The OEA Faculty Medical Education Journal Club hosts online exchanges that reference articles on medical education relevant to faculty teaching responsibilities. Summaries appear below.
*TUSM Faculty Educational Awards
2017 CDIM Louis N. Pangaro, MD, Educational Program Development Award:
v Joseph Rencic, MD, Associate Professor, Department of Medicine, Tufts Medical Center
v Robert Trowbridge, MD, FACP, Associate Professor, Department of Medicine, Maine Medical Center
*TUSM Faculty Educational Scholarship Publications
Bing-You R, Hayes V, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Feedback for Learners in Medical Education: What Is Known? A Scoping Review. Acad Med. 2017.
Bing-You R, Linder J, White P, Neumeyer D. Twelve Tips on Implementing Multiple Mini-Interviews in a Hybrid Admissions Model. MedEdPublish, 2016;5(3):78.
Bing-You R and Varaklis K. Organizing Graduate Medical Education Programs into Communities of Practice. Med Educ Online. 2016;21(1):31864.
Shaughnessy AF, Allen L, Duggan A. Attention Without Intention: Explicit Processing and Implicit Goal-setting in Family Medicine Residents' Written Reflections. Educ Prim Care. 2017.
*What is new in the Lit?!
Keister DM, Hansen SE, Dostal J. Teaching Resident Self-Assessment Through Triangulation of Faculty and Patient Feedback, Teaching and Learning in Medicine. 2017;29(1):25-30.
To accurately determine one’s ability in any clinical competency, an individual must be able to self-assess performance and identify personal limitations. Existing research demonstrates that physicians of all levels are unreliable self-assessors. This poses a concern in medical practice, which requires continuous updates to clinical competencies and awareness of personal limitations. Few published studies examine graduate medical education curricula designed to develop self-assessment skills. Conceptual models, such as self-determination theory, suggest that self-assessment is most effectively learned through reflective processes. The Family Medicine Residency Program at Lehigh Valley Health Network developed a learner-centered competency assessment process that integrates advising and performance review. The multisource, observable behavior-based process encourages conversation between resident and advisor. Utilizing feedback from clinical preceptors and patient surveys, advisors guide residents in determining individual learning needs in core competency areas, including relationship-centered care. Development of medical learners’ capacity to form relationships is one means to improving the patient experience. The authors in this retrospective case study evaluated the accuracy of senior residents’ self-assessment in relationship-centered care compared with that of junior residents. The study population included the 34 residents enrolled from AY 2009–2012. Data sets represented specific 6-month periods and have 3 component scores—Self, Faculty, and Patient—which were triangulated to determine concordance rates by postgraduate year level. The concordance rate among first-years was 26.7%, whereas third-years saw 60.0% concordance. A discordance analysis found the Patient score most often deviated from the other 2 scores, whereas the Faculty score was never the sole dissenter. When all 3 scores differed, the Self score frequently fell between the other 2 scores. The principles of self-determination theory provide a valuable framework for understanding the development of residents’ intrinsic motivation to become lifelong learners. The trend in improved concordance rates among senior residents suggests that prompting learners to triangulate feedback from multiple sources can lead to a shift in perspective about competency. Further studies are needed to determine whether our results are generalizable to other competencies and educational settings.
Krupat E, Pelletier SR, Dienstag JL. Academic Performance on First-Year Medical School Exams: How Well Does It Predict Later Performance on Knowledge-Based and Clinical Assessments?. Teaching and Learning in Medicine. 2017.
Medical educators have long expressed a desire to have indicators of medical student performance that have strong predictive validity. Predictors traditionally used fell into 4 general categories: demographic (e.g., gender), other background factors (e.g., college major), performance/aptitude (e.g., medical college admission test scores), and noncognitive factors (e.g., curiosity). These factors, however, have an inconsistent record of predicting student performance. In comparison to traditional predictive factors, the authors sought to determine the extent to which academic performance in the 1st-year of medical school, as measured by examination performance in the bottom quartile of the class in 7 required courses, predicted later performance on a variety of assessments, both knowledge based (e.g., United States Medical Licensing Examination Step 1 and Step IICK) and clinical skills based (e.g., clerkship grades and objective structured clinical exam performance). Of all predictors measured, number of appearances in the bottom quartile in Year 1 was the most strongly related to performance in knowledge-based assessments, as well as clinically related outcomes, and, for each outcome, bottom-quartile performance accounted for additional variance beyond that of the traditional predictors. Low academic performance in the 1st year of medical school is a meaningful risk factor with both predictive validity and predictive utility for low performance later in medical school. The question remains as to how we can incorporate this indicator into a system of formative assessment that effectively addresses the challenges of medical students once they have been identified.
Ramani S, Post SE, Könings K, Mann K, Katz JT, van der Vleuten C. “It's Just Not the Culture”: A Qualitative Study Exploring Residents' Perceptions of the Impact of Institutional Culture on Feedback. Teaching and Learning in Medicine. 2016.
Competency-based medical education requires ongoing performance-based feedback for professional growth. In several studies, medical trainees report that the quality of faculty feedback is inadequate. Sociocultural barriers to feedback exchanges are further amplified in graduate and postgraduate medical education settings, where trainees serve as frontline providers of patient care. Factors that affect institutional feedback culture, enhance feedback seeking, acceptance, and bidirectional feedback warrant further exploration in these settings. Using a constructivist grounded theory approach, the authors of this study sought to examine residents' perspectives on institutional factors that affect the quality of feedback, factors that influence receptivity to feedback, and quality and impact of faculty feedback. Four focus group discussions were conducted, with two investigators present at each. The authors performed a thematic analysis and identified five key themes, dominated by resident perceptions regarding the influence of institutional feedback culture. The theme labels are taken from direct participant quotes: (a) the cultural norm lacks clear expectations and messages around feedback, (b) the prevailing culture of niceness does not facilitate honest feedback, (c) bidirectional feedback is not part of the culture, (d) faculty-resident relationships impact credibility and receptivity to feedback, and (e) there is a need to establish a culture of longitudinal professional growth. Institutional culture could play a key role in influencing the quality, credibility, and acceptability of feedback. A polite culture promotes a positive learning environment but can be a barrier to honest feedback. Feedback initiatives focusing solely on techniques of feedback giving may not enhance meaningful feedback. Further research on factors that promote feedback seeking, receptivity to constructive feedback, and bidirectional feedback would provide valuable insights.
TEACHING AND LEARNING
Azzam A, Bresler D, Leon A, Maggio L, Whitaker E, Heilman J, Orlowitz J, Swisher V, Rasberry L, Otoide K, Trotter F, Ross W, McCue JD. Why Medical Schools Should Embrace Wikipedia: Final-Year Medical Student Contributions to Wikipedia Articles for Academic Credit at One School. Acad Med. 2017;92(2):194-200.
Most medical students use Wikipedia as an information source, yet medical schools do not train students to improve Wikipedia or use it critically. Between November 2013 and November 2015, the authors of this study offered fourth-year medical students a credit-bearing course to edit Wikipedia. The course was designed, delivered, and evaluated by faculty, medical librarians, and personnel from WikiProject Medicine, Wikipedia Education Foundation, and Translators Without Borders. The authors assessed the effect of the students' edits on Wikipedia's content, the effect of the course on student participants, and readership of students' chosen articles. Forty-three enrolled students made 1,528 edits (average 36/student), contributing 493,994 content bytes (average 11,488/student). They added higher-quality and removed lower-quality sources for a net addition of 274 references (average 6/student). As of July 2016, none of the contributions of the first 28 students (2013, 2014) have been reversed or vandalized. Students discovered a tension between comprehensiveness and readability/translatability, yet readability of most articles increased. Students felt they improved their articles, enjoyed giving back "specifically to Wikipedia," and broadened their sense of physician responsibilities in the socially networked information era. During only the "active editing months," Wikipedia traffic statistics indicate that the 43 articles were collectively viewed 1,116,065 times. Subsequent to students' efforts, these articles have been viewed nearly 22 million times. If other schools replicate and improve on this initiative, future multi-institution studies could more accurately measure the effect of medical students on Wikipedia, and vice versa.
Budden CR, Svechnikova K, White J. Why do surgeons teach? A qualitative analysis of motivation in excellent surgical educators. Medical Teacher. 2017;39(2):188-194.
Given that teaching is so vital to the maintenance of the medical profession, it is surprising that few authors have examined the factors that motivate physicians and surgeons to engage in this activity. The aim of this study was to examine the factors which motivate excellent surgical educators to teach. Grounded theory methodology was used to analyze transcribed semi-structured interviews. The top 20 ranked surgical educators at the University of Alberta were invited to participate. In total, 15 surgeons of various specialties were interviewed. There were five main factors that motivate surgeons to teach. These were: (1) a sense of responsibility to teach future physicians (2) an intrinsic enjoyment of teaching (3) the need to maintain and expand one’s own knowledge base (4) watching students develop into competent practicing physicians and playing a role in their success, and (5) fostering positive lifelong professional relationships with learners.
Kulasegaram KM, Chaudhary Z, Woods N, Dore K, Neville A, Norman G. Contexts, concepts and cognition: principles for the transfer of basic science knowledge. Med Educ. 2017;51(2):184-195.
Transfer of basic science aids novices in the development of clinical reasoning. The literature suggests that although transfer is often difficult for novices, it can be optimised by two complementary strategies: (i) focusing learners on conceptual knowledge of basic science or (ii) exposing learners to multiple contexts in which the basic science concepts may apply. The relative efficacy of each strategy as well as the mechanisms that facilitate transfer are unknown. In two sequential experiments, the authors compared both strategies and explored mechanistic changes in how learners address new transfer problems. Experiment 1 was a 2 × 3 design in which participants were randomised to learn three physiology concepts with or without emphasis on the conceptual structure of basic science via illustrative analogies and by means of one, two or three contexts during practice (operationalised as organ systems). Transfer of these concepts to explain pathologies in familiar organ systems (near transfer) and unfamiliar organ systems (far transfer) was evaluated during immediate and delayed testing. Experiment 2 examined whether exposure to conceptual analogies and multiple contexts changed how learners classified new problems. Experiment 1 showed that increasing context variation significantly improved far transfer performance but there was no difference between two and three contexts during practice. Similarly, the increased conceptual analogies led to higher performance for far transfer. Both interventions had independent but additive effects on overall performance. Experiment 2 showed that such analogies and context variation caused learners to shift to using structural characteristics to classify new problems even when there was superficial similarity to previous examples. Understanding problems based on conceptual structural characteristics is necessary for successful transfer. Transfer of basic science can be optimised by using multiple strategies that collectively emphasise conceptual structure. This means teaching must focus on conserved basic science knowledge and de-emphasise superficial features.
Lo L and Regehr G. Medical Students' Understanding of Directed Questioning by Their Clinical Preceptors. Teaching and Learning in Medicine. 2017;29(1):5-12.
Throughout clerkship, preceptors ask medical students questions for both assessment and teaching purposes. However, the cognitive and strategic aspects of students’ approaches to managing this situation have not been explored. Without an understanding of how students approach the question and answer activity, medical educators are unable to appreciate how effectively this activity fulfills their purposes of assessment or determine the activity’s associated educational effects. The authors used a convenience sample of nine 4th-year medical students who participated in semi-structured one-on-one interviews intended to explore student’s approaches to managing situations in which they have been challenged with questions from preceptors to which they do not know the answer. Through an iterative and recursive analytic reading of the interview transcripts themes relevant to the students’ considerations in answering such questions were identified. Students articulated deliberate strategies for managing the directed questioning activity, which at times focused on the optimization of their learning but always included considerations of image management. Managing image involved projecting not only being knowledgeable but also being teachable. The students indicated that their considerations in selecting an appropriate strategy in a given situation involved their perceptions of their preceptors’ intentions and preferences as well as several contextual factors. The medical students the authors interviewed were quite sophisticated in their understanding of the social nuances of the directed questioning process and described a variety of contextually invoked strategies to manage the situation and maintain a positive image.
Ramnanan CJ, Pound LD. Advances in medical education and practice: student perceptions of the flipped classroom. Adv Med Educ Pract. 2017;8:63–73.
The flipped classroom (FC) approach to teaching has been increasingly employed in undergraduate medical education in recent years. In FC applications, students are first exposed to content via online resources. Subsequent face-to-face class time can then be devoted to student-centered activities that promote active learning. Although the FC has been well received by students in other contexts, the perceptions of medical students regarding this innovation are unclear. This review serves as an early exploration into medical student perceptions of benefits and limitations of the FC. Medical students have generally expressed strong appreciation for the pre-class preparation activities (especially when facilitated by concise, readily accessed online tools) as well as for interactive, engaging small group classroom activities. Some students have expressed concerns with the FC and noted that suboptimal student preparation and insufficient direction and structure during active learning sessions may limit the student-centered benefits. Although students generally perceive that FC approaches can improve their learning and knowledge, this has not been conclusively shown via performances on assessment tools, which may be related to caveats with the assessment tools used. In any case, lifelong self-directed learning skills are perceived by medical students to be enhanced by the FC. In conclusion, medical students have generally expressed strong satisfaction with early applications of the FC to undergraduate medical education, and generally prefer this method to lecture-based instruction.
Sheu L, Kogan JR, Hauer KE. How Supervisor Experience Influences Trust, Supervision, and Trainee Learning: A Qualitative Study. Acad Med. 2017.
Appropriate trust and supervision facilitate trainees' growth toward unsupervised practice. The authors investigated how supervisor experience influences trust, supervision, and subsequently trainee learning. In a two-phase qualitative inductive content analysis, phase one entailed reviewing 44 internal medicine resident and attending supervisor interviews from two institutions (July 2013 to September 2014) for themes on how supervisor experience influences trust and supervision. Three supervisor exemplars (early, developing, experienced) were developed and shared in phase two focus groups at a single institution, wherein 23 trainees validated the exemplars and discussed how each impacted learning (November 2015). Phase one: Four domains of trust and supervision varying with experience emerged: data, approach, perspective, clinical. Phase two: Trainees felt the exemplars reflected their experiences, described their preferences and learning needs shifting over time, and emphasized the importance of supervisor flexibility to match their learning needs. With experience, supervisors differ in their approach to trust and supervision. Supervisors need to trust themselves before being able to trust others. Trainees perceive these differences and seek supervision approaches that align with their learning needs.
PROFESSIONALISM & PROFESSIONAL INDENTITY
Burns CA, Lambros MA, Atkinson HH, Russell G, Fitch MT. Preclinical medical student observations associated with later professionalism concerns. Med Teach. 2017;39(1):38-43.
Professionalism is a core physician competency, and identifying students at risk for poor professional development early in their careers may allow for mentoring. This study identified indicators in the preclinical years associated with later professionalism concerns. A retrospective analysis of observable indicators in the preclinical and clinical years was conducted using two classes of students (n=226). Relationships between five potential indicators of poor professionalism in the preclinical years and observations related to professional concerns in the clinical years were analyzed. Fifty-three medical students were identified with at least one preclinical indicator and one professionalism concern during the clinical years. Two observable preclinical indicators were significantly correlated with unprofessional conduct during the clinical years: Three or more absences from attendance-required sessions (odds ratio 4.47; p=.006) and negative peer assessment (odds ratio 3.35; p=.049). The authors identified two significant observable preclinical indicators associated with later professionalism concerns: excessive absences and negative peer assessments. Early recognition of students at risk for future professionalism struggles would provide an opportunity for proactive professional development prior to the clinical years, when students’ permanent records may be affected. Peer assessment, coupled with attention to frequent absences, may be a method to provide early recognition.
Cope A, Bezemer J, Mavroveli S, Kneebone R. What Attitudes and Values Are Incorporated Into Self as Part of Professional Identity Construction When Becoming a Surgeon? Acad Med. 2016.
The purpose of this research was to make explicit the attitudes and values of a community of surgeons, with the aim of understanding professional identity construction within a specific group of residents. Using a grounded theory method, the authors collected data from 16 postgraduate surgeons through interviews. They complemented these initial interview data with ethnographic observations and additional descriptive interviews to explore the attitudes and values learned by surgeons during residency training (2010-2013). The participants were attending surgeons and residents in a general surgical training program in a university teaching hospital in the United Kingdom. Participating surgeons described learning personal values or attitudes that they regarded as core to "becoming a surgeon" and key to professional identity construction. They described learning to be a perfectionist, to be accountable, and to self-manage and be resilient. They discussed learning to be self-critical, sometimes with the unintended consequence of seeming neurotic. They described learning effective teamwork, as well as learning to take initiative and be innovative, which enabled them to demonstrate leadership and drive actions and agendas forward within the health care organization where they worked. To the authors' knowledge, this is the first study to systematically explore the learning of professional identity amongst postgraduate surgeons. The study contributes to the literature on professional identity construction within medical education. The authors conclude that the demise of the apprenticeship model and the rise of duty hours limitations may affect not only the acquisition of technical skills but, more important, the construction of surgeon professional identity.
WELL BEING & LEARNING ENVIROMENT
Dyrbye LN, Satele D, Shanafelt TD. Healthy Exercise Habits Are Associated With Lower Risk of Burnout and Higher Quality of Life Among U.S. Medical Students. Acad Med. 2016.
Although burnout and low quality of life (QOL) are common among medical students, little remains known about personal fitness habits of medical students that may promote well-being. In 2012 the authors conducted a cross-sectional study of U.S. medical students to explore relationships between burnout, QOL, and compliance with Centers for Disease Control and Prevention (CDC) exercise recommendations. Among approximately 12,500 medical students invited to participate, 4,402 (35.2%) completed surveys. Most (2,738/4,367; 62.7%) engaged in aerobic exercise in accordance with CDC recommendations, while fewer (1,685/4,376; 38.5%) adhered to muscle strengthening recommendations. Burnout prevalence was lower among students who exercised aerobically consistent with CDC recommendations compared with those who exercised less (53.1% vs. 60.8%, P < .0001). Similarly, rates of burnout were also lower among students who strength trained consistent with CDC recommendations (51.8% vs. 58.6%, P < .0001). Overall QOL scores were higher for medical students adhering to CDC recommendations for aerobic exercise (7.2 vs. 6.6, P < .0001), strength training (7.2 vs. 6.8, P < .0001), or both aerobic and strength training (8.0 vs. 7.0, P < .0001). Compliance with CDC exercise guidelines remained independently associated with lower risk of burnout and higher QOL on multivariate analysis controlling for age, sex, relationship status, children, and year in school. Students whose aerobic exercise and/or strength training habits are consistent with CDC guidelines appear less likely to experience burnout and to have higher QOL.
Lau JN, Mazer LM, Liebert CA, Merrell SB, Lin DT, Harris I. A Mixed-Methods Analysis of a Novel Mistreatment Program for the Surgery Core Clerkship. Acad Med. 2017.
The purpose of this study is to review mistreatment reports from before and after implementation of a mistreatment program, and student ratings of and qualitative responses to the program to evaluate the short-term impact on students. In January 2014, a video- and discussion-based mistreatment program was implemented for the surgery clerkship at the Stanford University School of Medicine. The program aims to help students establish expectations for the learning environment; create a shared and personal definition of mistreatment; and promote advocacy and empowerment to address mistreatment. Counts and types of mistreatment were compared from a year before (January-December 2013) and two years after (January 2014-December 2015) implementation. Students' end-of-clerkship ratings and responses to open-ended questions were analyzed. From March 2014-December 2015, 141/164 (86%) students completed ratings, and all 47 (100%) students enrolled from January-August 2014 provided qualitative program evaluations. Most students rated the initial (108/141 [77%]) and final (120/141 [85%]) sessions as excellent or outstanding. In the qualitative analysis, students valued that the program helped establish expectations; allowed for sharing experiences; provided formal resources; and provided a supportive environment. Students felt the learning environment and culture were improved and reported increased interest in surgery. There were 14 mistreatment reports the year before the program, 9 in the program's first year, and 4 in the second year. The authors found a rotation-specific mistreatment program, focused on creating shared understanding about mistreatment, was well received among surgery clerkship students, and the number of mistreatment reports decreased each year following implementation.
*What is new in the Lit?!
Kent F, Francis-Cracknell A, McDonald R, Newton JM, Keating JL, Dodic M. How do interprofessional student teams interact in a primary care clinic? A qualitative analysis using activity theory. Adv in Health Sci Educ. 2016;21(4):749-60. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1007/s10459-015-9663-4.
Practice-based interprofessional education opportunities are proposed as a mechanism for health professionals to learn teamwork skills and gain an understanding of the roles of others. Primary care is an area of practice that offers a promising option for interprofessional student learning. This study, investigated what and how students from differing professions learn together. The findings inform the design of future interprofessional education initiatives. Using activity theory, the authors conducted an ethnographic investigation of interprofessional education in primary care. During a 5 months period, they observed 14 clinic sessions involving mixed discipline student teams who interviewed people with chronic disease. Teams were comprised of senior medicine, nursing, occupational therapy, pharmacy and physiotherapy entry level students. Semi-structured interviews were also conducted with seven clinical educators. Data were analysed to ascertain the objectives, tools, rules and division of labour. Two integrated activity systems were identified: (1) student teams gathering information to determine patients' health care needs and (2) patients either as health consumers or student educators. Unwritten rules regarding 'shared contribution', 'patient as key information source' and 'time constraints' were identified. Both the significance of software literacy on team leadership, and a pre-determined structure of enquiry, highlighted the importance of careful consideration of the tools used in interprofessional education, and the way they can influence practice. The systems of practice identified provide evidence of differing priorities and values, and multiple perspectives of how to manage health. This work reinforced the value of the patients' voice in clinical and education processes.
Chahine S, Holmes B, Kowalewski Z. In the minds of OSCE examiners: uncovering hidden assumptions. Adv in Health Sci Educ. 2016;21(3):609-25. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1007/s10459-015-9655-4.
The Objective Structured Clinical Exam (OSCE) is a widely used method of assessment in medical education. Rater cognition has become an important area of inquiry in the medical education assessment literature generally, and in the OSCE literature specifically, because of concerns about potential compromises of validity. In this study, a novel approach to mixed methods that combined Ordinal Logistic Hierarchical Linear Modeling and cognitive interviews was used to gain insights about what examiners were thinking during an OSCE. This study is based on data from the 2010 to 2014 administrations of the Clinician Assessment for Practice Program OSCE for International Medical Graduates (IMGs) in Nova Scotia. The quantitative data were examined alongside four follow-up cognitive interviews of examiners conducted after the 2014 administration. The quantitative results show that competencies of (1) Investigation and Management and (2) Counseling were highly predictive of the Overall Global score. These competencies were also described in the cognitive interviews as the most salient parts of OSCE. Examiners also found Communication Skills and Professional Behavior to be relevant but the quantitative results revealed these to be less predictive of the Overall Global score. The interviews also reveal that there is a tacit sequence by which IMGs are expected to proceed in an OSCE, starting with more basic competencies such as History Taking and building up to Investigation Management and Counseling. The combined results confirm that a hidden pattern exists with respect to how examiners rate candidates. This study has potential implications for research into rater cognition, and the design and scoring of practice-ready OSCEs.
De Biasio JC, Parkas V, Soriano RP. Longitudinal assessment of medical student attitudes toward older people. Medical Teacher. 2016;38(8):823-828. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2015.1112891.
Delivering adequate care to older people requires an increasing number of physicians competent in the treatment of this expanding subpopulation. Attitudes toward older adults are important as predictors of the quality of care of older people and of medical trainee likelihood to enter the geriatrics field. This study assessed the attitudes of 404 US medical students (MS) from the start of medical school to graduation using the University of California, Los Angeles (UCLA) Geriatrics Attitude Scale. It is the first study to utilize a longitudinal design to assess attitudes among students in a medical school with a longitudinal geriatrics clinical experience in the first two years and a required geriatrics clerkship in the third year. Participants' attitude scores toward older people were found to significantly decrease from 3.9 during the first two years to 3.7 during the final two. Significant differences existed between MS1 and MS3, MS1 and MS4, MS2 and MS3, and MS2 and MS4. Women and older students held significantly more positive attitudes than men and younger students. These results show that planned clinical exposures to older adults may not be sufficient to halt the decline in attitudes in medical school. A comprehensive empathy-building intervention embedded in the curriculum may better prevent this decline.
Kinnear B, Bensman R, Held J, O'Toole J, Schauer D, Warm E. Critical Deficiency Ratings in Milestone Assessment: A Review and Case Study. Acad Med. 2016.
The Accreditation Council for Graduate Medical Education (ACGME) requires programs to report learner progress using specialty-specific milestones. It is unclear how milestones can best identify critical deficiencies (CDs) in trainee performance. Specialties developed milestones independently of one another; not every specialty included CDs within milestones ratings. This study examined the proportion of ACGME milestone sets that include CD ratings, and describes one residency program's experiences using CD ratings in assessment. The authors reviewed ACGME milestones for all 99 specialties in November 2015, determining which rating scales contained CDs. The authors also reviewed three years of data (July 2012-June 2015) from the University of Cincinnati Medical Center (UCMC) internal medicine residency assessment system based on observable practice activities mapped to ACGME milestones. Data were analyzed by postgraduate year, assessor type, rotation, academic year, and core competency. The Mantel-Haenszel chi-square test was used to test for changes over time. Specialties demonstrated heterogeneity in accounting for CDs in ACGME milestones. The authors identified CDs across multiple core competencies and rotations. Despite some specialties not accounting for CDs in milestone assessment, UCMC's experience demonstrates that a significant proportion of residents may be rated as having a CD during training. Identification of CDs may allow programs to develop remediation and improvement plans.
Watling C, LaDonna KA, Lingard L, Voyer S, Hatala R. ‘Sometimes the work just needs to be done’: socio-cultural influences on direct observation in medical training. Med Educ. 2016;50(10): 1054–1064. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1111/medu.13062.
Direct observation promises to strengthen both coaching and assessment, and calls for its increased use in medical training abound. Despite its apparent potential, the uptake of direct observation in medical training remains surprisingly limited outside the formal assessment setting. The limited uptake of observation raises questions about cultural barriers to its use. In this study, the authors explore the influence of professional culture on the use of direct observation within medical training. Using a constructivist grounded theory approach, the authors interviewed 22 residents or fellows (10 male, 12 female) about their experiences of being observed during training. Participants represented a range of specialties and training levels. Data collection and analysis were conducted iteratively. Themes were identified using constant comparative analysis. Observation was used selectively; specialties tended to observe the clinical acts that they valued most. Despite these differences, the authors found two cultural values that consistently challenged the ready implementation of direct observation across specialties: (i) autonomy in learning and (ii) efficiency in health care provision. Furthermore, they found that direct observation was a primarily learner-driven activity, which left learners caught in the middle, wanting observation but also wanting to appear independent and efficient. The cultural values of autonomy in learning and practice and efficiency in health care provision challenge the integration of direct observation into clinical training. Medical learners are often expected to ask for observation, but such requests are socially and culturally fraught, and likely to constrain the wider uptake of direct observation.
TEACHING AND LEARNING
Bonnes SL, Ratelle JT, Halvorsen AJ, Carter KJ, Hafdahl LT, Wang AT, Mandrekar JN, Oxentenko AS, Beckman TJ, Wittich CM. Flipping the Quality Improvement Classroom in Residency Education. Acad Med. 2016. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000001412.
The flipped classroom (FC), in which instructional content is delivered before class with class time devoted to knowledge application, has the potential to engage residents. A Mayo Clinic Internal Medicine Residency Program study was conducted to validate an FC perception instrument (FCPI); determine whether participation improved FC perceptions; and determine associations between resident characteristics, change in quality improvement (QI) knowledge, and FC perception scores. The study found that residents who participated in the FC demonstrated improved QI knowledge compared with the control group. Residents valued the in-class application sessions more than the online component. These findings have important implications for graduate medical education as residency training programs increasingly use FC models.
Cook DA and Artino AR. Motivation to learn: an overview of contemporary theories. Med Educ. 2016;50(10):997–1014. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1111/medu.13074.
The purpose of this paper is to succinctly summarise five contemporary theories about motivation to learn, articulate key intersections and distinctions among these theories, and identify important considerations for future research. Motivation has been defined as the process whereby goal-directed activities are initiated and sustained. This paper focuses on defining motivation specifically in terms of expectancy-value theory, attribution theory, social-cognitive theory, goal orientation theory, and self-determination theory. Looking across all five theories, the authors note recurrent themes of competence, value, attributions, and interactions between individuals and the learning context. To avoid conceptual confusion, and perhaps more importantly to maximise the theory-building potential of their work, researchers must be careful (and precise) in how they define, operationalise and measure different motivational constructs. The authors suggest that motivation research continue to build theory and extend it to health professions domains, identify key outcomes and outcome measures, and test practical educational applications of the principles thus derived.
Gandomkar R, Mirzazadeh A, Jalili M, Yazdani K, Fata L, Sandars J. Self-regulated learning processes of medical students during an academic learning task. Med Educ. 2016; 50(10):1065–1074. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1111/medu.12975.
This study was designed to identify the self-regulated learning (SRL) processes of medical students during a biomedical science learning task and to examine the associations of the SRL processes with previous performance in biomedical science examinations and subsequent performance on a learning task. A sample of 76 Year 1 medical students were recruited based on their performance in biomedical science examinations and stratified into previous high and low performers. Participants were asked to complete a biomedical science learning task. Participants’ SRL processes were assessed before (self-efficacy, goal setting and strategic planning), during (metacognitive monitoring) and after (causal attributions and adaptive inferences) their completion of the task using an SRL microanalytic interview. Conclusions showed that self-efficacy, metacognitive monitoring and causal attributions measures were associated positively with previous performance. Causal attributions and adaptive inferences measures were associated positively with learning task performance. These findings may inform remediation interventions in the early years of medical school training.
Gooding HC, Mann K, Armstrong E. Twelve tips for applying the science of learning to health professions education. Medical Teacher. 2016. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1080/0142159X.2016.1231913.
Findings from the science of learning have clear implications for those responsible for teaching and curricular design. However, these data have been historically siloed from educators in practice, including those in health professions education. In this article, the authors aim to bring practical tips from the science of learning to health professions educators. They have chosen to organize the tips into six themes, highlighting strategies for 1) improving the processing of information, 2) promoting effortful learning for greater retention of knowledge over time, 3) applying learned information to new and varied contexts, 4) promoting the development of expertise, 5) harnessing the power of emotion for learning, and 6) teaching and learning in social contexts. The authors conclude with the importance of attending to metacognition in their learners and themselves. Health professions education can be strengthened by incorporating these evidence-based techniques.
Haws J, Rannelli L, Schaefer JP, Zarnke K, Coderre S, Ravani P, McLaughlin K. The attributes of an effective teacher differ between the classroom and the clinical setting. Adv in Health Sci Educ. 2016;21(4):833-40. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1007/s10459-016-9669-6.
Most training programs use learners' subjective ratings of their teachers as the primary measure of teaching effectiveness. In a recent study, the authors found that preclinical medical students' ratings of classroom teachers were associated with perceived charisma and physical attractiveness of the teacher, but not intellect. In this study, they explored whether the relationship between these variables and teaching effectiveness ratings holds in the clinical setting. The authors asked 27 Internal Medicine residents to rate teaching effectiveness of ten teachers with whom they had worked on a clinical rotation, in addition to rating each teacher's clinical skills, physical attractiveness, and charisma. Linear regression was used to study the association between these explanatory variables and teaching effectiveness ratings. No association was found between rating of physical attractiveness and teaching effectiveness. Clinical skill and charisma were independently associated with rating of teaching effectiveness (regression coefficients [95 % confidence interval] 0.73 [0.60, 0.85], p < 0.001 and 0.12 [0.01, 0.23], p = 0.03, respectively). The variables associated with effectiveness of classroom and clinical teachers differ, suggesting context specificity in teaching effectiveness ratings. Context specificity may be explained by differences in the exposure that learners have to teachers in the classroom versus clinical setting-so that raters in the clinical setting may base ratings upon observed behaviours rather than stereotype data. Alternatively, since subjective ratings of teaching effectiveness inevitably incorporate learners' context-specific needs, the attributes that make a teacher effective in one context may not meet the needs of learners in a different context.
Zgheib NK, Dimassi Z, Akl IB, Badr KF, Sabra R. The long-term impact of team-based learning on medical students’ team performance scores and on their peer evaluation scores. Medical Teacher. 2016;38(10):1017-1024. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2016.1147537.
The Faculty of Medicine at the American University of Beirut implemented a new medical curriculum, which included 90 team-based learning (TBL) sessions in years 1 and 2 of medical school. A validated team performance scale (TPS) and peer evaluation of communication skills, professionalism and personal development were collected at different time points during the two years. Grades on the individual and group readiness assurance tests and an evaluation form were collected after every TBL session. Students generally positively evaluated most TBL sessions as promoters of critical thinking and appreciated the self-learning experience, though they preferred and had better individual grades on those that entailed preparation of didactic lectures. There was a sustained and cumulative improvement in teamwork skills over time. Similar improvement was noted with peer evaluations of communication skills, professionalism, and personal development over time. This is the first report about such a longitudinal follow-up of medical students who were exposed to a large number of TBL sessions over two years. The results support the suggestion that TBL improves medical students' team dynamics and their perceived self-learning, problem solving and communication skills, as well as their professionalism and personal development.
Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking. Acad Med. 2016. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000001421.
Contemporary theories of clinical reasoning espouse a dual processing model, which consists of a rapid, intuitive component (Type 1) and a slower, logical and analytical component (Type 2). Although the general consensus is that this dual processing model is a valid representation of clinical reasoning, the causes of diagnostic errors remain unclear. Cognitive theories about human memory propose that such errors may arise from both Type 1 and Type 2 reasoning. Errors in Type 1 reasoning may be a consequence of the associative nature of memory, which can lead to cognitive biases. However, the literature indicates that, with increasing expertise (and knowledge), the likelihood of errors decreases. Errors in Type 2 reasoning may result from the limited capacity of working memory, which constrains computational processes. In this article, the authors review the medical literature to answer two substantial questions that arise from this work: (1) To what extent do diagnostic errors originate in Type 1 (intuitive) processes versus in Type 2 (analytical) processes? (2) To what extent are errors a consequence of cognitive biases versus a consequence of knowledge deficits? The literature suggests that both Type 1 and Type 2 processes contribute to errors. Although it is possible to experimentally induce cognitive biases, particularly availability bias, the extent to which these biases actually contribute to diagnostic errors is not well established. Educational strategies directed at the recognition of biases are ineffective in reducing errors; conversely, strategies focused on the reorganization of knowledge to reduce errors have small but consistent benefits.
Maggio LA, Sewell JL, Artino AR. The Literature Review: A Foundation for High-Quality Medical Education Research. Journal of Graduate Medical Education. 2016;8(3):297-303. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.4300/JGME-D-16-00175.1.
Despite a surge in published scholarship in medical education and rapid growth in journals that publish educational research, manuscript acceptance rates continue to fall. The purpose of this editorial is to provide a road map and practical recommendations for planning a literature review. By understanding the goals of a literature review and following a few basic processes, authors can enhance both the quality of their educational research and the likelihood of publication in the Journal of Graduate Medical Education (JGME) and in other journals. In medical education, no organization has articulated a formal definition of a literature review for a research paper; thus, a literature review can take a number of forms. Several organizations have published guidelines for conducting an intensive literature search intended for formal systematic reviews, both broadly (eg, PRISMA) and within medical education. The literature review is a vital part of medical education research and should occur throughout the research process to help researchers design a strong study and effectively communicate study results and importance. To achieve these goals, researchers are advised to plan and execute the literature review carefully. The guidance in this editorial provides considerations and recommendations that may improve the quality of literature reviews.
Phillips AW, Reddy S, Durning SJ. Improving response rates and evaluating nonresponse bias in surveys: AMEE Guide No. 102. Medical Teacher. 2016;38(3):217-228. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2015.1105945.
Robust response rates are essential for effective survey-based strategies. Researchers can improve survey validity by addressing both response rates and nonresponse bias. In this AMEE Guide, the authors explain response rate calculations and discuss methods for improving response rates to surveys as a whole (unit nonresponse) and to questions within a survey (item nonresponse). Finally, they introduce the concept of nonresponse bias and provide simple methods to measure it.
Varpio L, Amiel J, Richards BF. Writing competitive research conference abstracts: AMEE Guide no. 108. Medical Teacher. 2016;38(9):863-871. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1080/0142159X.2016.1211258.
The ability to write a competitive research conference abstract is an important skill for medical educators. A compelling and concise abstract can convince peer reviewers, conference selection committee members, and conference attendees that the research described therein is worthy for inclusion in the conference program and/or for their attendance in the meeting. This AMEE Guide is designed to help medical educators write research conference abstracts that can achieve these outcomes. To do so, this Guide examines the rhetorical context (i.e. the purpose, audience, and structure) of research conference abstracts, describes the abstract selection processes common to many medical education conferences, provides theory-based information and concrete suggestions on how to write persuasively, and offers some writing tips and some proofreading techniques that all authors can use. By attending to the aspects of the research conference abstract addressed in this Guide, the authors hope to help medical educators enhance this important text in their writing repertoire.
*TUSM Faculty Educational Scholarship Publications
Han PKJ, Piccirillo J, Gutheil C, Williams D, Wartak MM, Dufault C, Hallen S, Lucas FL, Joekes K. Development and Evaluation of an Online Risk Communication Teaching Program for Medical Students. Med.Sci.Educ. 2016. This article is published with open access at Springerlink.com. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1007/s40670-016-0290-3.
*TUSM Students Publications
Ostrander, K. Transformations: Reflections on a Longitudinal, Relationship-Centered Medical School Curriculum. Fam Med. 2016;48(7);567-8.
Dr. Ostrander is currently completing her PGYI in Pediatrics at the University of Vermont. The article was written while she was a TUSM medical student in the 2016 class on the Tufts/Maine track.
*MeEdPortal News & Updates
Faculty Affairs Collection Announcement
The AAMC Group on Faculty Affairs (GFA) is delighted to announce a new Faculty Affairs Collection in MedEdPORTAL. The objectives of the Faculty Affairs Collection are to provide (1) faculty affairs deans, staff, and other institutional leaders with tangible, practice-based, peer-reviewed resources for improving practice in faculty affairs, and (2) the opportunity for faculty affairs deans, staff, and other institutional leaders to disseminate best practices in faculty affairs through publishing resources developed, implemented, and refined at one or more institutions that can be adopted or adapted for use at other institutions. For more information, see https://www.mededportal.org/collections/gfa/
Lu W-H, Goolsarran N, Hamo CE, Frawley SM, Rowe C, Lane S. Teaching Patient Safety Using an Interprofessional Team-Based Learning Simulation Model in Residency Training. MedEdPORTAL Publications. 2016;12:10409. http://dx.doi.org/10.15766/mep_2374-8265.10409.
Teaching and learning patient safety require demonstration of competencies such as teamwork, communication skills, and recognition of systems error. This patient safety TBL simulation-training program was developed to fulfill core patient safety objectives outlined by the ACGME and ACGME Clinical Learning Environment Review Program. The goal of the program is to enhance patient safety and quality care concepts and facilitate hands-on teamwork skills and core attitudes towards patient safety. This program served as a mandatory part of the residency core curriculum. It was delivered as a 3-hour workshop session during medicine resident orientation. A total of 76 trainees participated, and 20 interprofessional teams were created. The workshop included an introductory presentation, one TBL activity, and three 1-hour interprofessional simulated application cases using either high-fidelity mannequins or standardized patients. Following each application case activity, trainees participated in a postcase scenario debriefing moderated by faculty facilitators. An independent-samples t test revealed that the Group Readiness Assurance Test scores were significantly higher than the Individual Readiness Assurance Test scores. Although the Readiness for Interprofessional Learning Survey’s Teamwork and Professional Identity subscale scores were higher post workshop compared to preworkshop, the differences were not statistically significant. Over 90% of the participants agreed that the safety concepts they learned would likely improve the quality of care they provide to future patients. A simulation model centered on an interprofessional team can be used as an important training technique to teach health care professionals realistic, hands-on principles of patient safety.
*What is new in the Lit?!
HEALTH SYSTEM SCIENCES
Leep Hunderfund AN, Dyrbye LN, Starr SR, Mandrekar J, Naessens JM, Tilburt JC, George P, Baxley EG, Gonzalo JD, Moriates C, Goold SD, Carney PA, Miller BM, Grethlein SJ, Fancher TL, Reed DA. Role Modeling and Regional Health Care Intensity: U.S. Medical Student Attitudes Toward and Experiences with Cost-Conscious Care. Acad Med. 2016. First published online.
The purpose of this study was to examine medical student attitudes toward cost-conscious care and whether regional health care intensity is associated with reported exposure to physician role-modeling behaviors related to cost-conscious care. Students at 10 U.S. medical schools were surveyed in 2015. Thirty-five items assessed attitudes toward, perceived barriers to and consequences of, and observed physician role-modeling behaviors related to cost-conscious care (using scales for cost-conscious and potentially wasteful behaviors; Cronbach alphas of 0.82 and 0.81, respectively). Regional health care intensity was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data. Of 5,992 students invited, 3,395 (57%) responded. Ninety percent (2,640/2,932) agreed physicians have a responsibility to contain costs. However, 48% (1,1416/2,960) thought ordering a test is easier than explaining why it is unnecessary, and 58% (1,685/2,928) agreed ordering fewer tests will increase the risk of malpractice litigation. In adjusted linear regression analyses, students in higher-health-care-intensity regions reported observing significantly fewer cost-conscious role-modeling behaviors: For each one-unit increase in the three health care intensity measures, scores on the 21-point cost-conscious role-modeling scale decreased by 4.4 (SE 0.7), 3.2 (0.6), and 3.9 (0.6) points, respectively (all P < .001). Medical students endorse barriers to cost-conscious care and encounter conflicting role-modeling behaviors, which are related to regional health care intensity. Enhancing role modeling in the learning environment may help prepare future physicians to address health care costs.
Reeves S, Fletcher S, Barr H, Birch I, Boet S, Davies N, McFadyen A, Rivera J, Kitto S. A BEME Systematic Review of the Effects of Interprofessional Education: BEME Guide No. 39. Medical Teacher. 2016;38(7):656-668. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2016.1173663.
Interprofessional education (IPE) aims to bring together different professionals to learn with, from, and about one another in order to collaborate more effectively in the delivery of safe, high-quality care for patients/clients. Given its potential for improving collaboration and care delivery, there have been repeated calls for the wider-scale implementation of IPE across education and clinical settings. Increasingly, a range of IPE initiatives are being implemented and evaluated which are adding to the growth of evidence for this form of education. The overall aim of this review is to update a previous BEME review published in 2007. In doing so, this update sought to synthesize the evolving nature of the IPE evidence. Medline, CINAHL, BEI, and ASSIA were searched from May 2005 to June 2014 and journal hand searches were undertaken. All potential abstracts and papers were screened to determine inclusion, and all included papers were assessed for methodological quality and those deemed as "high quality" were included. The authors employed the presage-process-product (3P) model and a modified Kirkpatrick model to analyze and synthesize the included studies. Twenty-five new IPE studies were added to the 21 studies from the previous review to form a complete data set of 46 high-quality IPE studies. The 3P model found that most of the presage and process factors identified from the previous review were further supported in the newer studies. In regard to the products (outcomes) reported, the results from this review continue to show far more positive than neutral or mixed outcomes reported in the included studies. The modified Kirkpatrick model suggested that learners respond well to IPE, their attitudes and perceptions of one another improve, and they report increases in collaborative knowledge and skills. There is more limited, but growing, evidence related to changes in behavior, organizational practice, and benefits to patients/clients. This updated review found that key context (presage) and process factors reported in the previous review continue to have resonance on the delivery of IPE. In addition, the newer studies have provided further evidence for the effects on IPE related to a number of different outcomes. Based on these conclusions, a series of key implications for the development of IPE are offered.
Vesel TP, O'Brien BC, Henry DM & van Schaik SM. Useful but Different: Resident Physician Perceptions of Interprofessional Feedback. Teaching and Learning in Medicine. 2016;28(2):125-134. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1080/10401334.2016.1146609.
Based on recently formulated interprofessional core competencies, physicians are expected to incorporate feedback from other healthcare professionals. Based on social identity theory, physicians likely differentiate between feedback from members of their own profession and others. The current study examined residents' experiences with, and perceptions of, interprofessional feedback. In 2013, Anesthesia, Obstetrics-Gynecology, Pediatrics, and Psychiatry residents completed a survey including questions about frequency of feedback from different professionals and its perceived value (5-point scale). The authors performed an analysis of variance to examine interactions between residency program and profession of feedback provider. They conducted follow-up interviews with a subset of residents to explore reasons for residents' survey ratings. 52% (131/254) of residents completed the survey, and 15 participated in interviews. 80% of residents reported receiving written feedback from physicians, 26% from nurses, and less than 10% from other professions. There was a significant interaction between residency program and feedback provider profession, F(21, 847) = 3.82, p < .001, and a significant main effect of feedback provider profession, F(7, 847) = 73.7, p < .001. On post hoc analyses, residents from all programs valued feedback from attending physicians higher than feedback from others, and anesthesia residents rated feedback from other professionals significantly lower than other residents. Ten major themes arose from qualitative data analysis, which revealed an overall positive attitude toward interprofessional feedback and clarified reasons behind residents' perceptions and identified barriers. Residents in the study reported limited exposure to interprofessional feedback and valued such feedback less than intraprofessional feedback. However, the data suggests opportunities exist for effective utilization of interprofessional feedback.
Warm EJ, Held JD, Hellmann M, Kelleher M, Kinnear B, Lee C, O'Toole JK, Mathis B, Mueller C, Sall D, Tolentino J, Schauer DP. Entrusting Observable Practice Activities and Milestones Over the 36 Months of an Internal Medicine Residency. Acad Med. 2016. First published online. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000001292.
Competency-based medical education and milestone reporting have led to increased interest in work-based assessments using entrustment over time as an assessment framework. Little is known about data collected from these assessments during residency. This study describes the results of entrustment of discrete work-based skills over 36 months in the University of Cincinnati internal medicine (IM) residency program. Attending physician and peer/allied health assessors provided entrustment ratings of resident performance on work-based observable practice activities (OPAs) mapped to Accreditation Council for Graduate Medicine Education/American Board of Internal Medicine reporting milestones for IM. These data were translated into milestones data and tracked longitudinally. The authors analyzed data from this new entrustment system's first 36 months (July 2012-June 2015). During this period, assessors made 364,728 milestone assessments (mapped from OPAs) of 189 residents. Residents received an annualized average of 83 assessment encounters, producing means of 3,987 milestone assessments and 4,325 words of narrative assessment. Mean entrustment ratings (range 1-5) from all assessors for all milestones rose from 2.46 for first-month residents to 3.92 for 36th-month residents (r = 0.9252, P < .001). Attending physicians' entrustment ratings were lower than peer/allied health assessors' ratings. Medical knowledge and patient care milestones were rated lower than professionalism and interpersonal and communication skills milestones. Entrustment of milestones appears to rise progressively over time, with differences by assessor type, competency, milestone, and resident. The authors suggest that further research is needed to elucidate the validity of these data in promotion, remediation, and reporting decisions.
Hauer KE, Cate OT, Boscardin CK, Iobst W, Holmboe ES, Chesluk B, Baron RB, O'Sullivan PS. Ensuring Resident Competence: A Narrative Review of the Literature on Group Decision Making to Inform the Work of Clinical Competency Committees. J Grad Med Educ. 2016;8(2):156-64. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.4300/JGME-D-15-00144.1.
The expectation for graduate medical education programs to ensure that trainees are progressing toward competence for unsupervised practice prompted requirements for a committee to make decisions regarding residents' progress, termed a clinical competency committee (CCC). The literature on the composition of these committees and how they share information and render decisions can inform the work of CCCs by highlighting vulnerabilities and best practices. The authors conducted a narrative review of the literature on group decision making that can help characterize the work of CCCs, including how they are populated and how they use information. English language studies of group decision making in medical education, psychology, and organizational behavior were used. The results highlighted 2 major themes: the value group members placed on the complementarity of members' experience and the lessons group members had learned about performance review through their teaching and committee work. Group processes revealed strengths and limitations in groups' understanding of their work, leader role, and information-sharing procedures. Time pressure was a threat to the quality of group work. The study suggests risks for committees that arise with homogeneous membership, limitations to available resident performance information, and processes that arise through experience rather than deriving from a well-articulated purpose of their work. Recommendations are presented to maximize the effectiveness of CCC processes, including their membership and access to, and interpretation of, information to yield evidence-based, well-reasoned judgments.
Cleary TJ, Durning SJ, Artino AR Jr. Microanalytic Assessment of Self-Regulated Learning During Clinical Reasoning Tasks: Recent Developments and Next Steps. Acad Med. 2016. First published online. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000001228.
Helping medical educators obtain and use assessment data to assist medical students, residents, and physicians in reducing diagnostic errors and other forms of ineffective clinical practice is of critical importance. Self-Regulated Learning-Microanalytic Assessment and Training is an assessment-to-intervention framework designed to address this need by generating data about trainees' strategic processes, regulatory processes, and motivational processes as they perform clinical activities. The authors reviewed several studies that have used an innovative assessment approach, called self-regulated learning (SRL) microanalysis, to generate data about how trainees regulate their thinking and actions during clinical reasoning tasks. Initial findings revealed that medical students often do not exhibit strategic thinking and action during clinical reasoning practice tasks even though some regulatory processes (e.g., planning) are predictive of important medical education outcomes. Further, trainees' motivation beliefs, strategic thinking, and self-evaluative judgments tend to shift rapidly during clinical skills practice and may also vary across different parts of a patient encounter. Collectively, these findings underscore the value of dynamically assessing trainees' SRL as they complete clinical tasks. The findings also set the stage for exploring how medical educators can best use SRL microanalytic assessment data to guide remedial practices and the provision of feedback to trainees. The authors discuss implications and future research directions for connecting assessments to intervention in medical education.
Dijkstra J, Latijnhouwers M, Norbart A, Tio RA. Assessing the ‘‘I’’ in Group Work Assessment: State of the Art and Recommendations for Practice. Med Teacher. 2016;38(7):675-682. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2016.1170796.
The use of group work assessment in medical education is becoming increasingly important to assess the competency of collaborator. However, debate continues on whether this does justice to individual development and assessment. This study focused on assessing the individual component within group work. The authors conducted an integrative literature review and complemented with a survey among representatives of all medical schools in the Netherlands to investigate current practices. The 14 studies included in the review showed that an individual component is mainly assessed by peer assessment of individual contributions. Process and product of group work were seldom used separately as criteria. The individual grade was most often based on a group grade and an algorithm to incorporate peer grades. The survey provided an overview of best practices and recommendations for implementing group work assessment. The study indicated that the main pitfall when using peer assessment for group work assessment lies in differentiating between the group work process and the resulting product of the group work. Hence, clear criteria are needed to avoid measuring only effort. The authors suggest that decisions about how to weigh assessment of the product and peer assessment of individual contribution should be carefully made and based on predetermined learning goals.
Conforti LN, Ross KM, Holmboe ES, Kogan JR. Do Faculty Benefit From Participating in a Standardized Patient Assessment as Part of Rater Training? A Qualitative Study. Acad Med. 2016;91(2):262-71. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000838.
The purpose of this study is to explore faculty's experience participating in a standardized patient (SP) assessment where they were observed and assessed and then received feedback about their own clinical skills as part of a rater training faculty development program on direct observation. In 2012, 45 general internist teaching faculty from 30 residency programs participated in an eight-station SP assessment with cases covering common clinical scenarios. Twenty-one participants (47%) received verbal feedback from SPs and a performance-based score report. All participants reflected on the experience through an independent written exercise, one-on-one interviews, and a focus group discussion. Grounded theory was used to analyze all three reflections. Eleven participants (24%) previously completed an SP assessment post training. Most found the SP assessment valuable and experienced emotions that increased their empathy for learners' experiences being observed, being assessed, and receiving nonspecific feedback. Participants receiving verbal feedback from SPs described different themes around personal improvement plans compared with the non-feedback group. The authors found that faculty experience many of the same emotions as trainees during SP encounters and view SP assessment as a valuable mechanism to improve their own clinical skills and assessments of trainees. SP assessments may be one approach to provide faculty feedback about core clinical skills needed in their own patient care as well as what they are expected to teach trainees. Actual changes in participants' clinical or assessor skills were not measured (more research is merited). However, findings hint at a "dual benefit" from incorporating SP assessment into a faculty development workshop about assessment.
Masters K, Ellaway RH, Topps D, Archibald D, Hogue RJ. Mobile Technologies in Medical Education: AMEE Guide No. 105. Medical Teacher. 2016;38(6):537-549. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2016.1141190.
Mobile technologies (including handheld and wearable devices) have the potential to enhance learning activities from basic medical undergraduate education through residency and beyond. In order to use these technologies successfully, medical educators need to be aware of the underpinning socio-theoretical concepts that influence their usage, the pre-clinical and clinical educational environment in which the educational activities occur, and the practical possibilities and limitations of their usage. This Guide builds upon the previous AMEE Guide to e-Learning in medical education by providing medical teachers with conceptual frameworks and practical examples of using mobile technologies in medical education. The goal is to help medical teachers to use these concepts and technologies at all levels of medical education to improve the education of medical and healthcare personnel, and ultimately contribute to improved patient healthcare. This Guide begins by reviewing some of the technological changes that have occurred in recent years, and then examines the theoretical basis (both social and educational) for understanding mobile technology usage. The Guide then progresses through a hierarchy of institutional, teacher and learner needs, identifying issues, problems and solutions for the effective use of mobile technology in medical education. The Guide ends with a brief look to the future.
Van Melle E. Using a Logic Model to Assist in the Planning, Implementation, and Evaluation of Educational Programs. Acad Med. 2016;91(10). First published online. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000001282.
A good logic model, developed over time and with many stakeholders, facilitates a common approach to program planning, implementation, and evaluation. In this Academic Medicine AM Last Page, the authors explain the basics of the logic model using an example, and provide tips for using and applying logic models.
Bunton, SA. Using Qualitative Research as a Means to an Effective Survey Instrument. Acad Med. 2016;91(8):1183. First published online. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000001277.
The academic medicine and health care fields have seen a recent spate of studies using various qualitative research methods. Even more recently, a move to establish standards for reporting qualitative research has emerged. The contributions of these qualitative approaches, which facilitate rich insight into an issue by focusing on the how and why of phenomena, are unique and important. Another way qualitative methods contribute to research is through their systematic use in the survey instrument development process. Explicitly applying steps of qualitative methods during the development of a quantitative survey can strengthen the instrument and yield more meaningful results. The qualitative methods explored in this study include: initial interviews with key stakeholders and representative members of the intended survey population; focus groups with stakeholders and members of the target research population; cognitive interviews with representatives of the survey population. The author suggests that designing high-quality survey instruments can be challenging, but that the systematic use of qualitative methods during the instrument development process can lead to enhanced survey outcomes, including: a comprehensive understanding of the issues impacting the study, the discovery of issues or response options that may have been missed, insight into crafting focused items, and a more robust, accurate, and actionable survey.
Cook DA and Bordage G. Twelve Tips on Writing Abstracts and Titles: How to Get People to Use and Cite your Work. Medical Teacher. 2016. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1080/0142159X.2016.1181732.
The authors share 12 practical tips on creating effective titles and abstracts for a journal publication or conference presentation. They suggest that, when crafting a title, authors should: (1) start thinking of the title from the start; (2) brainstorm many key words, create permutations, and ask others for input; (3) strive for an informative and indicative title; (4) start the title with the most important words; and (5) wait to finalize the title until the very end. When writing the abstract, authors should: (6) wait until the end to write the abstract; (7) copy and paste from main text as the starting point; (8) start with a detailed structured format; (9) describe what they did; (10) describe what they found; (11) highlight what readers can do with this information; and (12) ensure that the abstract aligns with the full text and conforms to submission guidelines.
Teaching and Learning
Kilgour JM, Grundy L, Monrouxe LV. A Rapid Review of the Factors Affecting Healthcare Students' Satisfaction with Small-Group, Active Learning Methods. Teaching and Learning in Medicine. 2016;28(1):15-25. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1080/10401334.2015.1107484.
Problem-based learning (PBL) and other small-group, active learning methodologies have been widely adopted into undergraduate and postgraduate healthcare curricula across the world. Although much research has examined student perceptions of these innovative teaching pedagogies, there are still questions over which factors influence these views. This study aims to identify these key elements that affect healthcare student satisfaction with PBL and other small-group learning methods, including case-based and team-based learning. A systematic rapid review method was used to identify high-quality original research papers from the healthcare education literature from between 2009 and 2014. All papers were critically appraised before inclusion in line with published guidelines. Narrative synthesis was achieved using an inductively developed, thematic framework approach. Fifty-four papers were included in the narrative synthesis. The evidence suggests that, despite an initial period of negative emotion and anxiety, the perspectives of healthcare students toward small-group, active learning methods are generally positive. The key factors influencing this satisfaction level include (a) the facilitator role, (b) tutorial structure, (c) individual student factors, (d) case authenticity, (e) increased feedback, (f) group harmony, and (g) resource availability. Insights: Student satisfaction is an important determinant of healthcare education quality, and the findings of this review may be of value in future curriculum design. The evidence described here suggests that an ideal curriculum may be based on an expert-led, hybrid PBL model.
*MeEdPortal News & Updates
Bailey M, Kay D, Berry A. Introduction to Entrustable Professional Activities Faculty Development Module. MedEdPORTAL Publications; 2015. Available from: https://www.mededportal.org/publication/10230; http://dx.doi.org/10.15766/mep_2374-8265.10230
The Association of American Medical Colleges recently introduced core Entrustable Professional Activities (EPAs) for entering residency in hopes of standardizing a common set of core behaviors that could be expected of all graduates. While the Core EPAs for Entering Residency Drafting Panel has delineated and documented the EPAs for implementation in undergraduate medical education programs as part of the Core EPA Faculty and Learners’ Guide available in iCollaborative (www.mededportal.com/icollaborative/resource/887), the amount of information presented in the 69-page resource can be overwhelming for the end users (preceptors and residents) who are responsible for educating medical students.
The goal of the Introduction to Entrustable Professional Activities module is to present the relevant information and scenarios for each EPA based on the settings where it is most likely to be observed. Users who complete the module will also have the opportunity to pinpoint behaviors that are linked to each EPA as part of the interactive scenarios that are embedded in the program. Based on the principles of adult learning, the Introduction to Entrustable Professional Activities module was designed to be relevant, practical, and self-directed. The module allows users complete control over the content they review and/or complete. All scenarios represent common interactions with students and student behaviors.
The module can be used as a stand-alone faculty development opportunity for clinical educators who are engaged in teaching and assessing medical students. The module takes approximately 45 minutes; however, users may exit and return to the content at any time.
*TUSM Faculty Educational Scholarship Publications
Curtiss CP. I’m Worried About People in Pain. Am J Nurs. 2016;116(1):11. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/01.NAJ.0000476145.19908.f4
Shaughnessy AF, Torro JR, Frame KA, Bakshi M. Evidence-based medicine and life-long learning competency requirements in new residency teaching standards. Evid Based Med. 2016;21(2):46-49. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1136/ebmed-2015-110349.
*What is new in the Lit?!
LEARNING & TEACHING
Alluri RK, Tsing P, Lee E, Napolitano J. A randomized controlled trial of high-fidelity simulation versus lecture-based education in preclinical medical students. Medical Teacher.2016;38(4):404-409. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2015.1031734.
The purpose of this study was to compare the efficacy of simulation versus lecture-based education among preclinical medical students. Twenty medical students participated in this randomized, controlled crossover study. Students were randomized to four groups. Each group received two simulations and two lectures covering four different topics. Students were administered a pre-test, post-test and delayed post-test. The mean percentage of questions answered correctly on each test was calculated. The mean of each student's change in score across the three tests was used to compare simulation- versus lecture-based education. Students in both the simulation and lecture groups demonstrated improvement between the pre-test and post-test (p < 0.05). Students in the simulation group demonstrated improvement between the immediate post-test and delayed post-test (p < 0.05), while students in the lecture group did not demonstrate improvement (p > 0.05). When comparing interventions, the change in score between the pre-test and post-test was similar among both the groups (p > 0.05). The change in score between the post-test and delayed post-test was greater in the simulation group (p < 0.05). High-fidelity simulation may serve as a viable didactic platform for preclinical medical education. Our study demonstrated equivalent immediate knowledge gain and superior long-term knowledge retention in comparison to lectures.
Kilgour JM, Grundy L, Monrouxe LV. A Rapid Review of the Factors Affecting Healthcare Students' Satisfaction with Small-Group, Active Learning Methods. Teaching and Learning in Medicine.2016;28(1):15-25. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1080/10401334.2015.1107484.
Problem-based learning (PBL) and other small-group, active learning methodologies have been widely adopted into undergraduate and postgraduate healthcare curricula across the world. Although much research has examined student perceptions of these innovative teaching pedagogies, there are still questions over which factors influence these views. This article aims to identify these key elements that affect healthcare student satisfaction with PBL and other small-group learning methods, including case-based and team-based learning. A systematic rapid review method was used to identify high-quality original research papers from the healthcare education literature from between 2009 and 2014. All papers were critically appraised before inclusion in line with published guidelines. Narrative synthesis was achieved using an inductively developed, thematic framework approach. Fifty-four papers were included in the narrative synthesis. The evidence suggests that, despite an initial period of negative emotion and anxiety, the perspectives of healthcare students toward small-group, active learning methods are generally positive. The key factors influencing this satisfaction level include (a) the facilitator role, (b) tutorial structure, (c) individual student factors, (d) case authenticity, (e) increased feedback, (f) group harmony, and (g) resource availability. Student satisfaction is an important determinant of healthcare education quality, and the findings of this review may be of value in future curriculum design. The evidence described here suggests that an ideal curriculum may be based on an expert-led, hybrid PBL model.
Zgheib NK, Dimassi Z, Akl IB, Badr KF, Sabra R. The long-term impact of team-based learning on medical students’ team performance scores and on their peer evaluation scores. Medical Teacher.2016. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2016.1147537.
The Faculty of Medicine at the American University of Beirut implemented a new medical curriculum, which included 90 team-based learning (TBL) sessions in years 1 and 2 of medical school. A validated team performance scale (TPS) and peer evaluation of communication skills, professionalism and personal development were collected at different time points during the two years. Grades on the individual and group readiness assurance tests and an evaluation form were collected after every TBL session. Students generally positively evaluated most TBL sessions as promoters of critical thinking and appreciated the self-learning experience, though they preferred and had better individual grades on those that entailed preparation of didactic lectures. There was a sustained and cumulative improvement in teamwork skills over time. Similar improvement was noted with peer evaluations of communication skills, professionalism, and personal development over time. This is the first report about such a longitudinal follow-up of medical students who were exposed to a large number of TBL sessions over two years. The results support the suggestion that TBL improves medical students' team dynamics and their perceived self-learning, problem solving and communication skills, as well as their professionalism and personal development.
Brehaut JC, Colquhoun HL, Eva KW, Carroll K, Sales A, Michie S, Ivers, N and Grimshaw, JM. Practice Feedback Interventions: 15 Suggestions for Optimizing Effectiveness. Ann Intern Med. 2016;164(6):435-441. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.7326/M15-2248.
The authors argue that electronic practice data are increasingly being used to provide feedback to encourage practice improvement. However, evidence suggests that despite decades of experience, the effects of such interventions vary greatly and are not improving over time. The authors further state that although guidance on providing more effective feedback does exist, it is distributed across a wide range of disciplines and theoretical perspectives. Through expert interviews; systematic reviews; and experience with providing, evaluating, and receiving practice feedback, the authors identified 15 suggestions that are believed to be associated with effective feedback interventions. These suggestions are intended to provide practical guidance to quality improvement professionals, information technology developers, educators, administrators, and practitioners who receive such interventions. Designing interventions with these suggestions in mind should improve their effect, and studying the mechanisms underlying these suggestions will advance a stagnant literature.
Conforti LN, Ross KM, Holmboe ES, Kogan JR. Do Faculty Benefit From Participating in a Standardized Patient Assessment as Part of Rater Training? A Qualitative Study. Acad Med. 2016;91(2):262-71.
The purpose of this study was to explore faculty's experience participating in a standardized patient (SP) assessment where they were observed and assessed and then received feedback about their own clinical skills as part of a rater training faculty development program on direct observation. In 2012, 45 general internist teaching faculty from 30 residency programs participated in an eight-station SP assessment with cases covering common clinical scenarios. Twenty-one participants (47%) received verbal feedback from SPs and a performance-based score report. All participants reflected on the experience through an independent written exercise, one-on-one interviews, and a focus group discussion. Grounded theory was used to analyze all three reflections. Eleven participants (24%) previously completed an SP assessment post training. Most found the SP assessment valuable and experienced emotions that increased their empathy for learners' experiences being observed, being assessed, and receiving nonspecific feedback. Participants receiving verbal feedback from SPs described different themes around personal improvement plans compared with the non-feedback group. Faculty experience many of the same emotions as trainees during SP encounters and view SP assessment as a valuable mechanism to improve their own clinical skills and assessments of trainees. SP assessments may be one approach to provide faculty feedback about core clinical skills needed in their own patient care as well as what they are expected to teach trainees. Although actual changes in participants' clinical or assessor skills were not measured (more research is merited), findings hint at a "dual benefit" from incorporating SP assessment into a faculty development workshop about assessment.
Cook DA, Kuper A, Hatala R, Ginsburg S. When Assessment Data Are Words: Validity Evidence for Qualitative Educational Assessments. Acad Med. 2016. First published online.
Quantitative scores fail to capture all important features of learner performance. This awareness has led to increased use of qualitative data when assessing health professionals. Yet the use of qualitative assessments is hampered by incomplete understanding of their role in forming judgments, and lack of consensus in how to appraise the rigor of judgments therein derived. The authors articulate the role of qualitative assessment as part of a comprehensive program of assessment, and translate the concept of validity to apply to judgments arising from qualitative assessments. They first identify standards for rigor in qualitative research, and then use two contemporary assessment validity frameworks to reorganize these standards for application to qualitative assessment. Standards for rigor in qualitative research include responsiveness, reflexivity, purposive sampling, thick description, triangulation, transparency, and transferability. These standards can be reframed using Messick's five sources of validity evidence (content, response process, internal structure, relationships with other variables, and consequences) and Kane's four inferences in validation (scoring, generalization, extrapolation, and implications). Evidence can be collected and evaluated for each evidence source or inference. The authors illustrate this approach using published research on learning portfolios. The authors advocate a "methods-neutral" approach to assessment, in which a clearly stated purpose determines the nature of and approach to data collection and analysis. Increased use of qualitative assessments will necessitate more rigorous judgments of the defensibility (validity) of inferences and decisions. Evidence should be strategically sought to inform a coherent validity argument.
Dudek NL, Dojeiji S, Day K, Varpio L. Feedback to Supervisors: Is Anonymity Really So Important?. Acad Med. 2016. First published online.
Research demonstrates that physicians benefit from regular feedback on their clinical supervision from their trainees. Several features of effective feedback are enabled by non-anonymous processes (i.e., open feedback). However, most resident-to-faculty feedback processes are anonymous given concerns of power differentials and possible reprisals. This exploratory study investigated resident experiences of giving faculty open feedback, advantages, and disadvantages. Between January and August 2014, nine graduates of a Canadian Physiatry residency program that uses open resident-to-faculty feedback participated in semi-structured interviews in which they described their experiences of this system. Three members of the research team analyzed transcripts for emergent themes using conventional content analysis. In June 2014, semi-structured group interviews were held with six residents who were actively enrolled in the program as a member-checking activity. Themes were refined on the basis of these data. Advantages of the open feedback system included giving timely feedback that was acted upon (thus enhancing residents' educational experiences), and improved ability to receive feedback (thanks to observing modeled behavior). Although some disadvantages were noted, they were often speculative (e.g., "I think others might have felt …") and were described as outweighed by advantages. Participants emphasized the program's "feedback culture" as an open feedback enabler. The relationship between the feedback giver and recipient has been described as influencing the uptake of feedback. These findings suggest that non-anonymous practices can enable a positive relationship in resident-to-faculty feedback. The benefits of an open system for resident-to-faculty feedback can be reaped if a "feedback culture" exists.
Humphrey-Murto S, Mihok M, Pugh D, Touchie C, Halman S, Wood TJ. Feedback in the OSCE: What Do Residents Remember?. Teaching and Learning in Medicine.2016;28(1):52-60. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1080/10401334.2015.1107487.
The move to competency-based education has heightened the importance of direct observation of clinical skills and effective feedback. The Objective Structured Clinical Examination (OSCE) is widely used for assessment and affords an opportunity for both direct observation and feedback to occur simultaneously. For feedback to be effective, it should include direct observation, assessment of performance, provision of feedback, reflection, decision-making, and use of feedback for learning and change. If one of the goals of feedback is to engage students to think about their performance (i.e., reflection), it would seem imperative that they can recall this feedback both immediately and into the future. This study explores recall of feedback in the context of an OSCE. Specifically, the purpose of this study was to (a) determine the amount and the accuracy of feedback that trainees remember immediately after an OSCE, as well as 1 month later, and (b) assess whether prompting immediate recall improved delayed recall. Internal medicine residents received 2 minutes of verbal feedback from physician examiners in the context of an OSCE. The feedback was audio-recorded and later transcribed. Residents were randomly allocated to the immediate recall group (immediate-RG; n = 10) or the delayed recall group (delayed-RG; n = 8). The immediate-RG completed a questionnaire prompting recall of feedback received immediately after the OSCE, and then again 1 month later. The delayed-RG completed a questionnaire only 1 month after the OSCE. The total number and accuracy of feedback points provided by examiners were compared to the points recalled by residents. Results comparing recall at 1 month between the immediate-RG and the delayed-RG were also studied. Physician examiners provided considerably more feedback points (M = 16.3) than the residents recalled immediately after the OSCE (M = 2.61, p < .001). There was no significant difference between the number of feedback points recalled upon completion of the OSCE (2.61) compared to 1 month later (M = 1.96, p = .06, Cohen's d = .70). Prompting immediate recall did not improve later recall. The mean accuracy score for feedback recall immediately after the OSCE was 4.3/9 or "somewhat representative," and at 1 month the score dropped to 3.5/9 or "not representative" (ns). This study suggests that residents recall very few feedback points immediately after the OSCE and 1 month later. The feedback points that are recalled are neither very accurate nor representative of the feedback actually provided.
Fargen KM, Drolet BC, Philibert I. Unprofessional Behaviors Among Tomorrow's Physicians: Review of the Literature With a Focus on Risk Factors, Temporal Trends, and Future Directions. Acad Med. 2016. First published online. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000001133.
Recent reports have identified concerning patterns of unprofessional and dishonest behavior by physician trainees. Despite this publicity, the prevalence and impact of these behaviors is not well described; thus, the authors aimed to review and analyze the various studies on unprofessional behavior among U.S. medical trainees. The authors performed a literature review. They sought all reports on unprofessional and dishonest behavior among U.S. medical school students or resident physicians published in English and indexed in PubMed between January 1980 and May 2014. A total of 51 publications met criteria for inclusion in the study. The data in these reports suggest that plagiarism, cheating on examinations, and listing fraudulent publications on residency/fellowship applications were reported in 5% to 15% of the student and resident populations that were studied. Other behaviors, such as inaccurately reporting that a medical examination was performed on a patient or falsifying duty hours, appear to be even more common (reportedly occurring among 40% to 50% of students and residents). The authors concluded that "Unprofessional behavior" lacks a unified definition. The data on the prevalence of unprofessional behavior in medical students and residents are limited. Unprofessional behaviors are common and appear to be occurring in various demographic groups within the medical trainee population. The relationship between unprofessional behaviors in training and future disciplinary action is poorly understood. Going forward, defining "unprofessional behavior"; developing validated instruments to evaluate such behaviors scientifically; and studying their incidence, motivations, and consequences are critical.
Mamykina L, Vawdrey DK, Hripcsak G. How Do Residents Spend Their Shift Time? A Time and Motion Study With a Particular Focus on the Use of Computers. Acad Med. 2016. First published online.
The purpose of this study was to understand how much time residents spend using computers compared with other activities, and what residents use computers for. This time and motion study was conducted in June and July 2010 at New York-Presbyterian/Columbia University Medical Center with seven residents (first-, second-, and third-year) on the general medicine service. An experienced observer shadowed residents during a single day shift, captured all their activities using an iPad application, and took field notes. The activities were captured using a validated taxonomy of clinical activities, expanded to describe computer-based activities with a greater level of detail. Residents spent 364.5 minutes (50.6%) of their shift time using computers, compared with 67.8 minutes (9.4%) interacting with patients. In addition, they spent 292.3 minutes (40.6%) talking with others in person, 186.0 minutes (25.8%) handling paper notes, 79.7 minutes (11.1%) in rounds, 80.0 minutes (11.1%) walking or waiting, and 54.0 minutes (7.5%) talking on the phone. Residents spent 685 minutes (59.6%) multitasking. Computer-based documentation activities amounted to 189.9 minutes (52.1%) of all computer-based activities time, with 128.7 minutes (35.3%) spent writing notes and 27.3 minutes (7.5%) reading notes composed by others. The study showed that residents spent considerably more time interacting with computers (over 50% of their shift time) than in direct contact with patients (less than 10% of their shift time). Some of this may be due to an increasing reliance on computing systems for access to patient data, further exacerbated by inefficiencies in the design of the electronic health record.
Masters K, Ellaway RH, Topps D, Archibald D, Hogue RJ. Mobile technologies in medical education: AMEE Guide No. 105. Medical Teacher.2016. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2016.1141190.
Mobile technologies (including handheld and wearable devices) have the potential to enhance learning activities from basic medical undergraduate education through residency and beyond. In order to use these technologies successfully, medical educators need to be aware of the underpinning socio-theoretical concepts that influence their usage, the pre-clinical and clinical educational environment in which the educational activities occur, and the practical possibilities and limitations of their usage. This Guide builds upon the previous AMEE Guide to e-Learning in medical education by providing medical teachers with conceptual frameworks and practical examples of using mobile technologies in medical education. The goal is to help medical teachers to use these concepts and technologies at all levels of medical education to improve the education of medical and healthcare personnel, and ultimately contribute to improved patient healthcare. This Guide begins by reviewing some of the technological changes that have occurred in recent years, and then examines the theoretical basis (both social and educational) for understanding mobile technology usage. From there, the Guide progresses through a hierarchy of institutional, teacher and learner needs, identifying issues, problems and solutions for the effective use of mobile technology in medical education. This Guide ends with a brief look to the future.
Pereira AG, Harrell HE, Weissman A, Smith CD, Dupras D, Kane GC. Important Skills for Internship and the Fourth-Year Medical School Courses to Acquire Them: A National Survey of Internal Medicine Residents. Acad Med. 2016. First published online. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000001134.
The purpose of this study was to obtain feedback from internal medicine residents, a key stakeholder group, regarding both the skills needed for internship and the fourth-year medical school courses that prepared them for residency. This feedback could inform fourth-year curriculum redesign efforts. All internal medicine residents taking the 2013-2014 Internal Medicine In-Training Examination were asked to rank the importance of learning 10 predefined skills prior to internship and to use a dropdown menu of 11 common fourth-year courses to rank the 3 most helpful in preparing for internship. The predefined skills were chosen based on a review of the literature, a national sub-internship curriculum, and expert consensus. Chi-square statistics were used to test for differences in responses between training levels. Of the 24,820 internal medicine residents who completed the exam, 20,484 (83%) completed the survey, had complete identification numbers, and consented to have their responses used for research. The three skills most frequently rated as very important were identifying when to seek additional help and expertise, prioritizing clinical tasks and managing time efficiently, and communicating with other providers around care transitions. The sub-internship/acting internship was most often selected as being the most helpful course in preparing for internship. These findings indicate which skills and fourth-year medical school courses internal medicine residents found most helpful in preparing for internship and confirm the findings of prior studies highlighting the perceived value of sub-internships. Internal medicine residents and medical educators agree on the skills students should learn prior to internship.
Post JA, Wittich CM, Thomas KG, Dupras DM, Halvorsen AJ, Mandrekar JN, Oxentenko AS, Beckman TJ. Rating the Quality of Entrustable Professional Activities: Content Validation and Associations with the Clinical Context. J Gen Intern Med. 2016;31(5):518-23.
Entrustable professional activities (EPAs) have been developed to assess resident physicians with respect to Accreditation Council for Graduate Medical Education (ACGME) competencies and milestones. Although the feasibility of using EPAs has been reported, we are unaware of previous validation studies on EPAs and potential associations between EPA quality scores and characteristics of educational programs. The authors aimed to validate an instrument for assessing the quality of EPAs for assessment of internal medicine residents, and to examine associations between EPA quality scores and features of rotations. This was a prospective content validation study to design an instrument to measure the quality of EPAs that were written for assessing internal medicine residents. Residency leadership at Mayo Clinic, Rochester participated in this study. This included the Program Director, Associate program directors and individual rotation directors. The authors reviewed salient literature. Items were developed to reflect domains of EPAs useful for assessment. The instrument underwent further testing and refinement. Each participating rotation director created EPAs that they felt would be meaningful to assess learner performance in their area. These 229 EPAs were then assessed with the QUEPA instrument to rate the quality of each EPA. Performance characteristics of the QUEPA are reported. Quality ratings of EPAs were compared to the primary ACGME competency, inpatient versus outpatient setting and specialty type. QUEPA tool scores demonstrated excellent reliability (ICC range 0.72 to 0.94). Higher ratings were given to inpatient versus outpatient (3.88, 3.66; p = 0.03) focused EPAs. Medical knowledge EPAs scored significantly lower than EPAs assessing other competencies (3.34, 4.00; p < 0.0001). The authors concluded that the QUEPA tool is supported by good validity evidence and may help in rating the quality of EPAs developed by individual programs. Programs should take care when writing EPAs for the outpatient setting or to assess medical knowledge, as these tended to be rated lower.
Sheu L, O'Sullivan PS, Aagaard EM, Tad-Y D, Harrell HE, Kogan JR, Nixon J, Hollander H, Hauer KE. How Residents Develop Trust in Interns: A Multi-Institutional Mixed-Methods Study. Acad Med. 2016. First published online.
Although residents trust interns to provide patient care, little is known about how trust forms. Using a multi-institutional mixed-methods study design, the authors interviewed (March-September 2014) internal medicine (IM) residents in their second or third postgraduate year at a single institution to address how they develop trust in interns. Transcript analysis using grounded theory yielded a model for resident trust. Authors tested (January-March 2015) the model with residents from five IM programs using a two-section quantitative survey (38 items; 31 rated 0 = not at all to 100 = very much; 7 rated 0 = strongly disagree to 100 = strongly agree) to identify influences on how residents form trust. Qualitative analysis of 29 interviews yielded 14 themes within five previously identified factors of trust (resident, intern, relationship, task, and context). Of 478 residents, 376 (78.7%) completed the survey. Factor analysis yielded 11 factors that influence trust. Respondents rated interns' characteristics (reliability, competence, and propensity to make errors) highest when indicating importance to trust (respective means 86.3 [standard deviation = 9.7], 76.4 [12.9], and 75.8 [20.0]). They also rated contextual factors highly as influencing trust (access to an electronic medical record, duty hours, and patient characteristics; respective means 79.8 [15.3], 73.1 [14.4], and 71.9 [20.0]). The authors concluded that residents form trust based on primarily intern- and context-specific factors. Residents appear to consider trust in a way that prioritizes interns' execution of essential patient care tasks safely within the complexities and constraints of the hospital environment.
*MeEdPortal News & Updates
New Submission Requirement: Educational Summary Report
As of November 15, 2015, all submissions to MedEdPORTAL Publications require an Educational Summary Report (ESR). The ESR provides a summary overview of the entire submission and serves as a guide for understanding the purpose and scope of the resource. Authors and users should be aware that a MedEdPORTAL publication consists of the ESR and all associated resources contained within the submission.
Authors with active submissions are strongly encouraged to convert their Instructor Guide to an ESR. This option is available to all authors with submissions in process. Regardless of submission status, developing an ESR will increase the quality and value of the submission and potential publication. Information found in an Instructor Guide easily translates into an ESR. Please note that depending on the status of the submission, the associate editor and/or peer reviewers will review the ESR prior to publication. If accepted, staff will reformat the ESR based on MeEdPORTAL’s new publication style format. For more information and guidance, please visit Developing an Educational Summary Report.
Gallego J, Knudsen J. LGBTQI* Defined: An Introduction to Understanding and Caring for the Queer Community. MedEdPORTAL Publications; 2015. Available from: https://www.mededportal.org/publication/10189
“LGBTQI* Defined: An Introduction to Understanding and Caring for the Queer Community” was designed to improve the quality of care provided to the LGBTQI* community by educating healthcare professionals about the complexities of queer culture. The curriculum uniquely and interactively deconstructs sex, gender, and sexual orientation as separately experienced entities comprising an individual’s identity. This innovative approach to teaching a challenging topic allows learners to discover a deeper understanding of their own identities while developing greater empathy for LGBTQI*-identified people. Additionally, the curriculum defines other terminology and identities relevant to the LGBTQI* population. Finally, “LGBTQI* Defined” provides learners with institutional considerations and specific clinical recommendations and techniques to help providers care for their future LGBTQI*-identified patients with compassion and cultural sensitivity.
Tapper E, Sullivan A, Tess A. Teaching Quality Improvement on the Wards: How We Do It. MedEdPORTAL Publications; 2015. Available from: https://www.mededportal.org/publication/10211; http://dx.doi.org/10.15766/mep_2374-8265.10211
Graduate medical education programs are being asked to formally teach their trainees quality improvement (QI) and patient safety by engaging them in their institutional QI work. Time allotted for educational activities can be limited. Finding time for new requirements may seem daunting. This is especially true for busy clinical rotations in the era of duty-hour limits. Additional educational requirements must be flexible and sensitive to the clinical commitments of house staff. Ideally, novel educational programs aims could accomplish multiple aims by combining new and old curricular goals. The authors believe that the key to engaging trainees in this work is to immerse them in solving the problems they see every day in their environment. The authors developed a modular QI curriculum with the goals of framing clinical problems in a QI context, efficiently teaching house staff about a specific clinical topic while enhancing knowledge of QI methodology, allowing house staff to contribute to the improvement of a relevant clinical process, and achieving CLER goals in the context of a specific clinical rotation. The approach the authors detail can be adapted to any clinical environment.
*TUSM Faculty Educational Scholarship Publications
Lauriat TL, Htut W, Malur C. Effect of Probationary Accreditation on Recruitment of Psychiatry Residents. Acad Psychiatry. 2016;40(1):192–193.
*What is new in the Lit?!
Regan L, Jung J, Kelen GD. Educational Value Units: A Mission-Based Approach to Assigning and Monitoring Faculty Teaching Activities in an Academic Medical Department. Acad Med.2016. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000001110
The authors argue that increasing emphasis on revenue generation could jeopardize the fundamental notion of what it means to be faculty. The authors further suggest that, despite being a core mission, education is often marginalized in academic medical departments, and expectations of faculty effort in this area are often vague. The authors propose mission-based budgeting (MBB), which refers to the allocation of resources based on core-mission-related priorities, as a potential solution. From December 2012 to March 2013, the authors developed an educational value unit (EVU) system (using an MBB approach) to assign and monitor teaching activities related to the core departmental educational mission at the Department of Emergency Medicine, Johns Hopkins Medicine. EVUs were based on learner contact time, with one EVU equal to roughly one hour of in-person time with medical students or residents. Core education faculty vetted the proposed system; educational leaders determined the total EVUs needed and assessed the impact of their equitable distribution among faculty; and faculty members selected preferences and were assigned EVU obligations. For academic year 2013–2014, 5,896 EVUs were distributed among 54 faculty. At the end of the year, complete EVU data were available for 47 faculty. Of these, only 6 failed to complete their assigned EVU obligations. All core teaching activities were covered, and educational efforts were distributed more equitably across faculty. The system is being refined, with an emphasis on incorporating learner outcome metrics, refining the teaching grid, incorporating failure to meet EVU obligations into yearly faculty evaluations, and disseminating the system to other departments and institutions.
Sargeant J, Lockyer J, Mann K, Holmboe E, Silver I, Armson H, Driessen E, MacLeod T, Yen W, Ross K, Power M. Facilitated Reflective Performance Feedback: Developing an Evidence- and Theory-Based Model That Builds Relationship, Explores Reactions and Content, and Coaches for Performance Change (R2C2). Acad Med. 2015;90(12):1698–1706. First published online July 21, 2015. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000809
The authors aimed to develop and conduct feasibility testing of an evidence-based and theory-informed model for facilitating performance feedback for physicians so as to enhance their acceptance and use of the feedback. The authors drew on earlier research which highlights not only the factors that influence giving, receiving, accepting, and using feedback but also the theoretical perspectives which enable the understanding of these influences. The authors undertook an iterative, multistage, qualitative study guided by two recognized research frameworks: the UK Medical Research Council guidelines for studying complex interventions
and realist evaluation. Using these frameworks, they conducted the research in four stages: (1) modeling, (2) facilitator preparation, (3) model feasibility testing, and (4) model refinement. They analyzed data, using content and thematic analysis, and used the findings from each stage to inform the subsequent stage. Findings support the facilitated
feedback model, its four phases—build relationship, explore reactions, explore content, coach for performance change (R2C2)—and the theoretical perspectives informing them. The findings contribute to understanding elements that enhance recipients’ engagement with, acceptance of, and productive use of feedback. Facilitators reported that the model made sense and the phases generally flowed logically. Recipients reported that the feedback process was helpful and that they appreciated the reflection stimulated by the model and the coaching. The authors concluded that the theory- and evidence-based reflective R2C2 Facilitated Feedback Model appears stable and helpful for physicians in facilitating their reflection on and use of formal performance assessment feedback.
Goldszmidt M, Faden L, Dornan T, van Merriënboer J, Bordage G, Lingard L. Attending Physician Variability: A Model of Four Supervisory Styles. Acad Med. 2015;90(11):1541–1546. First published online April 17, 2015. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000735
The authors claim that there is wide variability in how attending physician roles on teaching teams, including patient care and trainee learning, are enacted. This study sought to better understand variability by considering how different attendings configured and rationalized direct patient care, trainee oversight, and teaching activities. Constructivist grounded theory guided iterative data collection and analyses. Data were interviews with 24 attending physicians from two academic centers in Ontario, Canada, in 2012. During interviews, participants heard a hypothetical presentation and reflected on it as though it were presented to their team during a typical admission case review. Four supervisory styles were identified: direct care, empowerment, mixed practice, and minimalist. Driven by concerns for patient safety, direct care involves delegating minimal patient care responsibility to trainees. Focused on supporting trainees’ progressive independence, empowerment uses teaching and oversight strategies
to ensure quality of care. In mixed practice, patient care is privileged over teaching and is adjusted on the basis of trainee competence and contextual features such as patient volume. Minimalist style involves a high degree of trust in senior residents, delegating most patient care, and teaching to them. Attendings rarely discussed their styles with the team. The authors concluded that the model adds to the literature on variability in supervisory practice, showing that the four styles reflect different
ways of responding to tensions in the role and context. This model could be refined through observational research exploring the impact of context on style development and enactment. Making supervisory styles explicit could support improvement of team competence.
Bok HGJ, Jaarsma DADC, Spruijt A, Van Beukelen P, Van Der Vleuten CPM, Teunissen PW. Feedback-giving behaviour in performance evaluations during clinical clerkships. Medical Teacher. 2016;38(1):88-95. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2015.1017448
There are numerous studies on the effectiveness of the Mini-CEX, but little is known about how these factors influence teachers’ feedback-giving behaviour. In this study, the investigators examined teachers’ use of mini-CEX in performance evaluations to provide narrative feedback in undergraduate clinical training. Between February and June 2013, the investigators conducted interviews with 14 clinicians participated as teachers during undergraduate clinical clerkships in veterinary medicine. The 14 teachers all use mini-CEX instruments for feedback/evaluation of their students in clinical training. The interviews were designed to explore teachers’ perceptions of this specific feedback practice. The investigators coded interview transcripts and iteratively reduced and displayed data using template analysis. Three main themes of interrelated factors were identified that influenced teachers’ practice with regard to mini-CEX instruments: teacher-related factors; teacher–student interaction-related factors, and teacher–context interaction-related factors. Four issues (direct observation, relationship between teacher and student, verbal versus written feedback, formative versus summative purposes) that are pertinent to workplace-based performance evaluations were presented to clarify how different factors interact with each other and influence teachers’ feedback-giving behaviour. Embedding performance observation in clinical practice and establishing trustworthy teacher–student relationships in more longitudinal clinical clerkships were considered important in creating a learning environment that supports and facilitates the feedback exchange. The researchers identified 3 common themes and 4 problems when it comes to using the mini-CEX instrument for feedback evaluation. When teacher’s priorities and beliefs were in-line with using this type of method to provide teaching and feedback it proves to be very effective as prior literature suggests. Feedback is more actively sought by students and provided in the right context by teachers if there is a longer, more stable relationship between student and teacher. The more experienced a teacher is, the more proficient they are at delivering negative feedback in the appropriate context.
Onyura B, Baker L, Cameron B, Friesen F, Leslie K. Evidence for curricular and instructional design approaches in undergraduate medical education: An umbrella review. Medical Teacher. 2016;38(2):150–161. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2015.1009019
An umbrella review compiles evidence from multiple reviews into a single accessible document. This umbrella review synthesizes evidence from systematic reviews on curricular and instructional design approaches in undergraduate medical education, focusing on learning outcomes. The authors conducted bibliographic database searches in Medline, EMBASE and ERIC from database inception to May 2013 inclusive, and digital keyword searches of leading medical education journals. They identified 18,470 abstracts; 467 underwent duplicate full-text scrutiny. Thirty-six articles met all eligibility criteria. Articles were abstracted independently by three authors, using a modified Kirkpatrick model for evaluating learning outcomes. This review maps out empirical knowledge on the efficacy of a broad range of educational approaches in medical education. Critical knowledge gaps, and lapses in methodological rigor, are discussed, providing valuable insight for future research. The findings call attention to the need for adopting evaluative strategies that explore how contextual variabilities and individual (teacher/learner) differences influence efficacy of educational interventions. Additionally, the results underscore that extant empirical evidence does not always provide unequivocal answers about what approaches are most effective. Educators should incorporate best available empirical knowledge with experiential and contextual knowledge.
Cook DA. Twelve tips for getting your manuscript published. Medical Teacher.2016;38(1):41-50. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2015.1074989
In this article, the author proposes the following twelve practical tips for submitting a good manuscript and getting it published. The following tips are related to the preparation phase:
- Plan early
- Address authorship and expectations upfront
- Maintain control of the writing
- Ensure complete reporting
- Use electronic reference management software
- Polish carefully before submission
- Select the right journal
- Follow journal instructions precisely
The author also suggests the following tips if the manuscript is rejected:
- Get it back out the door quickly
- Carefully review all suggestions
When invited to revise and resubmit, the author recommends:
- Respond carefully to every suggestion
- Get input from others
In addition, the author also proposes detailed suggestions on how to create effective tables and figures, and on how to respond to reviewer critiques
LEARNING AND TEACHING
Chen CH, O’Sullivan P, Teherani A, Fogh S, Kobashi B, ten Cate O. Sequencing learning experiences to engage different level learners in the workplace: An interview study with excellent clinical teachers. Medical Teacher.2015;37(2):1090–1097. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2015.1009431
The authors claim that learning in the clinical workplace can appear to rely on opportunistic teaching. They further suggest that cognitive apprenticeship model describes assigning tasks based on learner rather than just workplace needs. This study aimed to determine how excellent clinical teachers select clinical learning experiences to support the workplace participation and development of different level learners. Using a constructivist grounded theory approach, the authors conducted semi-structured interviews with medical school faculty identified as excellent clinical teachers teaching multiple levels of learners. The authors explored their approach to teach different level learners and their perceived role in promoting learner development. The authors performed thematic analysis of the interview transcripts using open and axial coding. The authors interviewed 19 clinical teachers and identified three themes related to their teaching approach: sequencing of learning experiences, selection of learning activities and teacher responsibilities. All teachers used sequencing as a teaching strategy by varying content, complexity and expectations by learner level. The teachers initially selected learning activities based on learner level and adjusted for individual competencies over time. They identified teacher responsibilities for learner education and patient safety, and used sequencing to promote both. The authors concluded that excellent clinical teachers described strategies for matching available learning opportunities to learners’ developmental levels to safely engage learners and improve learning in the clinical workplace.
Rees EL, Quinn PJ, Davies B, Fotheringham V. How does peer teaching compare to faculty teaching? A systematic review and meta-analysis. Medical Teacher. Published Online: 27 Nov 2015.
The authors state that peer-teaching has become an established and common method to enhance student learning In undergraduate medical education. They also highlight that evidence suggests that peer-teaching provides learning benefits for both learners and tutors. The authors then aimed to describe the outcomes for medical students taught by peers through systematic review and meta-analysis of existing literature. The authors searched seven databases through 21 terms and their Boolean combinations. Studies reporting knowledge or skills outcomes of students taught by peers compared to those taught by faculty or qualified clinicians were included. Extracted data on students’ knowledge and skills outcomes were synthesized through a random effects model meta-analysis.
The search yielded 2292 studies. Five hundred and fifty-three duplicates and 1611 irrelevant articles were removed during title-screening. The abstracts of 128 papers were screened against the inclusion and exclusion criteria. The review included ten studies. Meta-analyses showed no significant difference in peer-teaching compared to faculty teaching for knowledge or skills outcomes, standardized mean differences were 0.07 (95% CI: -0.07, 0.21) and 0.11 (95% CI: -0.07, 1.29), respectively. The authors concluded that students taught by peers do not have significantly different outcomes to those taught by faculty. The authors suggest that, as the process of teaching helps to develop both tutor knowledge and teaching skills, peer-teaching should be supported.
Lockyer JM, Hodgson CS, Lee T, Faremo S, Fisher B, Dafoe W, Yiu V, Violato C. Clinical teaching as part of continuing professional development: Does teaching enhance clinical performance? Medical Teacher. Published Online: 30 Nov 2015.
The authors state that physicians identify teaching as a factor that enhances performance, although existing data to support this relationship is limited.
The authors then aimed to determine whether there were differences in clinical performance scores as assessed through multisource feedback (MSF) data based on clinical teaching. MSF data for 1831 family physicians, 1510 medical specialists, and 542 surgeons were collected from physicians’ medical colleagues, co-workers (e.g., nurses and pharmacists), and patients and examined in relation to information about physician teaching activities including percentage of time spent teaching during patient care and academic appointment. Multivariate analysis of variance, partial eta squared effect sizes, and Tukey’s HSD post hoc comparisons were used to determine between group differences in total MSF mean and subscale mean performance scores by teaching and academic appointment data. Results indicated that higher clinical performance scores were associated with holding any academic appointment and generally with any time teaching versus no teaching during patient care. This was most evident for data from medical colleagues, where these differences existed across all specialty groups. The authors concluded that more involvement in teaching was associated with higher clinical performance ratings from medical colleagues and co-workers. The authors suggest that these results may support promoting teaching as a method to enhance and maintain high-quality clinical performance.
Sternszus R, Macdonald ME, Steinert Y. Resident Role Modeling: “It Just Happens.” Academic Medicine. First published online. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000996
The authors state that role modeling by staff physicians is a significant component of the clinical
teaching of students and residents. However, they argue that the importance of resident role modeling has only recently emerged, and residents’ understanding of themselves as role models has yet to be explored. The authors then sought to understand residents’ perceptions of themselves as role models, describe how residents learn about role modeling, and identify ways
to improve resident role modeling. The authors conducted fourteen semi structured interviews with residents in internal medicine, general surgery, and pediatrics at the McGill University
Faculty of Medicine between April and September 2013. Interviews were audio recorded and subsequently transcribed for analysis; iterative analysis followed principles of qualitative. The authors identified four primary through data analysis: residents perceived role modeling as the demonstration of “good” behaviors in the clinical context; residents believed that learning from their role modeling “just happens” as long as learners are “watching”; residents did not equate role modeling with being a role model; and residents learned about role modeling from watching their positive and negative role models. The authors concluded that, while residents were aware that students and junior colleagues learned from their modeling, they were often not aware of role modeling as it was occurring; they also believed that learning from role modeling “just happens” and did not always see themselves as role models. The authors suggest that helping residents view effective role modeling as a deliberate process rather than something that “just happens” may improve clinical teaching across the continuum of medical education.
Krupat E, Richards JB, Sullivan AM, Fleenor TJ, Schwartzstein RM. Assessing the Effectiveness of Case-Based Collaborative Learning via Randomized Controlled Trial. Academic Medicine.
First published online. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000001004
Case-based collaborative learning (CBCL) is a novel small-group approach that borrows from team-based learning principles and incorporates elements of problem-based learning (PBL) and case-based learning. CBCL includes a preclass readiness assurance process and case-based in-class activities in which students respond to focused, open-ended questions individually, discuss their answers in groups of 4, and then reach consensus in larger groups of 16. The authors introduced CBCL and assessed its effectiveness in one course at Harvard Medical School. In a 2013 randomized controlled trial, 64 medical and dental student volunteers were assigned randomly to one of four 8-person PBL tutorial groups (control; n = 32) or one of two 16-person CBCL tutorial groups (experimental condition; n = 32) as part of a required first-year physiology course. Outcomes for the PBL and CBCL groups were compared using final exam scores, student responses to a post-course survey, and behavioral coding of portions of video-recorded class sessions. Results indicated that, overall, the course final exam scores for CBCL and PBL students were not significantly different. However, CBCL students whose mean exam performance in prior courses was below the participant median scored significantly higher than their PBL counterparts on the physiology course final exam. The most common adjectives students used to describe CBCL were “engaging,” “fun,” and “thought provoking.” Coding of observed
behaviors indicated that individual affect was significantly higher in the CBCL groups than in the
PBL groups. The authors concluded that CBCL is a viable, engaging, active learning method. It may particularly benefit students with lower academic performance.
Reyes JA, Greenberg L, Amdur R, Gehring J, Lesky LG. Effect of handoff skills training for students during the medicine clerkship: a quasi-randomized Study. Adv in Health Sci Educ.2016; 21(1):163–173. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1007/s10459-015-9621-1.
The authors claim that continuity is critical for safe patient care and its absence is associated with adverse outcomes. The authors further argue that continuity requires handoffs between physicians, but most published studies of educational interventions to improve handoffs have focused primarily on residents, despite interns expected to being proficient. The AAMC core entrustable activities for graduating medical students include handoffs as a milestone, but no controlled studies with students have assessed the impact of training in handoff skills. The purpose of this study was to assess the impact of an educational intervention to improve third-year medical student handoff skills, the durability of learned skills into the fourth year, and the transfer of skills from the simulated setting to the clinical environment. Trained evaluators used standardized patient cases and an observation tool to assess verbal handoff skills immediately post intervention and during the student’s fourth-year acting internship. Students were also observed doing real time sign-outs during their acting internship. Evaluators assessed untrained control students using a standardized case and performing a real-time sign-out. Intervention students mean score demonstrated improvement in handoff skills immediately after the workshop (2.6–3.8; p \ 0.0001) that persisted into their fourth year acting internship when compared to baseline performance (3.9–3.5; p = 0.06) and to untrained control students (3.5 vs. 2.5; p \ 0.001, d = 1.2). Intervention students evaluated in the clinical setting also scored higher than control students when assessed doing real-time handoffs (3.8 vs. 3.3; p = 0.032, d = 0.71). The authors conclude that these findings should be useful to others considering introducing handoff teaching in the undergraduate medical curriculum in preparation for post-graduate medical training.
Vaccani J-P, Javidnia H, Humphrey-Murto S. The effectiveness of webcast compared to live lectures as a teaching tool in medical school. Medical Teacher.2016;38(1):59-63. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2014.970990
The purpose of this study was to investigate whether webcast lectures are comparable to live lectures as a teaching tool in medical school. Three Otolaryngology-Head & Neck Surgery (OTO-HNS) lectures were given to third year medical students through their regular academic curriculum with one group receiving lectures in a live lecture format and the other group in a webcast format. All lectures (live or webcast) were given by the same lecturer and contained identical material. Three outcome measures were used: a student satisfaction survey, performance on the OTO-HNS component of their written examination, and performance on an OTO-HNS OSCE station in the general end of year OSCE examination session. The study findings showed that students’ performance on the written examination was equal between the two groups. The webcast group outperformed the live lecture group in the OSCE station. The majority of students in the webcast group felt it was an effective learning tool for them. Most viewed the lectures more than once, and felt that this was beneficial to their learning. The authors concluded that webcasts appear equally effective to live lectures as a teaching tool.
*MeEdPortal News & Updates
Chew K, van Merrienboer J, Durning S. Teaching Cognitive Biases in Clinical Decision Making: A Case-Based Discussion. MedEdPORTAL Publication; 2015. Available from: https://www.mededportal.org/publication/10138; http://dx.doi.org/10.15766/mep_2374-8265.10138
This resource consists of five case scenarios aimed to teach/test participants in identifying the inherent cognitive biases as well as in considering alternative diagnoses (“thinking out of the box”). These cases are embedded with cognitive biases commonly encountered in the clinical setting. By using a blueprint to guide the creation of these cases, at least two or more aspects of patient care are tested (e.g. history taking, physical exam, data interpretation, diagnosis). Theoretically, each of these cases is framed in such a way as to lead the participants into an obvious diagnosis. But besides the obvious diagnosis, there are subtle clinical cues that point to the likelihood of another more urgent or life threatening diagnosis that must be considered. The participants should be reminded that in real situations, the failure to consider these life-threatening conditions may be detrimental to the patient. Undergirding the construct of these cases is the theoretical basis that if the participants slow down and reflect on questions like "Is there any life or limb threat that I need to rule out in this patient?," "If I am wrong, what else could it be?," or "Do I have sufficient evidences to support or exclude this diagnosis?," the participants are more likely to avoid these cognitive biases and be able to pick up the second diagnoses.
New Health Equity Collection Available on MedEdPORTAL
MedEdPORTAL’s Health Equity Collection serves as the online destination for identifying, developing, and sharing resources to educate and engage medical students, resident trainees and faculty on health equity-related skills and concepts. For more information visit: https://www.mededportal.org/icollaborative/about/initiatives/healthequitycollection/
The AAMC recognizes that health and health care disparities arise from conditions in which people are born, live, work and age. These disparities are often persistent in certain populations such as racial/ethnic subgroups, the elderly, veterans, individuals from lower socioeconomic status backgrounds, persons with disabilities and LGBT and rural populations. While there is a vast amount of research aimed at identifying health inequities associated with these populations, the AAMC is committed to increasing the capacity of our member institutions to create the evidence-base for solutions to these health and healthcare gaps. To support these efforts, MedEdPORTAL seeks best practices and continuing education focused on optimizing learners’ acquisition of the competencies and skills needed to provide comprehensive, equity-promoting care for these populations.
*TUSM Faculty Educational Scholarship Publications
Blanco MA, Gruppen LD, Artino Jr. AR, Uijtdehaage S, Szauter K, Durning SJ. How to write an educational research grant: AMEE Guide No.101. Medical Teacher. 2015. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2015.1087483
*What is new in the Lit?!
Devine LA, Stroud L, Gupta R, Lorens E, Robertson S, Panisko D. Does Making the Numerical Values of Verbal Anchors on a Rating Scale Available to Examiners Inflate Scores on a Long Case Examination? Acad Med. 2015. First published online.
This study assessed the impact of making the numerical values of verbal anchors on a rating scale available to examiners in a long case examination (LCE). During the 2011–2012 academic year, the numerical values of verbal anchors on a rating scale for an internal medicine clerkship LCE were made available
to faculty examiners. Historically, and specifically in the control year of 2010–2011, examiners only saw the scale’s verbal anchors and were blinded
to the associated numerical values. To assess the impact of this change, the authors compared students’ LCE scores between the two cohort years. To assess for differences between the two cohorts, they compared students’ scores on other clerkship assessments, which remained the same between the two cohorts. From 2010–2011 (n = 226) to 2011–2012 (n = 218), the median
LCE score increased significantly from 82.11% to 85.02% (P < .01). Students’ performance on the other clerkship assessments was similar between cohorts. The authors concluded that providing examiners with the numerical values of verbal anchors on a rating scale, in addition to the verbal anchors themselves, led to a significant increase in students’ scores on an internal medicine clerkship LCE. The authors suggest that, when constructing or changing rating scales, educators must consider the potential impact of the rating scale structure on students’ scores.
van der Vleuten CPM, Schuwirth LWT, Driessen EW, Govaerts MJB, Heeneman S. Twelve Tips for programmatic assessment. Med Teach. 2015;37(7):641–646. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2014.973388
The authors argue that programmatic assessment is an integral approach to the design of an assessment program with the intent to optimize its learning function, its decision-making function and its curriculum quality-assurance function. Individual methods of assessment, purposefully chosen for their alignment with the curriculum outcomes and their information value for the learner, the teacher and the organization, are seen as individual data points. The information value of these individual data points is maximized by giving feedback to the learner. There is a decoupling of assessment moment and decision moment. Intermediate and high-stakes decisions are based on multiple data points after a meaningful aggregation of information and supported by rigorous organizational procedures to ensure their dependability. Self-regulation of learning, through analysis of the assessment information and the attainment of the ensuing learning goals, is scaffolded by a mentoring system. This approach is consistent with competency-based education frameworks. The authors state that programmatic assessment-for-learning can be applied to any part of the training continuum, provided that the underlying learning conception is constructivist. This paper provides concrete recommendations for implementation of programmatic assessment.
McBee E, Ratcliffe T, Picho K, Artino Jr. AR, Schuwirth L, Kelly W, Masel J, van der Vleuten C, Durning SJ. Consequences of contextual factors on clinical reasoning in resident physicians.
Adv in Health Sci Educ. 2015;20(5): 1225–1236. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1007/s10459-015-9597-x
The authors state that context specificity and the impact that contextual factors have on the complex process of clinical reasoning is poorly understood. Using situated cognition as the theoretical framework, the authors’ aim was to evaluate the verbalized clinical reasoning processes of resident physicians in order to describe what impact the presence of contextual factors have on their clinical reasoning. Participants viewed three video recorded clinical encounters portraying straightforward diagnoses in internal medicine with select patient contextual factors modified. After watching each video recording, participants completed a think- aloud protocol. Transcripts from the think-aloud protocols were analyzed using a constant comparative approach. After iterative coding, utterances were analyzed for emergent themes with utterances grouped into categories, themes and subthemes. Ten residents participated in the study with saturation reached during analysis. Participants universally acknowledged the presence of contextual factors in the video recordings. Four categories emerged as a consequence of the contextual factors: (1) emotional reactions (2) behavioral inferences (3) optimizing the doctor patient relationship and (4) difficulty with closure of the clinical encounter. The presence of contextual factors may impact clinical reasoning performance in resident physicians. When confronted with the presence of contextual factors in a clinical scenario, residents experienced difficulty with closure of the encounter, exhibited as diagnostic uncertainty. The authors suggest that this finding raises important questions about the relationship between contextual factors and clinical reasoning activities and how this relationship might influence the cost effectiveness of care. This study also provides insight into how the phenomena of context specificity may be explained using situated cognition theory.
Schmidt HG, Mamede S. How to improve the teaching of clinical reasoning: a narrative review and a proposal. Medical Education. 2015;49(10):961–973. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1111/medu.12775
The authors state that the development of clinical reasoning (CR) in students has traditionally been left to clinical rotations, which, however, often offer limited practice and suboptimal supervision. Medical schools begin to address these limitations by organizing pre-clinical CR courses. The purpose of this paper is to review the variety of approaches employed in the teaching of CR and to present a proposal to improve these practices. The authors conducted a narrative review of the literature on teaching CR. They searched PubMed and Web of Science for papers published until June 2014. Additional publications were identified in the references cited in the initial papers. The authors used theoretical considerations to characterize approaches and noted empirical findings, when available. Of the 48 reviewed papers, only 24 reported empirical findings. The approaches to teaching CR were shown to vary on two dimensions. The first pertains to the way the case information is presented. The case is either unfolded to students gradually – the ‘serial-cue’ approach – or is presented in a ‘whole-case’ format. The second dimension concerns the purpose of the exercise: is its aim to help students acquire or apply knowledge, or is its purpose to teach students a way of thinking? The authors argue that the most prevalent approach is the serial-cue approach, perhaps because it tries to directly simulate the diagnostic activities of doctors. Evidence supporting its effectiveness is, however, lacking. There is some empirical evidence that whole-case, knowledge-oriented approaches contribute to the improvement of students’ CR. However, thinking process-oriented approaches were shown to be largely ineffective. Based on research on how expertise develops in medicine, the authors argue that students in different phases of their training may benefit from different approaches to the teaching of CR.
Kulasegaram K, Manzone JC, Ku C, Skye A, PhD, Wadey V, Woods NN. Cause and Effect: Testing a Mechanism and Method for the Cognitive Integration of Basic Science. Acad Med. 2015;90(11):S63–S69. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000896
The authors claim that methods of integrating basic science with clinical knowledge are still debated in medical training. One possibility is increasing the spatial and temporal proximity of clinical content to basic science. An alternative model argues that teaching must purposefully expose relationships between the domains. The authors compared different methods of integrating basic science: causal explanations linking basic science to clinical features, presenting both domains separately but in proximity, and simply presenting clinical features. First-year undergraduate health professions students were randomized to four conditions: (1) science–causal explanations (SC), (2) basic science before clinical concepts (BC), (3) clinical concepts before basic science (CB), and (4) clinical features list only (FL). Based on assigned conditions, participants were given explanations for four disorders in neurology or rheumatology followed by a memory quiz and diagnostic test consisting of 12 cases which were repeated after one week. Ninety-four participants completed the study. No difference was found on memory test performance, but on the diagnostic test, a condition by time interaction was found
(F[3,88] = 3.05, P < .03, ηp2 = 0.10). Although all groups had similar immediate performance, the SC group had a minimal decrease in performance on delayed testing; the CB and FL groups had the greatest decreases. The authors concluded that these results suggest that creating proximity between basic science and clinical concepts may not guarantee cognitive integration. Although cause-and-effect explanations may
not be possible for all domains, making explicit and specific connections between domains will likely facilitate the benefits of integration for learners.
Gruppen LD, Durning SJ. Needles and Haystacks: Finding Funding for Medical Education Research. Acad Med. 2015. First published online. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000983
In this perspective article, the authors claim that medical education research suffers from a significant and persistent lack of funding. Although adequate funding has been shown to improve the quality of research, the authors state that there are a number of factors that continue to limit it. The authors then highlight that the competitive environment for medical education research funding makes it essential to understand strategies for improving the search for funding sources and the preparation of proposals. This article offers a number of resources, strategies, and suggestions for finding funding. Investigators must be able to frame their research in the context
of significant issues and principles in education. They must set their proposed work in the context of prior work and demonstrate its potential for significant new contributions. Because there are few funding sources earmarked for medical education research, researchers much also be creative, flexible, and adaptive as they seek to present their ideas in ways that are appealing and relevant to the goals of funders. The authors conclude that, above all, the search for funding requires persistence and perseverance.
van Schaik SM, Regehr G, Eva KW, Irby DM, O’Sullivan PS. Perceptions of Peer-to-Peer Interprofessional Feedback Among Students in the Health Professions. Acad Med. 2015. First published online. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000981
The authors claim that interprofessional teamwork should include interprofessional feedback to optimize performance and collaboration. They propose that social identity theory predicts that hierarchy and stereotypes may limit receptiveness to interprofessional feedback, but literature on this is sparse. This study explores perceptions among health professions students regarding interprofessional peer feedback received after a team exercise. In 2012–2013, students from seven health professions schools (medicine, pharmacy, nursing, dentistry, physical therapy, dietetics, and social work) participated in a team-based interprofessional exercise early in
clinical training. Afterward, they wrote anonymous feedback comments for each other. Each student subsequently completed an online survey to rate the usefulness and positivity (on five-point scales) of feedback received and guessed each comment’s source. Data analysis included analysis of variance to examine interactions (on usefulness and positivity ratings) between profession of feedback recipients and providers. Of 353 study participants, 242 (68.6%) accessed the feedback and 221 (62.6%) completed the survey. Overall, students perceived the feedback as useful (means across professions = 3.84–4.27) and positive (means = 4.17–4.86). There was no main effect of profession of the feedback provider, and no interactions between profession of recipient and profession of provider regardless of whether the actual or guessed provider profession was entered into the analysis. The authors conclude that these findings suggest that students have positive perceptions of interprofessional feedback without systematic bias against any specific group. Whether students actually
use interprofessional feedback for performance improvement and remain receptive toward such feedback as they progress in their professional education deserves further study.
LEARNING AND TEACHING
Gullo C, Ha TC, Cook S. Twelve tips for facilitating team-based learning. Medical Teacher. 2015;37(9):819-824. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2014.1001729
Team-based learning (TBL) has become a more commonly recognized and implemented pedagogical approach in curricula of numerous disciplines. The desire to place more autonomy on the student and spend less in-class time delivering content has resulted in complete or partial adoption of this style of learning in many educational settings. To provide faculty with tools that foster a well facilitated and interactive TBL learning environment the authors examined the published literature in the area of facilitation – specifically in TBL environments, and explored learning theories associated with team learning and our own experiences to create these facilitation tips. As a result, the authors created 12 tips for TBL facilitation designed to assist faculty to achieve an effective and engaging TBL learning environment. Applying these twelve tips while facilitating a TBL classroom session, will help to ensure maximal participation and optimal learning in a safe yet stimulating environment.
Wenrich MD, Jackson MB, Maestas RR, Wolfhagen IHAP, Scherpbier AJJ. From Cheerleader to Coach: The Developmental Progression of Bedside Teachers in Giving Feedback to Early Learners. Acad Med. 2015;90(11):S91–S97. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000901
The authors argue that little is known about the process of becoming an effective clinical teacher. Focusing on giving feedback to early learners, the authors asked: What is the developmental progression of clinician– teachers as they learn to give clinical skills feedback to medical students? This qualitative study included longitudinal interviews with clinician–teachers over five years in a new clinical skills teaching program for preclinical medical students. Techniques derived from grounded theory were used for initial analyses. The current study focused on one theme identified in initial analyses: giving feedback to students. Transcript passages were organized by interview year, coded, and discussed in year clusters; thematic codes were compared and emergent codes developed. Themes related to giving feedback demonstrated a dyadic structure: characteristic of less experienced teachers versus characteristic of experienced teachers. Seven dominant dyadic themes emerged, including teacher as cheerleader versus coach, concern about student fragility versus understanding resilience, and focus on creating a safe environment versus challenging students within a safe environment. The authors concluded that with consistent teaching, clinical teachers demonstrated progress in giving feedback to students in multiple areas, including understanding students’ developmental trajectory and needs, developing tools and strategies, and adopting a dynamic, challenging, inclusive team approach. Ongoing teaching opportunities with targeted faculty development may help improve clinician–teachers’ feedback skills and approaches.
Khanova J, Roth MT, Rodgers JE, McLaughlin JE. Student experiences across multiple flipped courses in a single curriculum. Medical Education 2015;49(10):1038–1048. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1111/medu.12807
The authors argue that the flipped classroom approach has garnered significant attention in health professions education, which has resulted in calls for curriculum-wide implementations of the model. However, research to support the development of evidence-based guidelines for large-scale flipped classroom implementations is lacking. This study was designed to examine how students experience the flipped classroom model of learning in multiple courses within a single curriculum, as well as to identify specific elements of flipped learning that students perceive as beneficial or challenging. A qualitative analysis of students’ comments (n = 6010) from mid-course and end-of-course evaluations of 10 flipped courses (in 2012–2014) was conducted. Common and recurring themes were identified through systematic iterative coding and sorting using the constant comparison method. Multiple coders, agreement through consensus and member checking were utilized to ensure the trustworthiness of findings. Several themes emerged from the analysis: (i) the perceived advantages of flipped learning coupled with concerns about implementation; (ii) the benefits of pre-class learning and factors that negatively affect these benefits, such as quality and quantity of learning materials, as well as overall increase in workload, especially in the context of multiple concurrent flipped courses; (iii) the role of the instructor in the flipped learning environment, particularly in engaging students in active learning and ensuring instructional alignment, and (iv) the need for assessments that emphasize the application of knowledge and critical thinking skills. The authors concluded that analysis of data from 10 flipped courses provided insight into common patterns of student learning experiences specific to the flipped learning model within a single curriculum. The study points to the challenges associated with scaling the implementation of the flipped classroom across multiple courses. Several core elements, critical to the effective design and implementation of the flipped classroom model, are identified.
Al-Eraky MM. Twelve Tips for teaching medical professionalism at all levels of medical education. Med Teach. 2015;37(11):1018–1025. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2015.1020288
The author claims that review of studies published in medical education journals over the last decade reveals that teaching medical professionalism is essential, yet challenging. According to a recent Best Evidence in Medical Education (BEME) guide, there is no consensus on a theoretical or practical model to integrate the teaching of professionalism into medical education. The aim of this article is to outline a practical manual for teaching professionalism at all levels of medical education. Drawing from research literature and author’s experience, Twelve Tips are listed and organized in four clusters with relevance to (1) the context, (2) the teachers, (3) the curriculum, and (4) the networking. With a better understanding of the guiding educational principles for teaching medical professionalism, medical educators will be able to teach one of the most challenging constructs in medical education.
Rougas S, Gentilesco B, Green E, Flores L. Twelve tips for addressing medical student and resident physician lapses in professionalism. Med Teach. 2015;37(10):901–907. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2014.1001730
The authors state that medical educators have gained significant ground in the practical and scholarly approach to professionalism. When a lapse occurs, thoughtful remediation to address the underlying issue can have a positive impact on medical students and resident physicians, while failure to address lapses, or to do so ineffectively, can have long-term consequences for learners and potentially patients. The authors argue that, despite these high stakes, educators are often hesitant to address lapses in professionalism, possibly due to a lack of time and familiarity with the process. Attention must be paid to generalizable, hands-on recommendations for daily use so that clinicians and administrators feel well equipped to tackle this often difficult yet valuable task. This article reviews the literature related to addressing unprofessional behavior among trainees in medicine and connects it to the shared experience of medical educators at one institution. The framework presented aims to provide practical guidance and empowerment for educators responsible for addressing medical student and resident physician lapses in professionalism.
*MeEdPortal News & Updates
Akerson E, Stewart A, Baldwin J, Gloeckner J, Bryson B, Cockley D. Got Ethics? Exploring the Value of Interprofessional Collaboration Through a Comparison of Discipline Specific Codes of Ethics. MedEdPORTAL Publications; 2013. Available from: https://www.mededportal.org/publication/9331#sthash.gtVJAuJr.dpuf
Quality health care requires that health professionals are well informed about the contributions of their own and other health professionals. Ethics is a shared, relevant concern among health and human service disciplines and is an ideal vehicle for students from different fields to learn about one another's disciplines and to participate in interprofessional discussions and problem solving. This session is relevant to a number of the general and specific core competencies named in the Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel, including: Work with individuals of other professions to maintain a climate of mutual respect and shared values; Respect the unique cultures, values, roles/responsibilities, and expertise of other health professions; Listen actively, and encourage ideas and opinions of other team members; Develop consensus on the ethical principles to guide all aspects of patient care and team work; Reflect on individual and team performance for individual, as well as team, performance improvement. The session can be used at any time in a course sequence and may be especially useful as an introductory session.
Kramer E, DiPace J, Frost M, Rassbach C. Faculty Development Series on Assessment in Graduate Medical Education: Practice-Based Learning and Improvement. MedEdPORTAL Publications; 2015. Available from: https://www.mededportal.org/publication/10102#sthash.fhpYlx00.dpuf
This resource is a set of PowerPoint slides that were designed for the purpose of faculty development. The slides are intended for presentation by a residency program director (or designee) in a didactic or workshop setting for the purpose of enhancing the faculty's ability to assess practice-based learning and improvement (PBLI) in trainees. This case-based presentation begins by defining the competency of PBLI, then explores various assessment tools available for evaluating learners in this competency. The presentation introduces the concept of The Pediatrics Milestone Project and demonstrates how Milestones can be used to better assess PBLI. The presentation concludes with a series of case studies where the participants are asked to assess the performance of the learners in the case studies. Speaker's notes are provided at the bottom of the slides to enable the presenter to have a deeper understanding of the content. The slides were left in PowerPoint format so that the speaker could hide slides and modify them to include local content, such as site-specific evaluation tools. The presentation requires 45-60 minutes to present in its entirety, but can be abbreviated or expanded as needed.
Newman L, Tibbles C, Atkins K, Burgin S, Fisher L, Kent T, Smith C, Aluko A, Ricciotti H. Resident-as-Teacher DVD Series. MedEdPORTAL Publications; 2015. Available from: https://www.mededportal.org/publication/10152#sthash.7xY2Q5Rd.dpuf
The authors developed this DVD, accompanying guides, and resources to help program directors, clinician educators, and residents take the first step in implementing a resident-as-teacher training program. The intent is to provide a platform that allows for efficient but comprehensive training of five essential clinical teaching topics. The DVD series may be used as part of a resident self-study program, as the basis of a facilitator-led teaching series for house staff, or as preparatory material for "flipped" classroom-type sessions. The overall goals for the series are to 1) initiate formal discussions with residents across clinical departments about the knowledge, skills, and behaviors associated with best teaching practices; 2) encourage application of adult learning principles in varied clinical settings; and 3) develop residents' confidence serving in clinical teaching and supervisory roles.
Assessing Change: Evaluating Cultural Competence Education and Training
To help educators identify curricular strategies and evaluation tools for re-use or enhancement, the AAMC commissioned an expert panel to review cultural competence studies that measured learner changes in attitudes, knowledge, and skills. This guide, which is based on the panel’s findings, provides these resources for educators and researchers:
- An inventory of the research studies that assess the outcomes of cultural competence education and training
- Four recommended strategies to advance the research and evaluation
- A Cultural Competence Assessment Tool Checklist, along with a guide to using the tool, to help educators and research measure facets of cultural competence in published assessment tools
- An overview of three evaluation approaches for curriculum development and evaluation
Review Criteria for Research Manuscripts, Second Edition
High-quality reviews are vital, both for ensuring the excellence of published scholarship and as a way to provide authors with important feedback that they can use to improve their scholarship
This guide intends to:
- Familiarize our reviewers with the purposes of review, approaches to or best practices for reviewing, and criteria for superlative research.
- Help reviewers organize and communicate their recommendations effectively to Academic Medicine and other journals.
- Help researchers by explaining the criteria used to evaluate their submissions.
- Improve peer review and the quality of published research.
*TUSM Faculty Educational Scholarship Publications
Baecher-Lind L, Chang K, Blanco MA. The learning environment in the obstetrics and gynecology clerkship: an exploratory study of students’ perceptions before and after the clerkship. Med Educ Online. 2015; 20:27273.
Angus S, Moriarty J, Nardino RJ, Chmielewski A, Rosenblum MJ. Internal Medicine Residents' Perspectives on Receiving Feedback in Milestone Format. Journal of Graduate Medical Education. June 2015; 7(2): 220-224.
*What is new in the Lit?!
Sawyer T, White M, , Zaveri P, Chang T, Ades A, French H, Anderson J, Auerbach M, Johnston L, and Kessler D. Learn, See, Practice, Prove, Do, Maintain: An Evidence-Based Pedagogical Framework for Procedural Skill Training in Medicine. Acad Med. Aug 2015;90(8):1025-33. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000734
In this perspective article, the authors propose an evidence-based pedagogical framework for procedural skill training. The framework was developed based on a review of the literature using a critical synthesis approach and builds on earlier models of procedural skill training in medicine. The authors begin by describing the fundamentals of procedural skill development. Then, a six-step pedagogical framework for procedural skills training is presented: Learn, See, Practice, Prove, Do, and Maintain. In this framework, procedural skill training begins with the learner acquiring requisite cognitive knowledge through didactic education (Learn) and observation of the procedure (See). The learner then progresses to the stage of psychomotor skill acquisition and is allowed to deliberately practice the procedure on a simulator (Practice). Simulation-based mastery learning is employed to allow the trainee to prove competency prior to performing the procedure on a patient (Prove). Once competency is demonstrated on a simulator, the trainee is allowed to perform the procedure on patients with direct supervision, until he or she can be entrusted to perform the procedure independently (Do). Maintenance of the skill is ensured through continued clinical practice, supplemented by simulation based training as needed (Maintain). Evidence in support of each component of the framework is presented. Implementation of the proposed framework presents a paradigm shift in procedural skill training. However, the authors believe that adoption of the framework will improve procedural skill training and patient safety.
Rawlings A, Knox AD, Park YS, Reddy S, Williams SR, Issa N, Jameel A, Tekian A. Development and Evaluation of Standardized Narrative Cases Depicting the General Surgery Professionalism Milestones. Acad Med. 2015 Aug;90(8):1109-15. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000739
The authors argue that the literature suggests that narrative cases are a promising tool to track residents’ progress. The authors conducted a study to demonstrate the process for developing and evaluating narrative cases representing the five levels of the professionalism milestones for general surgery. The authors identified 28 behaviors in the Accreditation Council for Graduate Medical Education general surgery professionalism milestones. They modified previously published narrative cases to fit these behaviors. To evaluate the quality of these cases, the authors developed a 28-item, five-point scale instrument, which 29 interdisciplinary faculty completed. The authors compared the faculty ratings by narrative case and specialty with the authors’ initial rankings of the cases by milestone level. They used t tests and analysis of variance to compare mean scores across specialties. The authors developed 10 narrative cases, 2 for each of the 5 milestone levels. Each case contained at least 20 of the 28 behaviors identified in the milestones. Mean faculty ratings matched the milestone levels. Reliability was good (G coefficient = 0.86, phi coefficient = 0.85), indicating consistency in raters’ ability to determine the proper milestone level for each case. The authors conclude that this process can be applied to other competencies and specialties to facilitate faculty awareness of resident performance descriptors and provide a frame of reference for milestones assessment.
van de Ridder JM, Peters CM, Stokking KM, de Ru JA, Ten Cate OT. Framing of feedback impacts student’s satisfaction, self-efficacy and performance. Adv Health Sci Educ Theory Pract. 2015 Aug;20(3):803-16. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1007/s10459-014-9567-8
The authors designed a randomised controlled trial to investigate the effect of positively and negatively framed feedback messages on satisfaction, self-efficacy, and performance. A single blind randomised controlled between-subject design was used, with framing of the feedback message (positively–negatively) as independent variable and examination of hearing abilities as the task. First year medical students’ (n = 59) satisfaction, self-efficacy, and performance were the dependent variables and were measured both directly after the intervention and after a 2 weeks delay. Students in the positively framed feedback condition were significantly more satisfied and showed significantly higher self-efficacy measured directly after the performance. Effect sizes found were large, i.e., partial g2 = 0.43 and g2 = 0.32 respectively. These students showed a better performance throughout the whole study. Significant performance differences were found both at the initial performance and when measured 2 weeks after the intervention: effects were of medium size, respectively r = -.31 and r = -.32. Over time in both conditions performance and self-efficacy decreased. The authors concluded that framing the feedback message in either a positive or negative manner affects students’ satisfaction and self-efficacy directly after the intervention be it that these effects seem to fade out over time. Performance may then be enhanced by positive framing, but additional studies need to confirm this. The authors recommend using a positive frame when giving feedback on clinical skills.
Bennett D, O’Flynn S, Kelly M. Peer assisted learning in the clinical setting: an activity systems analysis. Adv Health Sci Educ Theory Pract. 2015 Aug;20(3):595-610. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1007/s10459-014-9557-x
The authors argue that peer assisted learning (PAL) is a common feature of medical education. However, research on PAL has been based on processes and outcomes in controlled settings, such as clinical skills labs. The authors proposed that PAL in the clinical setting, a complex learning environment, requires fresh evaluation. In this paper, the authors describe the evaluation of a PAL intervention, introduced to support students’ transition into full time clinical attachments, using activity theory and activity systems analysis (ASA). The research question was How does PAL transfer to the clinical environment? Junior students on their first clinical attachments undertook a weekly same-level, reciprocal PAL activity. Qualitative data was collected after each session, and focus groups (n = 3) were held on completion. Data was analyzed using ASA. ASA revealed two competing activity systems on clinical attachment; Learning from Experts, which students saw as the primary function of the attachment and Learning with Peers, the PAL intervention. The latter took time from the first and was in tension with it. Tensions arose from student beliefs about how learning takes place in clinical settings, and the importance of social relationships, leading to variable engagement with PAL. Differing perspectives within the group were opportunities for expansive learning. The authors concluded that PAL in the clinical environment presents challenges specific to that context. The authors suggest that planning learning opportunities on clinical placements, must take account of how students learn in workplaces, and the complexity of the multiple competing activity systems related to learning and social activities.
Sargeant J, Lockyer J, Mann K, Holmboe E, Silver I, Armson H, Driessen E, MacLeod T, Yen W, Ross K, Power M. Facilitated Reflective Performance Feedback: Developing an Evidence- and Theory-Based Model That Builds Relationship, Explores Reactions and Content, and Coaches for Performance Change (R2C2). Acad Med. 2015.. First published online. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000809
The authors developed a feedback model drawing on earlier research which highlights not only the factors that influence giving, receiving, accepting, and using feedback but also the theoretical perspectives which enable the understanding of these influences.
The authors undertook an iterative, multistage, qualitative study guided by two recognized research frameworks: the UK Medical Research Council guidelines for studying complex interventions and realist evaluation. Using these frameworks, they conducted the research in four stages: (1) modeling, (2) facilitator preparation, (3) model feasibility testing, and (4) model refinement. They analyzed data, using content and thematic analysis, and used the findings from each stage to inform the subsequent stage. Findings supported the facilitated feedback model, its four phases—build relationship, explore reactions, explore content, coach for performance change (R2C2)—and the theoretical perspectives informing them. These findings contribute to understanding elements that enhance recipients’ engagement with, acceptance of, and productive use of feedback. Facilitators reported that the model made sense and the phases generally flowed logically. Recipients reported that the feedback process was helpful and that they appreciated the reflection stimulated by the model and the coaching. The authors concluded that the theory- and evidence-based reflective R2C2 Facilitated Feedback Model appears stable and helpful for physicians in facilitating their reflection on and use of formal performance assessment feedback.
Cate OT, Chen HC, Hoff RG, Peters H, Bok H, van der Schaaf M. Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99. Med Teach 2015, 1–20, Early Online. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2015.1060308
This Guide was written to support educators interested in building a competency-based workplace curriculum. It aims to provide an up-to-date overview of the literature on Entrustable Professional Activities (EPAs), supplemented with suggestions for practical application to curriculum construction, assessment and educational technology. The Guide first introduces concepts and definitions related to EPAs and then guidance for their identification, elaboration and validation, while clarifying common misunderstandings about EPAs. A matrix-mapping approach of combining EPAs with competencies is discussed, and related to existing concepts such as competency milestones. A specific section is devoted to entrustment decision-making as an inextricable part of working with EPAs. In using EPAs, assessment in the workplace is translated to entrustment decision-making for designated levels of permitted autonomy, ranging from acting under full supervision to providing supervision to a junior learner. A final section is devoted to the use of technology, including mobile devices and electronic portfolios to support feedback to trainees about their progress and to support entrustment decision-making by programme directors or clinical teams.
Steinert Y, Macdonald ME. Why physicians teach: giving back by paying it forward. Med Educ. 2015 Aug;49(8):773-82. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1111/medu.12782
The goal of this study was to explore what it means for physicians to teach students and residents in the in-patient setting. The authors conducted semi-structured interviews with 15 practicing physicians from the departments of internal medicine, surgery and pediatrics in three university teaching hospitals at McGill University, using an interpretive phenomenological methodology. Five themes elucidated the meaning of teaching for physicians in the in-patient setting: (i) teaching was perceived as an integral part of their identity; (ii) teaching allowed them to repay former teachers for their own training; (iii) teaching gave them an opportunity to contribute to the development of the next generation of physicians; (iv) teaching enabled them to learn, and (v) teaching was experienced as personally energizing and gratifying. Participants were morally and socially motivated to give time and effort through teaching (e.g. to pay forward their own privilege and thereby help to develop the next generation); teaching also gave them a sense of personal fulfilment (e.g. by allowing them to mould young minds and leave a legacy). The authors concluded that this study holds a number of implications for medical education with relevance to the recruitment and retention of clinical teachers, recognition of clinical teaching, and evidence-informed faculty development. The findings also suggest that teaching in an academic setting can bring joy and fulfilment to practicing physicians.
Walton JM, White J, Ross S. What’s on YOUR Facebook profile? Evaluation of an educational intervention to promote appropriate use of privacy settings by medical students on social networking sites. Med Educ Online. 2015 Jul 20;20:28708. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3402/meo.v20.28708
The purpose of this project was to examine the Internet presence of a graduating Canadian medical school class by scanning students’ public profiles on the social media site Facebook, incorporate this information into an educational activity addressing professionalism and social media, and evaluate the impact of this activity on student behavior. A systematic search for public Facebook profiles of each member of the class was conducted, and data were collected on the types of publicly visible material. These were presented as part of an educational session on social media and professionalism. One month later, the Facebook search was repeated. Of 152 students in the class, profiles were found for 121 (79.8%). The majority of students used appropriately restrictive privacy settings; however, a significant minority had publicly visible information, including comments, photographs, location, and status as a medical student. The educational innovation was well received with more than 90% of students agreeing that this topic was important and well addressed. A follow-up search found that many students had altered their privacy settings to make less information publicly available. The authors concluded that a small but significant proportion of students share potentially unprofessional content on social media. An interactive educational intervention, which includes specific disclosure of how participants appear to others on social media, resulted in a significant change in student behavior.
Sawatsky AP, Zickmund SL, Berlacher K, Lesky D, Granieri R. Understanding the challenges to facilitating active learning in the resident conferences: a qualitative study of internal medicine faculty and resident perspectives. Med Educ Online. 2015 Jul 7;20:27289. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3402/meo.v20.27289
The goal of this study was to identify challenges to facilitating active learning in resident conferences, both through identifying specific implementation barriers and identifying differences in perspective between faculty and residents on effective teaching and learning strategies. The investigators invited core residency faculty to participate in focus groups. Data were compared to previously collected data from seven resident focus groups. Three focus groups with 20 core faculty were conducted. The authors identified three domains pertaining to facilitating active learning in resident conferences: barriers to facilitating active learning formats, similarities and differences in faculty and resident learning preferences, and divergence between faculty and resident opinions about effective teaching strategies. Faculty identified several setting, faculty, and resident barriers to facilitating active learning in resident conferences. When compared to residents, faculty expressed similar learning preferences; the main differences were in motivations for conference attendance and type of content. Resident preferences and faculty perspectives differed on the amount of information appropriate for lecture and the role of active participation in resident conferences. This study highlights several challenges to facilitating active learning in resident conferences and provides insights for residency faculty who seek to transform the conference learning environment within their residency program.
Mookherjee S, Hunt S, Chou CL. Twelve tips for teaching evidence-based physical examination. Med Teach. 2015 Jul;37(6):543-50. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2014.959908
Practicing evidence-based physical examination (EBPE) requires clinicians to apply the diagnostic accuracy of PE findings in relation to a suspected disease. Though it is important to effectively teach EBPE, clinicians often find the topic challenging. There are few resources available to guide clinicians on strategies to teach EBPE. The authors seek to fill that need by presenting tips for effectively teaching EBPE in the clinical context. This report is based primarily on the authors’ experience and is supported by the available literature. The authors present 12 practical tips targeting the clinician educator. The first six tips condense key preparatory steps for the teacher, including basic statistics underpinning EBPE. The final six tips provide specific guidance on how to teach EBPE in the clinical environment. By practicing the 12 tips provided, clinicians will develop the confidence needed to effectively teach EBPE in inpatient or outpatient settings.
Gauthier S, Cavalcanti R, Goguen J, Sibbald M. Deliberate practice as a framework for evaluating feedback in residency training. Med Teach. 2015 Jul;37(6):551-7. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2014.956059
Using the theory of deliberate practice, a key component of Ericsson’s theory of expertise development, this study aims to evaluate the quality of written feedback given to learners. The authors created a feedback scoring system based on the key elements of deliberate practice and used it to assess the quality of written feedback provided to residents in 205 mini-CEX encounter forms. Scores were assigned to each feedback entry for identification of the following: Task, performance gap and action plan. The scoring system allowed for reliable identification of the components that facilitate deliberate practice in written feedback provided to trainees. However, only one of these components was identified in 70% of the feedback entries. A specific task was identified in 56%, whereas specific performance gaps and action plans were identified in only 3.9% and 13.7% of encounters, respectively. The authors concluded that scoring written feedback identified that tasks were often specifically described, but performance gaps and action plans were less frequently and specifically mentioned. Educators might improve feedback effectiveness by better articulating to trainees the gap between their performance and an expert standard, as well as by providing them with specific learning plans.
Feeley AM, Biggerstaff DL. Exam Success at Undergraduate and Graduate-Entry Medical Schools: Is Learning Style or Learning Approach More Important? A Critical Review Exploring Links Between Academic Success, Learning Styles, and Learning Approaches Among School-Leaver Entry (“Traditional”) and Graduate- Entry (“Nontraditional”) Medical Students. Teach Learn Med. 2015 Jul-Sep;27(3):237-44. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1080/10401334.2015.1046734
The literature on learning styles over many years has been replete with debate and disagreement. Researchers have yet to elucidate exactly which underlying constructs are measured by the many learning styles questionnaires available. Some academics question whether learning styles exist at all. When it comes to establishing the value of learning styles for medical students, a further issue emerges. The authors wanted to answer a very simple, practical question: what can the literature on learning styles tell us that we can use to help today’s medical students succeed academically at medical school? The authors conducted a literature review to synthesize the available evidence on how two different aspects of learning—the way in which students like to receive information in a learning environment (termed learning “styles”) and the motivations that drive their learning (termed learning “approaches”)—can impact on medical students’ academic achievement. The authors’ review confirms that although learning “styles” do not correlate with exam performance, learning “approaches” do: those with “strategic” and “deep” approaches to learning (i.e., motivated to do well and motivated to learn deeply respectively) perform consistently better in medical school examinations. Changes in medical school entrant demographics in the past decade have not altered these correlations. Optimistically, this review reveals that students’ learning approaches can change and more adaptive approaches may be learned. The authors suggest that, for educators wishing to help medical students succeed academically, current evidence demonstrates that helping students develop their own positive learning approach using “growth mind-set” is a more effective (and more feasible) than attempting to alter students’ learning styles.
Vaughn JL, Rickborn LR, Davis JA. Patients’ Attitudes Toward Medical Student Participation Across Specialties: A Systematic Review. Teach Learn Med. 2015 Jul-Sep;27(3):245-53. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1080/10401334.2015.1044750
Medical students commonly participate in patient care in a variety of different settings. However, a systematic review of patients’ attitudes toward medical student participation across specialties has not been performed. The authors searched 7 databases (CINAHL, Cochrane Library, ERIC, MEDLINE, PsycINFO, Scopus, and Web of Science) between January 1, 1999, and August 5, 2014. Two authors independently screened the results and selected articles that were written in English, were published in a peer reviewed journal, and used a structured or semi-structured survey or interview to determine patients’ attitudes toward medical student participation in their care. Study quality was assessed using the Medical Education Research Study Quality Instrument. Fifty-nine studies were included. Average study quality was low. Sixty-one unique evaluation instruments were used, and 34 instruments (56%) lacked validity data. Patient satisfaction was not significantly affected by medical student participation. However, patients’ acceptance of medical student participation varied widely between studies and depended on the type of participation. The most common reason for acceptance was a desire to contribute to the education of others, and the most common reason for refusal was concerns about privacy. Minorities were more likely to refuse medical student participation. Patients preferred to be informed before medical students participated in their care. The authors concluded that patient satisfaction is not significantly affected by medical student participation. However, patient satisfaction may be a poor surrogate marker of patients’ acceptance of medical students. Future research should employ validated evaluation instruments to further explore patients’ attitudes toward medical student participation.
*What is new in the Lit?!
Ahmadi S-F, Baradaran HR, Ahmadi E. Effectiveness of teaching evidence-based medicine to undergraduate medical students: A BEME systematic review. Medical Teacher. 2015, 37(1): 21–30. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.3109/0142159X.2014.971724.
The authors claim that, despite the widespread teaching of evidence-based medicine (EBM) to medical students, the relevant literature has not been synthesized appropriately as to its value and effectiveness. In this Best Evidence Medical Education (BEME) Guide, the authors systematically reviewed the literature regarding the impact of teaching EBM to medical students on their EBM knowledge, attitudes, skills and behaviors. Results indicated that 10,111 potential studies were initially found, of which 27 were included in the review. Six studies examined the effect of clinically integrated methods, of which five had a low quality and the other one used no validated assessment tool. Twelve studies evaluated the effects of seminars, workshops and short courses, of which 11 had a low quality and the other one lacked a validated assessment tool. Six studies examined e-learning, of which five having a high or acceptable quality reported e-learning to be as effective as traditional teaching in improving knowledge, attitudes and skills. One robust study found problem-based learning less effective compared to usual teaching. Two studies with high or moderate quality linked multicomponent interventions to improved knowledge and attitudes. No included study assessed the long-term effects of the teaching of EBM. The authors conclude that some EBM teaching strategies have the potential to improve knowledge, attitudes and skills in undergraduate medical students, but the evidenced base does not demonstrate superiority of one method. There is no evidence demonstrating transfer to clinical practice.
Aylward M, Nixon J, Gladding S. An Entrustable Professional Activity (EPA) for Handoffs as a Model for EPA Assessment Development. Acad Med. 2014 Oct;89(10):1335-40. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000317
The American Board of Internal Medicine and American Board of Pediatrics milestones, and the concept of entrustable professional activities (EPA)—skills essential to the practice of medicine that educators progressively entrust learners to perform—provide new approaches to assessing outcomes. The authors argue that although some defined EPAs exist for internal medicine and pediatrics residency programs, the continued development and implementation of EPAs remains challenging. As residency programs are expected to begin reporting milestone-based performance, however, they will need examples of how to overcome these challenges. The authors describe a model for the development and implementation of an EPA using the resident handoff as an example. The model includes nine steps: selecting the EPA, determining where skills are practiced and assessed, addressing barriers to assessment, determining components of the EPA, determining needed assessment tools, developing new assessments if needed, determining criteria for advancement through entrustment levels, mapping milestones to the EPA, and faculty development. Following implementation, 78% of interns at the University of Minnesota Medical School were observed giving handoffs and provided feedback. The authors suggest that this model of EPA development—which includes engaging stakeholders, an iterative process to describing the behavioral characteristics of each domain at each level of entrustment, and the development of specific assessment tools that support both formative feedback and summative decisions about entrustment—can serve as a model for EPA development for other clinical skills and specialty areas.
Chamberland M, Mamede S, St-Onge C, Setrakian J, Bergeron L, Schmidt H. Self-explanation in learning clinical reasoning: the added value of examples and prompts. Medical Education 2015: 49: 193–202. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1111/medu.12623.
The authors conducted a study aimed at assessing the impact on medical students’ diagnostic performance of: (i) combining students’ self-explanations (SEs) with their listening to examples of residents’ SEs, and (ii) the addition of prompts (specific questions) while working with examples. The study consisted of a training phase and an assessment phase conducted 1 week later. In the training phase, 54 Year 3 medical students were randomly assigned to one of three groups. In all groups, students first solved four clinical cases using SE. Subsequently, Group 1 listened to examples of residents’ SEs with prompts; Group 2 listened to examples of residents’ SEs without prompts, and the control group solved word puzzles. Then, all students again solved the same four cases. One week later, all students solved four similar and four different cases. Students’ diagnostic performance and diagnostic accuracy scores were assessed for each case at each time-point. Based on the study findings, the authors conclude that self-explanation seems to be an effective technique to help medical students learn clinical reasoning. Its impact is increased significantly by combining it with examples of residents’ SEs and prompts. The authors also suggest that although students’ exposure to examples of clinical reasoning is important, their ‘active processing’ of these examples appears to be critical to student’s learning from them.
Day FC, Srinivasan M, Der-Martirosian C, Griffin E, Hoffman JR, Wilkes, MS. A Comparison of Web-Based and Small-Group Palliative and End-of-Life Care Curricula:A Quasi-Randomized Controlled Study at One Institution. Acad Med. 2015;90(3):00–00. First published online: http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000607.
The authors conducted a study to compare the effect of Web-based eLearning versus small-group learning on medical student outcomes. Palliative and end-of-life (PEOL) education is ideal for this comparison, given the uneven access to PEOL experts and content nationally. In 2010, the authors enrolled all third-year medical students at the University of California, Davis School of Medicine into a quasi-randomized controlled trial of Web-based interactive education (eDoctoring) compared with small-group education (Doctoring) on PEOL clinical content over two months. Students participated in three 3-hour PEOL sessions with similar content. Outcomes included a 24-item PEOL-specific self-efficacy scale with three domains (diagnosis/treatment [Cronbach alpha = 0.92; CI: 0.91–0.93], communication/ prognosis [alpha = 0.95; CI: 0.93–0.96], and social impact/self-care [alpha = 0.91; CI: 0.88–0.92]); 8 knowledge items; 10 curricular advantage/disadvantages; and curricular satisfaction (both students and faculty). Findings showed equivalent gains in self-efficacy and knowledge between students participating in a Web-based PEOL curriculum in comparison with students learning similar content in a small-group format. The authors conclude that Web-based curricula can standardize content presentation when local teaching expertise is limited, but it may lead to decreased user satisfaction.
Dornan T, Tan N, Boshuizen H, Gick R, Isba R, Mann K, Scherpbier A, Spencer J, Timmins E. How and what do medical students learn in clerkships? Experience based learning (ExBL). Adv in Health Sci Educ (2014) 19(5):721–749. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1007/s10459-014-9501-0.
The authors aimed at developing a blueprint for clerkship education in ambulatory and inpatient settings, and in single encounters, traditional rotations, or longitudinal experiences. They identified 548 causal links between conditions, processes, and outcomes of clerkship education in 168 empirical papers published over 7 years, and synthesized a theory of how students learn. The authors suggest that students do so when they are given affective, pedagogic, and organizational support. Affective support comes from doctors’ and many other health workers’ interactions with students. Pedagogic support comes from informal interactions and modelling as well as doctors’ teaching, supervision, and precepting. Organizational support comes from every tier of a curriculum. Core learning processes of observing, rehearsing, and contributing to authentic clinical activities take place within triadic relationships between students, patients, and practitioners. The phrase ‘supported participation in practice’ best describes the educational process. Much of the learning that results is too tacit, complex, contextualized, and individual to be defined as a set of competencies. The authors conclude that clerkship education takes place within relationships between students, patients, and doctors, supported by informal, individual, contextualized, and affective elements of the learned curriculum, alongside formal, standardized elements of the taught and assessed curriculum. This research provides a blueprint for designing and evaluating clerkship curricula, as well as helping patients, students, and practitioners collaborate in educating tomorrow’s doctors.
Gaglani SM, Topol EJ. iMedEd: The Role of Mobile Health Technologies in Medical Education. Acad Med. 2014;89(9):1207-09. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000361.
The authors claim that, while much discussion has been devoted to how Mobile health (mHealth) technologies will impact the practice of medicine, surprisingly little has been written on the role these technologies will play in medical education. In this commentary, the authors describe the opportunities, applications, and challenges of mHealth apps and devices in medical education and argue that medical schools should make efforts to integrate these technologies into their curricula. The authors maintain that, by not doing so, medical educators risk producing a generation of clinicians underprepared for the changing realities of medical practice brought on by mHealth technologies.
Kost A, Chen FM. Socrates Was Not a Pimp: Changing the Paradigm of Questioning in Medical Education. Acad Med. 2015 Jan;90(1):20-4. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000446.
The authors explain that the slang term “pimping” is widely recognized by learners and educators in the clinical learning environment as the act of more senior members of the medical team publicly asking questions of more junior members. The authors argue that, although questioning as a pedagogical practice has many benefits, pimping, as described in the literature, evokes negative emotions in learners and leads to an environment that is not conducive to adult learning. They propose explicitly separating pimping from the larger practice of questioning, and make three recommendations for improving questioning practices. First, educators should examine the purpose of each question they pose to learners. Second, they should apply historic and modern interpretations of Socratic teaching methods that promote critical thinking skills. Finally, they should consider adult learning theories to make concrete changes to their questioning practices. These changes can result in questioning that is more learner centered, aids in the acquisition of knowledge and skills, performs helpful formative and summative assessments of the learner, and improves community in the clinical learning environment.
Nixon J, Wolpaw T, Schwartz A, Duffy B, Menk J, Bordage G. SNAPPS-Plus: An Educational Prescription for Students to Facilitate Formulating and Answering Clinical Questions. Acad Med. 2014 Aug; 89(8):1174-9. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000362.
The authors analyzed the content and quality of PICO-formatted questions (Patient–Intervention–Comparison–Outcome), and subsequent answers, from students’ educational prescriptions added to the final SNAPPS* Select step (SNAPPS-Plus). Students were instructed to use educational prescriptions to complement their bedside SNAPPS case presentations during their inpatient rotation. The authors concluded that the SNAPPS-Plus technique was easily integrated into the inpatient clerkship structure and guaranteed that virtually every case presentation following this model had a well-formulated question and answer.
*SNAPPS: is a learner-centered model for case presentations to the preceptor that consists of six steps: (1) Summarize briefly the history and findings; (2) Narrow the differential to two or three relevant possibilities; (3) Analyze the differential by comparing and contrasting the possibilities; (4) Probe the preceptor by asking questions about uncertainties, difficulties, or alternative approaches; (5) Plan management for the patient's medical issues; and (6) Select a case-related issue for self-directed learning.
Patel MS, Arora V, Patel MS, Kinney JM, Pauly MV, Asch DA. The Role of MD and MBA Training in the Professional Development of a Physician: A Survey of 30 Years of Graduates From the Wharton Health Care Management Program. Acad Med. 2014 Sep;89(9):1282-6. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1097/ACM.0000000000000366.
Given that the number of medical schools offering MD and MBA training has increased fivefold in the last two decades, the authors evaluated graduates’ perceptions of the role of such training on their career and professional development. In 2011, the authors surveyed physician graduates from the Wharton School MBA Program in Heath Care Management at the University of Pennsylvania from 1981 to 2010. Survey responses were analyzed and evaluated using grounded theory. Graduates with an MD and MBA reported mostly positive attitudes towards their training, and many were pursuing leadership and primarily nonclinical roles later in their careers. The authors conclude that these findings reveal new insights for policies affecting physician workforce, and that further study is necessary to evaluate whether similar trends exist more broadly.
van der Zwet J, De la Croix A, de Jonge L, Stalmeijer R, Scherpbier A, Teunissen P. The power of questions: a discourse analysis about doctor–student interaction. Med Ed 2014; 48(8): 806–819. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1111/medu.12493.
The authors claim that how people talk with one another influences their identity, their position and what they are allowed to do. This paper focuses on the opportunities and challenges of such moments of interaction between doctors and students during a clerkship characterized by short supervisory relationships. The authors conducted the study in a 10-week internal medicine clerkship. Nine students and 10 doctors who worked with these nine students participated by regularly describing moments of interaction, using dictaphones. The authors performed a critical discourse analysis of material sourced from a total of 184 audio diary entries and seven student debriefing interviews to reveal how participants discursively shaped the way they could think, speak and conduct themselves. Findings suggested that the ways in which doctors and students posed and answered questions represented a recurrent and influential feature in the diaries. This Question and Answer dynamic revealed six discourses of Basic Learning Need, Care and Attention, Power Game, Exchange of Currency, Distance, and Equality and Reciprocity. The authors conclude that by purposefully bringing power structures to the surface, they have addressed the complexity of learning and teaching as it occurs in day-to-day moments of interaction in a clerkship with little continuity in supervision. Both doctors and students should be supported to reflect critically on how they contribute to supervisory relationships with reference to, for example, the ways in which they ask or answer questions.
Watling C, Driessen E, van der Vleuten CP, Lingard L. Learning culture and feedback: an international study of medical athletes and musicians. Med Ed 2014; 48(7): 713–723. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1111/medu.12407.
The authors explored the unique perspectives of doctors who had also trained extensively in sport or music to: (i) distinguish the elements of the response to feedback that are determined by the individual learner from those determined by the learning culture, and (ii) understand how these elements interact in order to make recommendations for improving feedback in medical education. The authors conducted semi-structured interviews with 27 doctors or medical students who had high level training and competitive or performance experience in sport (n = 15) or music (n = 12). The authors found that individual learner traits, such as motivation and orientation toward feedback, appeared stable across learning contexts. Similarly, certain feedback characteristics, including specificity, credibility and action ability, were valued in sport, music and medicine alike. Learning culture influenced feedback in three ways: (i) by defining expectations for teachers and teacher–learner relationships; (ii) by establishing norms for and expectations of feedback, and (iii) by directing teachers’ and learners’ attention toward certain dimensions of performance. Learning culture therefore neither creates motivated learners nor defines ‘good feedback’; rather, it creates the conditions and opportunities that allow good feedback to occur and learners to respond. The authors conclude that an adequate understanding of feedback requires an integrated approach incorporating both the individual and the learning culture. Their research offers a clear direction for medicine’s learning culture: normalize feedback; promote trusting teacher–learner relationships; define clear performance goals, and ensure that the goals of learners and teachers align.
Weaver SJ, Dy SM, Rosen MA. Team-training in healthcare: a narrative synthesis of the literature. BMJ Qual Saf. 2014 May;23(5):359-72. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1136/bmjqs-2013-001848. Epub 2014 Feb 5.
The authors provide an updated review on the current state of team-training science and practice in acute care settings. They found that both simulation and classroom-based team-training interventions can improve teamwork processes (eg, communication, coordination and cooperation), and implementation has been associated with improvements in patient safety outcomes. Thirteen studies published between 2011 and 2012 reported statistically significant changes in teamwork behaviors, processes or emergent states and 10 reported significant improvement in clinical care processes or patient outcomes, including mortality and morbidity. Effects were reported across a range of clinical contexts. Larger effect sizes were reported for bundled team-training interventions that included tools and organizational changes to support sustainment and transfer of teamwork competencies into daily practice. The authors conclude that, overall, moderate-to-high-quality evidence suggests team-training can positively impact healthcare team processes and patient outcomes. Additionally, toolkits are available to support intervention development and implementation. Evidence suggests bundled team-training interventions and implementation strategies that embed effective teamwork as a foundation for other improvement efforts may offer greatest impact on patient outcomes.
Zazulia AR, Goldhoff P. Faculty and Medical Student Attitudes About Preclinical Classroom Attendance. Teach Learn Med. 2014. 26(4), 327–334. http://ezproxy.library.tufts.edu/login?url=http://dx.doi.org/10.1080/10401334.2014.945028.
This study examines differences in medical student and faculty attitudes regarding preclinical classroom attendance, and the impact of nonattendance on educators and the learning environment. Data was collected using internet-based surveys. Quantitative and qualitative methods of data analysis were performed. A total of 382 (79%) of 484 eligible students and 248 (64%) of 387 eligible faculty completed the survey. Both groups recognized a negative impact of poor attendance on faculty enthusiasm for teaching (students 83%, faculty 75%), but faculty were significantly more likely to endorse a negative impact on effectiveness of lectures (75% vs. 42%, p < .0001) and small-groups (92% vs. 76%, p < .0001) and a relationship between attendance and professionalism (88% vs. 68%, p < .0001). Students were significantly more likely to support free choice among learning opportunities (90% vs. 41%, p < .0001) including regularly missing class for research and community service activities (70% vs. 14%, p < .0001) and to consider lecture videos an adequate substitute for attendance (70% vs. 15%, p < .0001). Free-text responses suggested that students tended to view class going primarily as a tool for learning factual material, whereas many faculty viewed it as serving important functions in the professional socialization process. The authors concluded that, in this single-center cohort, medical student and teaching faculty attitudes differed regarding the importance of classroom attendance and its relationship to professionalism, findings that were at least partially explained by differing expectations of the purpose of the preclinical classroom experience.
*MeEdPortal News & Updates
Durham M, Lie D, Lohenry K. Interprofessional Care: an Introductory Session on the Roles of Health Professionals. MedEdPORTAL; 2014. Available from: www.mededportal.org/publication/9813.
Fishman L, Newman L. Dr. Novel and Dr. Sage: Developing Expertise in Leading Small Group Discussions. MedEdPORTAL; 2014. Available from: www.mededportal.org/publication/9838.
*TUSM Faculty Educational Scholarship Publications
Bing-You RG, Trowbridge RL, Kruithoff C, Daggett Jr JL. Unfreezing the Flexnerian Model: introducing longitudinal integrated clerkships in rural communities. Rural and Remote Health 14(3): 2944. (Online) 2014. Available from: http://www.rrh.org.au.
Blanchard RD, Visintainer PF, Hinchey KT. A Compass for Scholarship: The Scholarly Activity Expectations Rubric. JGME. 2014; 6(4): 636-38. DOI: http://dx.doi.org/10.4300/JGME-D-14-00235.1.
Blanchard RD, Artino AR, Visintainer, PF. Applying Clinical Research Skills to Conduct Education Research: Important Recommendations for Success. JGME. 2014; 6(4): 619-22. DOI: http://dx.doi.org/10.4300/ JGME-D-14-00443.1.
*What is new in the Lit?!
Norman, G. Data dredging, salami-slicing, and other successful strategies to ensure rejection: twelve tips on how to not get your paper published. Adv Health Sci Educ Theory Pract. 2014; 19(1): 1–5. doi: 10.1007/s10459-014-9494-8.
In this article, the editor of the journal highlights the common research mistakes authors fall into, which make their research products non-publishable. For example: providing insufficient theory or evidence to justify the study; not conducting a good literature review to identify a good research question; using pretest-posttest (pre-experimental) designs where authors compare “something” (post-intervention test) to “nothing” (pre-intervention test) so a change of some sort is actually expected; likewise, proving that something (simulation) plus something else (iPhone app) is greater than something alone (simulation); using self-assessment or satisfaction rates; developing multiple publications from one study modifying previously submitted texts; providing just p-values without supporting graphs and effect sizes; providing unnecessary data which confuse readers and tells very little; not stating which research question/s remains to be addressed.
Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD. Burnout Among U.S. Medical Students, Residents, and Early Career Physicians Relative to the General U.S. Population. Acad Med. 2014; 89(3): 443–451. doi: 10.1097/ACM.0000000000000134.
The authors conducted a national survey of medical students, residents/fellows, and early career physicians (≤ 5 years in practice) and of a probability-based sample of the general U.S. population to compare the prevalence of burnout and other forms of distress. The authors concluded that training appears to be the peak time for distress among physicians, but differences in the prevalence of burnout, depressive symptoms, and recent suicidal ideation are relatively small. At each stage, burnout is more prevalent among physicians than among their peers in the U.S. population.
Donnon T, Al Ansari A, Al Alawi S, Violato C. The Reliability, Validity, and Feasibility of Multisource Feedback Physician Assessment: A Systematic Review. Acad Med. 2014; 89(3):511–516. doi: 10.1097/ACM.0000000000000147.
The authors conducted a systematic review to investigate the reliability, generalizability, validity, and feasibility of multiple source feedback (MSF) for the assessment of physicians. The authors found that the use of MSF employing medical colleagues, coworkers, and patients as a method to assess physicians in practice has been shown to have high reliability, validity, and feasibility.
Burgess AW, McGregor DM, Mellis CM. Applying Established Guidelines to Team-Based Learning Programs in Medical Schools: A Systematic Review. Acad Med. 2014; 89(4):678-688. doi: 10.1097/ACM.0000000000000162.
The authors conducted a systematic review to establish the extent, design, and practice of TBL programs within medical schools to inform curriculum planners and educational designers. The authors identified 20 articles that satisfied the inclusion criteria. They found significant variability across the articles in terms of the application of the seven core design elements and the depth with which they were described. The majority of the articles, however, reported that TBL provided a positive learning experience for students. The authors concluded that faculty should adhere to a standardized TBL framework to better understand the impact and relative merits of each feature of their program.
Heiman H, Rasminsky S, Bierman JA, Evans DB, Kinner KG, Stamos J, Martinovich Z, McGaghie WC. Medical Students’ Observations, Practices, and Attitudes Regarding Electronic Health Record Documentation. Teaching and Learning in Medicine. 2014; 26(1), 49–55. doi: 10.1080/10401334.2013.857337.
The authors sought to understand medical students’ observations, practices, and attitudes regarding electronic documentation efficiency tools, and surveyed 3rd-year medical students at one medical school. Overall, 123 of 163 students (75%) responded; almost all frequently use an EHR for documentation. Eighty-six percent (102/119) reported at least sometimes observing residents copying data from other providers’ notes and 60% (70/116) reported observing attending physicians doing so. Most students (95%, 113/119) reported copying from their own previous notes, and 22% (26/119) reported copying from residents. Only 10% (12/119) indicated that copying from other providers is acceptable, whereas 83% (98/118) believe copying from their own notes is acceptable. Most students use templates and auto-inserted data; 43% (51/120) reported documenting while signed in under an attending's name. Greater use of documentation efficiency tools was associated with plans to enter a procedural specialty and with lack of awareness of the medical school copy–paste policy. The authors concluded that students frequently use a range of efficiency tools to document in the electronic health record, most commonly copying their own notes. Although the vast majority of students believe it is unacceptable to copy–paste from other providers, most have observed clinical supervisors doing so.
Roberts L, Lu WH, Go RA, Daroowalla F. Effect of Bedside Physical Diagnosis Training on Third-Year Medical Students’ Physical Exam Skills. Teaching and Learning in Medicine. 2014; 26(1), 81–85. doi: 10.1080/10401334.2013.857329.
The authors implemented a pilot program for 3rd-year medical students consisting of twice-weekly bedside diagnosis rounds as part of their 8-week medicine clerkship, and reviewed students’ objective structured clinical exam (OSCE) scores at the completion of the clerkship compared with prior years’ students who did not have the bedside physical diagnosis training. Students who were trained (n=109) had an overall higher OSCE physical exam score (p < .01) than students without the training (n = 85). The authors concluded that bedside physical diagnosis rounds appear to have elevated the overall OSCE score for 3rd-year medical students.
Yudkowsky R, Park YS, Riddle J, Palladino C, Bordage G. Clinically Discriminating Checklists Versus Thoroughness Checklists: Improving the Validity of Performance Test Scores.
Acad Med. 2014; 89(7). doi: 10.1097/ACM.0000000000000235.
The purpose of this study was to compare validity evidence for clinically discriminating versus thoroughness checklists, hypothesizing that evidence would favor the former. Based on the study findings, the authors concluded that limiting checklist items to those affecting diagnostic decisions resulted in better accuracy and psychometric indices. Thoroughness items performed without thinking do not reflect clinical reasoning ability and contribute construct-irrelevant variance to scores.
Papp KK, Huang GC, Lauzon Clabo LM, Delva D, Fischer M, Konopasek L, Schwartzstein RM, Gusic M. Milestones of Critical Thinking: A Developmental Model for Medicine and Nursing. Acad Med. 2014; 89 (5):715-720. doi: 10.1097/ACM.0000000000000220.
The authors have iteratively refined and proposed milestones in critical thinking. The attributes associated with unreflective, beginning, practicing, advanced, accomplished, and challenged critical thinkers are conceived as independent of an individual’s level of training. Depending on circumstances and environmental factors, even the most experienced clinician may demonstrate attributes associated with a challenged thinker. The authors use the illustrative case of a patient with abdominal pain to demonstrate how critical thinking may manifest in learners at different stages of development, analyzing how the learner at each stage applies information obtained in the patient interaction to arrive at a differential diagnosis and plan for evaluation. The authors share important considerations and provide this work as a foundation for the development of effective approaches to teaching and promoting critical thinking and to establishing expectations for learners in this essential meta-competency.
Angus S, Vu TR, Halvorsen AJ, Aiyer M, McKown K, Chmielewski AF, McDonald FS. What Skills Should New Internal Medicine Interns Have in July? A National Survey of Internal Medicine Residency Program Directors. Acad Med. 2014; 89(3): 432-435. doi: 10.1097/ACM.0000000000000133.
In this article the authors summarize the results of a survey study conducted by the Clerkship Directors in Internal Medicine subinternship task force, in collaboration with the Association of Program Directors in Internal Medicine, to determine which competencies or skills internal medicine residency program directors expected from new medical school graduates. Program directors were nearly uniform in ranking the skills they deemed most important for new interns—organization and time management and prioritization skills; effective communication skills; basic clinical skills; and knowing when to ask for assistance. These study outcomes can inform the development of a milestone-based curriculum for the fourth-year of medical school and for the internal medicine subinternship.
Shaheen AW, Denton GD, Stratton TD, Hoellein AR, Chretien KC. End-of-Life and Palliative Care Curricula in Internal Medicine Clerkships: A Report on the Presence, Value, and Design of Curricula as Rated by Clerkship Directors. Acad Med. 2014; 89(8). doi: 10.1097/ACM.0000000000000311.
The authors conducted a national study to investigate the presence of formal EOL/PC curricula within IM clerkships; the value placed by IM clerkship directors on this type of curricula; curricular design and implementation strategies; and related barriers and resources. The response rate was 77.0% (94/122). Of those responding, 75.8% (69/91) believed such training should occur in the IM clerkship, and 43.6% (41/94) reported formal curricula in EOL/PC. Multiple instructional modalities were used to deliver this content, with the majority of programs dedicating four or more hours to the curriculum. Curricula covered a wide range of topics, and student assessment tools were varied. Most felt that students valued this education. The qualitative analysis revealed differences in the values clerkship directors placed on teaching EOL/PC within the IM clerkship. The authors concluded that a substantial gap remains between those who have implemented and those who believe it belongs in the clerkship. Time, faculty, cost, and competing demands are the main barriers to implementation.
Freeman S, Eddy SL, McDonough M, Smith MK, Okoroafor N, Jordt H, Wenderoth MP. Active learning increases student performance in science, engineering, and mathematics. PNAS. 2014; 111(23). doi: 10.1073/pnas.1319030111.
The authors metaanalyzed 225 studies that reported data on examination scores or failure rates when comparing student performance in undergraduate science, technology, engineering, and mathematics (STEM) courses under traditional lecturing versus active learning. The effect sizes indicate that on average, student performance on examinations and concept inventories increased by 0.47 SDs under active learning (n = 158 studies), and that the odds ratio for failing was 1.95 under traditional lecturing (n = 67 studies). These results indicate that average examination scores improved by about 6% in active learning sections, and that students in classes with traditional lecturing were 1.5 times more likely to fail than were students in classes with active learning. Heterogeneity analyses indicated that both results hold across the STEM disciplines, that active learning increases scores on concept inventories more than on course examinations, and that active learning appears effective across all class sizes—although the greatest effects are in small (n ≤ 50) classes. Trim and fill analyses and fail-safe n calculations suggest that the results are not due to publication bias. The results also appear robust to variation in the methodological rigor of the included studies, based on the quality of controls over student quality and instructor identity. This is the largest and most comprehensive metaanalysis of undergraduate STEM education published to date. The results raise questions about the continued use of traditional lecturing as a control in research studies, and support active learning as the preferred, empirically validated teaching practice in regular classrooms.
Humbert AJ, Miech EJ. Measuring Gains in the Clinical Reasoning of Medical Students: Longitudinal Results From a School-Wide Script Concordance Test. Acad Med. 2014; 89(7). doi: 10.1097/ACM.0000000000000267.
The authors conducted a four-year observational study between 2008 and 2011. Students in two different cohorts took the same SCT as second-year medical students and then again as fourth-year medical students. The authors matched and analyzed same-student data from the two SCT administrations for the classes of 2011 and 2012. They used descriptive statistics, correlation coefficients, and paired t tests. Results indicated that medical students made statistically significant gains in their performance on an SCT over a two-year period. These findings demonstrate same-student gains in clinical reasoning over time as measured by the SCT and suggest that the SCT as a standardized instrument can help to evaluate growth in clinical reasoning skills.
*MeEdPortal News & Updates
Pincavage A, Lee W, Ratner S, Prochaska M, Davis A, Saathoff M, Arora V. Teaching Video and Workshop Exercises: "Putting the Patient First: Engineering Patient-Oriented Clinic Handoffs (EPOCH)". MedEdPORTAL; 2014. Available from: www.mededportal.org/publication/9686.
This teaching video and workshop aims to help residency programs improve patient-centered care during clinic handoffs, and train residents in various milestones, such as effective use of verbal and nonverbal skills to create rapport with patients.
May W, Nyquist J, Souder D. Using a Practice Based Learning and Improvement (PBLI) Exercise to Assess and Build Basic Patient Care and Communication Skills in Medical Students. MedEdPORTAL; 2014. Available from: www.mededportal.org/publication/9723.
This PBLI exercise is conducted with third-year medical students approximately twelve weeks into their third year but could be utilized with any health professions student early in their clinical training. This exercise incorporates skills in three competencies: patient care (PC), interpersonal and communication skills (ICS) and practice-based learning and improvement (PBLI).
Featured iCollaborative Resource
Leggio, Lisa (primary author). A Validated Tool to Evaluate Verbal Handovers in a Clinical Setting. MedEdPORTAL; iCollaborative 2014. Available from: https://www.mededportal.org/icollaborative/resource/836.
This tool measures the following components of verbal handovers: content, clinical judgment, organization/communication, professionalism, and setting.
Wallace, Erik (primary author). Health Care Systems and Delivery: A Team-Based Learning Module on the United States Health Care System. Available from: https://www.mededportal.org/icollaborative/resource/873.
This Team-Based Learning module is designed to teach learners in the health professions about health care systems and delivery in the United States. This is the first of three modules, based on "The Health Care Handbook," designed to focus on the basics of our complex health care systems. Learners will define medical errors, describe the challenges of creating a primary care workforce, analyze different hospital systems, and examine different governmental and non-governmental health care delivery systems. Finally, learners will put this information in the context of their own future employment as a physician was well as make decisions on what physicians to employ based on their knowledge, success, and failures within the health care system. The module can be used separately or combined with the modules on "Health Care Insurance and Economics" and "Health Care Policy and Reform."
Englander, Robert (primary author). Core Entrustable Professional Activities (EPAs) for Entering Residency. Available from:https://www.mededportal.org/icollaborative/resource/887.
The materials provided include a Curriculum Developers' Guide, and a Faculty and Learners' Guide. This publication is a beginning to what we hope will be an ongoing conversation about how to assure that students are well prepared for residency training and, ultimately, for unsupervised practice as physicians. Share your feedback on implementing the Core EPAS for Entering Residency at your sites. We would like to understand from you what works, in what contexts, and for whom.
*TUSM Faculty Educational Scholarship Publications
Bing-You RG, Hayes VM, Skolfield JL. Physicians shadowing by college students: what do patients think? BMC Research Notes. 2014; 7:146. doi:10.1186/1756-0500-7-146.
Blanco MA, Capello CF, Dorsch JL, Perry G, Zanetti M. A Survey Study of Evidence-Based Medicine Training in United States and Canadian Medical Schools. Journal of the Medical Library Association. 2014; 102(3):160-168.
Blanco MA, Maderer A, Oriel A, Epstein SK. How we launched a developmental student-as-teacher (SAT) program for all medical students. Med Teach. 2014; 36(5): 385–389. doi:10.3109/0142159X.2014.886770.
Ellaway RH, Albright S, Smothers V, Cameron T, Willett T. Curriculum inventory: Modeling, sharing and comparing medical education programs. Med Teach. 2014; 36(3): 208–215. doi: 10.3109/0142159x.2014.874552.
Erlich DE, Shaughnessy AF. Student–teacher education programme (STEP) by step: Transforming medical students into competent, confident teachers. Med Teach. 2014; 36(4): 322–332. doi:10.3109/0142159X.2014.887835.
Rothberg MB, Kleppel R, Friderici JL, Hinchey K. Implementing a Resident Research Program to Overcome Barriers to Resident Research. Acad Med. 2014. doi: 10.1097/ACM.0000000000000281.
*What is new in the Lit?!
Norman, G. Editorial. The decline and fall of the art of teaching? Adv in Health Sci Educ Theory Pract (2013); 18(5):869–871. doi: 10.1007/s10459-013-9478-0.
In this editorial, Geoff Norman reflects on the role of the teacher vis-à-vis the augment of online learning based on evidence from systemic reviews on the impact of face-to-face vs. online instruction.
Tractenberg RE, Gushta MM, Mulroney, SE, Weissinger PA. Multiple Choice Questions Can Be Designed Or Revised to Challenge Learners’ Critical Thinking. Adv in Health Sci Educ Theory Pract (2013); 18(5):945–961. doi: 10.1007/s10459-012-9434-4.
The authors argue that Integration of higher order thinking into MC exams is important, but widely known to be challenging—perhaps especially when content experts must think like novices. Multiple choice (MC) questions from a graduate physiology course were evaluated by cognitive-psychology (but not physiology) experts, and analyzed statistically, in order to test the independence of content expertise and cognitive complexity ratings of MC items. The authors conclude that targeting higher order thinking with MC questions can be achieved without changing item difficulties or other test characteristics, but this may be less likely if the content expert is left to assess items within their domain of expertise.
McLaughlin J, Roth MT, Glatt DM, Gharkholonarehe N, Davidson CA, Griffin LM, Esserman DA, Mumper RJ. The Flipped Classroom: A Course Redesign to Foster Learning and Engagement in a Health Professions School. Acad Med. 2014; 89(2):236-43. doi: 10.1097/ACM.0000000000000086.
This article describes how the authors flipped a required first-year pharmaceutics course to better address student’s learning needs, and outlines the research they conducted to examine the resulting outcomes. Class attendance, students’ learning, and the perceived value of this model all increased following participation in the flipped classroom. The authors conclude that this approach warrants careful consideration as educators aim to enhance learning, improve outcomes, and fully equip students to address 21st-century health care needs.
Gonzalo JD, Heist BS, Duffy BL, Dyrbye L, Fagan MJ, Ferenchick G, Harrell H, Hemmer PA, Kerrnan WN, Kogan JR, Rafferty C, Wong R, Elnicki DM. Identifying and Overcoming the Barriers to Bedside Rounds: A Multicenter Qualitative Study. Acad Med. 2014; 89(2):326-34. doi: 10.1097/ACM.0000000000000100.
This manuscript describes the findings of a 10-institutions qualitative study on inpatient attending physicians’ perceptions on reasons for the decrease in bedside rounds, methods to overcome trainee apprehensions, and proposed strategies to educate faculty. The study showed that primary barriers to rounding are systems- and time- related. Strategies for overcoming trainee apprehensions and educational faculty are identified.
Karani R, Fromme HB, Cayea D, Muller D, Schwartz A, Harris IB. How Medical Students Learn From Residents in the Workplace: A Qualitative Study. Acad Med. 2014; 89(3):00–00.
First published online. doi: 10.1097/ACM.0000000000000141.
In this qualitative study, the authors explore what third-year medical students learn from residents and what teaching strategies are used by excellent resident-teachers. Findings suggested that teaching strategies used by excellent resident-teachers fall into the following domains : role-modeling, focusing on teaching, creating a safe learning environment, providing experiential learning opportunities, giving feedback, setting expectations, and stimulating learning. Knowledge and skills students learned from residents were related to the following domains: patient care, communication, navigating the system, adaptability, functioning as a student/resident, lifelong learning, general comments, career/professional development, and medical content. Most of these content and teaching strategies areas are not emphasized in popular Resident-As-Teachers models, such as the One-Minute Preceptor. The content and teaching strategies identified by students in this study should serve as the foundation for future Resident-As-Teacher program development.
Gowda D, Blatt B, Fink MJ, Kosowicz LY, Baecker A, Silvestri RC. A Core Physical Exam for Medical Students: Results of a National Survey. Acad Med. 2014; 89:00–00.
First published online. doi: 10.1097/ACM.0000000000000137.
The authors sought to determine whether educator consensus existed on the concept and the specifics of a core physical exam for students. The authors proposed a 45-maneuver core physical exam to be performed by a medicine clerkship student on every newly admitted patient, and surveyed physical diagnosis course directors and internal medicine clerkship directors from all 132 U.S. allopathic medical schools to determine the extent of their agreement with the proposed 45 maneuvers and their opinions about the concept of a core exam. Educators closely agreed on the maneuvers this core exam should include.
Jain A, Petty EM, Jaber RM, Tackett S, Purkiss J, Fitzgerald J, White C. What is appropriate to post on social media? Ratings from students, faculty members and the public. Medical Education 2014; 48(2): 157–169. doi:10.1111/medu.12282.
The purpose of this study was to ascertain what medical students, doctors and the public felt was unprofessional for medical students, as future doctors, to post on a social media site, Facebook. According to the authors, the most significant conclusion of the study is that faculty members, medical students and the ‘public’ have different thresholds of what is acceptable on a social networking site. The study findings will prove useful for students to consider the perspectives of patients and faculty members when considering what type of content to post on their social media sites. The authors hope that their findings provide insight for discussions, awareness and the development of guidelines related to online professionalism for medical students.
*MeEdPortal News & Updates
Tews M, Quinn-Leering K, Fox C, Simonson J, Ellinas E, Lemen P. Residents as Educators: Giving Feedback. MedEdPORTAL; 2014. Available from: www.mededportal.org/publication/9658
Gregg A, Allen W, Black E, Davidson R, McCormack W. An Interdisciplinary Team-Based Learning Experience in Clinical Ethics. MedEdPORTAL; 2013. Available from:
Klein M, Beck A, Kahn R, Henize A, O'Toole J, Alcamo A, McLinden D. Video Curriculum on Screening for the Social Determinants of Health. MedEdPORTAL; 2013. Available from: www.mededportal.org/publication/9575
van Zuilen M, Caralis P, Granville L. Breaking Bad News: A Small Group Session Teaching Communication Skills for Delivering Bad News. MedEdPORTAL; 2013. Available from: www.mededportal.org/publication/9604
Featured iCollaborative Resource
Core Entrustable Professional Activities for Entering Residency
Robert Englander, MD, MPH
Association of American Medical Colleges
Efforts are underway in both the United States and Canada to better define the professional activities that all entering residents should be expected to perform on day one of residency without direct supervision. Available from: https://www.mededportal.org/icollaborative/resource/887
DREAM: MedEdPORTAL and Georgia Regents University launched the Directory and Repository of Educational Assessment Measures (DREAM). DREAM is a collection of assessments that have been tested in health professions education. The mission is to achieve excellence in health sciences education by providing easy-to-locate, publically accessible information about assessment tools to health science educators, educational researchers, and program/curriculum evaluators. Visit this repository at www.mededportal.org/dream to see the inaugural collection, which includes The Jefferson Scale of Physician Lifelong Learning (JeffSPLL and JeffSPLL-MS); The Patient-Practitioner Orientation Scale (PPOS); The Student Interest Questionnaire (SIQ); The Hypothesis-Driven Physical Exam (HDPE) among other evaluation tools.
*TUSM Faculty Educational Scholarship Publications
Han PK, Joekes K, Elwyn G, Mazor KM, Thomson R, Sedgwick P, Ibison J, Wong JB.
Development and evaluation of a risk communication curriculum for medical students.
Patient Educ Couns. 2014 Jan; 94(1):43-9. doi: 10.1016/j.pec.2013.09.009.
[This study was supported by our Innovations in Education Grant Awards]
Shaughnessy AF, Duggan AP. Family medicine residents' reactions to introducing a reflective exercise into training. EFH. 2013; 26(3):141-146. doi:10.4103/1357-6283.125987.
Matzkin E, md, Smith EL, Freccero D, Richardson AB. Adequacy of Education in Musculoskeletal Medicine. J Bone Joint Surg Am. 2005 Feb; 87(2):310-4. doi:10.2106/jbjs.d.01779.
Walt DR, Kuhlik A, Epstein SK, Demmer LA, Knight M, Chelmow D, Rosenblatt M, Bianchi DW. Lessons learned from the introduction of personalized genotyping into a medical school curriculum. Genet Med 2011; 13(1):63– 66. doi: 10.1097/GIM.0b013e3181f872ac.
Weiner SG, Totten VY, Jacquet GA, Douglass K, Birnbaumer DM, Promes SB, Martin IBK. Effective Teaching and Feedback Skills for International Emergency Medicine ‘‘Train the Trainers’’ Programs. J Emerg Med. 2013 Nov; 45(5):718-25. doi: 10.1016/j.jemermed.2013.04.040.
Carr DB, Bradshaw YS. Time to Flip the Pain Curriculum? Anesthesiology. 2014 Jan; 120 (1):12-4. doi: 10.1097/ALN.0000000000000054.
[The scholarly work of these faculty members is supported by our Innovations in Education Grant Awards]
Fishman SM, Young HM, Arwood EL, Chou R, Herr K, Murinson BB, Watt-Watson J, Carr DB,Gordon DB, Stevens BJ, Bakerjian D, Ballantyne JC, Courtenay M, Djukic M, Koebner IJ, Mongoven JM, Paice JA, Prasad R, Singh N, Sluka KA, St Marie B, Strassels SA. Core Competencies for Pain Management: Results of an Interprofessional Consensus Summit. Pain Med. 2013 Jul; 14(7):971-81. doi: 10.1111/pme.12107.
Englander,R, Cameron, T, Ballard, AJ, Dodge, J, Bull, J, Aschenbrener,CA. Toward a Common Taxonomy of Competency Domains for the Health Professions and Competencies for Physicians. Acad Med. 2013; 88(8):1088-94.doi:10.1097/ACM.0b013e31829a3b2b.
In this article, the authors describe their work to (1) identify domains of competence that could accommodate any health care profession and (2) extract a common set of competencies for physicians from existing health professions’ competency frameworks that would be robust enough to provide a single, relevant infrastructure for curricular resources in the Association of American Medical Colleges’ (AAMC’s) MedEdPORTAL and Curriculum Inventory and Reports (CIR) sites.
Goveia J, van Stiphout F, Cheung Z, Kamta B, Keijsers C, Valk G, Braak E. Educational interventions to improve the meaningful use of Electronic Health Records: A review of the literature: BEME Guide No. 29. Med.Teach 2013, e1–e10, Posted Online. doi: 10.3109/0142159X.2013.806984.
In this Best Evidence in Medical Education (BEME) guide, the authors summarize all evidence regarding the efficacy of different educational interventions to improve meaningful use of EHRs.
Kan Ma H, Min C, Neville A, Eva K. How Good Is Good? Students and Assessors’ Perceptions of Qualitative Markers of Performance. Teach & Lear Med. 2013: 25(1): 15–23. doi: 10.1080/10401334.2012.741545.
In this article the authors explore (a) the perceived value to be indicated by descriptor phrases commonly used for describing student performance, (b) the perceived weight of the different performance domains (e.g. communication skills, work ethic, knowledge base, etc), and (c) whether or not the perceived value of the descriptors changes as a function of the performance domains.
Kulasegaram KM, Martimianakis MA, Mylopoulos M, Whitehead CR, Woods NN. Cognition Before Curriculum: Rethinking the Integration of Basic Science and Clinical Learning. Acad Med. 2013.88 (10). doi: 10.1097/ACM.0b013e3182a45def.
In this critical narrative review, the authors analyzed literature published in the last 30 years (1982-2012) using a previously published integration framework. They included studies that documented approaches to integration at the level of programs, courses, or teaching sessions and that aimed to improve learning outcomes. The authors evaluated these studies for evidence of successful integration and to identify factors that contribute to integration.
Schumacher D, Englander R, Carraccio C. Developing the Master Learner: Applying Learning Theory to the Learner, the Teacher, and the Learning Environment. Acad Med 88 (11) November 2013. doi:10.1097/ACM.0b013e3182a6e8f8.
In this perspective paper, the authors explain how learning theories can inform the development of master learners, and describe practical strategies for the learner, the teacher and the learning environment.
*MeEdPortal News & Updates
Packard K, Cochran T, Huggett K, Doll J, Chelal H, Wilken M, Jorgenson D. The Interprofessional Team Reasoning Framework. MedEdPORTAL; 2013. Available from: www.mededportal.org/publication/9460
O'Sullivan P, Chauvin S, Wolf F, Richardson D, Blanco M. Authorship Issues in Publishing and Career Development Workshop. MedEdPORTAL; 2013. Available from: www.mededportal.org/publication/9309
Ferenchick G, Solomon D. Cloud-Based Assessment Tools for the Facilitation of Direct Observation and Assessment of Student Performance. MedEdPortal; 2013. Available from: https://www.mededportal.org/icollaborative/resource/817
*TUSM Faculty Educational Scholarship Publications
Kalish RA, Canoso JJ. Development of the seminar. Reumatol Clin. 2012 Dec-2013 Jan;8 Suppl 2:10-2. doi: 10.1016/j.reuma.2012.10.008. Epub 2012 Dec 8.
Meade, LB, Caverzagie, KJ, Swing, SR, Jones,RR, O’Malley, CW, Yamazaki,K, Zaas, AK. Playing With Curricular Milestones in the Educational Sandbox: Q-sort Results From an Internal Medicine Educational Collaborative. Academic Medicine, Vol. 88, No. 08 / August 2013. doi: 10.1097/ACM.0b013e31829a3967.
The Impact of Lecture Attendance and Other Variables on How Medical Students Evaluate Faculty in a Preclinical Program. Stanley I. Martin, MD, David P. Way, MEd, Nicole Verbeck, MPH, Rollin Nagel, PhD, John A. Davis, PhD, MD, and Dale D. Vandre, PhD. Published ahead-of-print. doi: 10.1097/ACM.0b013e318294e99a
Students' attendance at lecture, year, and class grade, as well as lecturer degree, effect students' evaluation of lecturers.
Social Media Use in Medical Education: A Systematic Review. Christine C. Cheston, MD, Tabor E. Flickinger, MD, MPH, and Margaret S. Chisolm, MD. Academic Medicine, Vol. 88, No. 6 / June 2013. doi: 10.1097/ACM.0b013e31828ffc23
Educators face challenges in adapting new technologies, but they also have opportunities for innovation.
MedEdPortal News & Updates
MedEdPORTAL® Publications introduces the DREAM collection! The Directory and Repository of Educational Assessment Measures (DREAM) is a “one-stop shop” peer reviewed, searchable database of assessment measures that have been used in health sciences education. The collection highlights formally MedEdPORTAL peer reviewed Critical Synthesis Packages, including an expert critical analysis of a given assessment measure, a copy of the assessment measure itself and any supplementary materials that aid in the administration of the tool. To view DREAM publications go to: https://www.mededportal.org/190142/search.html?r=10&s=rec&t=p&q=dream
TUSM Faculty Educational Scholarship Publications
Allen F. Shaughnessy, Jennifer Sparks, Molly Cohen-Osher, Kristen H. Goodell, Gregory L. Sawin, and Joseph Gravel, Jr (2013) Entrustable Professional Activities in Family Medicine. Journal of Graduate Medical Education. March 2013, Vol. 5, No. 1, pp. 112-118. doi: http://www.jgme.org/doi/pdf/10.4300/JGME-D-12-00034.1
Mailloux P. Covering All Bases: A Simulated, Longitudinal Case-Based Approach to Teaching Critical Care Fellows. MedEdPORTAL; 2013. Available from: www.mededportal.org/publication/9384
Meade LB, Borden SH, McArdle P, Rosenblum MJ, Picchioni MS, Hinchey KT. From theory to actual practice: creation and application of milestones in an internal medicine residency program, 2004-2010. Med Teach. 2012;34(9):717-23. doi: 10.3109/0142159X.2012.689441. Epub 2012 May 30
Snydman L, Chandler D, Rencic J, Sung YC. Peer observation and feedback of resident teaching. Clinical Teacher. 2013 Feb; 10(1):9-14. doi: 10.1111/j.1743-498X.2012.00591.x.
- February 2011
Twelve tips for implementing tools for direct observation of medical trainees’ clinical skills during patient encounters
Karen E. Hauer, Eric S. Holmboe, and Jennifer R. Kogan Medical Teacher 2011; 33: 27-33
Rethinking the basis of medical knowledge Ayelet Kuper & Marcel D’Eon Medical Education 2011; 45: 36-43
- September 2010
Formative Experiences of Emerging Physicians: Gauging the Impact of Events That Occur During Medical School
Beth B. Murinson, MD, PhD, MS, Brendan Klick, MS, Jennifer A. Haythornthwaite, PhD, Robert Shochet, MD, Rachel B. Levine, MD, MPH, and Scott M. Wright, MD Academic Medicine 2010 Aug; 85(8):1331-7
The Role of Assessment in Competency-Based Medical Education
E. Holmboe, J. Sherbino, D. Long, S. Swing, J. Frank for the International CBME Collaborators Medical Teacher 2010; 32: 676-682
- April 2010
Assessing the quality of clinical teaching: a preliminary study
Rosemarie L. Conigliaro & Terry D. Stratton Medical Education 2010 (44) 379-386
Twelve tips for doing effective Team-Based Learning (TBL)
Dean X. Parmelee & Larry K. Michaelsen Medical Teacher 2010, 32(2): 118-122
- January 2010
Relationship between clinical assessment and examination scores in determining clerkship grade
Stephen J. Lurie and Christopher J. Mooney. Medical Education 2010: 44 : 122-124
State of the science in health professional education: effective feedback
Julian C. Archer. Medical Education 2010: 44: 101-108
- September 2009
Effective Teaching and Learning on the Wards: Easier Said than Done?
Young, L., Orlandi, A., Galicher, B., and H. Heussler. Medical Education 43: 808-817, 2009
Interactive lecturing: strategies for increasing participation in large group presentations.
Y. Steinert & L. Snell. Medical Teacher, Vo. 21, No. 1, 1999