Disruptive behavior in the workplace: Challenges for gastroenterology fellows

AIM To assess first-year gastroenterology fellows' ability to address difficult interpersonal situations in the workplace using objective structured clinical examinations(OSCE).METHODS Two OSCEs("distracted care team" and "frazzled intern") were created to assess response to disruptive behavior. In case 1, a fellow used a colonoscopy simulator while interacting with a standardized patient(SP), nurse, and attending physician all played by actors. The nurse and attending were instructed to display specific disruptive behavior and disregard thefellow unless requested to stop the disruptive behavior and focus on the patient and procedure. In case 2, the fellow was to calm an intern managing a patient with massive gastrointestinal bleeding. The objective in both scenarios was to assess the fellows' ability to perform their duties while managing the disruptive behavior displayed by the actor. The SPs used checklists to rate fellows' performances. The fellows completed a selfassessment survey.RESULTS Twelve fellows from four gastrointestinal fellowship training programs participated in the OSCE. In the "distracted care team" case, one-third of the fellows interrupted the conflict and refocused attention to the patient. Half of the fellows were able to display professionalism despite the heated discussion nearby. Fellows scored lowest in the interprofessionalism portion of post-OSCE surveys, measuring their ability to handle the conflict. In the "frazzled intern" case, 68% of fellows were able to establish a calm and professional relationship with the SP. Despite this success, only half of the fellows were successfully communicate a plan to the SP and only a third scored "well done" in a domain that focused on allowing the intern to think through the case with the fellow's guidance.CONCLUSION Fellows must receive training on how to approach disruptive behavior. OSCEs are a tool that can assess fellow skills and set a culture for open discussion.     

Assessing cultural competency skills in gastroenterology fellowship training

AIM:To assess and teach cultural competency skills at the fellowship training level through the use of objective structured clinical examinations(OSCEs).METHODS:We revised four scenarios to infuse a specific focus on cross-cultural care,and to render them appropriate for gastroenterology fellows.Three are discussed here:(1)Poor Health Literacy;(2)Disclosing/Apologizing for a Complication to a Patient Who Mistrusts the Healthcare System;and(3)Breaking Bad News to a Fatalistic Patient.A fourth case emphasizing shared decision-making will be described elsewhere.Four stations were completed by fellows and observed live by four faculty members,and the fellows’performance was assessed.RESULTS:Eleven fellows from four programs participated in the four OSCE.In the"Poor Health Literacy"case,18%(2/11)of participants recognized that the standardized patient(SP)had below-basic health literacy.None successfully evaluated the SP’s reading skills in a culturally-sensitive manner.In"Disclosing/Apologizing for a Complication",4/11(36%)personally apologized for the complication.1/11 recognized the SP’s mistrust of the medical system.With"Breaking Bad News",27%(3/11)explored the patient’s values to identify her fatalistic beliefs.CONCLUSION:OSCEs can be used to assess deficiencies in culturally-competent care at the fellowship level.OSCEs also afford fellowships the opportunity to inform future training curricula.     

Development and implementation of an objective structured clinical examination to provide formative feedback on communication and interpersonal skills in geriatric training

Teaching and assessment of communication and interpersonal skills, one of the American Council for Graduate Medical Education-designated core competencies, is an important but difficult task in the training of physicians. Assessment of trainees offers an opportunity to provide explicit feedback on their skills and encourages learning. This article describes a pilot study in which clinician-educators affiliated with the geriatrics training programs at Beth Israel Deaconess Medical Center and Boston University Medical Center designed and piloted a novel Objective Structured Clinical Examination (OSCE) to assess the communication and interpersonal skills of medical, dental, and geriatric psychiatry fellows. The OSCE consisted of three stations where geriatricians and standardized patients evaluated candidates using specifically designed checklists and an abbreviated version of the Master Interview Rating Scale. Communication skills were assessed through performance of specific "real life" clinical tasks, such as obtaining a medical history, explaining a diagnosis and prognosis, giving therapeutic instructions, and counseling. Interpersonal skills were assessed through the effect of the communication between doctor and standardized patient on fostering trust, relieving anxiety, and establishing a therapeutic relationship. This pilot study demonstrated that the OSCE format of assessment provides a valid means of evaluating the communication and interpersonal skills of interdisciplinary geriatric trainees and provides a valuable forum for formative assessment and feedback. Given that geriatricians and non geriatricians involved in elder care both need communication and interpersonal skills, this novel OSCE can be used for assessment of these skills in trainees in diverse healthcare subspecialties.     

Entrustment and Mapping of Observable Practice Activities for Resident Assessment

Entrustable Professional Activities (EPAs) and the Next Accreditation System reporting milestones reduce general competencies into smaller evaluable parts. However, some EPAs and reporting milestones may be too broad to use as direct assessment tools. We describe our internal medicine residency curriculum and assessment system, which uses entrustment and mapping of observable practice activities (OPAs) for resident assessment. We created discrete OPAs for each resident rotation and learning experience. In combination, these serve as curricular foundation and tools for assessment. OPA performance is measured via a 5-point entrustment scale, and mapped to milestones and EPAs. Entrustment ratings of OPAs provide an opportunity for immediate structured feedback of specific clinical skills, and mapping OPAs to milestones and EPAs can be used for longitudinal assessment, promotion decisions, and reporting. Direct assessment and demonstration of progressive entrustment of trainee skill over time are important goals for all training programs. Systems that use OPAs mapped to milestones and EPAs provide the opportunity for achieving both, but require validation.     

Teaching about substance abuse with objective structured clinical exams

BACKGROUND: Although residents commonly manage substance abuse disorders, optimal approaches to teaching these specialized interviewing and intervention skills are unknown. OBJECTIVE: We developed a Substance Abuse Objective Structured Clinical Exam (OSCE) to teach addiction medicine competencies using immediate feedback. In this study we evaluated OSCE performance, examined associations between performance and self-assessed interest and competence in substance abuse, and assessed learning during the OSCE. DESIGN: Five-station OSCE, including different substance abuse disorders and readiness to change stages, administered during postgraduate year-3 ambulatory rotations for 2 years. PARTICIPANTS: One hundred and thirty-one internal and family medicine residents. MEASUREMENTS: Faculty and standardized patients (SPs) assessed residents' general communication, assessment, management, and global skills using 4-point scales. Residents completed a pre-OSCE survey of experience, interest and competence in substance abuse, and a post-OSCE survey evaluating its educational value. Learning during the OSCE was also assessed by measuring performance improvement from the first to the final OSCE station. RESULTS: Residents performed better (P<.001) in general communication (mean+/-SD across stations=3.12+/-0.35) than assessment (2.65+/-0.32) or management (2.58+/-0.44), and overall ratings were lowest in the contemplative alcohol abuse station (2.50+/-0.83). Performance was not associated with residents' self-assessed interest or competence. Perceived educational value of the OSCE was high, and feedback improved subsequent performance. CONCLUSIONS: Although internal and family medicine residents require additional training in specialized substance abuse skills, immediate feedback provided during an OSCE helped teach needed skills for assessing and managing substance abuse disorders.     

The Impact of Health Care Reform on Gastroenterology Fellows: Are Training Programs Preparing Them for the Future?

Objective : Health care reform is dramatically changing the practice and delivery of medical care. The goal of this investigation was to examine gastroenterology trainees' outlook on the impact of health care reform on training programs. Methods : A 24-question survey was mailed in February 1996 to 780 GI fellows obtained from the comprehensive American College of Gastroenterology (ACG) database. Results : A total of 362 fellows responded (46%): 85% were male, 57% Caucasian, 75% married, and 86% were university-based. Ninety-six percent of fellows believed that health care reform is adversely affecting the quality of health care and 94.1% felt that it was adversely affecting fellowship training. Eighty-eight percent expressed concern over the impact of health care reform on practice opportunities. Only 9% of fellows reported that their training program had established a specific educational program addressing health care reform. where 83% of fellows felt that their program should do so. Conclusion : Gastroenterology fellows are concerned about the impact of health care reform on the quality of care and the quality of their fellowship training. Trainees believe that programs are not providing sufficient education to help them respond to the changes in health care.     

Corrélation entre les notes obtenues aux ECOS et aux épreuves de connaissances et analyse des facteurs associés à une meilleure réussite aux ECOS chez les étudiants de DFASM1 et 2 au CHU de Dijon

RationaleObjective structured clinical examinations (OSCEs) were introduced to evaluate students not only on their knowledge, but also on their clinical skills and attitudes. The objectives were to study the correlation between OSCE scores and scores obtained to traditional knowledge examinations and to analyse factors associated with better OSCE performance in DFASM1 and 2 students at Dijon university hospital.MethodsThis was a prospective observational study conducted among all fourth and fifth year medical students in Dijon. The scores on the OSCE elective tests (2022) and the average score on the knowledge tests (2021–2022) were collected and their correlation measured. A questionnaire asked students about their demographic characteristics, their investment in formative and practicum OSCEs, their level of empathy (Jefferson questionnaire) and their personality traits (NEO-Pi-R).ResultsOf 549 students, 513 completed all tests. Scores on OSCE and faculty knowledge tests were correlated (r = 0.39, P < 0.001). Of these, 111 (20%) students responded to the questionnaire, and 97 were analized. We did not observe any significant difference between students who performed better on OSCEs than on knowledge tests and those who did not, regarding their age, their investment in formative tests, their personality traits or their level of empathy.ConclusionOur results underline the need to optimize the evaluation of empathy and clinical skills in OSCE tests, using new tools, in order to better discriminate between students on these skills.     

Canadian pediatric gastroenterology workforce: current status, concerns and future projections.

BACKGROUND: There is concern that the Canadian pediatric gastroenterology workforce is inadequate to meet health care demands of the pediatric population. The Canadian Association of Gastroenterology Pediatric Committee performed a survey to determine characteristics and future plans of the Canadian pediatric gastroenterology workforce and trainees. METHODS: Estimates of total and pediatric populations were obtained from the 2001 Census of Population, Statistics Canada (with estimates to July 1, 2005). Data on Canadian pediatric gastroenterologists, including clinical full-time equivalents, sex, work interests, opinions on workforce adequacy, retirement plans, fellowship training programs and future employment plans of fellows, were gathered through e-mail surveys and telephone correspondence in 2005 and 2006. RESULTS: Canada had an estimated population of 32,270,507 in 2005 (6,967,853 people aged zero to 17 years). The pediatric gastroenterology workforce was estimated at 9.2 specialists per million children. Women accounted for 50% of the workforce. Physician to pediatric population ratios varied, with Alberta demonstrating the highest and Saskatchewan the lowest ratios (1:69,404 versus 1:240,950, respectively). Between 1998 and 2005, Canadian pediatric gastroenterology fellowship programs trained 65 fellows (65% international trainees). Twenty-two fellows (34%) entered the Canadian workforce. CONCLUSIONS: The survey highlights the variable and overall low numbers of pediatric gastroenterologists across Canada, an increasingly female workforce, a greater percentage of part-time physicians and a small cohort of Canadian trainees. In conjunction with high projected retirement rates, greater demands on the workforce and desires to partake in nonclinical activities, there is concern for an increasing shortage of pediatric gastroenterologists in Canada in future years.     

Implementation of an OSCE at Kaohsiung Medical University

The Objective Structured Clinical Examination (OSCE), a tool to objectively and fairly assess medical students' clinical competences, has become widely used in medical education worldwide. However, most medical schools in Taiwan have just begun to adopt this assessment method. In 2003, Kaohsiung Medical University (KMU) established the first standardized patient (SP) program in Taiwan and applied SPs with an OSCE. This study reports the process of the implementation of an OSCE at KMU, which includes collecting information, visiting leading clinical skills centers, consulting medical educators from other countries, holding international conferences, establishing an OSCE committee, writing cases, training SPs, administrating the OSCE, and receiving feedback from medical students. Most students were satisfied with the assessment and appreciated the learning experience. Based on the experience in 2003, the OSCE committee decided to incorporate the OSCE into the medical curriculum as a measure to assess medical students' clinical competences. In addition to assessing medical students' clinical competence, the OSCE can also be applied to other professional health education, such as dentistry, nursing, and pharmacy. We are currently sharing our experience with other colleges at KMU.     

Evaluation of patient partners in the teaching of the musculoskeletal examination

OBJECTIVE: To evaluate student preferences and examination outcomes of 2 different methods of teaching musculoskeletal (MSK) medicine examination techniques. METHODS: Year 2 students in a 4 year graduate medical school were randomized to 3 teaching groups: students in Group 1 were taught by rheumatology fellows, Group 2 by patient partners, while group 3 were randomly allocated to either patient partner (3A) or rheumatology trainee (3B) teaching. All students were debriefed at the end of each teaching block of 4 weeks for feedback on their teaching experience using a standardized questionnaire. In addition, at the end of the academic year, all students sat an objective structured clinical examination (OSCE) in clinical skills that contained a rheumatology station. The effect of method of teaching on students' performance in the rheumatology station was analyzed. RESULTS: Eighty medical students participated in the study. Overall, there was no difference in student ratings of either mode of teaching, although the students reported that patient partner teaching gave more opportunity to practice MSK examination skills and also provided greater feedback to the student. Students reported a preference for rheumatology trainee teaching because they believed the teaching would be more relevant to the content of the examination. There was no statistically significant difference in the performance of the students in the OSCE rheumatology station in regard to the mode of teaching they had received prior to the examination. CONCLUSION: Patient partner teaching is as effective a method of teaching clinical skills in MSK medicine as a traditional resident based form of teaching, with student benefits from patient feedback and greater "hands-on" opportunities. The assessment process should incorporate patient partners to assess the unique aspects of patient educator based teaching of MSK examination techniques.     

The gastroenterology fellowship Match: how it failed and why it could succeed once again

The market for gastroenterology (GI) fellows adopted a centralized Match in 1986, and abandoned it in the late 1990s. We discuss why the Match initially was adopted, how and why it broke down, what differences this has made in the market for fellows, and what would be needed to restart the Match successfully. We assess the effects of the Match by comparing the GI fellows market now with when the Match was operating, and with the fellowship markets for internal medicine subspecialties that continue to use a Match. The breakdown of a well-functioning Match is rare, but may be caused by unusual shifts in market conditions, such as those experienced by gastroenterology in the late 1990s. The problems the gastroenterology Match originally was designed to solve re-emerged with the demise of the Match. The market has become more local and less national, than when there was a Match in place, and program recruitment of fellows occurs earlier and is more dispersed in time than internal medicine subspecialties that continue to use a Match. There is no evidence that the demise of the Match has had any effect on wages. The evidence strongly suggests that the Match could be reintroduced successfully, which would increase the mobility of potential GI fellows, allow potential fellows to compete for the widest range of programs, and allow programs to compete for the widest range of fellows.     

Training gastroenterology fellows to perform gastric polypectomy using a novel ex vivo model

AIM:To evaluate the effect of hands-on training of gastroenterology fellows in gastric polypectomy using an ex vivo simulator.METHODS:Eight gastroenterology fellows at Mackay Memorial Hospital,Taipei were evaluated in gastricpolypectomy techniques using a pig stomach with artificial polyps created by a rubber band ligation device.The performance of four second year(year-2)fellows who had undergone one year of clinical training was compared with that of four f irst year(year-1)fellows both before and after a...     

Gastroenterology training and career choices: a prospective longitudinal study of the impact of gender and of managed care

OBJECTIVE: We aimed to determine if gender differences exist in the selection and training of female and male gastroenterology fellows. METHODS: One hundred seventy-six of 218 training program directors returned an 18-question survey about their programs, including leave policies, training, and prevalence of female faculty. Two cohorts of graduating trainees from 1993 and 1995 (N = 393) returned anonymous surveys regarding their training program experiences, demographics, and business training. RESULTS: Female gastroenterology trainees are more likely to choose programs according to parental leave policies (p < 0.05), female faculty (0.2990 correlation coefficient), and "family reasons" (p < 0.04) than the male trainees. Female trainees were more likely to remain childless (p < 0.001) or have fewer children at the end of training despite marital status not unlike their male colleagues. Female trainees altered their family planning because of training program restrictions (20% vs 7%, p < 0.001). They perceived gender discrimination (39%) and sexual harassment (19%) during gastroenterology training. Trainees of both sexes had mentorship during training (65% vs 71%, ns); female trainees were more likely to have an opposite sex mentor (71% vs 3.4%) despite an almost 50% prevalence of female full-time and clinical faculty. Female trainees were apt to be less trained in advanced endoscopy (p < 0.005). Trainees of both sexes were influenced by the changing health care environment in career choice (49% vs 42%, ns); neither gender felt adequately prepared for the business aspects of gastroenterology. CONCLUSION: Alterations in gastroenterology training are needed to attract qualified female applicants. New graduates of both sexes lack practice management education.     

Identification des facteurs associés à la réussite aux examens cliniques objectifs et structurés dans la faculté de médecine de Rouen

ContextObjective structured clinical examination (OSCE) became a national exam at the end of medical studies in France. The aim of this study was to identify the predictive factors for success at OSCEs.MethodsAurvey query after the OSCEs was completed by fifth-year medicine students at Rouen Uuniversity.. Data on continuous variables were compared using the Mann-Whitney test. Data on quantitative variables were compared using the Spearman's correlation.ResultsTwo hundred and thirty-nine students, i.e., 98.7 % of the students, responded to the query. The median (IQR 25–75) OSCE score was 13.6/20 (12.5–14.2). Students’ personal factors significantly associated with a higher OSCE performance were female sex (median score of 13.7 versus 13.4; P = 0.03) and good health during the clerkship (median score of 13.6 versus 12.6; P = 0.02). A higher OSCE performance was associated with an increased number (≥6)  of medicine clerkships  (median score of 13.8 versus 13.3; P = 0.02) and a decreased number (<3) of surgery clerkships (median score of 13.7 versus 12.9; P = 0.009). There was no correlation between the OSCE score and medical school performance (Spearman's correlation, r = 0.24).ConclusionHomogenization of student's clerkships, assistance to students with health problems seem to be teaching approaches to promote success at OSCEs.     

Survey of clinical nutrition practices of Canadian gastroenterologists.

OBJECTIVE: Nutrition education is a required part of gastrointestinal training programs. The involvement of gastroenterologists in clinical nutrition once their training has been completed is unknown. The aim of the present study was to determine the practice pattern of gastroenterologists in clinical nutrition and their perceived adequacy of nutrition training during their gastroenterology (GI) fellowship. METHODS: The Canadian Association of Gastroenterology mailed a survey to all of its 463 Canadian clinician members and 88 trainee members. Components of the survey included knowledge of nutritional assessment and total parenteral nutrition, involvement in a nutrition support service, physician involvement in nutritional assessment and nutrition support teams, obesity management, insertion of gastrostomy (G) tubes and management of tube-related complications, and adequacy of training in clinical nutrition. RESULTS: Sixty per cent (n=279) of the Canadian Association of Gastroenterology clinicians and 38% (n=33) of the fellows responded. Of the clinicians, 80% were practicing adult gastroenterologists with the following demographics: those practicing full time in academic centres (42%), community practice (45%), completed training in the last 10 years (32%) and those that completed training in the United States (14%). Although only 6% had a primary focus of nutrition in their GI practices, 65% were involved in nutrition support (including total parenteral nutrition), 74% placed G tubes and 68% managed at least one of the major complications of G tube insertion. Respondents felt a gastroenterologist should be the physician's consultant on nutrition support services (89%). Areas of potential inadequate training included nutritional assessment, indications for nutrition support, management of obesity and management of G tube-related complications. The majority of clinicians (67%) and trainees (73%) felt that nutrition training in their GI fellowship was underemphasized. CONCLUSIONS: The majority of Canadian gastroenterologists are involved in nutrition support. However, this survey demonstrated that nutritional training is underemphasized in most training programs. It is important for GI fellowship programs to develop standardized nutrition training that prepares trainees for their practice.     

Training and certifying gastroenterologists as physician nutrition specialists

Because nutrition is an integral aspect of the science and practice of gastroenterology, all gastroenterology fellows should receive training in core aspects of nutrition (level 1 training). Some gastroenterologists also wish to train more extensively in nutrition (level 2) and become physician nutrition specialists. The Intersociety Professional Nutrition Education Consortium, composed of representatives from eight national societies with significant nutrition interests, including the American Gastroenterological Association, and three credentialing bodies, has developed a paradigm and training requirements for physician-nutrition specialists that recognizes their varied backgrounds and areas of interest. Opportunities exist for gastroenterology fellows to obtain physician nutrition specialist training within their gastroenterology fellowships and to be eligible to take the Certification Examination for Physician Nutrition Specialists offered by the new American Board of Physician Nutrition Specialists.* This article reviews the development of consensus on subspecialty training for physicians in nutrition; it also encourages directors of gastroenterology fellowships to develop training opportunities and gastroenterology fellows to consider identifying nutrition as an area of emphasis for their careers.     

Training in gastrointestinal motility

Gastrointestinal (GI) motility and functional GI disorders are common reasons for patients to see gastroenterologists. Knowledge of the evaluation and treatment of these disorders is important to appropriately care for these patients in clinical practice. Training in GI motility is important to GI fellows and their subsequent role as gastroenterologists. The aim of this paper is to discuss the importance of GI motility disorders for trainees in gastroenterology, provide some suggestions for training activities for GI fellows in GI motility, and discuss ways to address the unmet clinical need for caring for patients with GI motility disorders that gastroenterologists routinely see in their clinical practice.     

Fellows' perspective of HPB training programs in North America: results of a survey

Background

Sixteen hepatopancreatobiliary fellowship programs in North America are accredited by the Fellowship Council. This study aims to assess fellows' perceptions of their training program.

Implementing the objective structured clinical examination in a geriatrics fellowship program-a 3-year experience

The Objective Structured Clinical Examination (OSCE) appears to be an effective alternative for assessing not only medical knowledge, but also clinical skills, including effective communication and physical examination skills. The purpose of the current study was to implement an OSCE model in a geriatrics fellowship program and to compare the instrument with traditional essay examination. Seventy first- and second-year geriatric fellows were initially submitted to a traditional essay examination and scored from 0 to 10 by a faculty member. The same fellows subsequently underwent an OSCE with eight 10-minute stations covering a wide range of essential aspects of geriatric knowledge. Each OSCE station had an examiner responsible for its evaluation according to a predefined checklist. Checklist items were classified for analysis purposes as clinical knowledge items (CKI) and communication skills items (CSI); fellow responses were scored from 0 to 10.Although essay examinations took from 30 to 45 minutes to complete, 180-200 minutes were required to evaluate fellows using the proposed OSCE method. Fellows scored an average of 6.2 ± 1.2 on the traditional essay examination and 6.6 ± 1.0 on the OSCE (P < .001). Subanalyses of OSCE scores indicated that average performance on CKI was lower than the average on CSI (6.4 ± 1.1 vs. 8.4 ± 1.1; P < .001). Fellow performance on the essay examination was similar to their performance on CKI (P = .13). Second-year fellows performed better than first-year fellows on the essay examination (P < .001) and CKI (P = .05), but not on CSI (P = .25).The OSCE was successfully implemented as an educational strategy during a geriatrics fellowship program. Combining different testing modalities may provide the best assessment of competence for various domains of knowledge, skills, and behavior.     

National Study of Internal Medicine Manpower: XVI. Subspecialty fellowship programs, 1988 update

Much of the debate about medical manpower during the 1980s has focused on the growing number of medical subspecialists. We examined the number of subspecialty fellows since 1976, paying particular attention to data collected in the 1987-1988 academic year. The number of fellows in subspecialty training at a given time has increased by 27% since 1976; however, much of this increase is due to the increased length of the training programs. The number of first-year fellows has increased only 7% since 1976. Growth in the number of fellowships has varied by subspecialty. The number of fellowships in geriatrics, critical care, and general internal medicine has increased dramatically. Additionally, the traditional subspecialties-cardiology, pulmonary disease, gastroenterology, infectious diseases, rheumatology, and allergy-immunology-have all grown to some extent. Program directors in all subspecialties anticipate continued growth in the coming years.