February 2022 Faculty Development Tip

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Differences among Millennials vs Generation Z and the Effects This Plays on Medical Education

Abtin Farahmand, MD

Introduction:

Medical education continues to transform itself based on the generation of learners being educated. As an example with Millennials, medical schools and educators have reduced the number of large didactic sessions and have incorporated more technological educational platforms for these learners. From a medical school and in larger context health care perspective, Generation Z (also known as “iGen”) is now becoming the predominant demographic matriculating. From a medical education perspective, it has been demonstrated the importance of curtailing how education is taught based on the unique features of each generation.

Key Points:

  • Mental health is more prevalent than previous generations
  • Volunteering has diminished compared to previous generations
  • A higher need for mentorship and guidance rather than independent learning is seen among Generation Z

Whether this can be surmised from our society as a whole, there has been an increase in focus of mental health among medical students. This was prompted by reports demonstrating that nearly half of medical students suffered from burn out. Furthermore, studies have demonstrated nearly 12% of students faced suicidal ideation and over 80% demonstrate signs of psychological stressors in general. Medical schools have responded by having an increased emphasis and funding toward services such as counseling as well as adjusting educational experiences and grading rubrics to lower mental health disturbances. Unfortunately, Generation Z is faced with an even higher prevalence of mental health that is also getting worse in time. Reports demonstrate that between 2005-2017, there was nearly a 50% increase in suicidal ideations; this is as a reminder pre-COVID, which already has led to increase in burnout and stress among health care employees. It is important that our medical education for this generation emphasizes mental health safety and ways to mitigate mental health not only for the students’ sake, but also for their future patients as it has been demonstrated psychological distress leads to diminished abilities for individuals to empathize and be altruistic.

 

Volunteering is on the decline among Generation Z. Though nearly 75% of all medical schools have student-run clinics and volunteering is considered integral in the application process for medical school, less than a third of Generation Z students are likely to perform volunteer work once admitted to college. A recent survey demonstrated as few as 12% of first year college students participated in volunteer activities. Interestingly, there is a unique difference among this generation in how they tend to volunteer when they decide to do so. Generation Z is more likely to utilize entrepreneurial and technological skills to address a problem rather than direct “hands on work” if you will. This does lead to opportunities in medical schools to foster this generation’s unique focus on technology and entrepreneurship.

 

Generation Z tends to also have a more unique stance, when it comes to more sensitive or disturbing educational topics such as rape, abortion, addiction, abuse and assault. These are key subjects in medical education with the hopes that with education in these materials will allow physicians to be more empathetic and communicate more effectively when such topics arise with patients. Already in the undergraduate level, students within Generation Z have demanded for trigger or content warnings be issued prior to discussing such material and for there to be safe spaces for them to go to feel safe after such discussions. Interestingly, in 2018, fewer than 11% of students were aware of what a trigger warning is, and less than a third support their use in medical education. However, as generation Z becomes more immersed in medical education, likely there may have to be considerations of adjustments towards this sentiment.

 

Lastly, in terms of physical spaces for learning, Generation Z has been described as having nearly opposite sentiments compared to Millennials. Though Millennials, similar to previous generations, preferred large, open unstructured environments which allowed for communal work, Generation Z tends to prefer quiet spaces where task-specific activities are readily apparent. They also have a much higher preference towards mentorship as an expectation as a way of learning rather than learning materials independently.

 

As seen, each generation poses a new set of challenges for educators and educational systems to best optimize the learning experience. Generation Z is the newest generation entering the medical system and it is important from a healthcare perspective we adjust our learning for this new generation. A higher emphasis on mentorship, mental health, potential trigger warnings for disturbing materials, and a further emphasis on technological educational activities are some ways to cater towards this newer generation.

Reference:

Plochocki, Jeffrey. Several Ways Generation Z May Shape the Medical School Landscape. Journal of Medical Education and Curricular Development. Volume6:1-4. October 2019.

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May Faculty Development Tip-Finding Joy in Work After Hitting a Wall

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Finding joy in work after hitting a wall

Elizabeth Eisenhardt, MD

Healthcare providers have been experiencing an emotional and exhausting process as they work to navigate the Covid-19 pandemic. The challenges and hardships from this pandemic stretched most humans to the end of their coping capabilities. Many health care workers felt stress and felt challenging emotional responses to the pandemic on both a personal and professional level, and yet were required and needed to be high functioning at work and at home. Interestingly, while we have a possible end to the pandemic in sight and some hope as we race to vaccinate all Mainers, many people are feeling worse than they did the same time last year at the height of the pandemic and its subsequent lockdown. Personally I find myself on the verge of tears more frequently when my patients ask me how I am doing now versus a year ago. Why don’t I feel better now during this time of renewed action against the pandemic? Psychologist Lisa Damour explored this phenomenon recently in her podcast entitled “My kids and I have hit a wall. How do we keep going? 3/25/21. In it she talks about how it is difficult for people to maintain hope even while the pandemic situation is more hopeful because we still don’t know what to expect and what the future will hold.

If we are having trouble finding hope, we need to re-discover and celebrate the joy we have in our work to combat our burnout.
The IHI ( Institute for Healthcare Improvement) feels strongly that finding joy in our work helps to prevent burnout. They published a paper on restoring joy to the workplace after asking colleagues over and over “what matters to you?” This single question enabled them to understand the barriers to finding joy in work and to develop a framework to overcome them.

In this paper, they outline four steps that leaders can take to increase joy in the workplace. The steps are as follows:
1.) Ask staff, “what matters to you?” They describe how having these important discussions help to engage staff and to identify risk of burnout.
2.) Identify unique impediments. What are the day to day pebbles that are causing annoyance verses the larger boulders that exist on an organizational level?
3.) Commit to a systems approach . What can be a small systems change that has large staff benefit?
4.) Use improvement science. Study and discuss any changes made with staff.

Wellness discussions should also center around academics and teaching burnout. It has been shown that low job satisfaction was associated with nonstatistically significant trends toward fewer peer-reviewed first-author publications, lower teaching skills confidence, and lack of institutional grand rounds presentation. Burnout was associated with a nonstatistically significant trend toward lack of institutional grand rounds presentation. Institutions may discover via these wellness discussions that their academic providers need to have better protected academic time as too often clinical demands creep in at the expense of teaching or research.

In my leadership role, I have held many what matters to you conversations. While sometimes challenging ,they have never failed to bring forth a clearer understanding of what staff need to find more joy in their work, and assist me in understanding my staff’s needs. These conversations are important to have with students and learners as well.

During one of these recent discussions, it was clear that staff were craving a safe space to express their emotional and experiences on a given week with their colleagues. In response to this need, our office created a weekly wellness huddle. We wanted to highlight its importance, thus we incorporated it into our Operational Excellence program and made it one of our Key Performance Indicators. Using this improvement tool we made it a priority to hold a weekly huddle around staff wellness. We documented staff responses to the huddle, and their direct quotes around the experience. It has developed into a bonding time with our staff, and many have commented that it has been helpful. In this strange time of seeing new hope regarding the pandemic, but not feeling it on an individual level, we are refreshed each week with our huddle and have formed tighter team work and increased empathy because of it.

I strongly encourage using the “What matters to you?” conversation and holding these conversations frequently to engage staff and faculty to develop improvement ideas which are then studied using improvement science.

Resources:

Glasheen, J. J., Misky, G. J., Reid, M. B., Harrison, R. A., Sharpe, B., & Auerbach, A. (2011). Career satisfaction and burnout in academic hospital medicine. Archives of internal medicine, 171(8), 782-790.

Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. (Available at ihi.org)

Shanafelt, T. D., West, C. P., Sloan, J. A., Novotny, P. J., Poland, G. A., Menaker, R., … & Dyrbye, L. N. (2009). Career fit and burnout among academic faculty. Archives of Internal Medicine, 169(10), 990-995.

 

 

April Faculty Development Tip: The Education of Psychiatry – Caring for Patients Experiencing Homelessness

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The Education of Psychiatry – Caring for Patients Experiencing Homelessness

Malia E. Haddock, MS, PMHNP-BC

Although trainees incidentally care for patients experiencing homelessness throughout residency and beyond, intentional didactic and clinical experiences with homelessness create unique opportunities to increase interest, confidence and ability among resident psychiatrists in the care of underserved patients.

It is well known that individuals with unstable housing have disproportionally high rates of severe psychiatric and substance use disorders compared to their housed counterparts. Indeed, untreated psychiatric and substance use disorders are cited as primary causes of homelessness, and once homeless, psychiatrically-symptomatic individuals face additional barriers to accessing psychiatric care. Common obstacles include lack of affordable or reliable transportation, variable access to telephone/internet, and systems barriers such as scheduled appointments and attendance policies. However, intangible barriers such as provider discomfort with homelessness may further distance patients from psychiatric care.

HPATHI

The Health Professionals’ Attitudes Toward the Homeless Inventory (HPATHI) is a validated 19-item instrument designed to “assess medical students’ and physicians’ attitudes towards homeless persons and to measure their level of interest and confidence in their ability to deliver health-care services to the homeless population” (Buck et al., 2005).  The impetus for this inventory traces back to a 1985 publication on access to care among individuals with unstable housing. The report’s author, Elvy, writes, “The disinclination of the homeless to seek care may be due in part to the ways in which many health-care workers respond to them. A less investigated but possibly equally important circumstance is the attitudes that health-care professionals have toward the homeless” (as cited in Buck et al., 2005, p. 2). More contemporaneous academic discussions also play a role in HPATHI’s inception, particularly those involving the role of humanism and Social Determinants of Health curricula in undergraduate and graduate medical education (Buck et al., 2005).

Opportunities for Psychiatry

In “A Survey of American Psychiatric Residency Programs Concerning Education in Homelessness” McQuistion et al. found that while 60% of programs offered optional clinical and/or didactic experiences, only 11% of programs reported mandatory rotations in the care of patients experiencing homelessness. Lack of widespread mandatory programming was attributed to several factors, most notably lack of attending psychiatrists with expertise in caring for patients experiencing homelessness; lack of funding and/or logistical support to create programming; and perceived lack of homelessness in suburban and rural areas (2004).

Given the prevalence of severe psychiatric illness and substance use disorder among individuals experiencing homelessness, psychiatry trainees have much to gain from intentional exposure and training in this area. Over time, measurable improvements in interest, confidence and ability among learners may result in more accessible and culturally attuned care for this population.

 

Why HPATHI in Medical Education?

  • Acknowledges the impact of provider attitudes and behaviors on engagement with underserved patients
  • Raises awareness among educators and learners of the unique needs of patients with unstable housing
  • Establishes baseline data on attitudes, interest, confidence and ability in caring for patients experiencing homelessness
  • Uncovers experience and knowledge gaps that can be specifically addressed through curriculum development
  • Over time may lead to structural changes in both educational practice and care delivery to meet the needs of learners and underserved patients

References

Buck, D.S., Monteiro, F., Kneuper, S. et al. Design and validation of the Health Professionals’ Attitudes Toward the Homeless Inventory (HPATHI). BMC Med Educ 5, 2 (2005). https://doi.org/10.1186/1472-6920-5-2

McQuistion HL, Ranz JM, Gillig PM. A survey of American psychiatric residency programs concerning education in homelessness. Acad Psychiatry. 2004 Summer;28(2):116-21. doi: 10.1176/appi.ap.28.2.116. PMID: 15298863.

January Faculty Development Tip-Creating a Culture of Psychological Safety as Medical Educators

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Creating a Culture of Psychological Safety as Medical Educators

Jillian Gregory, DO

As the COVID-19 pandemic has led to changes in medical infrastructure in the US, many new medical teams, often with medical student and resident learners, have formed in varying capacities to help mitigate the influx of patients.  Many vaccination clinics, testing centers, outpatient and inpatient facilities, and ICUs have emerged and/or expanded. As medical educators and team leaders, creating a culture of psychological safety is a key to providing quality care for patients, and is integral to supporting our learners on the frontlines as they practice in unfamiliar territory.

Psychological safety (PS) is a term used to describe feeling comfortable, sharing thoughts, opinions, and observations without the fear of ridicule or embarrassment.  An example is a junior member of a team admitting an error they made to the attending physician without fear of shame. This same junior member should also feel safe admitting an error they attribute to the attending physician without fear of retribution. Psychological safety is strongly associated with how residents rate their clinical learning experience and has also long been recognized as part of successful patient safety and quality improvement processes (1,2).

How can you help to create a culture of psychological safety on your team as a medical educator and team leader? By inviting input from all team members, promoting active listening, and acknowledging the limits of your own knowledge.

The Agency for Healthcare Quality and Research suggests the use of these phrases by any member of the team during a meeting (3,4):

  1. Maybe someone has a different perspective? I’d really like to hear some other opinions.
  2. If you see anything you are concerned about, please speak up. We’re a team and we have each others backs.
  3. It’s totally fine to disagree. That is why we are talking about this together.
  4. Let’s go around and hear everyone’s reaction to this.
  5. I’m not sure I’ve done this right and would appreciate if someone can double check me.
  6. Thank you for pointing out my mistake. You just saved me from a bigger problem!

The Institute for Healthcare Improvement also recommends team leaders meet with the individuals who report to them in short one-on-one meetings. They should be asked for feedback and the response to this feedback is key. They then should conduct frequent huddles where some of the individual feedback received can be shared freely as a group (4). It is almost important to quickly address behaviors that are counterproductive to PS culture such as ignoring the opinions of team members or blaming others for mistakes.

By leading a team with PS in the forefront, educators and leaders can create an environment where every team member feels valued. Learners can feel safe and supported to speak up for clarity in their learning process and for the safety of their patients. Quality care can be delivered to patients in new environments, even with unfamiliar team members and in stressful situations.

For further reading: Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and Effective Care. White Paper. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017

References

  1. O’donovan R, Mcauliffe E. A systematic review of factors that enable psychological safety in healthcare teams. Int J Qual Health Care. 2020 Jun 4;32(4):240-250. doi: 10.1093/intqhc/mzaa025. PMID: 32232323
  2. Torralba, K.D., Jose, D. & Byrne, J. Psychological safety, the hidden curriculum, and ambiguity in medicine. Clin Rheumatol39, 667–671 (2020). https://doi.org/10.1007/s10067-019-04889-4
  3. Torralba KD, Loo LK, Byrne JM, et al. Does Psychological Safety Impact the Clinical Learning Environment for Resident Physicians? Results From the VA’s Learners’ Perceptions Survey. J Grad Med Educ. 2016;8(5):699-707. doi:10.4300/JGME-D-15-00719.1
  4. Creating Psychological Safety In Teams. Agency For Healthcare Research and Quality Website. Updated August 2018. Accessed January 14 2021. https://www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/psychological-safety.pdf

October 2020 Faculty Development Tip: How to construct good multiple-choice test questions

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MITE Monthly Tip
October 2020
Eric Brown, MD

How to construct good multiple-choice test questions:
Assessment, or testing, is an important aspect of medical teaching and learning. When done well, testing helps learners meet curricular goals while communicating what the teacher views as important. Multiple choice questions (MCQ) remain a mainstay in testing because they can assess a broad range of knowledge in short period of time, leading to a high degree of testing validity and reliability. When constructed well, MCQs can test higher order learning such as comprehension, application, and analysis. However, as anyone who has ever written a MCQ knows, they can be difficult and time-consuming to construct. Even educators formally trained in the process plan for up to an hour writing each question. For this reason, many poorly written MCQs still abound in medical education and only serve to confuse and frustrate learners. Hopefully these basic concepts and tips will help you demystify the process, avoid pitfalls, and better align learners with your curriculum.

1) Start with your learning objectives:
This probably goes without saying, but a direct relationship between learning objectives and test items must exist. Remember that learning objectives should be written around specific learner behavior and not what the program will “teach”. Following this rule will help avoid simply testing medical trivia.

2) MCQ Terminology:
The Stem
Most MCQs start with the stem, or lead in. The stem should be written as a complete sentence and the item should be answerable without reading all of the answer choices. Instead of a sentence completion (eg Treatment with beta-blockers has been shown to . . . ), the stem should be written as a complete sentence (eg Which of the following is a characteristic of treatment with selective beta-blockers?) Although clinical vignettes are used commonly as the stem, they should not be excessively verbose or contain “red herrings”. Remember that most MCQs should be written so that the learner can read and answer the question in under one minute.

Key point: The stem should be stated so that only one of the options can be substantiated and that option should be indisputably correct. As the question writer, it is wise to document (for later recall) the source of its validity. Above all, avoid negative phrasing.

The Options
These are your test-takers’ answer choices. Between three and five options is ideal. They should follow grammatically from the stem and all be of the same type (all diagnoses, all tests, all therapies). The options should all be similar in length and complexity and should not consistently overlap to avoid ambiguity.

Key point: Avoid options none of the above and all of the above. None of the above is problematic in questions of judgement, and it only informs what the test-taker knows is not correct. All of the above only requires that the test-taker understand two of the options.

The Distractors
These are the answer choices that are not correct. Distractors are essential to write well as they form the basis of an exam’s ability to discriminate (separate those who know from those you do not know).

Key point: The best distractors are statements that are accurate, but do not fully answer the question or incorrect statements that seem right to the test-taker.

3) Types of multiple-choice questions:
True/False question
These questions usually start with a stem and then ask learners to choose all the options that are true (or false). They are usually easy to write but have not been shown to discriminate well between learners that know the content and those that do not.

Key point: True/False type questions should generally be avoided. They are generally either too ambiguous or, when written to remove ambiguity, too easy without good discrimination.

Single best answer questions
This is the most common and best validated MCQ type. In their simplest form they test knowledge, but with some effort, and questions can be written to test comprehension and even higher order learning. This format helps avoid confusion on the part of the learner because they do not have to guess what the writer was “thinking”. Currently, the national board of medical examiners (NBME) uses only this type of question.

Key point: The NBME recommends the following basic rules for crafting an effective single best answer MCQ:
1) Rule 1: Each item should focus on an important concept or testing point.
2) Rule 2: Each item should assess application of knowledge, not recall of an isolated fact.
3) Rule 3: The item lead-in (and stem) should be focused, closed, and clear; the test-taker should be able to answer the item based on the stem and lead-in alone.
4) Rule 4: All options should be homogeneous and plausible, to avoid cueing to the correct option.
5) Rule 5: Always review items to identify and remove technical flaws that add irrelevant difficulty or benefit savvy test-takers.

Additional reading/references:

Mohammed O. Al-Rukban, DPHC, ABFM, SBFM. Guidelines for the construction of multiple choice questions tests. J Family Community Med. 2006 Sep-Dec; 13(3): 125–133.

Burton et. al. Multiple-Choice Test Items: Guidelines for University Faculty. Brigham Young University Testing Services and The Department of Instructional Science, 1991.

Dianne E. Campbell. How to write good multiple-choice questions. Journal of Paediatrics and Child Health 47 (2011) 322–325.

Jannette Collins, MD, Med. Education Techniques for Lifelong Learning: Writing Multiple-Choice Questions for Continuing Medical Education Activities and Self-Assessment Modules. Presented in the RSNA Faculty Development Workshop, October 2005.

Miguel A. Paniagua, MD and Kimberly A. Swygert, PhD. Constructing written test questions for the basic and clinical sciences. The National Board of Medical Examiners, 2016.

March 2020 Faculty Development: Tips for using learning theory to craft an effective PowerPoint presentation

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Tips for using learning theory to craft an effective PowerPoint presentation

Eric Brown MD

March 2020

We have all endured slide-based lectures that left us yawning or scratching our heads in confusion. Presentations with too many slides, too busy slides, or hard to see fonts and diagrams are common in medical education and can sabotage even the most dynamic speaker or an otherwise fascinating topic. Here are some tips for crafting slide-based visual aids that will better support your learning objectives and keep learners engaged

  • Remember that slides do not have to be the default option
    • For every presentation you give, ask yourself whether slide-based visuals are the ideal means to deliver your message.
      • For example, a lecture that introduces and then uses a lot of new terms may be better served with a handout with definitions that learners can reference throughout the talk.
  • Use a logical, time-tested story structure
    • The three-act storytelling structure has been around for thousands of years and is firmly imbedded in most learners’ long-term memory.
    • By visually accessing this structure in your learners’ long-term memory, you are able to create a clear pathway for learning new information in their limited-capacity working memory.[1]
      • Act 1: Introduces the setting, main character (or subject), and an unresolved state of affairs.
        • Slide titles in this phase of your talk should reference emotions or situations already familiar to the learner.
      • Act 2: Drives the story forward by picking up on the unresolved state of affairs.
        • Use a story-board approach for organizing concepts and sub-concepts.
        • Limit major concepts to 4-5.
        • Use a slide hierarchy with color coding or other visual cues to anchor the learner.
          • In this graphic, major concepts are all on slides with orange backgrounds while supporting concepts are yellow and sub-concepts are white. Visual adapted from Beyond Bullet Points 
        • Act 3: Frames a climax and resolution around your topic
          • Recycling visual cues from the first “act” can help solidify conclusions
  • Apply Mayer’s principles for designing instructional multimedia presentations
    • Four evidence-based principles for reducing learners’ extraneous processing[2]:
      • Coherence: Exclude extraneous words, pictures, and sounds
      • Signaling: Highlight essential material with yellow boxes or high contrast
      • Redundancy: Do not add on-screen text to narrated animations or videos
      • Spatial Contiguity: Place printed words next to corresponding graphics

 

  • Watch David JP Phillips “How to avoid death by PowerPoint” and then apply his “6 rules”[3] https://www.youtube.com/watch?v=Iwpi1Lm6dFo
    • One “message” per slide.
    • No text sentences (instead use written words/phrases as talking points)
      • When audience members read a sentence while you are speaking it, they hear nothing!
    • Size: The most important part of your slide should be the biggest.
      • For example, the title or heading on the slide should be smaller than the points you are trying to make.
    • Use contrast to your advantage.
      • Dark background with light text
      • Use high contrast to draw attention to important areas of busy slides
    • Six or less ‘objects’ per slide

Hopefully these tips help keep your audiences more engaged during you slide-based talks. When in doubt, try this mnemonic:

ONE message per slide

FEW matching colors

VERY FEW fonts

PHOTOS, not clipart

[1] Atkinson, Cliff (2011). Beyond Bullet Points: Using Microsoft PowerPoint to Create Presentations that Inform, Motivate, and Inspire. Microsoft Press, USA.

[2] Mayer, R. E. (2008). Applying the science of learning: Evidence-based principles for the design of multimedia instruction. American Psychologist, 63(8), 760–769.

[3] Phillips, David JP (2011). How to Avoid Death by PowerPoint. Presentation Skills Ltd. Ted Talk Video available on YouTube and davidjpphillips.com

 

 

 

 

January 2020 Faculty Development: How do Advanced Practice Providers fit into IPE at academic medical centers?

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How do Advanced Practice Providers fit into IPE at academic medical centers?

Angela Leclerc, PA-C

Does your service have one or more Advanced Practice Providers (APPs)?  Chances are you do, or you will!  Originally conceived in the 1960s to assist with the primary care shortage, APPs can be found in almost every specialty and subspecialty of medicine and surgery.  In addition, APPs now support a large part of the workforce at academic centers due to resident work hour restrictions, as well as the stable clinical competence a well-trained APP maintains.

APPs complete rigorous graduate programs prior to entering practice.  To be successful, the new APP requires additional postgraduate training as they are transitioning to practice.  A small percentage of APPs may complete a postgraduate residency/fellowship program in areas such as Emergency Medicine (EM), Critical Care Medicine, Cardiothoracic Surgery, Trauma Surgery or Hospital Medicine, just to name a few.  However, these postgraduate programs are not mandatory and 80% of applicants are new graduates (Maine Medical Center).  How do we leverage the current academic opportunities in your institution to incorporate and educate APPs, either through formal or informal postgraduate training, leading to improved safety, lower cost and improved retention through professional development?

Investing in the training of APPs leads to a high level of consistent competency (Figure 1) (1).

Figure 1

Clin Med 12(3):200-206 (2012)

The well-trained APP provides a consistent level of competence and beyond.  Here the graph on the left represents the PGY1-PGY3 resident while the graph on the right represents the fellow. The solid line labeled ”Physician Assistants” is the well-trained APP that has been practicing for at least 2 years on service.

Chekijian et al. aimed to describe best practices and considerations regarding the integration of APPs at four separate academic institutions in Emergency Medicine.  Yale has a postgraduate APP residency in EM that is 18 months in duration and directly parallels the medical residency for MDs with complete integration from the start date of the internship year through the 18 month program.  Expectations of review of board material also parallel the MD residency program.    At Brown, Physician Extender Development Program (PEDP) was developed for new graduate APPs for a 1 year period.  This includes 5 hours of lecture time each week with the EM residency program.  This program is overseen by the chief education APP as well as two other educational assistant APPs.  UMMS-Baystate program accepts up to two PAs a year into a 12 month residency program who are partially integrated into the physician residency program (2).

You may be curious of the impact of additional learners integrated with the residents and fellows.  Kahn et al. sent a survey to 1178 surgical residents to which 354 (30%) responded.  A large majority of the respondents were part of residencies where the APPs had been integrated into the ICU for 5 or more years (3).

Figure 2

J Surg Res 2015; 199:7-12

If you do not have a formal postgraduate training program to train your APPs, not to worry. Here are some quick tips you can incorporate now:

·         Incorporate your APP(s) into bedside teaching rounds
·         Invite new APPs to resident and medical school didactics
·         Train new APPs simultaneously with residents and medical students in simulation
·         Provide access to shared educations sites or drives for APPs (i.e. asynchronous learning)
·         Provide time for your APPs to attend Grand Rounds
·         Provide formal feedback and support for APP education in your department
·         Provide highly functioning APPs the opportunity to educate other learners on the healthcare team as well as participate ongoing professional development activities in the department
·         Put APPs in charge of the education of onboarding new APPs, have them collaborate with the department chief for incorporation of the new APPs with the medical student and resident learning activities

References:

  1. Ross N1, Parle J, Begg P, Kuhns D.  The case for the physician assistant. Clin Med (Lond). 2012 Jun;12(3):200-6.
  2. Chekijian SA1, Elia TR2, Monti JE3, Temin ES4. Integration of Advanced Practice Providers in Academic Emergency Departments: Best Practices and Considerations. AEM Educ Train. 2018 Nov 27;2(Suppl Suppl 1):S48-S55.
  3. Kahn SA, Davis SA, Banes CT, et al: Impact of advanced practice providers (nurse practitioners and physician assistants) on surgical residents’ critical care experience. J Surg Res 2015; 199:7-12.

November 2019 Faculty Development: Case in Point: How to Write an Effective Case Report or Series

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Case in Point: How to Write an Effective Case Report or Series

William J. Sauer, M.D.

Case reports continue to play a critical role in the advancement of medicine, particularly with regard to new disease entities (e.g. AIDS and Kaposi Sarcoma), adverse reactions (e.g. thalidomide associated birth defects), as well as other novel observations (see Table1).  As an example, there is currently a lot of attention from the CDC and NEJM correspondence regarding vaping-associated lung injury, yet a well written case report was published over two years ago.

 

 

 

Although often labelled as low quality of evidence, the objective of these publications are entirely different from a randomized controlled trial.  Instead of directly impacting medical decision making, case reports should inspire creativity, promote engagement, and further investigations.  They function to alert clinicians of new or rare phenomena that cannot be described in RCTs.  Several specialties, including surgery, infectious disease, and pharmacology, rely on case reports to support their foundation of knowledge.

In an era of information overload, the delivery of these “clinical stories” is particularly important as the audience can quickly become un-engaged.  Several resources, including the CARE (CAse REport) guidelines and checklist, should be used to ensure accurate and intriguing presentation of the intended message.

Tips from the CARE Guidelines include2:

  • Clearly identify the message. The title should succinctly describe the primary interest the author hopes to describe.
  • Create a timeline. The patient(s) chief complaints, clinical course, and outcome should be articulated in a chronological and engaging manner.
  • Complete the remainder using specialty-specific information with references. Highlight key words as well as references (if available) to summarize findings.
  • De-Identify patient information. Informed consent needs to be obtained.
  • Follow journal-specific submission requirements/ guidelines. Unfortunately, a smaller number of journals are publishing case reports/ series.

 

1) Vandenbroucke JP.  In Defense of Case Reports and Case Series.  Ann Intern Med. 2001; 134(4):330-4 (see attached PDF for article)

2) CARE case reports guidelines.  www.care-statement.org. (see attached PDF for article)

3) Gagnier JJ, et al.  The CARE Guidelines: Consensus-based Clinical Case Reporting Guideline Development.  Glob Adv Health Med. 2013; 2(5): 38-43.

4) Riley DS, et al.  CARE guidelines for case reports: explanation and elaboration document.  Journal of Clinical Epidemiology. 2017; 89:218-235

 

Tips for Being a Mentee

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Tips for Being a Mentee

Rebecca Hutchinson, MD

Many of us have benefited from excellent mentors who have given their time, expertise and guidance to help us develop to our fullest potential.  Please see earlier MITE tip (link here to July 2018 MITE tip) on characteristics of great mentors, which include enthusiasm for the project and mentee, tailored career guidance, dedicated time, encouraging work-life balance and serving as a role model for mentorship.  In this tip, I’d like to focus on strategies to use as a mentee to maximize your gain from your relationship with your mentor.

  1. Be the driver.1-3 Mentors are busy people who have many competing demands.  You’ll get the biggest bang for your buck if you take ownership and responsibility for determining what to discuss in the mentorship meeting.  Come prepared; identify in advance the ways in which this particular mentor might be able to help you before your meeting.1,3 It’s also important to evaluate your mentor-mentee relationship intermittently to ensure that it is helping you meet your goals; don’t stay in a relationship out of obligation.3  There are tools that can help you evaluate the utility of a particular mentor relationship.4
  2. Let yourself struggle a little – but not too much — before asking for help.3 You’ll learn and develop more if you take risks and try to solve some problems on your own.  On the other hand, you won’t be productive if you spend too much time stymied by a road block.  The balance between reaching out and struggling through is dependent on the particular mentor-mentee relationship; don’t be afraid to ask for feedback in your mentorship meeting about this.
  3. Show gratitude for, and be respectful of your mentors time.2 Your mentor is a busy person.  If you’re hoping to submit an abstract or you need your mentor to write you a recommendation letter, make sure to allow a reasonable amount of time.  One week is the minimum to review an abstract; several weeks are necessary for a letter of recommendation.  If you’re not sure, check-in with your mentor about what a reasonable amount of time might be for the task.
  4. Be enthusiastic and accountable.3 Having a positive attitude and being accountable goes a long way.  Set specific, measurable goals with deadlines, and then meet the deadlines you set!  If you didn’t meet the deadline, be clear about why not.
  5. Have regular meetings and take notes during these meetings. Meeting regularly is a key component of mentorship.3  Take notes during your meetings.  Some experts recommend keeping a “mentoring journal” where you keep all of your notes in one place.3,5
  6. Be open to feedback and remember feedback is bidirectional.2,3 Be open to feedback and try to see it as opportunities for growth and development.  If your mentor edits your writing and there’s more red than black, don’t take the editing personally.   Also, remember that you can give your mentor feedback; UCSF has a template for feedback that is helpful.5
  7. Mutually agree on format of communication.3,5 Your mentor might mostly communicate through email and may not use text messages for professional interactions.  Have a conversation early in your relationship to understand your mentors preferred method of communication.

 

 

 

Straus SE, Chatur F, Taylor M. Issues in the mentor–mentee relationship in academic medicine: A qualitative study. Academic medicine. 2009;84(1):135-139.

Straus SE, Johnson MO, Marquez C, Feldman MD. Characteristics of successful and failed mentoring relationships: a qualitative study across two academic health centers. Academic medicine: journal of the Association of American Medical Colleges. 2013;88(1):82.

Moores LK, Holley AB, Collen JF. Working With a Mentor: Effective Strategies During Fellowship and Early Career. Chest. 2018;153(4):799-804.

Wadhwa V, Nagy P, Chhabra A, Lee CS. How effective are your mentoring relationships? Mentoring quiz for residents. Current problems in diagnostic radiology. 2017;46(1):3-5.

Faculty Mentoring Toolkit. https://academicaffairs.ucsf.edu/ccfl/media/UCSF_Faculty_Mentoring_Program_Toolkit.pdf. Accessed September 26, 2019.

 

Want CME Credit for reading this tip?? Go Here: https://mainehealth.cloud-cme.com/MITEmonthlytipoctober

 

Encouraging Reflection to Deepen Learning and Combat Burnout

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Encouraging Reflection to Deepen Learning and Combat Burnout-Rebecca Hutchinson, MD

Kolb describes 4 stages of experiential learning, the type of adult learning that forms the cornerstone of medical education.1,2

Although all of these steps are important, reflection is believed to be particularly important to create deep or lasting learning.3  Reflection is a metacognitive process, or thinking about thinking; this process allows the learner to make connections between new information and prior experiences and knowledge.4  Effective reflection results in connections that increase accessibility of the learning, allowing application to relevant subsequent scenarios.  Reflection can be written or oral, there is no evidence to suggest superiority of one method over the other; this MITE tip will discuss methods of facilitating both.5

There are many ways that we can incorporate reflection into our education of medical trainees of all levels.  Prior to encounters, we can encourage reflection by explicitly discussing our objectives for the visit using questions such as: “What physical exam maneuvers might be most helpful to determine our management for the day?”  or “What questions should we ask the patient in order to further refine our differential diagnosis?”  This type of reflection will help the learner know what to focus on during the encounter, increasing the yield of the learning experience.  This type of ‘pre-visit’ exercise can help all members of the treatment team maximize their learning from a shared patient encounter even if they are not participating in an active way.  We can also encourage reflection after encounters.  Some examples of questions that could be used to reflect are:  “how did the physical exam compare to what we expected to find in this patient with advanced heart failure?” or “what emotion do you think the patient was having when you explained the plan for the day?”1

In addition to facilitating deep and lasting learning, reflection has also been shown to be an effective way to improve resiliency and well-being of the clinician as well as increase empathy for patients.6,7  It is particularly important to help learners take the time to reflect after challenging emotional experiences.  We can do this by having formal or informal debriefing sessions where all members of the care team have the opportunity to share how they are feeling or how the experience is impacting them personally.  We can also encourage reflection through writing, such as through the use of journaling.  Additionally, you could consider having medical students and/or residents do a writing exercise at the end of a month long rotation to encourage reflection.5  Some examples of prompts are: writing gratitude letters to patients, writing about a patient who surprised them and explaining why, reflecting on a time when they felt they communicated something difficult in a way that was effective (or not!).  One fun exercise to consider doing as a group to aid in reflection and team bonding is having everyone write a six-word story.  A famous example of this is “For sale: baby shoes, never worn,” attributed to Hemingway.  These writing exercises help our learners, but they can also help us.

References:

  1. Maudsley G, Strivens J: Promoting professional knowledge, experiential learning and critical thinking for medical students. Medical education 34:535-544, 2000
  2. Kolb DA, Boyatzis RE, Mainemelis C: Experiential learning theory: Previous research and new directions. Perspectives on thinking, learning, and cognitive styles 1:227-247, 2001
  3. Mann K, Gordon J, MacLeod A: Reflection and reflective practice in health professions education: a systematic review. Advances in health sciences education 14:595, 2009
  4. Sandars J: The use of reflection in medical education: AMEE Guide No. 44. Medical teacher 31:685-695, 2009
  5. Aronson L: Twelve tips for teaching reflection at all levels of medical education. Medical teacher 33:200-205, 2011
  6. Chen I, Forbes C: Reflective writing and its impact on empathy in medical education: systematic review. Journal of educational evaluation for health professions 11, 2014
  7. Zwack J, Schweitzer J: If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Academic Medicine 88:382-389, 2013