Academic Medicine最新文献

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: 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: 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.

Purpose: Cross-cover care (care for hospitalized patients when the primary team is absent) is a common graduate medical education responsibility; however, it may lead to increased preventable adverse events. Despite understanding the difficulties of cross-cover care, medical educators lack comprehensive knowledge of specific challenges that residents face and how they handle these challenges. This study explores the challenges residents experience when providing cross-cover care.

Method: The authors conducted 60 semistructured, qualitative interviews with 20 internal medicine and surgery residents at a single academic institution between October 2021 and April 2022. Each resident participated in 3 interviews, 2 immediately after a shift. Working inductively, the authors generated codes for important themes. Study design and data collection were guided by interpretive description, a qualitative approach for health care research focused on experiences and perceptions to develop meaningful findings. To illustrate residents' workflow and aid in quality improvement efforts, the authors created a process map.

Results: Seventeen cross-cover challenges were organized into 7 interrelated and overlapping themes: lack of baseline knowledge, inadequate or inaccurate information transfer from the primary team, unfamiliarity with cross-cover patients, high task volume leading to increased interruptions, ill-defined roles leading to unmet expectations from others, perceived decreased access to resources, and fatigue. The process map illustrates 4 cross-cover workflow components: information transfer from the primary team to the cross-cover team, direct handling of cross-cover tasks that are assigned by the primary team or that arise during the time of cross-cover, information transfer back to primary team and other care team members, and responsibilities that residents have overnight that are not directly related to cross-cover.

Conclusions: Residents face substantial challenges when providing cross-cover care, which have important implications for patient safety and resident well-being. The medical community should strive to develop educational and structural interventions to improve this process.

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.

Purpose: This study examines the quality of short narrative comments collected using an online workplace-based assessment (WBA) tool.

Method: The quality of comments collected by a WBA tool at the UPMC Ophthalmology Residency Training Program was evaluated between July 2017-June 2020. A randomized rating exercise involving 10 meta-raters from 6 institutions was performed to evaluate the value of narratives from deidentified WBAs. The tool captured a single-item entrustment competency question with brief comments. Comments were evaluated using a Quality of Assessment of Learning (QuAL) score (range, 0-5; ≥ 3 considered high quality) and on whether the assessor provided a feedback rationale.

Results: A total of 838 unique WBAs were collected from 15 attending evaluators. Comments were brief (median [interquartile range] length, 11 [7-17] words), yet 514 (61.3%) were rated as high quality (QuAL score ≥ 3). Of all 838 comments, 98 (11.7%) included a specific reason the evidence or suggestion was provided to the learner. Of these 98 comments, 94 (95.9%) met the high-quality feedback threshold. A higher QuAL score was associated with a higher postgraduate year (PGY) level (estimate [SE], 1.603 [0.428], P < .001 for PGY2 [reference]; 1.003 [0.389], P = .01 for PGY3; 1.079 [0.360], P = .003 for PGY4), suggesting more advanced learners receive higher-quality narrative comments. A correlation was found between a higher entrustment rating and a lower QuAL score (estimate [SE], -0.199 [0.053], P < .001). When the PGY level was controlled for, this association got stronger (estimate [SE], -0.310 [0.057], P < .001).

Conclusions: Analysis of WBA comments from attending physicians evaluated using the QuAL score demonstrated that most comments were high quality despite their brevity. Residents in later training years and with lower entrustment ratings received higher-quality comments. High-quality narrative assessments were longer and addressed rationale as part of the comment.

Abstract: Precision medical education (PME) represents a transformative approach in medical education, systematizing individualized and efficient learner competency development for enhanced patient care. While implementing PME has been described conceptually using the P4 medical education framework (proactive, personalized, participatory, predictive), many programs and institutions face implementation questions on navigating data integration complexities, resource constraints, cultural risk aversion to innovation, and more.To address such challenges, the authors of this Commentary propose 5 concrete, concurrent strategies for institutions and training programs to implement PME successfully. Of these strategies, 4 are aligned with the P4 framework. Strategy 1: Curate educational data, adhering to 8 foundational data principles (relevant, trusted, consistent, timely, accessible, connected, interactive, actionable), and integrate it into an education data warehouse to create a comprehensive learner profile. Strategy 2: Build institutional analytic capabilities, including leveraging existing resources and tools, such as artificial intelligence, to turn data into actionable insights. Strategy 3: Establish transparent, accountable governance structures with broad stakeholder engagement, emphasizing principled co-production of PME by learners, faculty, and educational leaders. Strategy 4: Continuously collect and evaluate outcomes tied to PME interventions, building validity evidence through predictive linkages. Strategy 5: Lead change to drive PME forward. This strategy cuts across all 4 other strategies to promote the effective adoption of systems and processes that drive PME into institutional culture.When successfully operationalized, PME enables precise, evidence-informed decision-making about and by learners, while benefiting faculty, coaches, and educational leaders. Through these strategies, programs and institutions can overcome implementation pitfalls and harness the full potential of PME to improve educational and patient care outcomes.