Is there a relationship between attending physicians' and residents' teaching skills and students' examination scores?

PURPOSE: Faculty development programs and faculty incentive systems have heightened the need to validate a connection between the quality of teaching and students' learning. This study was designed to determine the association between attending physicians' and residents' teacher ratings and their students' examination scores. METHOD: From a database of 362 students, 138 faculty, and 107 residents in internal medicine, student-faculty (n = 476) and student-resident (n = 474) pairs were identified. All students were in their third year, rotating on inpatient general medicine and cardiology services, July 1994 through June 1996, at a single institution. The outcome measure for students' knowledge was the NBME Subject Examination in internal medicine. To control for students' baseline knowledge, the predictors were scores on the USMLE Step 1 and a sequential examination (a clinically-based pre- and post-clerkship examination). Teaching abilities of faculty and residents were rated by a global item on the post-clerkship evaluation. Faculty's ratings used only scores from prior to the study period; residents' ratings included those scores students gave during the study period. RESULTS: Multivariate analyses showed faculty's teaching ratings were a small but significant predictor of the increase in students' knowledge. Residents' teaching ratings did not predict an increase in students' knowledge. CONCLUSION: Attending faculty's clinical teaching ability has a positive and significant effect on medical students' learning.     

Quality of discharge summaries prepared by first year internal medicine residents

ABSTRACT: BACKGROUND: Patients are particularly susceptible to medical error during transitions from inpatient to outpatient care. We evaluated discharge summaries produced by incoming postgraduate year 1 (PGY-1) internal medicine residents for their completeness, accuracy, and relevance to family physicians. METHODS: Consecutive discharge summaries prepared by PGY-1 residents for patients discharged from internal medicine wards were retrospectively evaluated by two independent reviewers for presence and accuracy of essential domains described by the Joint Commission for Hospital Accreditation. Family physicians rated the relevance of a separate sample of discharge summaries on domains that family physicians deemed important in previous studies. RESULTS: Ninety discharge summaries were assessed for completeness and accuracy. Most items were completely reported with a given item missing in 5 % of summaries or fewer, with the exception of the reason for medication changes, which was missing in 15.9 % of summaries. Discharge medication lists, medication changes, and the reason for medication changes---when present---were inaccurate in 35.7 %, 29.5 %, and 37.7 % of summaries, respectively. Twenty-one family physicians reviewed 68 discharge summaries. Communication of follow-up plans for further investigations was the most frequently identified area for improvement with 27.7 % of summaries rated as insufficient. CONCLUSIONS: This study found that medication details were frequently omitted or inaccurate, and that family physicians identified lack of clarity about follow-up plans regarding further investigations and visits to other consultants as the areas requiring the most improvement. Our findings will aid in the development of educational interventions for residents.     

The effect on reliability and sensitivity to level of training of combining analytic and holistic rating scales for assessing communication skills in an internal medicine resident OSCE

ObjectiveAlthough previous research has compared checklists to rating scales for assessing communication, the purpose of this study was to compare the effect on reliability and sensitivity to level of training of an analytic, a holistic, and a combined analytic-holistic rating scale in assessing communication skills.MethodsThe University of Alberta Internal Medicine Residency runs OSCEs for postgraduate year (PGY) 1 and 2 residents and another for PGY-4 residents. Communication stations were scored with an analytic scale (empathy, non-verbal skills, verbal skills, and coherence subscales) and a holistic scale. Authors analyzed reliability of individual and combined scales using generalizability theory and evaluated each scale's sensitivity to level of training.ResultsFor analytic, holistic, and combined scales, 12, 12, and 11 stations respectively yielded a Phi of 0.8 for the PGY-1,2 cohort, and 16, 16, and 14 stations yielded a Phi of 0.8 for the PGY-4 cohort. PGY-4 residents scored higher on the combined scale, the analytic rating scale, and the non-verbal and coherence subscales.ConclusionA combined analytic-holistic rating scale increased score reliability and was sensitive to level of training.Practice implicationsGiven increased validity evidence, OSCE developers should consider combining analytic and holistic scales when assessing communication skills.     

The effect of candidates' perceptions of the evaluation method on reliability of checklist and global rating scores in an objective structured clinical examination.

PURPOSE: Process-oriented global ratings, which assess "overall performance" on one or a number of domains, have been purported to capture nuances of expert performance better than checklists. Pilot data indicate that students change behaviors depending on their perceptions of how they are being scored, while experts do not. This study examines the impact of the students' orientation to the rating system on OSCE scores and the interstation reliability of the checklist and global scores. METHOD: A total of 57 third- and fourth-year medical students at one school were randomly assigned to two groups and performed a ten-station OSCE. Group 1 was told that scores were based on checklists. Group 2 was informed that performance would be rated using global ratings geared toward assessing overall competence. All candidates were scored by physician-examiners who were unaware of the students' orientations to the rating system and who used both checklists and global rating forms. RESULTS: A mixed two-factor ANOVA identified a significant interaction of rating form by group (F(1,55) = 5.5, p <.05), with Group 1 (checklist-oriented) having higher checklist scores but lower global scores than did Group 2 (oriented to global ratings). In addition, Group 1 had higher interstation alpha coefficients than did Group 2 for both global scores (0.74 versus 0.63) and checklist scores (0.63 versus 0.40). CONCLUSIONS: The interaction effect on total exam scores suggests that students adapt their behaviors to the system of evaluation. However, the lower reliability coefficients for both forms found in the process-oriented global-rating group suggest that an individual's capacity to adapt to the system of global rating forms is relatively station-specific, possibly depending on his or her expertise in the domain represented in each station.     

OSCE checklists do not capture increasing levels of expertise.

PURPOSE: To evaluate the effectiveness of binary content checklists in measuring increasing levels of clinical competence. METHOD: Fourteen clinical clerks, 14 family practice residents, and 14 family physicians participated in two 15-minute standardized patient interviews. An examiner rated each participant's performance using a binary content checklist and a global process rating. The participants provided a diagnosis two minutes into and at the end of the interview. RESULTS: On global scales, the experienced clinicians scored significantly better than did the residents and clerks, but on checklists, the experienced clinicians scored significantly worse than did the residents and clerks. Diagnostic accuracy increased for all groups between the two-minute and 15-minute marks without significant differences between the groups. CONCLUSION: These findings are consistent with the hypothesis that binary checklists may not be valid measures of increasing clinical competence.     

Global ratings of videotaped performance versus global ratings of actions recorded on checklists: a criterion for performance assessment with standardized patients.

PURPOSE: To test whether global ratings of checklists are a viable alternative to global ratings of actual clinical performance for use as a criterion for standardized-patient (SP) assessment. METHOD: Five faculty physicians independently observed and rated videotaped performances of 44 medical students on the seven SP cases that comprise the fourth-year assessment administered at The Morchand Center of Mount Sinai School of Medicine to students in the eight member schools in the New York City Consortium. A year later, the same panel of raters reviewed and rated checklists for the same 44 students on five of the same SP cases. RESULTS: The mean global ratings of clinical competence were higher with videotapes than checklists, whereas the mean global ratings of interpersonal and communication skills were lower with videotapes. The correlations for global ratings of clinical competence showed only moderate agreement between the videotape and checklist ratings; and for interpersonal and communication skills, the correlations were somewhat weaker. CONCLUSION: The results raise serious questions about the viability of global ratings of checklists as an alternative to ratings of observed clinical performance as a criterion for SP assessment.     

Effect of surgical training course on performance of minor surgical procedures in family medicine physicians' offices: an observational study

Aim

To examine the influence of a practical surgical course on the number of minor surgical procedures performed by family physicians.

Methods

We compared the number of minor surgical procedures performed by family physicians in 59 offices in the city of Osijek and surrounding rural area, Croatia, during 12 months before and after the 40-hour practical surgical course held in September 2006 by surgeons and family medicine specialists. Minor surgical procedures taught in the course included management of ingrown toenails, abscesses/comedones, and minor wounds, anesthesia application, disinfection, use and sterilization of surgical instruments, and antibiotic treatment.

Results

The number of minor surgical procedures performed in family medicine offices almost doubled (503 vs 906 after the course, P<0.001, Wilcoxon test). The median number of abscesses/comedones treatments per physician increased from 1 to 6 (P<0.001, Wilcoxon test), the number of managed wounds increased from 111 to 217 (P<0.001, Wilcoxon test), while the number of ingrown toenail resections increased from 120 to 186 (P = 0.004, Wilcoxon test). Fifty percent of physicians did not treat patients surgically, irrespective of the training. We found no association between the number of performed procedures and age, length of employment, or location of the physician’s office (urban vs rural). However, we found that male physicians performed more surgical treatments both before and after the course (abscesses/comedones: P<0.001 and P = 0.108 respectively; ingrown toenail resections: P = 0.008 and P = 0.008 respectively; minor wounds: P = 0.030 and P<0.001; respectively).

Conclusion

Practical courses can encourage practitioners to treat the patients surgically in their offices and, thus, increase the number of services offered in primary care. Female physicians should be more encouraged to perform minor surgical procedures in their offices.Surgical problems are a part of everyday routine of a family physician. Although some of the procedures are usually performed in the office, others, such as surgical treatment of comedones, abscesses, ingrown toenails or minor wounds management, are believed to be more complicated (1-3) and are usually referred to a surgeon. In fact, there is no reason for such a practice, because the complexity of these procedures, need for specialist’s knowledge and skills, or legal aspects do not exceed family physician’s competence and technical and logistical support (4-7).Primary health care practitioners, such as family physicians, should be encouraged to offer broader range of medical services in their every day work, including surgical ones (3,7-10). However, to do so, they should be not only properly equipped, but adequately trained as well.As a lack of time or practical experience (11) and inadequate training (12) are frequently cited as reasons for not performing minor surgical procedures in family medicine offices, an obvious solution would be to include more practical surgical workshops in the program of continuous medical education of family physicians. To confirm this hypothesis, we explored the influence of a course in practical surgery on the number of minor surgical procedures performed in family medicine offices, expecting to detect a significant increase.     

An objective structured clinical examination for the licentiate: report of the pilot project of the Medical Council of Canada.

The Medical Council of Canada (MCC) administers a qualifying examination for the issuance of a license to practice medicine. To date, this examination does not test the clinical skills of history taking, physical examination, and communication. The MCC is implementing an objective structured clinical examination (OSCE) to test these skills in October 1992. A pilot examination was developed to test the feasibility, reliability, and validity of running a multisite, two-form, four-hour, 20-station OSCE for national licensure. In February 1991, 240 volunteer first- and second-year residents were tested at four sites. The candidates were randomly assigned to one of two forms of the test and one of two sites for two of the four sites. Generalizability analysis revealed that the variance due to form was 0.0 and that due to site was .16 compared with a total variance of 280.86. The reliabilities (inter-station) were .56 and .60 for the two forms. Station total-test score correlations, used to measure station validity, were significant for 38 of the 40 stations used (range .14-.60). The results of the OSCE correlated moderately with the MCC qualifying examination; these correlations were .32 and .35 for the two test forms. Content validity was assessed by postexamination questionnaires given to the physician examiners using a scale of 0 (low) to 10 (high). The physicians' mean ratings were: importance of the stations, 8.1 (SD, 1.8); success of the examination in testing core skills, 8.1 (SD, 1.6); and degree of challenge, 7.8 (SD, 2.1). The results indicate that a full-scale national administration of an OSCE for licensure is feasible using the model developed. Aspects of validity have been established and strategies to augment reliability have been developed.     

Didactic teaching conferences for IM residents: who attends, and is attendance related to medical certifying examination scores?

PURPOSE: Didactic teaching conferences are a cornerstone of residents' training in internal medicine, yet these programs have received little formal evaluation. This study determines the factors associated with residents' attendance at didactic teaching conferences and the relationship of attendance to residents' scores on medical certification examinations. METHOD: The attendance of 81 residents was recorded at 199 conferences at one university hospital's internal medicine residency program during the 1996-97 academic year. Characteristics of the conferences were recorded, including the date, whether lunch was provided, the daily census on the medicine general wards, daily ambient temperature, and conference type. Residents' scores on the United States Medical Licensing Examination (USMLE) Step 2 and American Board of Internal Medicine (ABIM) certification examination were collected. RESULTS: Residents' attendance at conferences was 34% overall or 54% excluding excused absences. Adjusting for the conferences' and residents' characteristics, attendance declined by one third as the year progressed. Providing lunch at noon conferences enhanced residents' attendance (odds ratio [OR] 1.26 overall and OR 1.64 for residents on inpatient rotations). Higher attendance was not associated with improvement in standardized medical knowledge test scores. CONCLUSIONS: Absenteeism and waning attendance through the year have important implications for structuring didactic internal medicine teaching. Providing lunch improves attendance, but this incentive should be weighed against the potential burdens of the pharmaceutical industry's funding of these lunches. The lack of relationship between attendance and residents' adjusted board scores calls for a better understanding of the value of this high-intensity medical education intervention.     

The relationship of residents' autonomy and use of a teaching hospital's resources

This 1990 study examines the relationship between the degree of use of patient care resources and the degree of supervision of residents by attending physicians (as perceived by residents) at a large midwestern teaching hospital. Ratings of the degree of clinical autonomy allowed residents by 65 attending physicians--each of whom had a general internal medicine practice with a significant hospital component--were provided by 23 former internal medicine chief residents and 17 internal medicine residents who were in their third year at the time of the study. A regression model was used to test the association between hospital resource use (as shown by total hospital charges to patients and their lengths of stay) and the residents' mean ratings of the degrees of autonomy the attending physicians permitted residents, for 7,169 of these physicians' patients discharged between 1986 and 1989 in 28 diagnosis-related groups. The analysis was controlled for patients' insurance status and chronic disease comorbidities. The patients whose attending physicians were rated as allowing substantial clinical autonomy had significantly lower total charges and lengths of stay (p less than .0001). These results suggest that internal medicine residents have an inherently conservative practice style that values low-intensity workups and rapid discharge of patients.     

A controlled trial of a short course to improve residents' communication with patients at the end of life.

PURPOSE: High-quality palliative care requires physicians who communicate effectively, yet many do not receive adequate training. Leading efforts to demonstrate the effectiveness of such training have involved time-intensive programs that included primarily attending physicians, which have been conducted outside of the United States. The goal was to evaluate the effect of a short course to improve residents' communication skills delivering bad news and eliciting patients' preferences for end-of-life care. METHOD: This prospective trial enrolled internal medicine residents at Duke University Medical Center from 1999 to 2001. The course consisted of small-group teaching with lecture, discussion, and role-play. The outcome measure was observed communication skills delivering bad news and eliciting patients' preferences for end-of-life treatment, assessed via audio-recorded standardized patient encounters before and after receiving the intervention. RESULTS: Thirty-seven residents received the intervention and 19 were in the control group. Residents attending the course demonstrated statistically significant increases in their overall skill ratings in the delivery of bad news, with improvement in the specific areas of information giving and responding to emotional cues. Although cumulative scores for discussions about patient preferences for treatment did not increase, residents demonstrated enhanced specific skills including discussing probability, presenting clinical scenarios, and asking about prior experience with end-of-life decision making. CONCLUSION: A relatively short, intensive course can improve the end-of-life communication skills of U.S. medical residents.     

The preferred learning style among residents and faculty members of an internal medicine residency program

OBJECTIVE: To determine the preferred learning style, as defined by David Kolb, and predictors of the different learning styles among residents and faculty members at an internal medicine residency program. DESIGN/SETTING: A cross sectional study of internal medicine residents and faculty members at Morehouse School of Medicine was performed using the Kolb Learning Style Inventory (LSI) version 3.1. MEASUREMENTS: The Kolb LSI is a questionnaire of 12 sentences, each with four phrases for sentence completion that are to be ranked according to how they apply to the subject. RESULTS: Forty-two out of 59 questionnaires that were given out to residents and attending physicians were properly completed and returned. Assimilating style was the predominant learning style among residents (42%) and attending physicians (55%). There was no significant association between age, gender or medical education status, and learning styles. CONCLUSIONS: The understanding of residents' learning styles may facilitate instructional rapport between residents and attending physicians, thereby improving residents' academic performance.     

Developing case-specific checklists for standardized-patient-based assessments in internal medicine: A review of the literature.

PURPOSE: To review the literature on the methods used in writing case-specific checklists for studies of internal medicine physicians' performances that were assessed by standardized patients. METHOD: The authors searched Medline, Embase, Psychlit, and ERIC for articles in English published between 1966 and February 1998. The following search string was used: "[(standardi(*) or simulat(*) or programm(*)) near (patient(*) or client(*) or consultati(*))] and internal medicine." The authors then searched the reference lists of papers retrieved from the database searches, as well as those from seven proceedings of the International Ottawa Conference on Medical Education and Assessment. RESULTS: The procedure yielded 29 relevant articles: database searches yielded 14 published reports dealing with case-specific checklists, 11 articles were culled from the reference lists of these papers, and the Ottawa Conference proceedings yielded four articles. Only 12 articles reported specifically on the development of checklists. In general, there were three sources used for developing checklists: panels of experts, the investigators themselves, and responses from expert physicians to written protocols. No article indicated that researchers had relied exclusively on data from the literature to compose their checklists. Only three articles indicated that literature sources had informed their checklist development. All articles except one relied on explicit criteria for the inclusion of items on the checklists. In 21 of the 29 articles, the checklists had been scored by SPs, but the scoring of specific items on the checklists varied according to the purpose of the SP-physician encounter. Only four of the articles made the checklists available or indicated that the checklists could be obtained from the authors. CONCLUSION: The development of case-specific checklists for SP examinations of physicians' performance has received little attention. To judge the validity of studies of physicians' performances that use SPs, the development processes for the checklists need to be more fully described to enable readers to evaluate the validity and reliability of the studies.     

Shared decision making: views of first-year residents and clinic patients.

PURPOSE: Patients' and physicians' views of their roles in decision making have implications for patient care and medical education. This study was designed to determine perspectives of residents and patients on the amount of control each should have in health care decisions. METHOD: Data were collected from a self-administered questionnaire of 45 first-year residents and a parallel structured interview with 92 patients from three resident clinics. Information Seeking (IS) and Decision Making (DM) scales from the Autonomy Preference Index were supplemented by five clinical scenarios focused on decisions concerning hypertension, depression, cholecystectomy, hysterectomy, and prostate cancer. Analysis of variance (ANOVA) and repeated-measures ANOVA were used to test for significant differences in scores. RESULTS: Patients' and residents' mean scores on IS were practically equivalent, indicating strong desire for information sharing. For DM, patients indicated a desire for slightly less than equal control in decisions, while residents thought patients should have a more than equal role. Given the specific clinical scenarios, the picture varied. Patients wanted equal roles in the hypertension, depression, and prostate cancer scenarios, while residents wanted to have more control in these decisions. Conversely, patients wanted greater control in the hysterectomy and cholecystectomy scenarios, and residents wanted a less than equal role in these decisions. Patients thought consultants such as surgeons desired the same role as their physicians, but residents assumed consultants wanted more control. CONCLUSIONS: Patients from a disadvantaged population indicated a strong desire for information and participation in making decisions about their care. Understanding the similarities and discrepancies in patients' and first-year residents' perspectives on shared decision making can have consequences for the patient-physician relationship and medical education.     

A comparison of global ratings and checklist scores from an undergraduate assessment using an anesthesia simulator.

PURPOSE: To determine the correlation between global ratings and criterion-based checklist scores, and inter-rater reliability of global ratings and criterion-based checklist scores, in a performance assessment using an anesthesia simulator. METHOD: All final-year medical students at the University of Toronto were invited to work through a 15-minute faculty-facilitated scenario using an anesthesia simulator. Students' performances were videotaped and analyzed by two faculty using a 25-point criterion-based checklist and a five-point global rating of competency (1 = clear failure, 5 = superior performance). Correlations between global ratings and checklist scores, as well as specific performance competencies (knowledge, technical skills, and judgment), were determined. Checklist and global scores were converted to percentages; means of the two marks were compared. Mean reliability of a single rater for both checklist and global ratings was determined. RESULTS: The correlation between checklist and global ratings was.74. Mean ratings of both checklist and global scores were low (58.67, SD = 14.96, and 57.08, SD = 24.27, respectively); these differences were not statistically significant. For a single rater, the mean reliability score across rater pairs for checklist scores was.77 (range.58-.93). Mean reliability score across rater pairs for global ratings was.62 (.40-.77). Global ratings correlated more highly with technical skills and judgment (r =.51 and r =.53, respectively) than with knowledge. (r =.24) CONCLUSION: Inter-rater reliability was higher for checklist scores than for global ratings; however, global ratings demonstrated acceptable inter-rater reliability and may be useful for competency assessment in performance assessments using simulators.     

Assessment of a 360-degree instrument to evaluate residents' competency in interpersonal and communication skills.

OBJECTIVE: To test the reliability of the 360-degree evaluation instrument for assessing residents' competency in interpersonal and communication skills. METHOD: Ten-item questionnaires were distributed to residents and evaluators at Monmouth Medical Center in Long Branch, New Jersey, in March/April, 2002. The scoring scale was 1-5; the highest score was 50. Data were maintained strictly confidential; each resident was assigned a code. Completed data sheets were collated by category and entered into a spreadsheet. The total and mean scores by each category of evaluator were calculated for each resident and a rank order list created. Shrout-Fleiss (model 2) intraclass correlation coefficients measured reliability of ratings within each group of evaluators. Reliability/reproducibility among evaluators' scores were tested by the Pearson correlation coefficient (p <.05). RESULTS: Intraclass correlation coefficients showed a narrow range, from.85-.54. The highest ranked resident overall ranked high and the lowest was low with most evaluators. The rank order among fellow residents was markedly different from other evaluator categories. Pearson correlation coefficients showed significant correlation between faculty and ancillary staff, (p =.002). Patients as evaluators did show intraclass correlation, but did not correlate significantly with other categories. Scores from colleagues correlated negatively with all other categories of evaluators. CONCLUSIONS: The 360-degree instrument appears to be reliable to evaluate residents' competency in interpersonal and communication skills. Information from the assessment may provide feedback to residents. Areas of improvement identified by the scores would suggest areas for improvement and further ongoing assessment.     

Patients don't present with five choices: an alternative to multiple-choice tests in assessing physicians' competence.

PURPOSE: To evaluate an open-ended, computer-scored testing format designed to overcome certain limitations of multiple-choice questions. METHOD: Test items covering content in family medicine were administered in two different formats to 7,036 resident physicians in 380 training programs, and to 35 experienced, board-certified physicians in conjunction with the In-training Examination of the American Board of Family Practice. Examinees completed a booklet of 40 open-ended, uncued (UnQ) test items by selecting the answer to each item from a list of over 500 responses. Similar items were administered using the standard multiple-choice question (MCQ) format. One year later, another test of 40 UnQ test items dealing with core content in family medicine was administered to 7,138 residents. RESULTS: Examinees completed over 560,000 UnQ responses with high compliance and few errors. Both reliability and validity for the UnQ format were higher than for the MCQ format, and the UnQ items discriminated more accurately among levels of physicians' experience. The UnQ format almost eliminated the possibility that the physicians could answer questions by sight recognition or random guessing, and it was particularly effective in measuring knowledge of core content. CONCLUSIONS: This study supports the feasibility of administering open-ended test items to enhance tests of physicians' competence.     

Do individual attendings' post-rotation performance ratings detect residents' clinical performance deficiencies?

PURPOSE: To determine whether attending physicians' post-rotation performance ratings and written comments detect surgery residents' clinical performance deficits. METHOD: Residents' performance records from 1997-2002 in the Department of Surgery, Southern Illinois University School of Medicine, were reviewed to determine the percentage of times end-of-rotation performance ratings and/or comments detected deficiencies leading to negative end-of-year progress decisions. RESULTS: Thirteen of 1,986 individual post-rotation ratings (0.7%) nominally noted a deficit. Post-rotation ratings of "good" or below were predictive of negative end-of-year progress decisions. Eighteen percent of residents determined to have some deficiency requiring remediation received no post-rotation performance ratings indicating that deficiency. Written comments on post-rotation evaluation forms detected deficits more accurately than did numeric ratings. Physicians detected technical skills performance deficits more frequently than applied knowledge and professional behavior deficits. More physicians' post-rotation numeric ratings contradicted performance deficits than supported them. More written comments supported deficits than contradicted them in the technical skills area. In the applied knowledge and professional behavior areas, more written comments contradicted deficits than supported them. CONCLUSIONS: A large percentage of performance deficiencies only became apparent when the attending physicians discussed performance at the annual evaluation meetings. Annual evaluation meetings may (1) make patterns of residents' behavior apparent that were not previously apparent to individual physicians, (2) provide evidence that strengthens the individual attending's preexisting convictions about residents' performance deficiencies, or (3) lead to erroneous conclusions. The authors believe deficiencies were real and that their findings can be explained by a combination of reasons one and two.     

Continuity of care: a casualty of the 80-hour work week.

The controversy concerning the limit of residents' work time to 80 hours a week has generated unprecedented dismay for many involved in graduate medical education, particularly surgeons. The author maintains that 80 hours a week is too short a time for surgery residents to provide excellent care and that this new rule undercuts the importance of continuity of care, a principle highly valued by surgeons. General surgeons and those specialty surgeons most closely associated with them think of themselves as the last "compleat physicians," who should and can take care of the entire patient, and that when difficulties arise, they should not transfer the patient to another physician but instead ask someone else to help them continue to care for the patient. The author traces the arbitrary choice of an 80-hour work week (instead of a 92-hour one) to several sources, including the leadership of internal medicine, which he feels has largely de-emphasized patient contact for many years and has become focused on research and/or administration. He also maintains that the issue of moonlighting has also driven the push for an 80-hour work week, and that the view of moonlighting by surgical residencies (i.e., that it is almost always counterproductive) is different from that of other residencies. He concludes by acknowledging that the 80-hour work week and the abandonment of the principle of continuity of care are societal decisions, and have occurred because surgeons and other physicians did not make their case strongly enough or in time.     

Specialty choices of students who actually have choices: the influence of excellent clinical teachers.

PURPOSE: To determine the influence of the quality of attending physicians and residents on the specialty choices of excellent medical students, who actually have a broad choice of specialties. METHOD: In 1993-94 and 1994-95, 169 third-year students at the University of Kentucky College of Medicine were randomly assigned to two one-month rotations on general medicine inpatient wards. At the end of each rotation, the students confidentially evaluated the attending physician and the supervising resident (different for each rotation) with whom they had worked. Data were collected for 62 attending physicians and 89 residents. The authors analyzed the influences of the "best" and "worst" clinical instructors (those rated in the top and the bottom 20% by all students with whom they had worked over the two years) on "excellent" medical students (the 52 students whose USMLE I scores were in the top 30% of their class). RESULTS: Using regression approaches from the general linear model, the authors found that independent predictors of internal medicine residency choice for excellent medical students were exposure to highly rated internal medicine attendings (p = .02) and residents (p = .03). Nine of 29 (30%) of the excellent students who worked with a "best" medicine clinical instructor chose an internal medicine residency, while none of the 23 excellent medical students who did not work with a "best" medicine clinical instructor did so. The authors found no correlation in students' ratings of their pairs of attendings and residents, suggesting that rater bias did not explain the results. CONCLUSION: Better medical students who work with the best internal medicine attending physicians and residents in their internal medicine clerkship are more likely to choose an internal medicine residency.