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Patlolla SH, Truesdell AG, Basir MB, Rab ST, Singh M, Belford PM, Zhao DX, Vallabhajosyula S. No "July Effect" in the management and outcomes of acute myocardial infarction: An 18-year United States national study. Catheter Cardiovasc Interv 2023; 101:264-273. [PMID: 36617382 DOI: 10.1002/ccd.30553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/08/2022] [Accepted: 12/31/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND There has been conflicting reports on the effect of new trainees on clinical outcomes at teaching hospitals in the first training month (July in the United States of America). We sought to assess this "July effect" in a contemporary acute myocardial infarction (AMI) population. METHODS Adult (>18 years) AMI hospitalizations in May and July in urban teaching and urban nonteaching hospitals in the United States were identified from the HCUP-NIS database (2000-2017). In-hospital mortality was compared between May and July admissions. A difference-in-difference analysis comparing a change in outcome from May to July in teaching hospitals to a change in outcome from May to July in nonteaching hospitals was also performed. RESULTS A total of 1,312,006 AMI hospitalizations from urban teaching (n = 710,593; 54.2%) or nonteaching (n = 601,413; 45.8%) hospitals in the months of May and July were evaluated. May admissions in teaching hospitals, had greater comorbidity, higher rates of acute multiorgan failure (10.6% vs. 10.2%, p < 0.001) and lower rates of cardiac arrest when compared to July admissions. July AMI admissions had lower in-hospital mortality compared to May (5.6% vs. 5.8%; adjusted odds ratio 0.94 [95% confidence interval 0.92-0.97]; p < 0.001) in teaching hospitals. Using the difference-in-difference model, there was no evidence of a July effect for in-hospital mortality (p = 0.19). CONCLUSIONS There was no July effect for in-hospital mortality in this contemporary AMI population.
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Affiliation(s)
- Sri Harsha Patlolla
- Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | | | - Mir B Basir
- Division of Cardiovascular Medicine, Henry Ford Hospital and Health System, Detroit, Michigan, USA
| | - Syed T Rab
- Division of Cardiovascular Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter Matthew Belford
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - David X Zhao
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Saraschandra Vallabhajosyula
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Section of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Ricotta DN, Richards JB, Atkins KM, Hayes MM, McOwen K, Soffler MI, Tibbles CD, Whelan AJ, Schwartzstein RM. Self-Directed Learning in Medical Education: Training for a Lifetime of Discovery. TEACHING AND LEARNING IN MEDICINE 2022; 34:530-540. [PMID: 34279167 DOI: 10.1080/10401334.2021.1938074] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/26/2021] [Indexed: 06/13/2023]
Abstract
Issue: Life-long learning is a skill that is central to competent health professionals, and medical educators have sought to understand how adult professionals learn, adapt to new information, and independently seek to learn more. Accrediting bodies now mandate that training programs teach in ways that promote self-directed learning (SDL) but do not provide adequate guidance on how to address this requirement. Evidence: The model for the SDL mandate in physician training is based mostly on early childhood and secondary education evidence and literature, and may not capture the unique environment of medical training and clinical education. Furthermore, there is uncertainty about how medical schools and postgraduate training programs should implement and evaluate SDL educational interventions. The Shapiro Institute for Education and Research, in conjunction with the Association of American Medical Colleges, convened teams from eight medical schools from North America to address the challenge of defining, implementing, and evaluating SDL and the structures needed to nurture and support its development in health professional training. Implications: In this commentary, the authors describe SDL in Medical Education, (SDL-ME), which is a construct of learning and pedagogy specific to medical students and physicians in training. SDL-ME builds on the foundations of SDL and self-regulated learning theory, but is specifically contextualized for the unique responsibilities of physicians to patients, inter-professional teams, and society. Through consensus, the authors offer suggestions for training programs to teach and evaluate SDL-ME. To teach self-directed learning requires placing the construct in the context of patient care and of an obligation to society at large. The SDL-ME construct builds upon SDL and SRL frameworks and suggests SDL as foundational to health professional identity formation.KEYWORDSself-directed learning; graduate medical education; undergraduate medical education; theoretical frameworksSupplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1938074 .
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Affiliation(s)
- Daniel N Ricotta
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy B Richards
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - K Meredith Atkins
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret M Hayes
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine McOwen
- Association of American Medical Colleges, Washington, District of Columbia, USA
| | - Morgan I Soffler
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Carrie D Tibbles
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Alison J Whelan
- Association of American Medical Colleges, Washington, District of Columbia, USA
| | - Richard M Schwartzstein
- Carl J. Shapiro Center for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Sawatsky AP, O'Brien BC, Hafferty FW. Autonomy and developing physicians: Reimagining supervision using self-determination theory. MEDICAL EDUCATION 2022; 56:56-63. [PMID: 34091940 DOI: 10.1111/medu.14580] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/26/2021] [Accepted: 06/01/2021] [Indexed: 06/12/2023]
Abstract
In this article, we address the question, 'What is the role of autonomy in physician development?' Medical education is a developmental process, and autonomy plays a motivational role in physician development. Calls for increased supervision of residents have raised concerns that the resulting decreased autonomy might interfere with resident development, leading the authors to explore the relationship between supervision and autonomy. The medical education literature posits a simple inverse relationship between supervision and autonomy. Within competency frameworks, autonomy is operationalised as independence and viewed as the end goal of training. Alternatively, there is emerging empirical literature describing autonomy and supervision as dynamic and developmental constructs and point towards more complex relationship between supervision and autonomy. Self-determination theory (SDT) presents a framework for understanding this dynamic relationship and the role of autonomy in physician development. Within SDT, autonomy is a fundamental psychological need, associated with motivation for learning, self-regulation and an internal locus of control. Supporting learner autonomy can afford learners the opportunity to internalise the values and norms of the profession, leading to an integrated regulation of their behaviours and actions. Conceptualising autonomy through the lens of SDT provides an avenue for education interventions and future research on supervision and autonomy. Educators can integrate supervision and autonomy support in the clinical setting, seeking to motivate learner development by balancing optimal challenge and support and integrating autonomy support with 'hands-on' approaches to supervision. SDT also provides a theoretical framework relevant to current discussions regarding feedback conversations and coaching in medical education. Lastly, conceptualising autonomy using SDT opens new avenues for investigation, exploring the complex relationship between supervision and autonomy and developing efforts to integrate autonomy support with clinical supervision.
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Affiliation(s)
- Adam P Sawatsky
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bridget C O'Brien
- Department of Medicine and Center for Faculty Educators, University of California, San Francisco, CA, USA
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Hansen SE, Defenbaugh N, Mathieu SS, Garufi LC, Dostal JA. A Mixed-Methods Exploration of the Developmental Trajectory of Autonomous Motivation in Graduate Medical Learners. MEDICAL SCIENCE EDUCATOR 2021; 31:2017-2031. [PMID: 34956711 PMCID: PMC8651867 DOI: 10.1007/s40670-021-01396-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/29/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Self-determination theory (SDT), when applied to curricular construction, emphasizes curiosity, self-awareness, and resilience. Physicians need these qualities to face the challenges of clinical practice. SDT offers a lens for medical educators to track learner development toward sustainable, rewarding careers. This study describes the changes observed in learner communications about feelings of competence, relatedness, and autonomy across a 3-year family medicine training program designed to develop activated, lifelong learners. METHODS This retrospective, mixed-methods case study uses a phenomenological approach to explore how 51 learners described their experiences at various intervals in residency training. Data collected from 2009 to 2015 from resident focus groups, competency assessment meetings, and faculty assessment reports inform a 3-stage analysis process to determine learner motivation levels along the SDT continuum. RESULTS Aggregated qualitative and quantitative data show residents' progression from introjection (controlled motivation) in PGY1, to identification (autonomous motivation) in PGY2, and integration (autonomous) by the end of PGY3. The examination of a single learner's data set reveals an advanced motivation level in PGY1 (identification), followed by a period of retrograde in PGY2 (introjection), then rebounding in PGY3 (identification), which illustrates how motivation level can be affected by external competency requirements and challenges related to career transitions. DISCUSSION The examination of self-motivation in medical learners has implications for curriculum development, assessment, teaching and self-directed learning, and resilience training. Learner awareness of intrinsic motivation, and the curriculum designed around it, can better prepare residents for challenges during residency and help them flourish in twenty-first-century medicine.
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Affiliation(s)
- Susan E. Hansen
- Lehigh Valley Health Network Family Medicine Residency Program, PO Box 1806, Allentown, PA 18101 USA
- University of South Florida Morsani College of Medicine, Tampa, FL USA
| | | | - Susan Snyder Mathieu
- Lehigh Valley Health Network Family Medicine Residency Program, PO Box 1806, Allentown, PA 18101 USA
- University of South Florida Morsani College of Medicine, Tampa, FL USA
| | | | - Julie A. Dostal
- University of South Florida Morsani College of Medicine, Tampa, FL USA
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Forte M, Morson N, Mirchandani N, Grundland B, Fernando O, Rubenstein W. How Teachers Adapt Their Cognitive Strategies When Using Entrustment Scales. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:S87-S92. [PMID: 34348370 DOI: 10.1097/acm.0000000000004287] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE Rater cognition is a field of study focused on individual cognitive processes used by medical teachers when completing assessments. Much has been written about the role of rater cognition in the use of traditional assessment scales. Entrustment scales (ES) are becoming the tool of choice for workplace-based assessments. It is not known how moving to an entrustment framework may cause teachers to adapt their cognitive rating strategies. This study aimed to explore this gap by asking teachers to describe their thinking when making rating decisions using a validated ES. METHOD Using purposive sampling, family medicine teachers supervising obstetrical care were invited to participate in cognitive interviews. Teachers were interviewed between December 2018 and March 2019 using retrospective verbal protocol analysis. They were asked to describe their experiences of rating residents in the last 6 months using new ES. Constructivist grounded theory guided data collection and analysis. Interviews were recorded, transcribed, and analyzed iteratively. A constant comparative approach was used to code and analyze the data until consensus was reached regarding emerging themes. RESULTS There was variability in how teachers used the ES. Faculty describe several ways in which they ultimately navigated the tool to say what they wanted to say. Four key themes emerged: (1) teachers interpreted the anchors differently based on their cognitive framework, (2) teachers differed in how they were able to cognitively shift away from traditional rating scales, (3) teachers struggled to limit assessments to a report on observed behavior, and (4) teachers contextualized their ratings. CONCLUSIONS Variability in teachers' interpretation of learner performance persists in entrustment frameworks. Rater's individual cognitive strategies and how they observe, process, and integrate their thoughts into assessments form part of a rich picture of learner progress. These insights can be harnessed to contribute to decisions regarding readiness for unsupervised practice.
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Affiliation(s)
- Milena Forte
- M. Forte is assistant professor, Postgraduate lead, Office of Education Scholarship, Maternity Care lead, Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0001-9387-0184
| | - Natalie Morson
- N. Morson is lecturer, Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Natasha Mirchandani
- N. Mirchandani is assistant professor, Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Batya Grundland
- B. Grundland is assistant professor and associate postgraduate program director, Curriculum & Remediation, Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Oshan Fernando
- O. Fernando is research associate, Office of Education Scholarship, Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0002-4600-9399
| | - Warren Rubenstein
- W. Rubenstein is associate professor, Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Colleti Júnior J, Kawaguchi A, Araujo ORD, Garros D. Clinical practices related to high-flow nasal cannulas in pediatric critical care in Brazil compared to other countries: a Brazilian survey. Rev Bras Ter Intensiva 2021; 33:384-393. [PMID: 35107549 PMCID: PMC8555393 DOI: 10.5935/0103-507x.20210055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/29/2020] [Indexed: 11/20/2022] Open
Abstract
Objetivo Descrever as práticas clínicas atuais relacionadas à
utilização de cânula nasal de alto fluxo por
intensivistas pediátricos brasileiros e compará-las com as de
outros países. Métodos Para o estudo principal, foi administrado um questionário a
intensivistas pediátricos em países das Américas do
Norte e do Sul, Ásia, Europa e Austrália/Nova Zelândia.
Comparou-se a coorte brasileira com coortes dos Estados Unidos,
Canadá, Reino Unido e Índia. Resultados Responderam ao questionário 501 médicos, dos quais 127 eram do
Brasil. Apenas 63,8% dos participantes brasileiros tinham disponibilidade de
cânula nasal de alto fluxo, em contraste com 100% dos participantes
no Reino Unido, no Canadá e nos Estados Unidos. Coube ao
médico responsável a decisão de iniciar a
utilização de uma cânula nasal de alto fluxo segundo
responderam 61,2% dos brasileiros, 95,5% dos localizados no Reino Unido,
96,6% dos participantes dos Estados Unidos, 96,8% dos médicos
canadenses e 84,7% dos participantes da Índia; 62% dos participantes do
Brasil, 96,3% do Reino Unido, 96,6% dos Estados Unidos, 96,8% do
Canadá e 84,7% da Índia relataram que o médico
responsável era quem definia o desmame ou modificava as regulagens da
cânula nasal de alto fluxo. Quando ocorreu falha da cânula
nasal de alto fluxo por desconforto respiratório ou
insuficiência respiratória, 82% dos participantes do Brasil
considerariam uma tentativa com ventilação não invasiva
antes da intubação endotraqueal, em comparação
com 93% do Reino Unido, 88% dos Estados Unidos, 91,5% do Canadá e
76,8% da Índia. Mais intensivistas brasileiros (6,5%) do que do Reino Unido,
Estados Unidos e Índia (1,6% para todos) afirmaram utilizar sedativos com
frequência concomitantemente à cânula nasal de alto
fluxo. Conclusão A disponibilidade de cânulas nasais de alto fluxo no Brasil ainda
não é difundida. Há algumas divergências nas
práticas clínicas entre intensivistas brasileiros e seus
colegas estrangeiros, principalmente nos processos e nas tomadas de
decisão relacionados a iniciar e desmamar o tratamento com
cânula nasal de alto fluxo.
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Affiliation(s)
- José Colleti Júnior
- Unidade de Terapia Intensiva Pediátrica, Hospital Santa Catarina - São Paulo (SP), Brasil
| | - Atsushi Kawaguchi
- Departamento de Pediatria, Universidade de Montreal, CHU Sainte-Justine - Montreal, QC, Canadá
| | - Orlei Ribeiro de Araujo
- Grupo de Apoio ao Adolescente e à Criança com Câncer, Instituto de Oncologia Pediátrica, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| | - Daniel Garros
- Departamento de Pediatria, Division of Critical Care, Stollery Children's Hospital, University of Alberta - Edmonton, AB, Canadá
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Schumacher DJ, Cate OT, Damodaran A, Richardson D, Hamstra SJ, Ross S, Hodgson J, Touchie C, Molgaard L, Gofton W, Carraccio C. Clarifying essential terminology in entrustment. MEDICAL TEACHER 2021; 43:737-744. [PMID: 33989100 DOI: 10.1080/0142159x.2021.1924365] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
With the rapid uptake of entrustable professional activties and entrustment decision-making as an approach in undergraduate and graduate education in medicine and other health professions, there is a risk of confusion in the use of new terminologies. The authors seek to clarify the use of many words related to the concept of entrustment, based on existing literature, with the aim to establish logical consistency in their use. The list of proposed definitions includes independence, autonomy, supervision, unsupervised practice, oversight, general and task-specific trustworthiness, trust, entrust(ment), entrustable professional activity, entrustment decision, entrustability, entrustment-supervision scale, retrospective and prospective entrustment-supervision scales, and entrustment-based discussion. The authors conclude that a shared understanding of the language around entrustment is critical to strengthen bridges among stages of training and practice, such as undergraduate medical education, graduate medical education, and continuing professional development. Shared language and understanding provide the foundation for consistency in interpretation and implementation across the educational continuum.
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Affiliation(s)
- Daniel J Schumacher
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Olle Ten Cate
- Center for Research Development of Education, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arvin Damodaran
- Prince of Wales Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Denyse Richardson
- Department of Medicine, University of Toronto, Toronto, Canada
- The Royal College of Physicians and Surgeons, Ottowa, Canada
| | - Stanley J Hamstra
- Accreditation Council for Graduate Medical Education, Chicago, IL, USA
- University of Ottawa, Ontario, Canada
- Department of Medical Education, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Shelley Ross
- Department of Family Medicine, University of Alberta, Edmonton, Canada
| | - Jennie Hodgson
- Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA, USA
| | - Claire Touchie
- The Medical Council of Canada, University of Ottawa, Ottawa, Canada
| | - Laura Molgaard
- University of Minnesota College of Veterinary Medicine, St. Paul, MN, USA
| | - Wade Gofton
- Royal College of Physicians and Surgeons of Canada, University of Ottawa, Ottawa, Canada
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Salwi S, Erath A, Patel PD, Kaur K, Mitchell MB. Aligning patient and physician views on educational pelvic examinations under anaesthesia: the medical student perspective. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106473. [PMID: 32958692 DOI: 10.1136/medethics-2020-106473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/30/2020] [Accepted: 08/02/2020] [Indexed: 06/11/2023]
Abstract
Recent media articles have stirred controversy over anecdotal reports of medical students practising educational pelvic examinations on women under anaesthesia without explicit consent. The understandable public outrage that followed merits a substantive response from the medical community. As medical students, we offer a unique perspective on consent for trainee involvement informed by the transitional stage we occupy between patient and physician. We start by contextualising the role of educational pelvic examinations under anaesthesia (EUAs) within general clinical skill development in medical education. Then we analyse two main barriers to achieving explicit consent for educational pelvic EUAs: ambiguity within professional guidelines on how to operationalize 'explicit consent' and divergent patient and physician perspectives on harm which prevent physicians from understanding what a reasonable patient would want to know before a procedure. To overcome these barriers, we advocate for more research on patient perspectives to empower the reasonable patient standard. Next, we call for minimum disclosure standards informed by this research and created in conjunction with students, physicians and patients to improve the informed consent process and relieve medical student moral injury caused by performing 'unconsented' educational pelvic exams.
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Affiliation(s)
- Sanjana Salwi
- Medical Ethics Law and Policy Student Group, Vanderbilt University, Nashville, TN, USA
- School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Alexandra Erath
- Medical Ethics Law and Policy Student Group, Vanderbilt University, Nashville, TN, USA
- School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Pious D Patel
- School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Karampreet Kaur
- School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Margaret B Mitchell
- Medical Ethics Law and Policy Student Group, Vanderbilt University, Nashville, TN, USA
- School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Waddimba AC, Mohr DC, Beckman HB, Meterko MM. Physicians' perceptions of autonomy support during transition to value-based reimbursement: A multi-center psychometric evaluation of six-item and three-item measures. PLoS One 2020; 15:e0230907. [PMID: 32236139 PMCID: PMC7112234 DOI: 10.1371/journal.pone.0230907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 03/12/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Successive health system reforms have steadily eroded physician autonomy. Escalating accountability demands placed on physicians concurrent with diminishing autonomy plus widespread "cost cutting" endanger clinical work-life quality and, in turn, threaten patient-care quality, safety, and continuity. This has engendered a renewed emphasis on bettering physician work-life to safeguard patient care. Research indicates that autonomy support could be an effective intervention point in this dynamic, and that improving healthcare practitioners' experience of autonomy can promote better patient outcomes. New measures of autonomy support towards physicians during systemic/organizational transformation are thus needed. OBJECTIVE We investigated the validity and reliability of two versions of a brief measure of physicians' perceptions of autonomy support. DESIGN Psychometric evaluation of practitioners' responses to a theory-based, pilot-tested, multi-center, cross-sectional survey-questionnaire. PARTICIPANTS Physicians serving in California, Massachusetts, or upstate New York clinical practices implementing pay-for-performance incentives were eligible. We obtained responses from 1,534 (35.14%) of 4,365 physicians surveyed. ANALYSIS We randomly partitioned the study sample equitably into derivation and validation subsamples. We conducted parallel analysis, inter-item/point-biserial correlations, and item-response-theory-based graded response modeling on six autonomy support items. Three items with the highest (a) point-biserial correlations, (b) item-level discrimination and (c) information capture were used to construct a short-form (3-item) version of the full (6-item) autonomy scale. We utilized exploratory structural equation modeling and confirmatory factor analysis to establish the factor structure and construct validity of the full-length and short-form scales before comparing their factor invariance, reliability and interrater agreement across physician subgroups. FINDINGS All six autonomy support items loaded highly onto one factor accounting for the majority of variance and demonstrating good data fit. The three most discriminating and informative items loaded equally well onto a single factor with similar goodness-of-fit to the data. The three-item scale correlated highly with its six-item parent, showing equally high sensitivity and specificity in discriminating high autonomy support. Variability in scores nested predominantly at within- rather than between-subgroup levels. CONCLUSIONS AND IMPLICATIONS Our data supported the factor structure, construct validity, internal consistency, and reliability of six- and three-item autonomy support scales. These brief tools are easily incorporated into multi-dimensional questionnaires at relatively low cost.
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Affiliation(s)
- Anthony C Waddimba
- Baylor Scott and White Research Institute, Dallas, Texas, United States of America
- Department of Surgery, Health Systems Science, Baylor University Medical Center, Dallas, Texas, United States of America
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Howard B Beckman
- Departments of Family Medicine, Internal Medicine & Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
- Common Ground Health, Rochester, New York, United States of America
| | - Mark M Meterko
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Performance Measurement, VA Office of Analytics and Business Intelligence (OABI), Washington, D.C., United States of America
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10
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Carbo AR, Huang GC. Promoting clinical autonomy in medical learners. CLINICAL TEACHER 2019; 16:454-457. [DOI: 10.1111/tct.13066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Alexander R Carbo
- Department of MedicineBeth Israel Deaconess Medical Center Boston Massachusetts USA
- Department of MedicineHarvard Medical School Boston Massachusetts USA
| | - Grace C Huang
- Department of MedicineBeth Israel Deaconess Medical Center Boston Massachusetts USA
- Department of MedicineHarvard Medical School Boston Massachusetts USA
- Carl J Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center Boston Massachusetts USA
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11
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Factors and Behaviors Related to the Promotion of Pediatric Hospital Medicine Fellow Autonomy: A Qualitative Study of Faculty. Acad Pediatr 2019; 19:703-711. [PMID: 31077880 DOI: 10.1016/j.acap.2019.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/24/2019] [Accepted: 05/04/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To identify factors that influence faculty to promote or reduce the expression of autonomy for pediatric hospital medicine (PHM) fellows and describe behaviors faculty employ to support fellow autonomy in the clinical setting. METHODS This was a multicenter, qualitative study using semistructured interviews with core faculty in PHM fellowships. Data were transcribed verbatim and analyzed using a phenomenological approach. Each transcript was coded independently by 2 trained reviewers who then met to reconcile differences. Codes were identified using an iterative approach and organized into themes. Investigators engaged in peer debriefing during data collection, and member checking confirmed the results. RESULTS Interviews were conducted December 2016 to January 2017 with 20 faculty from 5 PHM fellowships. Most participants were female (12, 60%) and assistant (13, 65%) or associate (6, 30%) professors. Data analysis yielded 6 themes. Themes reflect the importance of faculty experience, style, and approach to balancing patient care with education in the provision of autonomy for PHM fellows. Faculty appreciation for the role of autonomy in medical education, investment in their roles as educators, and investment in PHM fellowship training are also influential factors. Finally, fellow clinical, educational, leadership, and communication skills influence the provision of autonomy. Faculty employ various levels of supervision, scaffolding techniques, and direct observation with feedback to support fellow autonomy. Professional development was considered essential for developing these skills. CONCLUSIONS We identified 6 themes related to faculty provision of autonomy to PHM fellows, as well as strategies employed by faculty to support fellow autonomy.
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Karp NC, Hauer KE, Sheu L. Trusted to Learn: a Qualitative Study of Clerkship Students' Perspectives on Trust in the Clinical Learning Environment. J Gen Intern Med 2019; 34:662-668. [PMID: 30993622 PMCID: PMC6502927 DOI: 10.1007/s11606-019-04883-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Trust informs supervision decisions in medical training. Factors that influence trust differ depending on learners' and supervisors' level. Research has focused on resident trainees; questions exist about how medical students experience entrustment. OBJECTIVE This study examines how clerkship students perceive supervisors' trust in them and its impact on their learning. DESIGN Qualitative study using individual semi-structured interviews. PARTICIPANTS Clerkship medical students at the University of California, San Francisco. APPROACH We invited 30 core clerkship students to participate in interviews (October 2017 to February 2018) eliciting examples of appropriate, over-, and under-trust. We coded and analyzed transcripts using thematic analysis. KEY RESULTS Sixteen (53%) students participated. Three major themes arose: trust as scaffolding for learning, effects of trust on the learning environment, and consequences of trust for patients. Appropriate trust usually involved coaching and close guidance, often with more junior supervisors (interns or residents). These situations fostered students' motivation to learn, sense of value on the team, and perceived benefits to patients. Over-trust was characterized by task assignment without clear instruction, supervision, or feedback. Over-trust prompted student anxiety and stress, and concerns for potential patient harm. Under-trust was characterized by lack of clarity about the student role, leading to frustration and discontent, with unclear impact on patients. Students attributed inappropriate trust to contextual and supervisor factors and did not feel empowered to intervene due to concerns about performance evaluations and hierarchy. CONCLUSIONS As early learners in the clinical workplace, students frame trust as entailing high levels of support. It is important for medical educators to consider ways to train resident and faculty supervisors to enact trust and supervision for students differently than for residents. Structures that encourage students and supervisors to discuss trust and supervision in a transparent way can enhance learning.
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Affiliation(s)
- Nathan C Karp
- School of Medicine, University of California, San Francisco, 513 Parnassus Ave, San Francisco, CA, 94143-0410, USA.
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Karen E Hauer
- School of Medicine, University of California, San Francisco, 513 Parnassus Ave, San Francisco, CA, 94143-0410, USA
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Leslie Sheu
- School of Medicine, University of California, San Francisco, 513 Parnassus Ave, San Francisco, CA, 94143-0410, USA
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Sheu L, Kogan JR, Hauer KE. How Supervisor Experience Influences Trust, Supervision, and Trainee Learning: A Qualitative Study. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:1320-1327. [PMID: 28079727 DOI: 10.1097/acm.0000000000001560] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
PURPOSE Appropriate trust and supervision facilitate trainees' growth toward unsupervised practice. The authors investigated how supervisor experience influences trust, supervision, and subsequently trainee learning. METHOD 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). RESULTS Phase one: Four domains of trust and supervision varying with experience emerged: data, approach, perspective, clinical. Early supervisors were detail oriented and determined trust depending on task completion (data), were rule based (approach), drew on their experiences as trainees to guide supervision (perspective), and felt less confident clinically compared with more experienced supervisors (clinical). Experienced supervisors determined trust holistically (data), checked key aspects of patient care selectively and covertly (approach), reflected on individual experiences supervising (perspective), and felt comfortable managing clinical problems and gauging trainee abilities (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. CONCLUSIONS 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.
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Affiliation(s)
- Leslie Sheu
- L. Sheu is assistant professor of medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. J.R. Kogan is professor of medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. K.E. Hauer is professor of medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California
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Olmos-Vega FM, Dolmans DHJM, Vargas-Castro N, Stalmeijer RE. Dealing with the tension: how residents seek autonomy and participation in the workplace. MEDICAL EDUCATION 2017; 51:699-707. [PMID: 28436048 DOI: 10.1111/medu.13326] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 11/07/2016] [Accepted: 02/10/2017] [Indexed: 05/14/2023]
Abstract
CONTEXT The workplace can be a strenuous setting for residents: although it offers a wealth of learning opportunities, residents find themselves juggling their responsibilities. Even though supervisors regulate what is afforded to residents, the former find it difficult to strike the proper balance between residents' independence and support, which could create tensions. But what tensions do residents experience during clinical supervision and how do they cope with them to maximise their learning opportunities? Understanding how residents act on different affordances in the workplace is of paramount importance, as it influences their learning. METHOD Residents from different levels of training and disciplines participated in three focus groups (n = 19) and 10 semi-structured interviews (n = 10). The authors recruited these trainees using purposive and convenience sampling. Audio-recordings were transcribed verbatim and the ensuing scripts were analysed using a constructivist grounded theory methodology. RESULTS Residents reported that the autonomy and practice opportunities given by their supervisors were either excessive or too limited, and both were perceived as tensions. When in excess, trainees enlisted the help of their supervisor or peers, depending on how safe they recognised the learning environment to be. When practice opportunities were curtailed, trainees tried to negotiate more if they felt the learning environment was safe. When they did not, trainees became passive observers. Learning from each engagement was subject to the extent of intersubjectivity achieved between the actors involved. CONCLUSIONS Tensions arose when supervisors did not give trainees the desired degree of autonomy and opportunities to participate. Trainees responded in various ways to maximise their learning opportunities. For these different engagement-related responses to enhance workplace learning in specialty training, achieving intersubjectivity between trainee and supervisor seems foundational.
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Affiliation(s)
- Francisco M Olmos-Vega
- Department of Anaesthesiology, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
- School of Health Professions Education, Maastricht University, Maastricht, the Netherlands
| | - Diana H J M Dolmans
- School of Health Professions Education, Maastricht University, Maastricht, the Netherlands
| | - Nicolas Vargas-Castro
- Department of Anaesthesiology, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Renée E Stalmeijer
- School of Health Professions Education, Maastricht University, Maastricht, the Netherlands
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Drolet BC, Brower JP, Miller BM. Trainee Involvement in Patient Care: A Necessity and Reality in Teaching Hospitals. J Grad Med Educ 2017; 9:159-161. [PMID: 28439345 PMCID: PMC5398130 DOI: 10.4300/jgme-d-16-00232.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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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. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:1406-1415. [PMID: 26983076 DOI: 10.1097/acm.0000000000001164] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
PURPOSE Although residents trust interns to provide patient care, little is known about how trust forms. METHOD 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. RESULTS 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]). CONCLUSIONS 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.
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Affiliation(s)
- Leslie Sheu
- L. Sheu is chief resident in internal medicine, University of California, San Francisco School of Medicine, San Francisco, California.P.S. O'Sullivan is professor of medicine, University of California, San Francisco School of Medicine, San Francisco, California.E.M. Aagaard is professor of medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.D. Tad-y is assistant professor of medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.H.E. Harrell is professor of medicine, Department of Medicine, University of Florida College of Medicine, Gainesville, Florida.J.R. Kogan is associate professor of medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.J. Nixon is professor of medicine and pediatrics, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota.H. Hollander is professor of medicine, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California.K.E. Hauer is professor of medicine, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
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Abstract
This article is the third in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on the clinical aspects of fellowship training including the impact of the clinical environment, modalities for teaching and evaluation, and threats and opportunities in clinical education.
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Affiliation(s)
- Bradley D. Freeman
- Corresponding author: Bradley D. Freeman, MD, Washington University School of Medicine, Box 8109, 660 South Euclid Avenue, St. Louis, MO 63110,
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Freeman BD. Is It Time to Rethink Postgraduate Training Requirements for Licensure? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:20-22. [PMID: 26445079 DOI: 10.1097/acm.0000000000000881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Approaches to postgraduate medical training have evolved substantially in recent years, reflecting the complexity of the educational mission. Residency programs seek to produce clinicians who achieve board certification as an attestation of their competency. Certification criteria are established by the American Board of Medical Specialties, are consistent from state to state, and include periods of supervised instruction ranging from as few as three years (for primary care specialties) to much longer for selected disciplines. In contrast, minimum postgraduate training criteria necessary for licensure as an independent practitioner are established by state medical boards and vary significantly among and within jurisdictions. In most states, licenses can be granted to individuals who have completed as little as one year of postgraduate training. The discrepancy between the minimum time commitment necessary to become a competent physician and that to be licensed as an independent practitioner has implications for health care quality and safety. Data are lacking as to the number of licenses issued nationally to individuals who have only partially completed residency training and the nature of practices they pursue. Extrapolating from available evidence, these individuals may very well provide care inferior to those who have satisfied training requirements for certification eligibility and be more prone to problematic behavior resulting in disciplinary action. Efforts to establish more rigorous licensure criteria will require dialog between members of the academic community, professional organizations, state medical boards, and legislatures. The recently proposed Interstate Medical Licensure Compact may serve as a prototype for achieving this goal.
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Affiliation(s)
- Bradley D Freeman
- B.D. Freeman is professor of surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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Impact of an Overnight Internal Medicine Academic Hospitalist Program on Patient Outcomes. J Gen Intern Med 2015; 30:1795-802. [PMID: 25990190 PMCID: PMC4636563 DOI: 10.1007/s11606-015-3389-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 04/07/2015] [Accepted: 04/28/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Many academic hospitals have implemented overnight hospitalists to supervise house staff and improve outcomes, but few studies have described the impact of this role. OBJECTIVE To investigate the effect of an overnight academic hospitalist program on patient-level outcomes. Secondary objectives were to describe the program's revenue generation and work tasks. DESIGN Retrospective interrupted time-series analysis of patients admitted to the medicine service before and after implementation of the program. PARTICIPANTS All patients aged 18 and older admitted to the acute or intermediate care units between 7:00 p.m. and 6:59 a.m. during the period before (April 2011-August 2012) and after (September 2012-April 2014) program implementation. INTERVENTION An on-site attending-level physician directly supervising medicine house staff overnight, providing clinical care during high-volume periods, and ensuring safe handoffs to daytime providers. MAIN MEASURES Primary outcomes included in-hospital mortality, 30-day hospital readmissions, length of stay, and upgrades in care on the night of admission and during hospitalization. Multivariable models estimated the effect on outcomes after adjusting for secular trends. Revenue generation and work tasks are reported descriptively. KEY RESULTS During the study period, 6484 patients were admitted to the medicine service: 2722 (42 %) before and 3762 (58 %) after implementation. No differences were found in mortality (1.1 % vs. 0.9 %, p=0.38), 30-day readmissions (14.8 % vs. 15.6 %, p=0.39), mean length of stay (3.09 vs. 3.08 days, p=0.86), or upgrades to intensive care on the night of admission (0.4 % vs. 0.7 %, p=0.11) or during hospitalization (3.5 % vs. 4.2 %, p=0.20). During the first year, hospitalists billed 1209 patient encounters (3.3/shift) and 63 procedures (0.2/shift), and supervised 1939 patient admissions (6.12/shift) while supervising house staff 3-h/shifts. CONCLUSIONS Implementation of an overnight academic hospitalist program showed no impact on several important clinical outcomes, and revenue generation was modest. As overnight hospitalist programs develop, investigations are needed to delineate the return on investment and focus on other outcomes that may be more sensitive to change, such as errors and provider/patient satisfaction.
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21
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Korf BR. Pushing the envelope in genomics education. Genet Med 2015; 17:857-8. [PMID: 25790159 DOI: 10.1038/gim.2015.20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 01/20/2015] [Indexed: 11/09/2022] Open
Affiliation(s)
- Bruce R Korf
- Department of Genetics, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Sanderson SC, Linderman MD, Zinberg R, Bashir A, Kasarskis A, Zweig M, Suckiel S, Shah H, Mahajan M, Diaz GA, Schadt EE. How do students react to analyzing their own genomes in a whole-genome sequencing course?: outcomes of a longitudinal cohort study. Genet Med 2015; 17:866-74. [PMID: 25634025 DOI: 10.1038/gim.2014.203] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 12/12/2014] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Health-care professionals need to be trained to work with whole-genome sequencing (WGS) in their practice. Our aim was to explore how students responded to a novel genome analysis course that included the option to analyze their own genomes. METHODS This was an observational cohort study. Questionnaires were administered before (T3) and after the genome analysis course (T4), as well as 6 months later (T5). In-depth interviews were conducted at T5. RESULTS All students (n = 19) opted to analyze their own genomes. At T5, 12 of 15 students stated that analyzing their own genomes had been useful. Ten reported they had applied their knowledge in the workplace. Technical WGS knowledge increased (mean of 63.8% at T3, mean of 72.5% at T4; P = 0.005). In-depth interviews suggested that analyzing their own genomes may increase students' motivation to learn and their understanding of the patient experience. Most (but not all) of the students reported low levels of WGS results-related distress and low levels of regret about their decision to analyze their own genomes. CONCLUSION Giving students the option of analyzing their own genomes may increase motivation to learn, but some students may experience personal WGS results-related distress and regret. Additional evidence is required before considering incorporating optional personal genome analysis into medical education on a large scale.
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Affiliation(s)
- Saskia C Sanderson
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Michael D Linderman
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Icahn Institute of Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Randi Zinberg
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ali Bashir
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Icahn Institute of Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrew Kasarskis
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Icahn Institute of Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Micol Zweig
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sabrina Suckiel
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hardik Shah
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Icahn Institute of Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Milind Mahajan
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Icahn Institute of Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - George A Diaz
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eric E Schadt
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Icahn Institute of Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Kusurkar RA, Croiset G. Autonomy support for autonomous motivation in medical education. MEDICAL EDUCATION ONLINE 2015; 20:27951. [PMID: 25953033 PMCID: PMC4424234 DOI: 10.3402/meo.v20.27951] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
BACKGROUND Medical students often study only to fare well in their examinations or pursue a specific specialty, or study only those topics that they perceive to be useful in medical practice. The motivation for study in these cases comes from external or internal pressures or from the desire to obtain rewards. Self-determination theory (SDT) classifies this type of motivation as controlled motivation and the type of motivation that comes from genuine interest or personal value as autonomous motivation. Autonomous motivation, in comparison with controlled motivation, has been associated with better learning, academic success, and less exhaustion. SDT endorses autonomous motivation and suggests that autonomy support is important for autonomous motivation. The meaning of autonomy is misinterpreted by many. This article tries to focus on how to be autonomy-supportive in medical education. DISCUSSION Autonomy support refers to the perception of choice in learning. Some of the ways of supporting autonomy in medical education are small group teaching, problem-based learning, and gradual increase in responsibility of patients. Autonomy-supportive teaching behavior is not a trait and can be learned. Autonomy support in medical education is not limited to bringing in changes in the medical curriculum for students; it is about an overall change in the way of thinking and working in medical schools that foster autonomy among those involved in education. Research into autonomy in medical education is limited. Some topics that need to be investigated are the ideas and perceptions of students and teachers about autonomy in learning. CONCLUSION Autonomy support in medical education can enhance autonomous motivation of students for medical study and practice and make them autonomy-supportive in their future medical practice and teaching.
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Affiliation(s)
- Rashmi A Kusurkar
- Research in Education, VUmc School of Medical Sciences, Amsterdam, The Netherlands;
| | - Gerda Croiset
- Research in Education, VUmc School of Medical Sciences, Amsterdam, The Netherlands
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Kost A, Chen FM. Socrates was not a pimp: changing the paradigm of questioning in medical education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2015; 90:20-4. [PMID: 25099239 DOI: 10.1097/acm.0000000000000446] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
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. 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. Medical educators may employ pimping as a pedagogic technique because of beliefs that it is a Socratic teaching method. Although problems with pimping have previously been identified, no alternative techniques for questioning in the clinical environment were suggested. The authors posit that using the term "pimping" to describe questioning in medical education is harmful and unprofessional, and they propose clearly defining pimping as "questioning with the intent to shame or humiliate the learner to maintain the power hierarchy in medical education." Explicitly separating pimping from the larger practice of questioning allows the authors to 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.
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Affiliation(s)
- Amanda Kost
- Dr. Kost is assistant professor, Department of Family Medicine, University of Washington, Seattle, Washington. Dr. Chen is associate professor, Department of Family Medicine, University of Washington, Seattle, Washington
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Lindeman BM, Sacks BC, Hirose K, Lipsett PA. Duty hours and perceived competence in surgery: are interns ready? J Surg Res 2014; 190:16-21. [DOI: 10.1016/j.jss.2014.03.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 03/04/2014] [Accepted: 03/12/2014] [Indexed: 10/25/2022]
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Leipzig RM, Sauvigné K, Granville LJ, Harper GM, Kirk LM, Levine SA, Mosqueda L, Parks SM, Fernandez HM. What Is a Geriatrician? American Geriatrics Society and Association of Directors of Geriatric Academic Programs End-of-Training Entrustable Professional Activities for Geriatric Medicine. J Am Geriatr Soc 2014; 62:924-9. [DOI: 10.1111/jgs.12825] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Karen Sauvigné
- Icahn School of Medicine at Mount Sinai; New York New York
| | | | | | - Lynne M. Kirk
- University of Texas Southwestern Medical Center; Dallas Texas
| | - Sharon A. Levine
- Boston University School of Medicine and Boston Medical Center; Boston Massachusetts
| | - Laura Mosqueda
- Irvine School of Medicine; University of California; Orange California
| | - Susan Mockus Parks
- Jefferson Medical College; Thomas Jefferson University; Philadelphia Pennsylvania
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