Seeking Consistency and Fairness in the Assessment of Professionalism

This month’s Journal Club post was written by Alex Fiorentino, MD, Maine Track ’17, based on the following article:  Basing the Evaluation of Professionalism on Observable Behavior: A Cautionary Tale by Ginsburg, Regehr, and Lingard1.

Though an estimated 90% of U.S. medical schools offer some type of formal instruction in professionalism2, it is difficult for medical educators to agree upon what constitutes professionalism, much less apply a consistent standard of professionalism to trainees3.  In the setting of increasing efforts to evaluate trainees via direct observation of competencies, the authors of the above study set out to assess whether observation of student behaviors can serve as the basis for consistent and legitimate evaluation of professionalism.

Discussion Questions:

  1. How would you define professional behavior – and unprofessional behavior – among medical trainees?
  2. Which is more useful for determining whether a lapse in professionalism has occurred: an account of exactly what a trainee did, or an explanation of why they did it?
  3. Are there situations in medicine in which truthfulness represents an unprofessional course of action, or is lying always unprofessional?
  4. Can professionalism be taught? If so, what would be your ideal method for teaching it?

 

References:

  1. Ginsburg S, Regehr G, Lingard L. Basing the evaluation of professionalism on observable behaviors: a cautionary tale. Academic Medicine, 2004 Oct;79(10 Suppl):S1-4.
  1. Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism in undergraduate medical education. JAMA, 1999 Sep 1;282(9):830-2.
  1. DeAngelis CD. Medical professionalism. JAMA, 2015 May 12;313(18):1837-8. doi: 10.1001/jama.2015.3597.

 

How Do Residents Spend Their Shift Time? A Time and Motion Study with a Particular Focus on the Use of Computers

How Do Residents Spend Their Shift Time? A Time and Motion Study with a Particular Focus on the Use of Computers

This month’s journal club was written by Benjamin Levin, MD, Maine Track ’16, with reference to the following article: How do residents spend their shift time? A time and motion study with a particular focus on the use of computers, Lena Mamykina, PhD, David Vawdrey, PhD, George Hripcsak, MD, MS, Academic Medicine, Published online March 29, 2016. 

Medicine is constantly evolving; we live in an era where copious amounts of medical information are at our fingertips. With a mandate on EHR usage, residents are spending more time on the computer documenting and looking up patient information.   This access to information and creation of information has altered the practice of medicine and changed resident education.

A recent study published in Academic Medicine recorded and analyzed how residents on a general medicine service used their time with a focus on how they utilize computers. I’ll leave it up to the reader to decide if the results are surprising or not and to think about the following questions.

-Does the distribution of documentation and clinical activity correspond with your own experience?

-Are we experiencing documentation and information overload?

-Is resident education suffering due to the burden of documentation?

-Should there be concerns about quality after examining the results of this study?

 

Mens sana in corpore sana: Student Well-Being and the Development of Resilience


Mens sana in corpore sano: Student Well-being and the Development of Resilience 

This month’s journal club post references a Medical Education article:  Mens sana in corpore sana: Student Well-Being and the Development of Resilience by Diana F. Wood

We’ve all heard the seasoned attending lamenting the modern era of work-hour restrictions and 24 hour attending support in comparison to their training wild wild west. For decades, residents learned medicine through a baptism by fire, with those trained in the era recounting 100+ hour work weeks, unsupervised paracenteses in the ED with nothing more than an EKG probe and an LP needle, and shifts long enough to make a stretcher in the corner look more comfortable than the penthouse suite of a Hilton. Much like military boot-camp, many survivors of this antiquated training herald it as the only way to develop the resiliency needed to become an exceptional physician. However, as study after study has shown, this resilience (if truly gained) comes at a high price to patients and trainees alike.

Yet in the modern world of elongated terms of parental support and petting zoos to alleviate student’s stress, is it possible that well-intended institutional support has crippled the development of resilience and may even counterintuitively be contributing to physician burn-out? Studies show that medical students, particularly males, continue to show signs of burnout manifested in depression, reduced empathy, and changed attitudes toward palliative care and cadaveric dissection.

  1. How can students be taught resilience without compromising patient safety or contributing to burnout?
  2. What, if any, unique attributes did physicians learn prior to work-hour restrictions?
  3. What, if any, unique attributes do physicians learn now after emplacement of work-hour restrictions
  4. Are there any forms of resident/medical student support which may be deleterious to the development of resilience?

References:

1. Farnan JM, Petty LA, Georgitis E, Martin S, Chiu E, Prochaska M, Arora VM. A systematic review: the effect of clinical supervision on patient and residency education outcomes. Acad Med 2012;87:428–42.
2. Quince T, Abbas M, Murugesu S, Crawley F, Hyde S, Wood D, Benson J. Leadership and management in the undergraduate medical curriculum: a qualitative study of students’ attitudes and opinions at one UK medical school. BMJ Open 2014;4:e005353.
3. Goldie J, Dowie A, Cotton P, Morrison J. Professionalism. In: Walsh K ed. Oxford Textbook of Medical Education. Oxford university press; 2013. p. 274–6.
4. Papdakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med 2004;79:244–9.
5. Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ2016;50(1):132–149.
6. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD. Burnout among US medical students, residents and early career physicians relative to the general US population. Acad Med 2014;89:443–51.
7. Briggs ARJ, Clark J, Hall I. Building bridges: understanding student transition to university. Quality in Higher Education 2012;18:3–21.
8. Adams R. Surge in young people seeking help for exam stress. http://www.theguardian.com/education/2015/may/14/calls-to-childline-over-exam-stress-break-records. [Accessed 11 August 2015].
9. Cohen D, Winstanley S, Palmer P. Allen J, Howells S, Greene G, Rhydderch M. Factors that impact on medical student wellbeing – perspectives of risks. 2013. http://www.gmc-uk.org/Factors_that_impact_on_medical_student_wellbeing____Perspectives_of_risks_53959480.pdf. Accessed [26 August 2015].
10. Shapiro J. From strength to strength. https://www.insidehighered.com/views/2014/12/15/essay-importance-not-trying-protect-students-everything-may-upset-them. Accessed [11 August 2015].
11. Havergal C. Partnership agreements ‘infantilise’ students. https://www.timeshighereducation.co.uk/news/partnership-agreements-infantilise-students-colloquium-hears/2016060.article. Accessed [11 August 2015].
12. Quince TA, Wood DF, Parker RA, Benson J. Prevalence and persistence of depression among undergraduate medical students: a longitudinal study at one UK medical school. BMJ Open 2012;2:e001519.
13. Quince TA, Parker RA, Wood DF, Benson JA. Stability of empathy among medical students: a longitudinal study at one UK medical school. BMC Med Educ 2011;11:90.
14. Quince T, Barclay S, Spear M, Parker R, Wood D. Student attitudes towards cadaveric dissection at a UK medical school. Anatomical Sciences Education 2011;4:200–7.
15. Barclay S, Whyte R, Thiemann P, Benson J, Wood DF, Parker RA, Quince T. An important but stressful part of their future work: medical students’ attitudes to palliative care throughout their course. J Pain Symptom Manage 2015;49:231–42.
16. Whyte R, Quince T, Benson J, Wood D, Barclay S. Medical students’ experience of personal loss: incidence and implications. BMC Med Educ 2013;13:36.
17. Thiemann P, Quince T, Benson J, Wood D, Barclay S. Medical Students’ Death Anxiety: Severity and Association with Psychological Health and Attitudes Toward Palliative Care. J Pain Symptom Manage 2015;50:335-–342.e2.
18. Howe A, Smajdor A, Stöckl A. Towards an understanding of resilience and its relevance to medical training. Med Educ 2012;46(4):349–56.

The Effect of Burnout on Medical Errors and Professionalism in First-Year Internal Medicine Residents

The Effect of Burnout on Medical Errors and Professionalism in First-Year Internal Medicine Residents 

This month’s journal club was written by Jenny MacDowell, M’17, with reference to the following article: The Effect of Burnout on Medical Errors and Professionalism in First-Year Internal Medicine Residents by Kwah, MD, Weintraub, MD, Fallar, PhD, and Ripp, MD, MPH. 

The relationship between resident burnout, professionalism, and medical errors is unclear.   This cohort study aimed to determine whether burnout correlated with objective measures of medical errors and professionalism such as medication prescription errors.  Burnout was measured using the Maslach Burnout inventory following three domains: emotional exhaustion, depersonalization, and sense of personal accomplishment.  Medication prescription error rate was the chosen medical error metric measured.  Professionalism was measured by examining discharge summaries completed within 48 hours, outpatient charts completed within 72 hours, and the average time to review outpatient laboratory results.

The study found that residents with burnout at the end of the year had a lower rate of medication prescription errors (0.553 vs. 0.780, p=0.007).  The professionalism metrics had no significant difference between residents with or without burnout.

Discussion questions:

  • How do the results of this study conflict with the concept of the Yerkes-Dodson curve?http://sourcesofinsight.com/yerkes-dodson-human-performance-curve/
  • Are you surprised by the results of this study and why?
  • What could be the underlying reason residents with burnout had a decrease in medical error?
  • Are the results clinically significant?

References:

Kwah, Jason, Jennifer Weintraub, Robert Fallar, and Jonathan Ripp. “The Effect of Burnout on Medical Errors and Professionalism in First-Year Internal Medicine Residents.” Journal of Graduate Medical Education 8.4 (2016): 597-600.

Respect: An Analysis of Medical Student Narratives Concerning Respect/Disrespect in the Clinical Environment

Respect: An Analysis of Medical Student Narratives Concerning Respect/Disrespect in the Clinical Environment

This month’s journal club was written by Nate Rogers, MS4, with reference to the following article:  Exploring the Meaning of Respect in Medical Student Education: an Analysis of Student Narratives by Karnieli-Miller O, Taylor AC, Cottingham AH, et al.

Respect is an aspect of communication that is vital in developing a trustful and a supportive environment, whether in educational, professional, or clinical settings. Widely recognized in society and the medical literature as a requisite characteristic of a good physician, respect has variably been described as:

  • Positive attitudes towards the dignity and value of others
  • Remaining non-judgmental toward diversity and the uniqueness of others
  • Ensuring patient autonomy
  • Attention to codes of conduct
  • Maintenance of confidentiality and privacy

Disrespectful behavior towards students affects more than the individuals experiencing the disrespect—patients suffer too. Research shows that medical students’ ability to provide respectful care to their patients declines when those students feel abused and belittled. Despite wide recognition of respect as a crucial physician attribute, relatively little research has been performed to clarify the definition and experience of respect in social interactions. The following research by Karnieli-Miller et al. aims to initiate the bridging of this knowledge gap by describing narratives of respect and disrespect experienced by third-year medical students during their internal medicine training. Please consider the following questions for discussion as you review the attached article:

  1. As can be seen above, disrespect is quite a broad term with many possible interpretations. List some general examples of disrespectful behavior, whether intended or unintended. Is there a difference between these types of disrespectful behavior? Why or why not?
  2. What incidents of disrespect have you witnessed in your medical training? Consider all the different possible interactions in the hospital (e.g., between attending physicians, residents, medical students, nurses, administration, janitorial staff, etc.). What was the outcome of this event?
  3. What are examples of times you have been treated with disrespect? How did they make you feel? Do you believe the disrespect was intended? How did you respond? Why?
  4. What is an example of a time you may have treated someone else with disrespect? How did it make you feel? Was the disrespect intended? How do you believe it made the other person feel? How did they respond?
  5. What are concrete steps you can take to reduce disrespect in the clinical environment and in medical education? Steps you can take to become kinder/more respectful personally? How would you respond to disrespect now, whether as a victim or a bystander?

 References:

  1. Karnieli-Miller O, Taylor AC, Cottingham AH, et al. Exploring the Meaning of Respect in Medical Student Education: an Analysis of Student Narratives. J Gen Intern Med. 25(12):1309-14. doi:10.1007/s11606-010-1471-1.
  2. Baldwin DC Jr, Daugherty SR, Eckenfels EJ. Student perceptions of mistreatment and harassment during medical school—A survey of ten United States schools. West J Med. 1991;155:140–5.

The Future of Debriefing Training

This month’s journal club was written by Karl Santiago, M’17, referencing a Simulation in Healthcare article Development for Simulation Programs: Five Issues for the Future of Debriefing Training by Cheng A, Grant V, Dieckmann P, Arora S, Robinson T, and Eppich W:

Simulation-based education is dependent on high-quality debriefing. Debriefing allows for leaders and learners to reflect on an encounter; explore mental models, procedural skills, and teamwork dynamics; and identify directions for improvement and deeper understanding. Given the crucial nature of debriefing sessions, Cheng et al. outline the current state of debriefing training and pose five issues for its future, with implications for individual simulation programs and the simulation community at-large.

Discussion Questions:

  • Think back to prior debriefings in which you participated: What worked well and what did not?
  • Should the debriefing process be standardized?
  • Do you invite constructive feedback on your debriefing from peers and learners?
  • How do we best assess the quality of debriefing?
  • Can debriefing within simulation programs support a culture of feedback medical institutions?

Reference:

Cheng A, Grant V, Dieckmann P, Arora S, Robinson T, Eppich W. Faculty Development for Simulation Programs: Five Issues for the Future of Debriefing Training. Sim Healthcare. 2015;10(4):217-222. doi:10.1097/SIH.0000000000000090.

Seven Dirty Words: Hot-Button Language That Undermines Interprofessional Education and Practice

This month’s journal club was a collaboration between Tom Van der Kloot, MD and Sarah Hallen, MD. Seven Dirty Words: Hot-Button Language That Undermines Interprofessional Education and Practice, by Peter S. Cahn, PhD. Language can acts as an overlooked factor threatening the success of interprofessional education and practice. Words choices can affect a number of situations that do not foster collaboration. The author writes as an outsider looking in; noting the negative responses triggered by certain language.

Discussion Questions:

1) How important do you feel language is in influencing culture?
2) Of the seven words (and suggested alternatives) discussed in this article, which resonate with you, and why? Which would you contest, and why?
3) Are there other words/phrases that you feel have negative impact on interprofessional function and culture in the healthcare setting?

The Role of the Arts in Medical Education

This Journal Club Post was written by Kelly Brooks, M’16. This review article looks to synthesize the literature on a growing body of research that looks to examine the role of the arts in medical education based on the article by Lake, Jackson, and Hardman:A fresh perspective on medical education: the lens of the arts.

“We maintain that the ‘usefulness’ of the arts cannot simply be judged by the standards that have been set for technical competency, albeit that this is the dominant paradigm through which medicine and medical education currently function. To fall into this trap would be to miss the very essence of what makes the arts distinctive and important. The arts can, however, provide medical educators with a penetrating and dynamic set of tools for rethinking medical education and medical practice.” 1

 

Studies have shown that using the visual arts in medical education can improve medical students’ observational and diagnostic skills. 4,5 Investigators were able to show that students trained in this manner were more likely to accurately and fully describe clinical photographs of patients with medical conditions than students who participated only in the standard curriculum. Furthermore, students also improved their observational skills and increased their awareness of emotion and empathy.

 

Unlike other evidence-based models of education, evaluating the effectiveness of an arts-based education intervention is complex and nuanced. However, a review of the literature concluded that using the arts in medical education can be utilized and informs the following aspects of medical education: 1

1) a tool for professional development

2) a means for developing skills in the practice of teaching (pedagogy)

3) to critically approach the current approach of medical education

4) to view medical practice as a succession of performances

 

Discussion:

1) Consider ways to integrate the arts into your medical teaching practice (teaching students about observation, physical diagnosis and clinical reasoning).

2) How can skills of the humanities help in reflecting on your own personal clinical practice?

3) Can you relate how different mediums / art forms can inform or hone skills related to the practice of medicine? For example, what can creative movement/dance teach us about gaining surgical / procedural skills?

4) Consider taking 10-15min at the end of a work day, to freely write about a difficult patient encounter. What types of skills do creating narratives / creative writing exercises bring to medical education?

 

Sources:

1 Lake J, Jackson L, Hardman C. A fresh perspective on medical education: the lens of the arts. Medical Education, 2015 Aug;49(8):759-72. doi: 10.1111/medu.12768. PMID: 26152488

2 Bleakley A. When I say… the medical humanities in medical education. Medical Education, 2015 Oct;49(10):959-60. doi: 10.1111/medu.12769. PMID: 26383067

3 Dennhardt S, Apramian T, Lingard L, Torabi N, Arntfield S. Rethinking research in the medical humanities: a scoping review and narrative synthesis of quantitative outcome studies. Medical Education, 2016 Mar;50(3):285-99. doi: 10.1111/medu.12812. PMID: 26896014

4 Edmonds K, Hammond MF. How can visual arts help doctors develop medical insight. Int J Art Design Education 2012; 31 (1): 78-89.

5 Shapiro J, Rucker L, Beck J. Training the clinical eye and mind: using the arts to develop medical students’ observational and pattern recognition skills. Medical Education 2006; 40: 263–268.

 

In the media:

 

Resident Perceptions of Giving and Receiving Peer-to-Peer Feedback

This month’s journal club was written by Molly Curtis, M’16 referencing a Journal of Graduate Medical Education article: Resident Perceptions of Giving and Receiving Peer-to-Peer Feedback by de la Cruz MS, Kopec MT and Wimsatt LA.

Peer feedback has the potential to add an important and new dimension to the resident feedback process and foster a “feedback culture” within a residency program. Alternatively, it is conceivable that such feedback may strain interpersonal working relationships and evoke negative emotions. In order to maximize the level of engagement and applicability of peer feedback it is important to explore resident perceptions of the feedback process. De la Cruz et al. piloted an online peer assessment tool with family medicine residents at University of Michigan to gain insight into the peer feedback process.

 

Discussion questions:

  • Do you think that peer-to-peer feedback is as valuable as attending feedback?
  • Is peer-to-peer feedback more or less threatening to the receiver?
  • What do you see as the potential role of peer evaluation in residency education?
  • If you were asked to evaluate a peer, what barriers would get in the way of providing meaningful feedback?
  • Do you feel that competency in peer-to-peer feedback delivery is an essential professional skill?
  • Do you feel that you are adequately prepared to give peer feedback?
  • What components might make peer evaluation successful and useful to you?
  • If a more formal peer evaluation system was incorporated into MMC residency programs, what would you want it to include?

 

1. de la Cruz, Maria Syl D., Kopec, Michael T., Wimsatt, Leslie A. Resident Perceptions of Giving and Receiving Peer-to-Peer Feedback. Journal of Graduate Medical Education, June 2015. DOI: http://dx.doi.org/10.4300/JGME-D-14-00388.1

The FIRST Trial: Patient Outcomes vs. Work/Life Balance

This month’s journal club was written by Andrew Rogers, MS4 looking at the advanced online publication of the article: National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training by Bilimoria KY, Chung JW, Hedges LV, et al with a follow up perspective that can be found here.

The ACGME duty hour regulations have been a hotly debated issue since their implementation. Originally employed over concerns for patient safety there has been little direct evidence on improvement in patient outcomes. However, recently there has been an increase in focus on resident job satisfaction and the prevention of burnout. While the FIRST Trial does not report a significant difference in patient outcomes, should we prioritize and establish a work/life balance for residency?

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