Service: an essential component of graduate medical education

Chalk Talks for the Clinical Setting: Evaluation of a Medical Education Workshop for Fellows

Introduction

Chalk talks are effective teaching tools in the clinical setting. However, data on optimal strategies for teaching medical educators how to develop and deliver them are limited. We designed and implemented two 50-minute workshops to help subspecialty fellows across GME create and deliver a chalk talk.

Methods

The first workshop comprised a demonstration of an effective chalk talk and a discussion of best practices for creating chalk talks; the second was a practice session where fellows presented their chalk talks and received feedback from faculty and peers. We evaluated pre- and postworkshop confidence in the ability to create and deliver a chalk talk and develop learning objectives. Secondary outcomes were faculty and peer evaluations of the chalk talks.

Results

Eighteen of 33 participants (54% response rate) completed both pre- and postsession surveys. Fellows reported improved confidence in their ability to create a chalk talk (22% vs. 83%, p < .001), deliver a chalk talk (17% vs. 83%, p < .001), and develop well-written learning objectives (11% vs. 83%, p < .001). After the workshop, participants were more likely to correctly identify a chalk talk that made use of an advanced organizer (67% vs. 89%, p < .05). Thirty-eight faculty and peers completed feedback evaluations of participants' chalk talks; most rated fellows' chalk talks highly in domains of content, delivery, design, learning objectives, and engagement.

Discussion

The incorporation of these workshop within a course on medical education can effectively develop clinical teaching skills among subspecialty fellows in GME.

Competency-based medical curriculum: Exploring the preclinical medical teachers' pedagogical and technical readiness levels

Background The medical curriculum for undergraduates was revised by the Medical Council of India in 2019, after 21 years. We did this study to determine teachers' pedagogical and technical readiness to implement the competency-based curriculum in medical colleges and determine factors that affect readiness, from their perspective. Methods We conducted a cross-sectional survey in the form of an online questionnaire. The qualitative data were coded numerically and were analysed using frequencies and proportions. Pearson Chi-square test was used to study the association among variables. Results The majority (85%) of respondents had attended a curriculum implementation training programme; 62.2% with experience <5 years, 56.1% with experience 5-10 years and a minority of 13.3% with >10 years' experience were ready to a 'great extent' to implement the new curriculum; 54.1% agreed to re-frame lectures and 64.9% possessed technological skills to suit the needs of a competency-based curriculum. About 77% agreed that it will provide a rich learning environment, inspire self-directed learning while 52% believed it will promote scientific thinking and provide better learning outcomes in the long run. Conclusion Medical teachers had a positive attitude towards implementation of the new curriculum. However, numerous factors such as low teacher-student ratio, textbooks designed according to the traditional curriculum, limited teachers' training and cumbersome paperwork may hinder its successful implementation. Updation of teachers' knowledge and skills through seminars/workshops is recommended to facilitate delivery of the new curriculum. Like any other ongoing reforms in medical education, competency-based curriculum is a work in process.

Scratching beneath the surface: How organisational culture influences curricular reform

INTRODUCTION

Curricular reform is often proposed as the means to improve medical education and training. However, reform itself may not lead to noticeable change, possibly because the influence of organisational culture on change is given insufficient attention. We used a national reform of early-years surgical training as a natural opportunity to examine the interplay between organisational culture and change in surgical education. Our specific research question was: in what ways did organisational culture influence the implementation of Improving Surgical Training (IST)?

METHODS

This is a qualitative study underpinned by social constructivism. Interviews were conducted with core surgical trainees (n = 46) and their supervising consultants (n = 25) across Scotland in 2020-2021. Data coding and analysis were initially inductive. The themes indicated the importance of many cultural factors as barriers or enablers to IST implementation. We therefore carried out a deductive, secondary data analysis using Johnson's (1988) cultural web model to identify and examine the different elements of organisational culture and their impact on IST.

RESULTS

The cultural web enabled a detailed understanding of how organisational culture influenced IST implementation as per Johnson's six elements-Rituals and Routines (e.g. departmental rotas), Stories (e.g. historical training norms and culture), Symbols (e.g. feedback mechanisms, visibility and value placed on education), Power Structures (e.g. who has the power in local contexts), Organisational Structures (e.g. relationships and accountability) and the Control System (e.g. consultant job plans and service targets)-and how these interact. However, it did not shed light on the influence of exogenous events on change.

CONCLUSION

Our data reveal cultural reasons why this curricular reform met with varying degrees of success across different hospital sites, reinforcing that curricular reform is not simply about putting recommendations into practice. Many different aspects of context must be considered when planning and evaluating change in medical education and training.

Trainee perceptions of resident duty hour restrictions: a qualitative study of online discussion forums

OBJECTIVE

Resident duty hour (RDH) restrictions in postgraduate medical education is a controversial yet important topic for study. There is limited literature on authentic trainee perceptions surrounding RDH restrictions to inform evaluation and future planning. Online forums are a widely accessible, yet underused resource, for insight into trainee perceptions. Our objective was to qualitatively assess trainee perceptions of RDH restrictions on online discussion forums.

SETTING

Online discussion forums; Premed101 (Canadian forum) and Student Doctor Network (SDN) (American forum).

PARTICIPANTS

6630 posts from 161 discussion threads; comprising 429 posts in 14 threads from Premed101 and 6201 posts in 147 threads from SDN. Posters included medical students, residents and attending physicians.

DESIGN

Data were analysed inductively and iteratively to create themes and subthemes. Cocoding, consensus-based decision making and an audit trail were used to ensure trustworthiness.

RESULTS

Key findings distilled across both forums include: the relationship between hours worked and competence, the inapplicability of blanket RDH restrictions to all specialties and the inter-relationship between fatigue and patient safety. Discussions of RDH restriction compliance and perceived consequence for the reporting of violations were also featured on the American SDN forum.

CONCLUSIONS

The findings of this study reveal multiple themes pertinent to the implementation and revision of RDH restrictions. The most prominent theme was the inapplicability of blanket restrictions on duty hours theme due to the diversity of training needs across specialties and the environmental context of training programmes. Other discussions included the inter-relationship of patient safety and resident competence with duty hours. Lastly, concerns regarding the lack of transparency and psychological safety surrounding RDH violations, were discussed.

Effect of Resident Physicians in a Supervisory Role on Efficiency in the Emergency Department

INTRODUCTION

While patient throughput and emergency department (ED) length of stay (LOS) are recognized as important metrics in the delivery of efficient care, they must be balanced with the educational mission of academic centers. Prior studies examining the impact of learners on throughput and LOS when staffing directly with attending physicians have yielded mixed results. Herein we sought to examine the impact of a staffing model involving a supervisory resident "pre-attending" (PAT) on ED throughput and LOS, as this model offers a valuable educational experience for residents, but may do so at the expense of operational efficiency.

METHODS

We retrospectively analyzed 26,702 unique patient encounters at a university-affiliated community ED between July 1, 2017-January 1,2019. The experimental group was comprised of patients seen primarily by midlevel providers, who staffed with a PAT, who subsequently staffed with an attending physician. The control group was comprised of patients seen by midlevel providers and staffed directly with attendings without a PAT. We used a parametric hazard model to analyze the effect of the presence of a PAT on service time, controlling for potential confounders including timing of presentation and patient demographics.

RESULTS

The presence of a PAT is associated with a statistically significant increase in service time of five minutes (p = 0.006). Holding other variables equal, predicted service time in the experimental group was 173 minutes (95% confidence interval (CI), 171-176), while that for controls was 168 minutes (95% CI, 165-171).

CONCLUSION

The presence of a PAT is associated with a statistically significant increase in service time, but the magnitude (five minutes) is likely operationally insignificant. The negligible increase in service time is offset by the benefit to residents' training. The results of this study may be helpful for residency programs considering the addition of a PAT shift structure.

Accreditation Improves Quality of Oncology Education in Low- and Middle-Income Countries: Perspectives of African Oncologists

The purpose of this study is to understand the perspectives of African Oncologists on the role of accreditation and on global standards. We developed a survey that addressed African oncologists' opinions on the role of accreditation. The survey also included 187 standards from World Federation of Medical Education Postgraduate medical education (PGME) standards, American Council of Graduate Medical Education (ACGME)-I standards for hematology/oncology, and the Royal College of Physician and Surgeons of Canada Medical Oncology standards. A 3-point scale was employed for each standard: 1 = not important, 2 = important but not essential, 3 = essential. The survey was sent to 79 physicians, 38 responded. Eighty-seven percent agreed that accreditation ensures quality. Forty-five percent agreed it will not increase migration of qualified doctors. Twenty-two individuals who completed the entire survey were analyzed for the standards. Five standards received the highest ratings of 3 (essential) from all respondents. One standard received a rating of < 2.0. The majority of standards had ratings between 2.6 and 2.94 indicating African oncologists found most standards to be useful. Ratings < 2.6 were mostly related to resource constraints. Most African Oncologists believed that accreditation ensures quality of education, and most standards were considered important. This data is useful for developing and adapting accreditation standards in resource-constrained settings.

Value-Added Activities in Medical Education: A Multisite Survey of First- and Second-Year Medical Students' Perceptions and Factors Influencing Their Potential Engagement

PURPOSE

To describe attitudes of first- and second-year U.S. medical students toward value-added medical education, assess their self-reported desire to participate in value-added activities, and identify potentially modifiable factors influencing their engagement.

METHOD

The authors conducted a cross-sectional survey of first- and second-year students at nine U.S. medical schools in 2017. Survey items measured students' attitudes toward value-added medical education (n = 7), desire to participate in value-added activities (n = 20), and factors influencing potential engagement (n = 18).

RESULTS

Of 2,670 students invited to participate, 1,372 (51%) responded. Seventy-six percent (1,043/1,368) moderately or strongly agreed they should make meaningful contributions to patient care. Students' desire to participate was highest for patient care activities approximating those traditionally performed by physicians, followed by systems improvement activities and lowest for activities not typically performed by physicians. Factors increasing desire to participate included opportunities to interact with practicing physicians (1,182/1,244; 95%), patients (1,177/1,246; 95%), and residents or fellows (1,166/1,246; 94%). Factors decreasing desire to participate included making changes to the health care system (365/1,227; 30%), interacting with patients via phone or electronic communication (410/1,243; 33%), and lack of curricular time (634/1,233; 51%).

CONCLUSIONS

First- and second-year medical students agree they should add value to patient care, but their desire to participate in value-added activities varies depending on the nature of the tasks. Medical schools may be able to increase students' desire to participate by enabling face-to-face interactions with patients, embedding students in health care teams, and providing dedicated curricular time.

Fellow as Clinical Teacher (FACT) Curriculum: Improving Fellows' Teaching Skills During Inpatient Consultation

INTRODUCTION

Multiple barriers, including time constraints, a demanding teaching environment, and lack of longitudinal relationships with residents, make it challenging for fellows and learners to engage in effective teaching during consultation.

METHODS

The Fellow as Clinical Teacher (FACT) curriculum was developed to overcome such barriers and improve fellow teaching in the setting of inpatient consultation. The FACT curriculum consists of two 45- to 60-minute small-group sessions designed for subspecialty fellows. The first session focuses on overcoming barriers to teaching and application of the principles of adult learning theory. The second introduces the PARTNER (partner with resident, assess the learner, reinforce positives, teaching objectives, new knowledge, execute recommendations, review) framework for teaching during consultation and uses video examples to model the application of this framework, allowing fellows to practice its implementation through role-play.

RESULTS

Previously, the FACT curriculum was shown to improve teaching skills of rheumatology and pulmonary/critical care fellows as evaluated by objective structured teaching exercises. Here, the curriculum has been expanded to 51 internal medicine and pediatrics fellows in 15 different training programs. The curriculum improved fellow teaching skills as assessed by self-assessment surveys. It was highly rated by participants, and fellows reported being more likely to teach during consultation following this educational intervention.

DISCUSSION

The FACT curriculum can be integrated into subspecialty training programs to improve the teaching skills of internal medicine and pediatrics fellows in the setting of inpatient consultation. Ultimately, improved teaching from fellows may have broad-reaching effects for residents, patients, and the fellows themselves.

Defining Service and Education in Pediatrics

Program directors (PDs) and trainees are often queried regarding the balance of service and education during pediatric residency training. We aimed to use qualitative methods to learn how pediatric residents and PDs define service and education and to identify activities that exemplify these concepts. Focus groups of pediatric residents and PDs were performed and the data qualitatively analyzed. Thematic analysis revealed 4 themes from focus group data: (1) misalignment of the perceived definition of service; (2) agreement about the definition of education; (3) overlapping perceptions of the value of service to training; and (4) additional suggestions for improved integration of education and service. Pediatric residents hold positive definitions of service and believe that service adds value to their education. Importantly, the discovery of heterogeneous definitions of service between pediatric residents and PDs warrants further investigation and may have ramifications for Accreditation Council for Graduate Medical Education and those responsible for residency curricula.

Balancing health care education and patient care in the UK workplace: a realist synthesis

CONTEXT

Patient care activity has recently increased without a proportionate rise in workforce numbers, impacting negatively on health care workplace learning. Health care professionals are prepared in part by spending time in clinical practice, and for medical staff this constitutes a contribution to service. Although stakeholders have identified the balance between health care professional education and patient care as a key priority for medical education research, there have been very few reviews to date on this important topic.

METHODS

We conducted a realist synthesis of the UK literature from 1998 to answer two research questions. (1) What are the key workplace interventions designed to help achieve a balance between health care professional education and patient care delivery? (2) In what ways do interventions enable or inhibit this balance within the health care workplace, for whom and in what contexts? We followed Pawson's five stages of realist review: clarifying scope, searching for evidence, assessment of quality, data extraction and data synthesis.

RESULTS

The most common interventions identified for balancing health care professional education and patient care delivery were ward round teaching, protected learning time and continuous professional development. The most common positive outcomes were simultaneous improvements in learning and patient care or improved learning or improved patient care. The most common contexts in which interventions were effective were primary care, postgraduate trainee, nurse and allied health professional contexts. By far the most common mechanisms through which interventions worked were organisational funding, workload management and support.

CONCLUSION

Our novel findings extend existing literature in this emerging area of health care education research. We provide recommendations for the development of educational policy and practice at the individual, interpersonal and organisational levels and call for more research using realist approaches to evaluate the increasing range of complex interventions to help balance health care professional education and patient care delivery.

Implementing competency-based medical education: What changes in curricular structure and processes are needed?

Medical educators must prepare for a number of challenges when they decide to implement a competency-based curriculum. Many of these challenges will pertain to three key aspects of implementation: organizing the structural changes that will be necessary to deliver new curricula and methods of assessment; modifying the processes of teaching and evaluation; and helping to change the culture of education so that the CBME paradigm gains acceptance. This paper focuses on nine key considerations that will support positive change in first two of these areas. Key considerations include: ensuring that educational continuity exists amongst all levels of medical education, altering how time is used in medical education, involving CBME in human health resources planning, ensuring that competent doctors work in competent health care systems, ensuring that information technology supports CBME, ensuring that faculty development is supported, ensuring that the rights and responsibilities of the learner are appropriately balanced in the workplace, preparing for the costs of change, and having appropriate leadership in order to achieve success in implementation.

Use of Fellow as Clinical Teacher (FACT) Curriculum for Teaching During Consultation: Effect on Subspecialty Fellow Teaching Skills

BACKGROUND

Subspecialty consultation in inpatient care is increasing. Teaching by subspecialty fellows in a consultation setting may be an important source of work-based learning for students and residents. However, teaching and evaluation of learners in this context may be challenging due to personal and systems-based barriers.

OBJECTIVE

We developed and evaluated a framework designed to overcome barriers to teaching and to improve fellow teaching skills during inpatient consultation.

METHODS

The PARTNER (Partner with resident, Assess the learner, Reinforce positives, Teaching objectives, New knowledge, Execute recommendations, Review) framework was delivered to rheumatology and pulmonary and critical care medicine fellows at 3 academic medical centers as part of a 2-session Fellow as Clinical Teacher (FACT) curriculum. Fellows' teaching skills were evaluated using an objective structured teaching exercise (OSTE) pre- and postcurriculum, and at the end of the academic year. Self-assessment surveys were used to evaluate fellows' self-perception of teaching skills.

RESULTS

Twelve of 16 eligible fellows (75%) participated in the program and completed 73 OSTE cases. Teaching skills measured by OSTEs and self-assessment surveys improved after administration of the FACT curriculum. There was no significant skill decay at the end-of-year evaluation. The curriculum was rated highly, and 73% (8 of 11) of fellows stated they would teach more frequently as a result of the intervention.

CONCLUSIONS

The FACT curriculum was practical and feasible, and significantly improved fellows' teaching skills teaching during inpatient consultation.

Humanism and professionalism education for pediatric hematology-oncology fellows: A model for pediatric subspecialty training

BACKGROUND

Humanism and professionalism are virtues intrinsic to the practice of medicine, for which we lack a standard, evidence-based approach for teaching and evaluation. Pediatric hematology-oncology (PHO) fellowship training brings new and significant stressors, making it an attractive setting for innovation in humanism and professionalism training.

PROCEDURE

We electronically surveyed a national sample of PHO fellows to identify fellows' educational needs in humanism and professionalism. Next, we developed a case-based, faculty-facilitated discussion curriculum to teach this content within pilot fellowship programs. We assessed whether fellowships would decide to offer the curriculum, feasibility of administering the curriculum, and satisfaction of fellow and faculty participants.

RESULTS

Surveys were completed by 187 fellows (35%). A minority (29%) reported that their training program offers a formal curriculum in humanism and/or professionalism. A majority desires more formal teaching on balancing clinical practice and research (85%), coping with death/dying (85%), bereavement (78%), balancing work and personal life (75%), navigating challenging relationships with patients (74%), and depression/burn out (71%). These six topics were condensed into four case-based modules, which proved feasible to deliver at all pilot sites. Ten fellowship programs agreed to administer the novel curriculum. The majority (90%) of responding fellows and faculty reported the sessions touched on issues important for training, stimulated reflective communication, and were valuable.

CONCLUSIONS

Pediatric hematology-oncology fellows identify numerous gaps in their training related to humanism and professionalism. This curriculum offers an opportunity to systematically address these educational needs and can serve as a model for wider implementation. Pediatr Blood Cancer 2015;62:335-340. © 2014 Wiley Periodicals, Inc.

A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes

BACKGROUND

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour resident duty limits. In 2011 the ACGME mandated 16-hour duty maximums for PGY1 (post graduate year) residents. The stated goals were to improve patient safety, resident well-being, and education. A systematic review and meta-analysis were performed to evaluate the impact of resident duty hours (RDH) on clinical and educational outcomes in surgery.

METHODS

A systematic review (1980-2013) was executed on CINAHL, Cochrane Database, Embase, Medline, and Scopus. Quality of articles was assessed using the GRADE guidelines. Sixteen-hour shifts and night float systems were analyzed separately. Articles that examined mortality data were combined in a random-effects meta-analysis to evaluate the impact of RDH on patient mortality.

RESULTS

A total of 135 articles met the inclusion criteria. Among these, 42% (N = 57) were considered moderate-high quality. There was no overall improvement in patient outcomes as a result of RDH; however, some studies suggest increased complication rates in high-acuity patients. There was no improvement in education related to RDH restrictions, and performance on certification examinations has declined in some specialties. Survey studies revealed a perception of worsened education and patient safety. There were improvements in resident wellness after the 80-hour workweek, but there was little improvement or negative effects on wellness after 16-hour duty maximums were implemented.

CONCLUSIONS

Recent RDH changes are not consistently associated with improvements in resident well-being, and have negative impacts on patient outcomes and performance on certification examinations. Greater flexibility to accommodate resident training needs is required. Further erosion of training time should be considered with great caution.

Decreasing inter-resident conflict by using computer-generated on-call schedules

OBJECTIVE

Although significant attention has been paid to the number of hours worked by residents, little consideration has been given to how the hours are assigned. This project describes an alternative to having Chief Residents manually create on-call schedules. In order to enhance objectivity and transparency, reduce perceived inequities in the process, and reduce inter-resident conflict, Harvard South Shore Psychiatry Residency Training Program experimented with a computer-generated on-call schedule.

METHOD

A locally written MATLAB script generated an on-call schedule for academic year (AY) 2012-2013. Measurements to assess the manual scheduling method (from AY 2011-2012) and the computer-generated method included the balance in the total number of hours assigned to individual residents; the number of call switches over two six-month periods; and survey of the residents' perception of fairness of the two scheduling methods and preferences.

RESULTS

A retrospective analysis of the AY 2011-2012 Chief Resident-generated call schedule found a range of differences of up to 25.8% between total hours assigned to individual residents in a given year. In the AY 2012-2013 computer-generated schedule, the differences in total hours assigned were reduced to a maximum of 6.1%. There were 63% fewer call switches resulting from the computer-generated as compared to the Chief Resident-generated method. Resident survey response rate was 76%. Seventy-seven percent of resident respondents (N = 22) perceived the computer-generated method to be fairer, and 90.9% of residents preferred having a summary table of hours of call per resident. Residents perceived the computer-generated method as resulting in less inter-resident conflict.

CONCLUSION

Methods for assigning duty hour schedules that are transparent, equitable, and require less Chief involvement may result in perceptions of greater fairness and less inter-resident conflict.

Balancing education and service in graduate medical education: data from pediatric trainees and program directors

PURPOSE

To measure pediatric program directors' (PDs') and trainees' perceptions of and expectations for the balance of service and education in their training programs.

METHOD

In fall 2011, an electronic survey was sent to PDs and trainees at Boston Children's Hospital. Respondents described perceptions and expectations for service and education and rated the education and service inherent to 12 vignettes. Wilcoxon rank sum tests measured the agreement between PD and trainee perceptions and ratings of service and education assigned to each vignette.

RESULTS

Responses were received from 28/39 PDs (78%) and 223/430 trainees (52%). Seventy-five (34%) trainees responded that their education had been compromised by excessive service obligations; only 1 (4%) PD agreed (P < .0001). Although 132 (59%) trainees reported that service obligations usually/sometimes predominated over clinical education, only 3 (11%) PDs agreed (P < .0001). One hundred trainees (45%) thought rotations never/rarely/sometimes provided a balance between education and clinical demands compared with 2 PDs (7%) (P < .0001). Both groups agreed that service can, without formal teaching, be considered educational. Trainees scored 6 vignettes as having greater educational value (P ≤ .01) and 10 as having lower service content (P ≤ .04) than PDs did.

CONCLUSIONS

Trainees and medical educators hold mismatched impressions of their training programs' balance of service and education. Trainees are more likely to report an overabundance of service. These data may impact the interpretation of Accreditation Council for Graduate Medical Education survey results and should be incorporated into dialogue about future curricular design initiatives.

The joys and challenges of caring for patients

Optimal care of patients involves the integration of both the scientific and humanistic aspects of medicine. However, the tremendous focus on technology can easily overshadow the personal effect of patient care. The complex relationship between the physician and the patient is a reciprocal one. Not only does the physician influence the experience of the patient, but the patient may leave a significant impression on the physician. Their interactions provide a myriad of opportunities for greater insight into the human condition, but may also contribute toward the struggle of physicians to maintain their own well-being. Enhanced awareness of the significance of these human interactions is at the core of caring for patients.