What Behaviors Define a Good Physician? Assessing and Communicating About Noncognitive Skills

Public Board Score Reporting Undermines Holistic Review for Residency Selection

Holistic review has become the gold standard for residency selection. As a result, many programs are de-emphasizing standardized exam scores and other normative metrics. However, if standardized exam scores predict passing of an initial certifying exam, this may lead to an increase in board failure rates within specific residency training programs who do not emphasize test scores on entry. Currently, the board pass rates of residency programs from many of the American Board of Medical Subspecialities (ABMS) are publicly reported as a rolling average. In theory, this should create accountability but may also create pressure and distort the way residency program selects applicants. The risk to programs of having a lower board pass rate publicly reported incentivizes programs to focus increasingly on standardized test scores, threatening holistic review. All programs do not recruit students entering residency with an identical chance of passing boards. Therefore, we believe the ABMS member boards should stop publicly reporting raw certifying exam rates above a certain threshold for normative comparison. We strongly encourage the use of learning analytics to create a residency "expected board pass rate" that would be a better metric for program evaluation and accreditation.

A thematic content analysis of the structure and effects of good doctor abilities in China

BACKGROUND

The efforts to explore and build the structure of good doctor abilities are important because they help improve the quality of education for medical students and better standardize the working performance of doctors. However, at present, no worldwide standards for such a structure have been established. In this study, we endeavoured to map the structure of good doctor abilities and identify their effects.

METHODS

With a focus on China, a thematic content analysis was adopted in this study to analyse the personal profiles of 50 widely recognized good doctors. NVivo11 software was used.

RESULTS

The Structure and Effects of Good Doctor Abilities in China model was proposed, and interpretations were made based on AMO theory. Good doctor abilities fall within six categories: rigorous clinical thinking, skilled in diagnosis and therapy, clinical empathy, continuous learning and innovation, enhancing and sharing experiences, and communication and coordination. These abilities have positive impacts on doctors' work performances and social benefits by encouraging good behaviours, ultimately promoting the sustainable development of the hospitals where they serve.

CONCLUSIONS

In this study, we established a model of the structure and effects of good-doctor abilities in China and interpreted its mechanism, innovation and theory diversification in "good-doctor" research. Moreover, this study has practical significance because it provides systematic and well-targeted criteria for improving the professionalism of doctors, promoting more good doctor behaviours, providing guidance for regulating doctors' conduct and providing a reference for medical education and working performance reviews worldwide.

Building on Strengths: An Affirmational and Systems-Level Approach to Revisiting Character in Medicine

ABSTRACT

Although U.S. medical education has continued to place increased emphasis on defining competency standards and ensuring accountability to the public, health care inequities have persisted, several basic health outcomes have worsened, public trust in the health care system has eroded, and moral distress, burnout, and attrition among practicing physicians have escalated. These opposing trends beg the question of how the "good doctor" concept may be strengthened. In this perspective, the authors argue that revisiting the construct of physician character from an affirmational perspective could meaningfully improve medical education's impact on overall health by more holistically conceptualizing what-and who-a good doctor is. The authors introduce positive psychology's framework of character strengths, probe the distinction between character strengths and medical professionalism, and summarize the role of character strengths in promoting physician engagement and well-being in health care work. They contend that a systems-level approach to cultivating character strengths will foster physician moral agency and well-being and, by extension, transformational change in health care. Consistent with best practice in modern character education, the authors propose that institutions mindfully cultivate moral community among all stakeholders (students, faculty, staff, postgraduate trainees, and patients) and that moral community interaction centers on each member's personal aspirations with respect to living a good life, guided by the character strengths framework and informed by patient perspectives.

Effects of grit on medical students' wellbeing during clerkships: a longitudinal observational cohort study

Introduction

In medical education, the clerkship phase is a demanding period during which medical students learn to navigate the responsibilities of medical school and clinical medicine. Grit, a personal quality regarded as a non-cognitive trait, refers to perseverance and passion; specifically, it represents the ability to endure hardship and work industriously toward a goal. Most studies analysed grit as a single concept and few studies have investigated the effect of grit on the well-being of medical students through the whole-specialty training (i.e. surgical and non-surgical specialty rotations) required in clinical clerkships. Therefore, this study investigated whether associations exist between medical students' grit, measured by the two subconstructs of perseverance and passion, and their well-being during clerkships in surgical and non-surgical specialty units.

Methods

This one-year prospective web-based questionnaire study enrolled fifth-year medical students at a tertiary medical centre in central Taiwan between September 2017 and July 2018 in their first-year clerkship. The students' sex, age, and grit were measured at the start of their clerkship. Routine surveys were conducted over one year to assess burnout and compassion satisfaction for students' well-being, and the training specialty characteristics of the surgical and non-surgical specialty departments were recorded. This study included 92 medical students and 1,055 survey responses from individual specialty rotations. Descriptive, univariate and multivariate analyses were performed.

Results

Our results revealed that medical students' perseverance, as part of grit, was related to lower burnout and higher compassion satisfaction during clerkships, but not the subconstruct of passion. Moreover, the positive trait of perseverance measured in our study had greater explanatory power for compassion satisfaction than for burnout. Furthermore, the results revealed that older medical students suffered from less burnout than their younger counterparts, and that male medical students expressed higher compassion satisfaction than their female counterparts.

Discussion

Perseverance, as a subconstruct of grit, is a positive personal quality for medical students' clerkships, and methods driving the cultivation of perseverance in medical education should be considered. In addition, even though positive traits such as perseverance equipped medical students for compassion satisfaction, additional factors attributed to medical students' burnout must be identified.

Professionalism Policies and Practices as Experienced by First-Generation Medical Students, Residents, and Physicians

Phenomenon: While professionalism is largely understood to be complex and dynamic, it is oftentimes implemented as if it were static and concrete. As a result, policies and practices reflect dominant historical norms of the medical profession, which can cause tension for trainees from marginalized groups. One such group comprises those who identify as first-generation physicians - those whose parents have not earned an associate's degree or higher. This group is highly diverse in terms of gender, race, ethnicity, and socioeconomic status; however, their experiences with institutional professionalism policies and practices has not yet been fully explored. In this study, our aims were to understand the ways in which these participants experience professionalism, and to inform how professionalism can be more inclusively conceptualized. Approach: In November 2022-March 2023, we conducted semi-structured interviews with 11 first-generation medical students, residents, and physicians and analyzed select national and institutional professionalism policies in relation to key themes identified in the interviews. The interviews were designed to elicit participants' experiences with professionalism and where they experienced tension and challenges because of their first-gen identity. Data were analyzed using thematic analysis through a critical perspective, focused on identifying tensions because of systemic and historical factors. Findings: Participants described the ways in which they experienced tension between what was written, enacted, desirable, and possible around the following elements of professionalism: physical appearance; attendance and leaves of absence; and patient care. They described a deep connection to patient care but that this joy is often overshadowed by other elements of professionalism as well as healthcare system barriers. They also shared the ways in which they wish to contribute to changing how their institutions conceptualize professionalism. Insights: Given their unique paths to and through medicine and their marginalized status in medicine, first-generation interviewees provided a necessary lens for viewing the concept of professionalism that has been largely absent in medicine. These findings contribute to our understanding of professionalism conceptually, but also practically. As professionalism evolves, it is important for institutions to translate professionalism's complexity into educational practice as well as to involve diverse voices in refining professionalism definitions and policies.

Incorporating a situational judgement test in residency selections: clinical, educational and organizational outcomes

BACKGROUND

Computer-based assessment for sampling personal characteristics (Casper), an online situational judgement test, is a broad measure of personal and professional qualities. We examined the impact of Casper in the residency selection process on professionalism concerns, learning interventions and resource utilization at an institution.

METHODS

In 2022, admissions data and information in the files of residents in difficulty (over three years pre- and post- Casper implementation) was used to determine the number of residents in difficulty, CanMEDS roles requiring a learning intervention, types of learning interventions (informal learning plans vs. formal remediation or probation), and impact on the utilization of institutional resource (costs and time). Professionalism concerns were mapped to the 4I domains of a professionalism framework, and their severity was considered in mild, moderate, and major categories. Descriptive statistics and between group comparisons were used for quantitative data.

RESULTS

In the pre- and post- Casper cohorts the number of residents in difficulty (16 vs. 15) and the number of learning interventions (18 vs. 16) were similar. Professionalism concerns as an outcome measure decreased by 35% from 12/16 to 6/15 (p < 0.05), were reduced in all 4I domains (involvement, integrity, interaction, introspection) and in their severity. Formal learning interventions (15 vs. 5) and informal learning plans (3 vs. 11) were significantly different in the pre- and post-Casper cohorts respectively (p < 0.05). This reduction in formal learning interventions was associated with a 96% reduction in costs f(rom hundreds to tens of thousands of dollars and a reduction in time for learning interventions (from years to months).

CONCLUSIONS

Justifiable from multiple stakeholder perspectives, use of an SJT (Casper) improves a clinical performance measure (professionalism concerns) and permits the institution to redirect its limited resources (cost savings and time) to enhance institutional endeavors and improve learner well-being and quality of programs.

Education Research: Introduction of a Standardized Communication Card to Facilitate Patient-as-Teacher Training for Medical Students in the Neurology Clerkship

Background and Objectives

Enhanced communication has been recognized as an effective strategy to improve patient safety and care quality. While some communication skills can be taught in traditional didactic settings, learning from patient encounters is critical. Currently, patients are becoming increasingly involved as teachers for medical students within both the clinical and classroom setting. The goal of this study was to characterize medical student reflections about patient interactions using a standardized Patient and Teacher Communication Card. We aimed to identify how the introduction of this tool changed students' follow-up practices and affected patient care.

Methods

We used a cross-sectional concurrent mixed-methods study to characterize student-patient communication. Medical students taking the neurology clerkship between 2017 and 2022 were asked to complete the Communication Card during at least 1 patient encounter. The Communication Card was used to generate a learning opportunity by providing questions for the students to ask the patient. Following the encounter, the card collected qualitative data from the student's perspective through 2 open-ended questions: (Q1) How has the card changed how you follow-up with patients after rounds? (Q2) How did this follow-up affect patient care? We used a conventional content analysis approach to characterize student responses.

Results

A total of 460 students completed the card (MS2: n = 67 [14.6%]; MS3: n = 260 [56.5%], and MS4: n = 133 [28.9%]). Students cited 4 ways in which the card changed their follow-up with patients: (1) ensuring understanding; (2) following up more; (3) building rapport; and (4) guiding challenging conversations. Ensuring understanding was cited by half of the students in all years. Students cited ways in which the card affected patient care: (1) prompting further discussion with the team and/or patient; (2) impression of the patient feeling more comfortable; (3) addressing patient concerns; and (4) impression of increased trust.

Discussion

Overall, students' reflections after patient conversations were very positive. Future work should consider studying the impact of this communication tool on patients' perspectives and determine whether they align with the student's perception. In addition, implementation of a Communication Card throughout the other clerkships should be considered to enhance the medical school curriculum.

Building Authentic Connection in the Patient-Physician Relationship

INTRODUCTION/OBJECTIVES

Delivering optimal patient care is impacted by a physician's ability to build trusting relationships with patients. Identifying techniques for rapport building is important for promoting patient-physician collaboration and improved patient outcomes. This study sought to characterize the approaches highly skilled primary care physicians (PCPs) use to effectively connect with diverse patients.

METHODS

Using an inductive thematic analysis approach, we analyzed semi-structured interview transcripts with 10 PCPs identified by leadership and/or colleagues for having exceptional patient communication skills. PCPs practiced in 3 diverse clinic settings: (1) academic medical center, (2) Veterans Affairs clinic, and (3) safety-net community clinic.

RESULTS AND CONCLUSIONS

The thematic analysis yielded 5 themes that enable physicians to establish connections with patients: Respect for the Patient, Engaged Curiosity, Focused Listening, Mutual Participation, and Self-Awareness. Underlying all of these themes was a quality of authenticity, or a state of symmetry between one's internal experience and external words and actions. Adopting these communication techniques while allowing for adaptability in order to remain authentic in one's interactions with patients may facilitate improved connection and trust with patients. Encouraging physician authenticity in the patient-physician relationship supports a shift toward relationship-centered care. Additional medical education training is needed to facilitate authentic connection between physicians and patients.

Inconsistently reporting post-licensure EPA specifications in different clinical professions hampers fidelity and practice translation: a scoping review

BACKGROUND

Entrustable Professional Activities (EPAs) are defined units of professional practice entrusted to professionals once they have attained the specific competencies required to complete the end-to-end task. They provide a contemporary framework for capturing real-world clinical skillsets and integrating clinical education with practice. Our scoping review question was: how are post-licensure EPAs reported in peer reviewed literature, in different clinical professions?

METHOD

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist, Arksey and O'Malley and Joanna Briggs Institute (JBI) methodology. Searching ten electronic databases returned 1622 articles, with 173 articles included. Data extracted included demographics, EPA discipline, titles and further specifications.

RESULTS

All articles were published between 2007-2021 across sixteen country contexts. The majority were from North America (n = 162, 73%) describing medical sub-specialty EPAs (n = 126, 94%). There were comparably few EPA frameworks reported in clinical professions other than medicine (n = 11, 6%). Many articles reported only EPA titles without further explanation and limited content validation. The majority did not include information about the EPA design process. Few EPAs and frameworks were reported according to all the recommended EPA attributes. There was unclear distinction between specialty-specific EPAs and those that could be useful across disciplines.

DISCUSSION

Our review highlights the large volume of EPAs reported in post-licensure medicine, including the volume disparity compared to other clinical professions. Basing our enquiry upon existing guidelines for EPA attributes and features, our experience in conducting the review and our primary finding demonstrated heterogeneity of EPA reporting according to these specifications. To promote EPA fidelity, and quality appraisal, and to reduce interpretation subjectivity, we advocate: diligently reporting EPA attributes and features; including reference or citation to EPA design and content validity information; and considering distinguishing EPAs as specialty-specific or transdisciplinary.

CONCLUSION

A large volume of post-licensure EPAs were identified in medicine relative to other clinical professions. EPA specifications were absent or variously reported in the literature, risking ambiguous interpretation. The authors recommend that future EPAs are reported with reference to established and evolving construct recommendations, which is integral to concept fidelity and translation to practice and education.