Academic Medicine最新文献

Purpose: This study describes the structure and timing of the clinical education components of MD-PhD programs to illustrate how variations in preclerkship curriculum correlate with the opportunity for early clinical exposure and other key program characteristics.

Method: A survey was disseminated to U.S. MD-PhD programs on May 25, 2022, asking about the preclerkship curriculum length (long [> 18 months], medium [13-18 months], or short [12 months]), United States Medical Licensing Examination Step 1 timing (relative to the PhD training and clerkships), and opportunity for clerkships before the PhD phase. This survey was supplemented with data from publicly available sources to include 92 MD-PhD programs.

Results: This study found a wide range of MD-PhD clinical curricula. A strong association was found between shorter preclerkship curriculum length and the opportunity for clerkships before the PhD (10 of 50 programs [20%] with long preclerkship curriculum, 19 of 35 programs [54%] with medium preclerkship curriculum, and 7 of 7 programs [100%] with short preclerkship curriculum, P < .001). Variations in United States Medical Licensing Examination Step 1 timing also exist based on preclerkship curriculum length and the opportunity for clerkships before the PhD. Shorter preclerkship curriculum length was associated with National Institutes of Health funding of the MD-PhD program (20 [40%] of long, 25 [69%] of medium, and 6 [86%] of short preclerkship curricula, P = .006) and larger MD-PhD program size (35 students with long, 70 with medium, and 86 with short preclerkship curricula, P < .001). Preclerkship curriculum length was not associated with public vs private medical schools, although the West had shorter preclerkship curricula.

Conclusions: This study underscores the need for collaborative efforts to gain insights into the effectiveness and implications of educational interventions in MD-PhD programs, ultimately informing future training strategies and policies.

Purpose: With the introduction of physician assistants and nurse practitioners (i.e., advanced practice clinicians [APCs]), the landscape of graduate medical education (GME) has fundamentally changed. Whereas APCs' role in GME settings has been mainly described as substitutes for postgraduate medical trainees, APCs are increasingly considered integrated and collaborative team members. However, APCs' contributions to trainees' education and learning remain underexplored. This critical review synthesized the literature available on how APCs contribute to trainees' workplace learning and how these contributions are enabled.

Method: The authors searched PubMed, Embase, Web of Science, CINAHL, and PsycINFO for articles published from database inception dates through April 2023 for articles reporting on educational or guiding behaviors of APCs in GME contexts, resulting in 1,830 articles for possible inclusion. Using a critical review approach, the analysis was informed by a previously published framework describing workplace guidance behaviors and the authors' clinical and research expertise.

Results: A total of 58 articles were included in the study. Advanced practice clinicians contribute to trainees' workplace learning through a variety of guidance behaviors, including learning from patient care, demonstrating, support, socialization, feedback, involvement in evaluations, and other unspecified contributions. Thematic analysis indicated that APCs' contributions were enabled by their close working relationships with trainees, their unique perspective within the workplace, and the extent to which they were formally incorporated within workplace learning.

Conclusions: This critical review offers a concrete description of ways APCs are contributing to trainees' learning and education in the GME workplace across the literature. These results suggest that APCs could be a potentially untapped source for further optimizing workplace learning. However, unlocking this potential will require a shift in the conceptualization of APCs' role in the workplace. Opportunities for APC professional development and formalization of APCs' educational role should be considered.

Abstract: Most medical schools have instituted undergraduate medical education (UME) well-being programs in recent years in response to high rates of medical student distress, but there is currently significant variability in the structure of UME well-being programs and limited guidance on how to best structure such programs to achieve success. In this article, the authors, all leaders of medical student well-being programs at their home institutions and members of the Association of American Medical Colleges Group on Student Affairs Committee on Student Affairs Working Group on Medical Student Well-Being between 2019 and 2023 offer guidance to the national community on how best to structure a UME well-being program. They use the current literature and their professional experiences leading well-being efforts at 7 different institutions to review the case for addressing medical student well-being, propose a guiding model, and make recommendations for strategies to implement this model.The proposed guiding model emphasizes the importance of the learning environment and efficiency of learning to medical student well-being, as well as personal resilience. Based on this model, the authors recommend specific and tangible well-being strategies to implement systemic interventions to improve the learning environment, efficiency of learning, and personal resilience, including formalizing the well-being program; hiring qualified, dedicated, and empowered well-being leadership with clear responsibilities; acting as a central hub for resources and as a liaison with mental health care; and establishing robust program evaluation methods.

Problem: Holistic review is a multifaceted concept that aims to increase diversity and applicant fit with program needs by complementing traditional academic requirements with appraisal of a wider range of personal characteristics and experiences. Behavioral interviewing has been practiced and studied in human resources, business, and organizational psychology for over 50 years. Its premise is that future performance can be anticipated from past actions. However, many of the interview approaches within the holistic framework are resource intensive and logistically challenging.

Approach: The Vanderbilt University School of Medicine instituted a competency-based behavioral interview (CBBI) to augment the selection process in 2012. Behavioral interviews are based on key competencies needed for entering students and require applicants to reflect on their actual experiences and what they learned from them. The authors reviewed 5 years of experience (2015-2019) to evaluate how CBBI scores contributed to the overall assessment of applicants for admission.

Outcomes: The final admission committee decision for each applicant was determined by reviewing multiple factors, with no single assessment determining the final score. The CBBI and summary interview scores showed a strong association ( P < .005), suggesting that the summary interviewer, who had access to the full applicant file, and the CBBI interviewer, who did not, assessed similar strengths despite the 2 different approaches, or that the strengths assessed tracked in the same direction. Students whose 2 interview scores were not aligned were less likely to be accepted to the school.

Next steps: The review raised awareness about the cultural aspects of interpreting the competencies and the need to expand our cultural framework throughout interviewer training. Findings indicate that CBBIs have the potential to reduce bias related to overreliance on standardized metrics; however, additional innovation and research are needed.

Abstract: With the recent widespread growth and interest among medical educators, analysis of how departments of medical education are structured and their intersection with existing structures within the same institution, such as an office of medical education and/or academy of educators, is warranted. Based on a review of the literature, the authors determined there was a need for an inventory of what medical schools have to offer their faculty, whether it be an office, an academy, or a department. This project sought to inventory the current structures of medical education departments, offices, and academies at U.S. medical schools to explore reporting structure, functions, and characteristics of these entities. Data were extracted from A Snapshot of Medical Student Education in the United States and Canada: Reports From 145 Schools, published in 2020 in the journal Academic Medicine , for each reporting institution. This led to exploration of medical school websites to catalogue institutional structures. Data collected in this inventory demonstrate the range of structures used by medical schools to offer faculty support for their work as teachers and educational researchers. The hypothesis was that departments of medical education would be the least prevalent structures identified in U.S. medical schools, which was indeed a finding. Although the search yielded considerable data for the inventory, there is a dearth of published literature describing current models and characteristics of these different entities. Significant difficulties were encountered locating information clearly delineating roles and responsibilities of each entity on many medical schools' public-facing web pages. Findings are significant because they underscore the challenges medical education leaders have in obtaining information to research, compare, select, and design the administrative model(s) best suited to support faculty educators at their institution. Future work should include creating a detailed catalogue with descriptive information supplied by schools.

Abstract: Letters of reference (LORs) are a common component of the application process for residency training programs. With the United States Medical Licensing Examination Step 1 transitioning to pass/fail grading and with the increasing use of holistic review, the potential role of LORs is rising in importance. Among some key benefits are the ability to provide a broader and more holistic view of applicants, which can include highlighting elements of experiences or skills that could be missed in their application, as well as providing a third-party assessment of the applicant external to their rotation experiences. However, LORs also face issues, including variation in quality, challenges with comparability, and risk of bias. In this article, the authors discuss the unique benefits, limitations, and best practice recommendations for LORs in academic medicine. The authors also discuss future directions, including the role of artificial intelligence, unblinded, and co-created LORs.

Problem: Medical school graduates enter a complex health care delivery system involving interprofessional teamwork and multifaceted value-based patient care decisions. However, current curricula on health systems science (HSS) are piecemeal, lecture based, and confined to preclinical training.

Approach: The VISTA program is a longitudinal, immersive learning curriculum integrated into the University of Chicago Pritzker School of Medicine curriculum between 2016 and 2018. Key components include a unit-based nursing interprofessional team experience, a discharge objective structured clinical examination (OSCE), a patient safety simulation, and the implementation of a Choosing Wisely SmartPhrase. Graduates before 2016-2017 and after 2018-2020 VISTA implementation completed a Likert-style survey assessing attitudes, knowledge, and behaviors on HSS topics. A free response question solicited improvement areas. The Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) was also examined.

Outcomes: The overall VISTA survey response rate was 59%, with 126 fourth-year medical student respondents before VISTA and 120 after VISTA. Compared with pre-VISTA graduates, post-VISTA graduates reported a significantly higher rate of competence on the HSS questions, with the greatest increases seen in effective communication at discharge (n = 73/126 [57.9%] to 116/120 [96.7%], P < .001), knowledge on safety event reporting (n = 53/126 [42.1%] to 96/120 [79.8%], P < .001), and considering costs in making health care decisions (n = 76/126 [60.3%] to 117/120 [97.5%], P < .001). All were directly addressed through experiential learning interventions, and 2 were intended practice behaviors. VISTA graduate responses to free-text questions demonstrated a more nuanced understanding of HSS compared with pre-VISTA responses. The AAMC GQ data showed increased agreement with an item that mapped to HSS understanding.

Next steps: The VISTA program provides a model for institutions to enhance HSS education between curricular overhauls. Next steps include implementing value-added roles and additional immersive learning exercises.