Academic Medicine最新文献

Purpose: Resident physicians experience high rates of burnout and depression but rarely prioritize their well-being or seek mental health care. The Accreditation Council for Graduate Medical Education mandated that training programs prioritize resident wellness and emotional and mental health to ensure readily available and accessible mental health care. To help meet that requirement and circumvent barriers to accessing care, the University of California San Diego Healer Education Assessment & Referral (HEAR) Program offers residents and fellows short-term therapy for coping with challenges that threaten their well-being. This report describes the results of a pilot study designed to evaluate the feasibility and effectiveness of the HEAR Program's resident therapy program.

Method: The cohort included residents and fellows who completed at least 1 postbaseline assessment from January to May 2022. Measures of fulfillment, burnout, self-compassion, quality of life, depression, and suicidal ideation were assessed and compared before and up to 12 weeks after enrollment.

Results: Of the 39 residents who consented to participation, 30 completed at least 1 postbaseline assessment. Most outcomes improved after therapy, with significant increases in fulfillment (mean [SE] coefficient, 0.24 [0.08]; z score, 2.86; P = .004), self-compassion (mean [SE] coefficient, 0.37 [0.07]; z score, 5.72; P < .001), and quality of life ( P < .001) and significant reductions in burnout (Stanford burnout scale: mean [SE] coefficient, -0.27 [0.07]; z score, -4.01; P < .001; single-item burnout scale: mean [SE] coefficient, -0.34 [0.08]; z score, -4.37; P < .001) and depression severity (mean [SE] coefficient, -1.08 [0.25]; z score, -4.36; P < .001).

Conclusions: This pilot study noted improvements in fulfillment, compassion, quality of life, and function, as well as reductions in burnout and depression severity, among resident physicians. Future studies in larger cohorts are needed to validate these findings and inform further optimization of this program.

Abstract: Although most students complete Step 1 before clerkships, some institutions delay the exam until after clerkships. The change to pass/fail grading adds additional complexity that should be considered when deciding about exam timing. Both early and late administration may affect learning outcomes, learner behavior, student well-being, and residency match success. Step 1 completion before clerkships promotes learning outcomes (e.g., integration and mastery of foundational material), may encourage students to focus on the curriculum, and may better prepare students for clinical science exams (CSEs). However, delaying the exam ensures that students maintain foundational knowledge and may encourage clinical educators to demonstrate basic science illustrations. An early Step 1 may affect learner behavior by allowing clerkship students to focus on clinical learning. The associated National Board of Medical Examiners performance report may also be used for Step 2 and CSE preparation. However, delaying Step 1 allows greater scheduling flexibility based on developmental milestones. Administration of Step 1 before clerkships removes a significant stressor from the clinical year and decompresses the residency application period. However, a delayed Step 1 reduces the pressure on students to engage in numerous extracurricular and research activities to distinguish themselves due to the pass/fail change. An early Step 1 exam may also lead to improved CSE performance, which is often linked to clerkship honors criteria, an increasingly valuable distinction for residency match success after the change to pass/fail. In contrast, delaying Step 1 is associated with higher first-time pass rates, which may be especially important for students at risk for failure. Medical educators and students should collaboratively approach the question of Step 1 timing, considering these factors within the context of the medical school program, curricular constraints and priorities, and students' individual needs and goals.

Problem: The persistent underrepresentation of American Indians and Alaska Natives (AIANs) in the health professions and the decline of AIAN matriculants into health-related programs suggest interventions are needed. The authors developed Healers, a text message mentoring service, to engage and support AIANs interested in the health professions.

Approach: Healers, launched in 2018, seeks to reach urban and rural high school/college-aged AIANs and other AIANs. Individuals subscribe by texting "HEALER" to a numeric code using their mobile device. Two concurrent intervention strategies include (1) a 17-week schedule of scripted texts and (2) live weekly office hours with 2 health pathway coaches. During the pilot year (June 2018 to June 2019), participants were recruited via national conferences, health fairs, social media, and word of mouth. Intake and exit surveys were conducted. Content analysis of text messages received during office hours was conducted.

Outcomes: During the pilot, 304 subscribers opted into Healers and generated 2,933 text messages. Intake survey respondents included high school students (n = 18/77, 23.4%), college students (n = 29/77, 37.7%), and others (n = 29/77, 37.7%). They represented 60 Tribes from 28 U.S. states. Among exit survey respondents, 26/28 (92.9%) reported Healers was useful, 25/27 (92.6%) reported it exposed them to new health professions, 26/27 (96.3%) expressed stories from AIAN health professionals were valuable, and 25/26 (96.2%) reported pursuing a health professions career seemed possible. Five themes emerged from the analysis of 346 texts received from participants during office hours: cultural support, mentorship, opportunities, wellness, and community building.

Next steps: Based on the pilot data concerning reach and impact, the Healers service has continued to enroll subscribers, host office hours, and promote the program. Future research should examine which careers interest participants and factors leading to successful enrollment in health pathway programs and attainment of health professions degrees.

Purpose: To avoid overreliance on metrics and better identify candidates who add value to the learning environment, some medical schools and residency programs have begun using holistic review for screening and selection, but limited data support or refute this use. This scoping review examines holistic review definitions and practice in medical education, summarizes research findings, and identifies gaps for future research.

Method: The authors searched 7 databases using a comprehensive search strategy including the keywords holistic, attributes, mission-based, mission-centric , and socially accountable for articles on holistic review within undergraduate medical education (UME) and graduate medical education (GME) published from database inception through July 5, 2024. Author pairs independently screened articles for inclusion and extracted data. Discrepancies were resolved via discussion. Quantitative and qualitative synthesis was performed.

Results: 6,511 articles were identified, with 33 included in this review. Twenty-five studies (76%) focused exclusively on GME, with only a few assessing holistic review in UME. Holistic review was implemented at 3 main stages: screening, interviewing, and ranking. Common rationales included service patterns, patient-physician identity concordance, enhancing patient trust, professional advocacy, and educational benefits. Holistic review elements varied, with most falling within the Association of American Medical Colleges experiences, attributes, and metrics framework. Nearly all studies reported an increase in the percentage of underrepresented in medicine trainees interviewed or selected. Several studies also demonstrated increases in other groups (e.g., women, lower socioeconomic status). Many studies included additional interventions to promote diversity, limiting the ability to assess holistic review in isolation.

Conclusions: This scoping review summarizes the literature on the rationale, development and implementation process, structure and components, outcomes assessed, barriers, and strategies for success for holistic review. This work can inform institutions and departments seeking to develop or refine their own holistic review systems and serve as a nidus for future research.

Purpose: This study examines sense of belonging (belongingness) in a large population of medical students, residents, and fellows and associations with learner burnout, organizational recruitment retention indicators, and potentially modifiable learning environment factors.

Method: All medical students, residents, and fellows at Mayo Clinic sites were surveyed between October and November 2020 with items measuring sense of belonging in 3 contexts (school or program, organization, surrounding community), burnout (2 Maslach Burnout Inventory items), recruitment retention indicators (likelihood of recommending the organization and accepting a job offer), potentially modifiable learning environment factors, and demographics (age, gender, race and ethnicity, LGBTQ+ identification, disability, socioeconomic background).

Results: Of 2,257 learners surveyed, 1,261 (56%) responded. The percentage of learners reporting a somewhat or very strong sense of belonging was highest in the school or program (994 of 1,227 [81%]) followed by the organization (957 of 1,222 [78%]) and surrounding community (728 of 1,203 [61%]). In adjusted analyses, learners with very strong organization belongingness had lower odds of burnout (odds ratio [OR], 0.05; 95% CI, 0.02-0.12) and higher odds of being likely to recommend the organization (OR, 505.23; 95% CI, 121.54-2,100.18) and accept a job offer (OR, 38.68; 95% CI, 15.72-95.15; all P < .001). School or program and community belongingness also correlated strongly with these outcomes. In multivariable analyses, social support remained associated with higher odds of belongingness in all 3 contexts; favorable ratings of faculty relationships and leadership representation remained associated with higher odds of belongingness in 2 contexts (school or program and organization); and favorable ratings of diversity, equity, and inclusion learning climate remained associated with belongingness in 1 context (community).

Conclusions: Sense of belonging among medical students, residents, and fellows varies across contexts, correlates strongly with burnout and organizational recruitment retention indicators, and is associated with multiple potentially modifiable learning environment factors.

Purpose: The objective structured clinical examination (OSCE) assesses clinical competence in health sciences education. There is little research regarding the reliability and validity of using an OSCE during the transition from undergraduate to graduate medical education. The goal of this study was to measure the reliability of a unique 2-rater Entrustable Professional Activity (EPA)-based OSCE format for transition to internship using generalizability theory for estimating reliability.

Method: During the 2018 to 2022 academic years, 5 cohorts of interns (n = 230) at the University of Iowa Hospital and Clinics participated in a 6-station OSCE assessment delivered during orientation. A univariate and multivariate generalizability study (G study) was conducted on the scores generated by the 3 cases in the orientation OSCE that shared the 2-rater format. This analysis was supplemented with an associated decision study (D study).

Results: The univariate G study for the cases that used a simulated patient and a faculty rater demonstrated that this OSCE generated a moderately reliable score with 3 cases. The D study showed that increasing the OCSE to 12 cases yielded a mean score reliable enough ( G = 0.76) for making high-stakes normative decisions regarding remediation and readiness to practice. The universe score correlation between 2 types of raters was 0.398. The faculty ratings displayed a larger proportion of universe (true) score variance and yielded a more reliable ( G = 0.433) score compared with the standardized patient ratings ( G = 0.337).

Conclusions: This study provides insight into the development of an EPA-based OSCE. The univariate G study demonstrated that when using the 2 rater types, this assessment could generate a moderately reliable score with 3 cases. The multivariate G study showed that the 2 types of raters assessed different aspects of clinical skills, and faculty raters were more reliable.

Abstract: The Accreditation Council for Graduate Medical Education (ACGME) plays a pivotal role in ensuring the quality of graduate medical education (GME) training across the United States. Central to the success of this mission are designated institutional officials (DIOs), who usually serve as chief GME officers within the ACGME-accredited sponsoring institutions (SIs). Despite the critical role of DIOs, the qualifications, level of administrative support, and responsibilities of DIOs are not defined and vary significantly among SIs. Although responsibilities mandated by ACGME Institutional Requirements provide a framework, the actual scope of work of DIOs often extends far beyond what is outlined in the ACGME Institutional Requirements, involving collaboration with a wide variety of institutional stakeholders and harnessing the GME enterprise to achieve institutional goals. Nearly all DIOs face a multitude of challenges, including adapting to new ACGME requirements and initiatives, addressing resident and fellow wellness concerns, promoting health equity, nurturing scholarly endeavors, and advocating for their residents and fellows. Additionally, emerging technologies and innovations as well as the changing financial climate for SIs and the health care facilities that host GME learners can present both educational opportunities and new challenges for DIOs in ensuring trainees are prepared for their roles as the next generation of physicians. As the health care landscape evolves, DIOs will continue to play a vital role in shaping the educational experiences of physicians in training while balancing institutional priorities and ensuring high-quality patient care.