Academic Medicine最新文献

Problem: Pervasive health inequities require new approaches to medical education to equip future physicians to address unjust disparities in health outcomes. Few curricula exist that focus on development of competencies and leadership skills in health equity, and little is known about the content that should be included.

Approach: Vanderbilt University Medical Center and Vanderbilt University School of Medicine developed and implemented the Graduate Certificate in Health Equity (CHE) to address this educational gap. The CHE proposal was approved in summer 2019, enrollment began in October 2019, and the first course was offered in February 2020. The CHE includes 11 objectives, and programming spans medical school years 2 to 4. Students must complete 2 foundational courses, 2 health equity-focused electives, and a health equity immersion experience.

Outcomes: Seventy-three students have enrolled since the CHE launched in academic year 2019 to 2020. In year 1, 14 third-year students enrolled in an inaugural condensed version and 16 second-year students enrolled in the full program. In subsequent years, 16 students (year 2), 15 students (year 3), and 12 students (year 4) enrolled. To date, 38 medical students have graduated. The CHE has engaged 16 community partners, including community health centers, immigrant and refugee services, rural health programs, and the LGBTQI+ community, as lecturers and hosts for immersion experiences.

Next steps: Future work will focus on updating objectives and developing a rigorous evaluation scheme. The CHE team members will follow up with graduates to determine how the CHE influenced their care for marginalized and minoritized patients, ability to identify and address systemic and structural barriers, and career development. The CHE is a potential model for other institutions to adapt and implement. Accruing a critical mass of institutions with health equity-focused programming for medical students is necessary to develop future leaders in health equity.

Purpose: Physician proficiency in clinical encounter documentation is a universal expectation of medical education. However, deficiencies in note writing are frequently identified, which have implications for patient safety, health care quality, and cost. This study aimed to create a compendium of tools for educators' practical implementation or future research.

Method: A scoping review was conducted using the Arksey and O'Malley framework. PubMed, Embase, Ovid All EBM Reviews, Web of Science, and MedEdPortal were searched for articles published from database inception to November 16, 2023, using the following search terms: documentation, note-writing, patient note, electronic health record note, entrustable professional activity 5, and other terms. For each note-writing assessment tool, information on setting, section(s) of note that was assessed, tool properties, numbers and roles of note writers and graders, weight given, if used in grading, learner performance, and stakeholder satisfaction and feasibility was extracted and summarized.

Results: A total of 5,257 articles were identified; 32 studies were included. Eleven studies (34.4%) were published since 2018. Twenty-two studies (68.8%) outlined creating an original assessment tool, whereas 10 (31.2%) assessed a curriculum intervention using a tool. Tools varied in length and complexity. None provided data on equity or fairness to student or resident note writers or about readability for patients. Note writers often had missing or incomplete documentation (mean [SD] total tool score of 60.3% [19.4%] averaged over 25 studies), often improving after intervention. Selected patient note assessment tool studies have been cited a mean (SD) of 6.3 (9.2) times. Approximately half of the tools (53.1%) or their accompanying articles were open access.

Conclusions: Diverse tools have been published to assess patient notes, often identifying deficiencies. This compendium may assist educators and researchers in improving patient care documentation.

Purpose: This study examines the gaps in early career physician readiness for independent practice after graduating from their final graduate medical education (GME) program.

Method: The authors conducted a literature search of 4 online databases (PubMed, Scopus, Health Business Elite, and Education Resources Information Center) using the following terms: population terms (GME, fellow, resident, and others), early career terms (onboarding, hiring, early career, ready, and others), readiness terms (readiness, preparedness, knowledge, skills, competence), and independence terms (attending, physician, independent practice). The databases were searched on March 12, 2024, for articles that explored GME graduate gaps in readiness for independent practice; assessment tools, curricula, or curricular need aimed at gaps in early career physician readiness; or an area where GME graduates need more knowledge and skills. They extracted specific gaps in preparedness and categorized them using existing competency frameworks.

Results: The search returned 116 articles addressing gaps in preparedness for independent practice among recent GME graduates. Surgery yielded more articles than any other specialty (43 [37%]). Overall, 192 individual gaps were extracted; the greatest number of gaps came from patient care (75 [39%]) followed by personal and professional development (44 [23%]). The most frequently identified gaps were procedural independence (10 occurrences), practice management (9 occurrences), and billing (7 occurrences).

Conclusions: Despite advances in GME, learners still struggle when transitioning to independent practice. Personal and professional development is a useful categorization for many gaps and should be considered for inclusion as a GME competency. Systematic assessment of new-to-practice attendings could help stakeholders better understand the true outcomes of GME programs. Concerted investment by specialty societies may drive greater understanding and innovative solutions. Additional study could help address the challenges in the GME-to-practice transition.

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: Mistreatment of health care workers and learners by patients and their families is prevalent at all levels of training. This mistreatment has negative consequences and disproportionately affects women and historically marginalized and excluded groups.

Approach: The authors designed and piloted a preliminary practice-based curriculum consisting of a discussion of literature, a framework for responding to mistreatment in the moment, and interactive simulated mistreatment encounters with trained patient actors. Feedback was generally positive, but participants consistently requested greater diversity in the representation of mistreatment. Using funds from the Josiah Macy Jr. Foundation Catalyst Award for Transformation in Graduate Medical Education, the authors expanded and improved the curriculum to meet the needs of a diverse population of learners. Effectiveness of the curriculum was measured using pre- and post-curriculum surveys.

Outcomes: The curriculum was delivered over multiple sessions from January 2022 to March 2024 with grant-funded interventions starting in January 2024. Participants included medical students, house officers, and faculty, and 678 participants completed pre-curriculum surveys. Upon implementation of grant-funded interventions, post-curriculum surveys showed improvements in respondents' self-reported plan to use skills demonstrated in the session (4.76 to 4.85, P = .006) and plan to address mistreatment with their teams moving forward (4.75 to 4.81, P = .045).

Next steps: All health care workers and learners deserve to feel safe, respected, and welcome in their work and in training. The foundation of this curriculum will support expansion to meet the needs of all patient-facing health care workers and learners at the pilot institution and beyond.

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.