The Undergraduate to Graduate Medical Education Transition as a Systems Problem: A Root Cause Analysis

Using Group Concept Mapping to Explore Medical Education's Blind Spots

PHENOMENON

All individuals and groups have blind spots that can lead to mistakes, perpetuate biases, and limit innovations. The goal of this study was to better understand how blind spots manifest in medical education by seeking them out in the U.S.

APPROACH

We conducted group concept mapping (GCM), a research method that involves brainstorming ideas, sorting them according to conceptual similarity, generating a point map that represents consensus among sorters, and interpreting the cluster maps to arrive at a final concept map. Participants in this study were stakeholders from the U.S. medical education system (i.e., learners, educators, administrators, regulators, researchers, and commercial resource producers) and those from the broader U.S. health system (i.e., patients, nurses, public health professionals, and health system administrators). All participants brainstormed ideas to the focus prompt: "To educate physicians who can meet the health needs of patients in the U.S. health system, medical education should become less blind to (or pay more attention to) …" Responses to this prompt were reviewed and synthesized by our study team to prepare them for sorting, which was done by a subset of participants from the medical education system. GCM software combined sorting solutions using a multidimensional scaling analysis to produce a point map and performed cluster analyses to generate cluster solution options. Our study team reviewed and interpreted all cluster solutions from five to 25 clusters to decide upon the final concept map.

FINDINGS

Twenty-seven stakeholders shared 298 blind spots during brainstorming. To decrease redundancy, we reduced these to 208 in preparation for sorting. Ten stakeholders independently sorted the blind spots, and the final concept map included 9 domains and 72 subdomains of blind spots that related to (1) admissions processes; (2) teaching practices; (3) assessment and curricular designs; (4) inequities in education and health; (5) professional growth and identity formation; (6) patient perspectives; (7) teamwork and leadership; (8) health systems care models and financial practices; and (9) government and business policies.

INSIGHTS

Soliciting perspectives from diverse stakeholders to identify blind spots in medical education uncovered a wide array of issues that deserve more attention. The concept map may also be used to help prioritize resources and direct interventions that can stimulate change and bring medical education into better alignment with the health needs of patients and communities.

Surgery and Surgical Training Before Graduate Medical Education: A Blue Ribbon Committee II, Medical Student Education Subcommittee Report

OBJECTIVE

To update and add to the first report commissioned by the Blue Ribbon Committee (BRC) about 20 years prior.

BACKGROUND

Following a summit in late 2022 commissioned by the American Board of Surgery regarding competency-based reforms in surgical education and through a partnership with the American College of Surgeons and other stakeholders, a BRC-II on surgical education was formed. The BRC-II would have 7 subcommittees. This paper details the work of the Medical Student Subcommittee within the BRC-II.

METHODS

The subcommittee's work, supported by staff from the American College of Surgeons, entailed a thorough literature review, which involved collating and aggregating the findings, identifying key challenges and opportunities, and committing to draft recommendations. These recommendations were then presented and refined through discussions with the BRC at large in multiple virtual and in-person settings.

RESULTS

The subcommittee's work is detailed below and further summarized in table format. The section below elucidates the medical student education continuum and discusses the pertinent topics of recruitment, surgical engagement in medical student training and the surgical image, training for the current surgical practice model, trainee selection for graduate medical education, and optimizing the transition from undergraduate medical education to graduate medical education.

CONCLUSIONS

The last 2 decades have shown significant changes and shifts in medical education and surgical practice. The findings of BRC-II in this manuscript help to structure the current and future necessary improvements, focusing on different aspects of medical student education.

Internal Medicine Acting Internship Trends in Rotation Structure and Student Responsibilities: Results from a 2023 National Survey

BACKGROUND

The acting internship (AI) in internal medicine plays a key role in the transition from medical school to residency. While there have been recent changes in medical education including a pass/fail USMLE Step 1 and increasing use of competency-based assessment, there has not been a large survey of the state of the AI in many years.

OBJECTIVE

To assess the current landscape of the internal medicine AI and identify areas in need of standardization.

DESIGN

This was a voluntary online survey of medical schools in the United States (U.S.).

PARTICIPANTS

Course directors of the AI rotation at U.S. medical schools.

MAIN MEASURES

Number of AI rotations required for graduation, length of AI rotation, types of services allowed for AI, clinical responsibilities of students, curricular components.

KEY RESULTS

Response rate was 50.7% (71/140 LCME accredited schools). All responding institutions require at least one AI for graduation, with nearly all schools integrating students into resident teaching teams, and almost half also allowing AI students to work on hospitalist services. Students carry 3-4 patients per day on average with a maximum of 5-6 in most institutions. Students are responsible for most aspects of patient care including notes, orders, interprofessional communication, and transitions of care. Night call or night float responsibilities are infrequently required. The structured curriculum published by AAIM is used by only 41% of schools.

CONCLUSIONS

The internal medicine AI continues to be a staple in the medical school experience, but there is variation in the structure, curriculum, and expectations on the rotation. Opportunities exist to improve standardization of the AI experience and expectations to better prepare medical students for the transition from medical school to residency.

Resident Recruitment in a New Era

ABSTRACT

This chapter focuses on resident recruitment and recent US National Resident Matching Program changes and the impact in the evaluation and ranking of applicants within the specialty of anesthesiology. Recruitment challenges are examined as well as program strategies and potential future directions. Also discussed are DEI initiatives within the recruitment process.

Lifelong Learning Indicators in Medical Students After a Novel Communication Skills Session

CONTEXT

A growth mindset and mastery approach have gained attention as useful learning orientations in medical education, however few studies of interventions to foster these orientations exist.

OBJECTIVES

We sought to discover whether a communication skills session on delivering serious news could foster a communication growth mindset and/or a mastery approach in medical students.

METHODS

This was an interventional survey study of third-year medical students before and after a session on delivering serious news. Students were administered a communication mindset survey before and after the session; achievement goal and learning environment surveys were administered after the session. Chi-square tests were used to assess the difference in pre and post mindsets. Logistic regression was used to determine the odds of achieving a mastery approach with pre- and post-communication growth mindset as the independent variables.

RESULTS

Students' communication growth mindset increased from 79% (n = 186) before the intervention to 92% (n = 142) after the intervention. Achievement goal analysis demonstrated that 64% (n = 91) of students had a mastery approach, 14% (n = 20) had a performance approach and 22% (n = 32) had an avoidant approach. Ninety-nine percent (n = 151) felt the session provided a safe learning environment. The odds of having a mastery approach correlated with both pre and post-intervention growth mindset, with post-session growth mindset having the strongest correlation.

CONCLUSIONS

A novel communication skills session on delivering serious news fostered a communication growth mindset in third year medical students. Most students exhibited a mastery approach to learning; this approach was more likely when they had a growth mindset.

Beware False Growth Mindset: Building Growth Mindset in Medical Education Is Essential but Complicated

ABSTRACT

Mindset theory aims to explain how learners' beliefs about intelligence and learning affect how they perceive effort, react to failure, and respond to feedback in challenging learning contexts. Mindset theory distinguishes between growth mindset (the belief that human capacities can be developed over time) and fixed mindset (the belief that human capacities are inherent and unchangeable). Efforts to develop growth mindset in learners have shown a wide range of benefits, including positive effects on students' resilience, commitment to lifelong learning, and persistence in a field of study, with notable impacts on learners who are struggling, learners from minoritized groups, and women in scientific fields. In recent years, mindset theory interventions have caught the interest of medical educators hoping to engage learners as partners in their own learning and progression to competence. Educators hoping to apply this theory to educational programs and learner-teacher interactions in ways that promote growth mindsets would benefit from awareness of the concept of false growth mindset , a term coined by Carol Dweck to refer to common pitfalls in the theory's application. In this article, the authors highlight important findings from mindset interventions in medical education, identify common pitfalls of false growth mindset in the context of medical learners, and offer suggestions for how educators and institutions can better instigate changes to promote growth mindsets within medical education.

Exploring Competency-Based Medical Education Through the Lens of the UME-GME Transition: A Qualitative Study

PURPOSE

Competency-based medical education (CBME) represents a shift to a paradigm with shared definitions, explicit outcomes, and assessments of competence. The groundwork has been laid to ensure all learners achieve the desired outcomes along the medical education continuum using the principles of CBME. However, this continuum spans the major transition from undergraduate medical education (UME) to graduate medical education (GME) that is also evolving. This study explores the experiences of medical educators working to use CBME assessments in the context of the UME-GME transition and their perspectives on the existing challenges.

METHOD

This study used a constructivist-oriented qualitative methodology. In-depth, semistructured interviews of UME and GME leaders in CBME were performed between February 2019 and January 2020 via Zoom. When possible, each interviewee was interviewed by 2 team members, one with UME and one with GME experience, which allowed follow-up questions to be pursued that reflected the perspectives of both UME and GME educators more fully. A multistep iterative process of thematic analysis was used to analyze the transcripts and identify patterns across interviews.

RESULTS

The 9 interviewees represented a broad swath of UME and GME leadership positions, though most had an internal medicine training background. Analysis identified 4 overarching themes: mistrust (a trust chasm exists between UME and GME); misaligned goals (the residency selection process is antithetical to CBME); inadequate communication (communication regarding competence is infrequent, often unidirectional, and lacks a shared language); and inflexible timeframes (current training timeframes do not account for individual learners' competency trajectories).

CONCLUSIONS

Despite the mutual desire and commitment to move to CBME across the continuum, mistrust, misaligned goals, inadequate communication, and inflexible timeframes confound such efforts of individual schools and programs. If current efforts to improve the UME-GME transition address the themes identified, educators may be more successful implementing CBME along the continuum.