medical Council of Canada Qualifying Examination (MCCQE) Part II at three test centers, the authors recruited participants, who read and diagnosed a series of 25 written cases of varying difficulty. The authors computed accuracy and response time (RT) for each case. Results Seventy-five Canadian medical graduates (of 95 potential participants) participated. The overall correlation between RT and accuracy was −0.54; accuracy, then, was strongly associated with more rapid RT. This negative relationship with RT held for 23 of 25 cases individually and overall when the authors controlled for participants’ knowledge, as judged by their MCCQE Part I and II scores. For 19 of 25 cases, accuracy on each case was positively related to experience with that specific diagnosis. A participant’s performance on the test overall was significantly correlated with his or her performance on both the MCCQE Part I and II. Conclusions These results are inconsistent with clinical reasoning models that presume that System 1 reasoning is necessarily more error prone than System 2. These results suggest instead that rapid diagnosis is accurate and relates to other measures of competence.

At the membranes of care: stories in narrative medicine.

Abstract: Recognizing clinical medicine as a narrative undertaking fortified by learnable skills in understanding stories has helped doctors and teachers to face otherwise vexing problems in medical practice and education in the areas of professionalism, medical interviewing, reflective practice, patient-centered care, and self-awareness. The emerging practices of narrative medicine give clinicians fresh methods with which to make contact with patients and to come to understand their points of view. This essay provides a brief review of narrative theory regarding the structure of stories, suggesting that clinical texts contain and can reveal information in excess of their plots. Through close reading of the form and content of two clinical texts-an excerpt from a medical chart and a portion of an audiotaped interview with a medical student-and a reflection on a short section of a modernist novel, the author suggests ways to expand conventional medical routines of recognizing the meanings of patients' situations. The contributions of close reading and reflective writing to clinical practice may occur by increasing the capacities to perceive and then to represent the perceived, thereby making available to a writer that which otherwise might remain out of awareness. A clinical case is given to exemplify the consequences in practice of adopting the methods of narrative medicine. A metaphor of the activated cellular membrane is proposed as a figure for the effective clinician/patient contact.

The effects of patient handoff characteristics on subsequent care: a systematic review and areas for future research.

Abstract: Purpose To summarize the available evidence about patient handoff characteristics and their impact on subsequent patient care in hospitals. Method In January and February 2011, the authors searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, CINAHL, PsycINFO, ERIC, ISI Web of Science, and the reference lists of relevant articles to carry out their systematic review. They selected articles that (1) had patient handoffs in hospitals as their explicit research focus and (2) reported at least one statistical test of an association between a handoff characteristic and outcome. They assessed study quality using 11 quality indicators. Results The authors identified 18 articles reporting 37 statistical associations between a handoff characteristic and outcome. The only handoff characteristic investigated in more than one study was the use of a standardized handoff sheet. Seven of those 12 studies reported significant improvements after introduction of the sheet. Four of the 18 studies used a randomized controlled trial design. Conclusions Published research is highly diverse and idiosyncratic regarding the handoff characteristics and outcomes assessed and the methodologies used, so comparing studies and drawing general conclusions about the field are difficult endeavors. The quality of research on the topic is rather preliminary, and there is not yet enough research to inform evidence-based handoff strategies. Future research, then, should focus on research methods, which outcomes should be assessed, handoff characteristics beyond information transfer, mechanisms that link handoff characteristics and outcomes, and the conditions that moderate the characteristics' effects.

Reflection in/and writing: pedagogy and practice in medical education.

Abstract: During the past decade, "reflection" and "reflective writing" have become familiar terms and practices in medical education. The authors of this article argue that the use of the terms requires more thoughtfulness and precision, particularly because medical educators ask students to do so much reflection and reflective writing. First, the authors discuss John Dewey's thoughts on the elements of reflection. Then the authors turn the discussion to composition studies in an effort to form a more robust conception of reflective writing. In particular, they examine what the discipline of composition studies refers to as the writing process. Next, they offer two approaches to teaching composition: the expressivist orientation and the critical/cultural studies orientation. The authors examine the vigorous debate over how to respond to reflective writing, and, finally, they offer a set of recommendations for incorporating reflection and reflective writing into the medical curriculum.

Perspective: Medical education in medical ethics and humanities as the foundation for developing medical professionalism.

Abstract: Medical education accreditation organizations require medical ethics and humanities education to develop professionalism in medical learners, yet there has never been a comprehensive critical appraisal of medical education in ethics and humanities. The Project to Rebalance and Integrate Medical Education (PRIME) I Workshop, convened in May 2010, undertook the first critical appraisal of the definitions, goals, and objectives of medical ethics and humanities teaching. The authors describe assembling a national expert panel of educators representing the disciplines of ethics, history, literature, and the visual arts. This panel was tasked with describing the major pedagogical goals of art, ethics, history, and literature in medical education, how these disciplines should be integrated with one another in medical education, and how they could be best integrated into undergraduate and graduate medical education. The authors present the recommendations resulting from the PRIME I discussion, centered on three main themes. The major goal of medical education in ethics and humanities is to promote humanistic skills and professional conduct in physicians. Patient-centered skills enable learners to become medical professionals, whereas critical thinking skills assist learners to critically appraise the concept and implementation of medical professionalism. Implementation of a comprehensive medical ethics and humanities curriculum in medical school and residency requires clear direction and academic support and should be based on clear goals and objectives that can be reliably assessed. The PRIME expert panel concurred that medical ethics and humanities education is essential for professional development in medicine.