Academic Medicine最新文献

Abstract: Undergraduate medical educators seek to optimize student learning, improve grading transparency and fairness, and provide useful information to residency programs. Recently, the United States Medical Licensing Examination's shift to pass/fail scoring for Step 1 disrupted curricular and assessment operations, and schools' tiered grading practices have been scrutinized. In noting that significant institutional time and energy were being expended in addressing the current levels of student grade appeals, 6 public and private medical schools in the Northeastern United States engaged in an examination of grade appeals via a root cause analysis (RCA). From November 2021 to April 2022, the authors reviewed specific instances of grading challenges that the team of educators encountered previously. From May to June 2022, the authors met for a facilitated discussion of the question, "Why are students challenging grading processes and systems or outcomes?" From July to October 2022, the authors identified root causes by analyzing results from the fishbone diagram (process, equipment, materials, people, and environment) and using the "five whys" technique. Several potential explanations for grade appeals and challenging grading systems across institutions were identified, including variability in the quality or experience of evaluators, lack of clarity about the goals and expectations of clerkships and a lack of transparency about the grading process, having a tiered grading system, technical issues with equipment, and clinical productivity demands of faculty. In proposing solutions to root causes identified in the RCA, factors were mapped to Liaison Committee on Medical Education (LCME) standards to facilitate quality and process improvements in grading. Aiming to support the learning environment and a fair and equivalent assessment process, the authors present a novel RCA and LCME method that can contribute to improving grading systems and has the potential to enhance learning and success.

Problem: The field of hospice and palliative medicine (HPM) is grappling with a significant workforce shortage. An untapped source of growth for the HPM specialist workforce is mid-career physicians interested in specialist training and certification. This study describes a pilot competency-based, time-variable (CBTV) fellowship program for mid-career physicians interested in HPM, called the Mid-Career Fellowship.

Approach: The pilot program was approved by the Accreditation Council for Graduate Medical Education (ACGME) Advancing Innovation in Residency Education program in consultation with certification boards. The Mid-Career Fellowship enrolled 2 mid-career fellows in July 2019 at the University of Pennsylvania, ultimately expanding in July 2020 and July 2021 to 7 participating sites. Clinical training in the fellowship was scheduled on an interrupted, part-time basis, with full- or partial-week clinical HPM rotations scheduled to accommodate fellows' other professional and academic responsibilities. Mid-career fellows' progression on HPM competencies was assessed through direct observation during HPM clinical rotations using validated assessments and the ACGME HPM milestones framework. Participants and traditional HPM fellows were surveyed for their perceptions of the program.

Outcomes: From July 2019-June 2024, the Mid-Career Fellowship had enrolled 22 individuals and produced 14 graduates across the 7 participating sites. As of June 2024, 12 of 14 (86%) graduates had entered full- or part-time practice in an HPM specialty. Two mid-career fellows have passed the biannual HPM board certification, with additional fellows being eligible to sit for the certification exam in fall 2024.

Next steps: Aspects of the program could be adapted by other specialties facing workforce shortages. Future work is needed to determine the long-term impact of this training and the role of similar programs in other specialties. The authors' next steps will be to conduct qualitative analyses of such programs' impact on professional development for participants.

Purpose: Competency-based, time-variable training (CBTVT) uses educational outcomes rather than time to determine learner readiness to progress through training. Clinical competency committees (CCCs) are critical components of CBTVT because they ultimately render time-variable promotion decisions. However, the effect of time variability on CCC member decision-making remains unclear. In this study, the authors explored the effect of time variability on the decision-making of CCC members at an internal medicine residency program.

Method: The authors used an evaluative case study approach to study the University of Cincinnati internal medicine residency program's CBTVT pilot, called Transitioning in Internal Medicine Education Leveraging Entrustment Scores Synthesis (TIMELESS), with 2 to 3 residents per postgraduate year participating longitudinally between October 2020 and March 2022. Taking a constructionist worldview, the authors used semistructured interviews with members of the TIMELESS CCC to explore how time variability affected their decision-making about resident promotion. Interviews and observations were completed between February 2021 and January 2022.

Results: In total, the authors completed 16 interviews with 11 unique CCC members. Participants reported that time variability significantly affected their decision-making process. The authors developed 3 related themes. First, time variability created a sense of increased stakes of promotion decisions. Second, the increased perceived stakes of decisions led to more deliberate decision-making. Third, time in training and clinical experience still influenced time-variable promotion decisions.

Conclusions: Time variability changed CCC member perception of the decision-making (more risk, higher stakes), with subsequent change in their behaviors (in-depth review, active decision-making). Although many time-based programs make entrustment determinations that are not linked to tangible consequences (i.e., Would I trust?), TIMELESS asked CCC members to make entrustment decisions that were consequential (i.e., Will I trust?).

Problem: Compassionate communication is an essential component of compassionate care and involves recognizing another person who needs compassion, relating to their suffering, and reacting verbally and/or nonverbally to their needs. Higher-quality compassionate communication facilitates positive patient-clinician relationships, which in turn lead to the development of trust, higher rates of adherence, and reduced health care costs. However, patients report that compassionate communication is lacking across many health care interactions. Research is needed to evaluate innovative educational programs that facilitate improved compassionate communication.

Approach: This report evaluates the Sanford Compassionate Communication Academy Fellowship at UC San Diego Health, a 60-hour arts and humanities fellowship that teaches compassionate communication to clinicians alongside artists using Kirkpatrick's 4-level evaluation model. At the time of this analysis, 27 fellows participated in the fellowship, using improvisation and theater exercises, role-play, visual thinking strategy, narrative reflection, poetry, literature, and principles drawn from journalism to build personal skills and learn to facilitate a compassionate communication curriculum. This analysis of 30 hours of field notes and 30- to 40-minute interviews conducted from January 2022 to November 2023 was guided by transformative learning theory.

Outcomes: Five themes contributed to improved compassionate communication: empathic listening, pacing, checking for understanding, improved teaching and mentoring, and mechanisms for transformation. In interviews, fellows described how improving these various skills has positively transformed their communication with patients and students. Participants identified 6 innovative mechanisms for transformation: dedicated time and resources, reflective practice, environment of care and safety, arts and humanities integration, colearning between artists and clinicians, and the train-the-trainer model.

Next steps: Next steps include conducting additional studies to evaluate the fellowship's effect using mixed methods with added patient and student perspectives. In addition, training will be offered to other institutions, and different delivery modalities and durations of instruction will be compared.

Purpose: This study describes graduate medical education (GME) placement outcomes for recent U.S. medical school graduates and examines racial and ethnic differences in GME placement among these graduates.

Method: This retrospective, observational study used data collected from and about U.S. medical school graduates for academic years 2015-2016 through 2021-2022. An individual-level, deidentified database was constructed to examine GME placement at graduation in association with race and ethnicity, as well as other demographic and academic and professional development variables. Multilevel (nested by school) logistic regression models identified variables independently associated with GME placement at graduation, reporting unadjusted odds ratios (UORs) and adjusted odds ratios (AORs) with 95% CIs.

Results: The study sample included 140,072 of 140,073 eligible graduates (> 99.9%; 1 graduate missing gender information was excluded), of whom 136,022 (97.1%) were placed in GME at graduation. Proportions of graduates placed in GME varied by race and ethnicity and by each covariable examined. In addition, proportions of graduates placed in GME varied by school (N = 152; mean [SD], 96.9% [3.4%]; P < .001). In multilevel (nested by school) models, GME placement UORs were lower for (among other groups examined) Asian (UOR, 0.76; 95% CI, 0.70-0.83), Black or African American (UOR, 0.44; 95% CI, 0.39-0.49), and Hispanic (UOR, 0.70; 95% CI, 0.60-0.80) graduates (vs White). The GME placement AORs, adjusted for all covariables, were similar for Asian (AOR, 0.96; 95% CI, 0.87-1.07), Black or African American (AOR, 0.89; 95% CI, 0.77-1.02), and Hispanic (AOR, 1.06; 95% CI, 0.89-1.25) graduates (vs White).

Conclusions: The proportion of graduates placed in GME at graduation during the 7 years of the study was high. However, there were racial and ethnic differences in this outcome during the study period.