Reimagining Undergraduate Medical Education in a Post-COVID-19 Landscape

Online education due to the COVID-19 pandemic caused many medical schools to increasingly employ asynchronous and virtual learning that favored student independence and flexibility. At the same time, the COVID-19 pandemic highlighted existing shortcomings of the healthcare field in providing for marginalized and underserved communities. This perspective piece details the authors’ opinions as medical students and medical educators on how to leverage the aspects of pandemic medical education to train physicians who can better address these needs.KEY WORDS: undergraduate medical education, social determinants of health, virtual learning

“American medical education needed a revolution,” writes Professor Jon M. Barry in The Great Influenza: The Story of the Deadliest Pandemic in History¹. He described a different era of medical education, a time in the late 1800s when medical students graduated without having ever touched a patient. The revolution began at Johns Hopkins Hospital with William Osler’s teaching hospital model for postgraduate training, a model that spread across the nation and has formed the foundation for modern medical education². A few decades later, the Flexner Report commissioned by the American Medical Association codified recommendations for standardized curriculum based on Osler’s program at Hopkins, giving rise to the biomedical model of medical education^{3, 4}. In the same decade, the 1918 influenza pandemic, one of the deadliest pandemics in the history of humankind, infected approximately one-third of the world’s population, causing an estimated 50 million deaths⁵. Clearly, as Barry describes, it was a time of great crisis, ripe for great change.The Flexner Report and 1918 pandemic thus led to many medical schools adopting the biomedical model and overhauling their curricula. Since then, shortcomings of the Flexner Report, such as limiting the opportunities of Black physicians and excluding social determinants of health from the medical model^{4, 6}, have been acknowledged and medical education has increasingly prioritized diversity and inclusion and public health education to better serve the diverse health needs of society^7–9. The biopsychosocial model of medicine has largely supplanted the biomedical model^{7, 8}, and many medical schools have modified their biomedical curricula to incorporate systems-based learning and social determinants of health.Yet healthcare is far from perfect today, with issues of cost, access, and systemic inequality still plaguing patients. As medical students and medical educators, we strive for a medical education that will better prepare the next generation of physicians to address these failures of the profession. We also have experienced how the current COVID-19 pandemic, similar to the 1918 influenza pandemic, has caused great crises in healthcare and changes in medical education^10–12. As vaccines have made a post-COVID era more tangible, we believe the medical field is once again ripe for revolution. In this perspective piece, we detail how we can leverage the current flux in medical education, capitalizing on asynchronous and virtual learning with a focus on social determinants and disparities, to better train physicians who will be prepared to serve the public health in a post-COVID era.     

The Internal Medicine Subinternship—Now More Important than Ever: A Joint CDIM-APDIM Position Paper

For decades, the internal medicine (IM) subinternship has served as a critical interface between undergraduate and graduate medical education. As such, the vast majority of U.S. medical schools offer this rotation to help students prepare for post-graduate training. Historically an experiential rotation, a formal curriculum with specific learning objectives was eventually developed for this course in 2002. Since then, graduate medical education (GME) has changed significantly with the regulation of duty hours, adoption of competency-based education, and development of training milestones and entrustable professional activities. In response to these and many other changes to residency training and medical practice, in 2010, the Association of Program Directors in Internal Medicine (APDIM) surveyed its members—with input from the Clerkship Directors in Internal Medicine (CDIM) Subinternship Task Force—to determine which core skills program directors expected from new medical school graduates. The results of that survey helped to inform a joint CDIM-APDIM committee’s decision to re-evaluate the goals of the IM subinternship in an effort to enhance the transition from medical school to residency. This joint committee defined the minimum expectations of what constitutes an IM subinternship rotation, proposed recommended skills for IM subinterns, and discussed challenges and future directions for this crucial course.The internal medicine (IM) subinternship is a longstanding pillar in undergraduate medical education (UME) that arose out of necessity in response to intern shortages during World War II, rather than a perceived educational need. This rotation for senior medical students to serve as acting interns was a logical extension of the “progressive graded responsibility” concept already in place for residency programs, and became widely adopted after the war.¹ Since then, medical specialization evolved and changed residency education, which in turn gave rise to subinternships in other specialties.^2,3 Although the IM subinternship has remained an integral component of medical education and is offered at most medical schools, it has largely been an experiential rotation without clearly defined curricular goals.² In 1992, Federman was the first to specifically address the IM subinternship’s role in the continuum of IM education.⁴ Subsequently, Fagan and colleagues outlined more specific recommendations regarding the IM subinternship structure and experience.³In 2002, the Clerkship Directors in Internal Medicine (CDIM) Subinternship Task Force published its core curriculum for the IM subinternship.^5–7 This curriculum’s specific objectives were based upon a needs assessment from IM residency program directors, subinternship directors, and interns.⁵ Since that publication, graduate medical education (GME) and medical practice have changed significantly with the Accreditation Council for Graduate Medical Education (ACGME) regulations on duty hours and supervision; development of competency-based education, training, and evaluation; increased emphasis on transitions of care, patient safety, and quality improvement; and the widespread adoption of electronic health records (EHR). These changes have impacted clinical teaching and learning at the UME level. Duty-hour regulations have resulted in faculty and residents perceiving less time to teach students, reduced continuity of patient care, and decreased volume and variety of patient exposures for students.^8–13 Billing and medico-legal concerns have resulted in many institutions prohibiting students from using EHRs.¹⁴     

The Value of Narrative Medical Writing in Internal Medicine Residency

Narrative medical writing can be utilized to help increase the value and patient-centeredness of health care. By supporting initiatives in areas such as population health management, quality improvement and health disparities, it provides benefits that are particularly relevant to physicians focused on health care improvement, reform and redesign. Graduate medical education (GME) represents a key time and opportunity for internists to learn and practice this form of writing. However, due to a number of local and systems factors, many have limited opportunities to engage in narrative medical writing compared to other non-clinical activities. By capitalizing on the momentum created by recent GME reform, several strategies can be utilized to overcome these barriers and establish narrative medical writing as a viable professional and communication skill.KEY WORDS: communication skills, health communication, medical education-graduateMedical writing is a broad term defined as the discipline of writing scientific documents for a range of regulatory, academic and commercial purposes.¹ While some forms are irrelevant to clinicians, a value-driven approach to narrative medical writing—which uses reflection and critical thinking to educate and inform others about important issues in medicine through stories—can enable physicians’ efforts to improve individual and societal health.Narrative medical writing supports physicians’ roles as clinicians and patient advocates. By encouraging doctors to examine their relationships with patients, peers and our society at large, narrative writing allows them to practice with greater empathy and perspective.² It is also an effective and accessible form of peer-to-peer and peer-to-public medical writing, which are important for improving key health outcomes, including patient satisfaction and health behaviors.³To achieve these benefits, physicians should gain proficiency in these forms of writing early in their careers. Medical school educators have recognized the social and educational advantages of narrative writing, using it to elucidate the effectiveness of medical education⁴ and issues around bioethics⁵ and professionalism.⁶ Writing is also a key medium for self-reflection, which can improve communication skills among learners as part of a comprehensive educational approach.⁷While certain forms of writing (e.g., research writing) command a strong presence in graduate medical education (GME), there are few organized efforts to encourage narrative medical writing in residency training. This is problematic not only because communication skills must be learned and practiced repeatedly,³ but because narrative writing also has the potential to enhance a number of professional interests, and residency is a critical period for learners to solidify those passions and attendant skill sets.We believe that if emphasized in GME, narratives can both improve professional development (e.g., greater reflection, stronger communication skills) and enhance a number of ongoing health care efforts. As a part of the recent GME reform, the Clinical Learning Environment Review (CLER) Program represents a unique opportunity to integrate narrative medical writing into internal medicine residency training. Created by the Accreditation Council for Graduate Medical Education, this program provides assistance in determining institutional attributes that optimize clinical learning environments.⁸     

What Educators Can Learn from the Biopsychosocial-Spiritual Model of Patient Care: Time for Holistic Medical Education

Medical students and residents experience burnout at a high rate and encounter threats to their well-being throughout training. It may be helpful to consider a holistic model of education to create educational environments in which trainees flourish. As clinician educators, the biopsychosocial-spiritual model of patient care has helped shape the way we care for patients. Using the biopsychosocial-spiritual model of patient care as a framework, we examine the ways in which clinician educators can support the physical, psychological, social, and spiritual needs of their trainees. The current state of trainee well-being in each of these areas is reviewed. We discuss potential interventions and opportunities for further research to help clinician educators develop a contextualized, holistic approach to the formation of their trainees.KEY WORDS: well-being, biopsychosocial, burnout, medical education, residency, holistic

The epidemic of burnout and depression among medical students, trainees, and attendings has long been known.^1,2 Burnout is associated with a decline in professionalism and altruism, increased medical errors, and worse patient outcomes.^3,4 The COVID-19 pandemic and the burden it has placed on trainees have importantly revitalized the conversation on improving trainee well-being.⁵ Much of the discourse on trainee well-being, however, has centered on unidimensional aspects of well-being, such as life satisfaction, burnout, or work-life balance.⁶ To equate well-being with unidimensional measures misses critical components of our experience as human beings. As educators, it may be useful to instead view the well-being of our trainees through the lens of “human flourishing.” Human flourishing brings into view not only happiness and life satisfaction, but also physical health, mental health, meaning, purpose, virtue, and fulfilling relationships.^7,8 In order to create educational environments in which our trainees flourish as both physicians and human beings, we must take a page from our own playbook as clinicians. Just as we believe it is critical for a physician to understand the patient’s values, beliefs, social-connectedness, and life experience, so too ought we as educators strive to understand those same qualities in our trainees.For over forty years, the biopsychosocial model of patient care has helped shape the way we care for patients.^9,10 First introduced by Engel,⁹ biopsychosocially oriented clinical practice calls us to consider the experience of the human being in front of us rather than the patient to be diagnosed. Much has been written regarding strategies for providing care for the “whole person,” recognizing that a patient is not simply a patient or diagnosis, but rather a human being with ambitions, family, relationships, and culture.^11–13 The biopsychosocial model of patient care has been further expanded to incorporate spirituality, termed the biopsychosocial-spiritual model.^14,15 Spirituality has been defined as an individual’s “relationship with the transcendent,”¹⁵ which can take many forms, including but not limited to organized religion. In clinical practice, spiritual well-being has been associated with less depression¹⁶ and increased quality of life.¹⁷ As medical educators, there is a lesson here to be learned. We believe that it is time for holistic education for the trainee.Practically, how might a holistic model of medical education look? Using the biopsychosocial-spiritual model of patient care as a framework, we will examine the ways in which clinician educators can support the physical, psychological, social, and spiritual needs of their trainees (Table ​(Table11). Table 1.Suggested Strategies for a Biopsychosocial-Spiritual Model of Medical Education

The Adverse Effect of Weight Stigma on the Well-Being of Medical Students with Overweight or Obesity: Findings from a National Survey

BACKGROUND

The stigma of obesity is a common and overt social bias. Negative attitudes and derogatory humor about overweight/obese individuals are commonplace among health care providers and medical students. As such, medical school may be particularly threatening for students who are overweight or obese.

OBJECTIVE

The purpose of our study was to assess the frequency that obese/overweight students report being stigmatized, the degree to which stigma is internalized, and the impact of these factors on their well-being.

DESIGN

We performed cross-sectional analysis of data from the Medical Student Cognitive Habits and Growth Evaluation Study (CHANGES) survey.

PARTICIPANTS

A total of 4,687 first-year medical students (1,146 overweight/obese) from a stratified random sample of 49 medical schools participated in the study.

MAIN MEASURES

Implicit and explicit self-stigma were measured with the Implicit Association Test and Anti-Fat Attitudes Questionnaire. Overall health, anxiety, depression, fatigue, self-esteem, sense of mastery, social support, loneliness, and use of alcohol/drugs to cope with stress were measured using previously validated scales.

KEY RESULTS

Among obese and overweight students, perceived stigma was associated with each measured component of well-being, including anxiety (beta coefficient [b] = 0.18; standard error [SE] = 0.03; p < 0.001) and depression (b = 0.20; SE = 0.03; p < 0.001). Among the subscales of the explicit self-stigma measure, dislike of obese people was associated with several factors, including depression (b = 0.07; SE = 0.01; p < 0.001), a lower sense of mastery (b = −0.10; SE = 0.02; p < 0.001), and greater likelihood of using drugs or alcohol to cope with stress (b = 0.05; SE = 0.01; p < 0.001). Fear of becoming fat was associated with each measured component of well-being, including lower body esteem (b = −0.25; SE = 0.01; p < 0.001) and less social support (b = −0.06; SE = 0.01; p < 0.001). Implicit self-stigma was not consistently associated with well-being factors. Compared to normal-weight/underweight peers, overweight/obese medical students had worse overall health (b = −0.33; SE = 0.03; p < 0.001) and body esteem (b = −0.70; SE = 0.02; p < 0.001), and overweight/obese female students reported less social support (b = −0.12; SE = 0.03; p < 0.001) and more loneliness (b = 0.22; SE = 0.04; p < 0.001).

CONCLUSIONS

Perceived and internalized weight stigma may contribute to worse well-being among overweight/obese medical students.KEY WORDS: Medical students, Stigmatization, Psychological stress, Obesity, Body weightTo succeed academically and professionally, medical students must withstand the stress of medical school, including learning new and complex material, meeting faculty expectations, interacting with patients, making new friends and colleagues, and assimilating the culture of medicine.^1–3 Ability to cope with stress is important to health and professional development, as medical student stress is linked to burnout, substance use, mental health problems, suicidal thoughts, and poor academic performance.^1,4–6 Stress also disproportionately affects female medical students, who may then be more vulnerable to these outcomes.^5,7–9Self-esteem, physical and emotional health, fatigue, sense of mastery, and social support all affect vulnerability to stress.^10,11 Members of stigmatized groups, including overweight/obese individuals, may face additional stress.^12–17 Experiences of weight-related stigma can have negative effects on self-esteem, health, and well-being.^{12–14,17–23} Overweight/obese individuals may also be self-stigmatized, i.e., exhibit negative, self-deprecating attitudes about themselves, which may worsen their overall well-being.^24–26These additional stressors may challenge students’ ability to cope in the competitive medical school environment. Although little is known about the experience of these medical students, several studies have documented strong anti-fat attitudes among health care providers and trainees,^27–31 and suggest that overweight/obese individuals are a common target of derogatory humor among medical students.^32,33The present study aimed to assess whether stigma or self-stigma is associated with factors that affect vulnerability to stress among overweight and obese medical students. We hypothesized that 1) these medical students, and female students in particular, have worse self-reported outcomes than normal-weight/underweight medical students on factors affecting vulnerability to stress; and that 2) among overweight/obese students, experiencing more stigma/self-stigma is associated with worse outcomes.     

Past,present and future of respiratory research: A survey of Canadian health care professionals

BACKGROUND:

The Canadian Respiratory Health Professionals (CRHP) is the multidisciplinary health care professional group of the Canadian Lung Association. Although the CRHP has a growing number of highly qualified researchers, the landscape of their research in Canada has not been described.

OBJECTIVES:

To describe the level of respiratory research engagement; identify barriers and facilitators to research engagement; describe the experience and interest in developing research skills; and identify priority areas of future respiratory research among health care professionals.

METHODS:

An online survey of CRHP members was used to collect demographic information; barriers and facilitators to conducting research; future directions in respiratory research; and research funding and mentorship. Experience with and interest in ‘upskilling’ research skills were also evaluated.

RESULTS:

A total of 119 surveys were completed (22% response rate), of which 69 (58%) respondents were engaged in respiratory research. Reasons for not being involved in respiratory research were lack of mentorship, support and funding. The top research areas were chronic obstructive pulmonary disease (74%) and asthma (41%). The top facilitators for research engagement were amount of funding (29%) and mentorship (28%). Respondents in research positions rated their experience in research skills as high; those in nonresearch positions as low. However, both groups expressed interest in improving their research skills.

CONCLUSIONS:

Areas of development, such as research skills, greater funding opportunities and mentorship to increase the research capacity of health care professionals in respiratory health were identified. Health professional researchers have an important role in the national respiratory research strategy to increase interdisciplinary engagement and build collaborative teams.     

The Quality of Written Feedback by Attendings of Internal Medicine Residents

BACKGROUND

Attending evaluations are commonly used to evaluate residents.

OBJECTIVES

Evaluate the quality of written feedback of internal medicine residents.

DESIGN

Retrospective.

PARTICIPANTS

Internal medicine residents and faculty at the Medical College of Wisconsin from 2004 to 2012.

MAIN MEASURES

From monthly evaluations of residents by attendings, a randomly selected sample of 500 written comments by attendings were qualitatively coded and rated as high-, moderate-, or low-quality feedback by two independent coders with good inter-rater reliability (kappa: 0.94). Small group exercises with residents and attendings also coded the utterances as high, moderate, or low quality and developed criteria for this categorization. In-service examination scores were correlated with written feedback.

KEY RESULTS

There were 228 internal medicine residents who had 6,603 evaluations by 334 attendings. Among 500 randomly selected written comments, there were 2,056 unique utterances: 29 % were coded as nonspecific statements, 20 % were comments about resident personality, 16 % about patient care, 14 % interpersonal communication, 7 % medical knowledge, 6 % professionalism, and 4 % each on practice-based learning and systems-based practice. Based on criteria developed by group exercises, the majority of written comments were rated as moderate quality (65 %); 22 % were rated as high quality and 13 % as low quality. Attendings who provided high-quality feedback rated residents significantly lower in all six of the Accreditation Council for Graduate Medical Education (ACGME) competencies (p <0.0005 for all), and had a greater range of scores. Negative comments on medical knowledge were associated with lower in-service examination scores.

CONCLUSIONS

Most attending written evaluation was of moderate or low quality. Attendings who provided high-quality feedback appeared to be more discriminating, providing significantly lower ratings of residents in all six ACGME core competencies, and across a greater range. Attendings’ negative written comments on medical knowledge correlated with lower in-service training scores.KEY WORDS: medical education, feedback, evaluation, medical residencyAn important obligation of program directors and attendings in medical education programs is to provide feedback to their learners.^1–3 Feedback is “specific information about the comparison between a trainee’s observed performance and a standard, given with the intent to improve trainee’s performance,”⁴ and is an essential component for the growth of trainees.^2,5 Unfortunately, despite considerable information on the subject, the quality of oral and written feedback is often low.³ Previous studies have shown that feedback tends to be nonspecific, is not provided in a timely manner, and does not provide learners with sufficient information to improve their performance.^6–9 Residents and attendings frequently disagree on the quality and quantity of feedback provided,^10–15 with the result that feedback is commonly cited as needing improvement.^16,17Several studies have examined feedback. Frye and colleagues found that feedback varied widely in its organization, level of interaction, and depth.¹⁸ Kogan found that feedback was complex, that there was considerable variability in feedback techniques, and that many factors affected how staff felt about delivering feedback.¹⁹ Delva found that feedback was affected by four factors: learning culture, relationships, purpose of feedback, and emotional responses to feedback.²⁰ Ende found that feedback was often implicit and inferential rather than explicit, and consequently was frequently misunderstood by residents.²¹ Several papers have provided opinions on improving feedback quality.^2,4,11,22,23 For example, Skeff characterized high-quality feedback as specific, emphasizing behavior, frequent, selective, timely, balanced, tailored to the learning climate, interactive, labeled as feedback, and resulting in an action plan for improving performance.²⁴ However, few studies have directly observed and evaluated feedback quality; most rely on resident and attending surveys of their opinions about the quality of feedback delivered. No previous study has developed criteria for assessing written feedback quality. The objectives of our study were to 1) describe the characteristics of written feedback, 2) correlate written feedback with ratings of residents by their attendings and with scores on the in-service training examination, 3) develop criteria for assessing feedback quality, and 4) use that schema to rate the quality of written feedback.     

The Structural Analysis: Incorporating Structurally Competent Clinical Reasoning into Case-Based Presentations

Structural and social determinants of health account for the health disparities we see along social hierarchies, and their impact has been made more evident by the recent COVID-19 pandemic. There have been increasing calls to incorporate structural competency into medical education. The structural and social context, however, has yet to be fully integrated into everyday clinical practice and little has been published on how to concretely imbed structural competency into clinical reasoning. The authors provide a framework for structural analysis, which incorporates four key steps: (1) developing a prioritized clinical problem list, (2) identifying social and structural root causes for clinical problems, (3) constructing and documenting a prioritized structural problem list, and (4) brainstorming solutions to address structural barriers and social needs. They show how structural analysis can be used to operationalize structural reasoning into everyday inpatient and outpatient clinical assessments.KEY WORDS: social determinants of health, structural competency, medical education

The majority of health outcomes are the result of social determinants of health or the conditions in which people are born, grow, work, live, and age. These are influenced by the structural determinants of health, or the social, economic, and political mechanisms and policies that generate, configure, and maintain social hierarchies.¹ Structural and social determinants of health (SSDH) account for health disparities, and their impact has been made evident by the recent COVID-19 pandemic.²Undergraduate and graduate medical accreditation bodies have called for the inclusion of education on SSDH and health equity.^3,4 In 2014, Metzl and Hansen published a framework for imbedding SSDH into medical education. Known as structural competency, it calls for the reframing of behaviors and disease as downstream implications of upstream decisions about structures and social systems.⁵ While a number of undergraduate structural competency curricula have been published^6,7 and there are calls to embed structural competency into graduate education,^8–10 less has been published on how to operationalize structural competency into routine bedside clinical teaching.Recently, several hospital systems have recognized the importance of SSDH and begun universal screening for unmet patient-level social needs, for example, food insecurity, medication affordability, and transportation barriers.^11–14 These initiatives have facilitated explicit discussion of how social needs directly impact health. Still, gaps remain in how to train learners to incorporate SSDH within traditional clinical reasoning.^15,16 In the absence of an analytic framework, screening for social needs alone risks incomplete conceptualizations of the links between SSDH and health outcomes.¹⁷ In clinical practices that are not yet equipped to address SSDH, educational interventions can pave the way by arming learners with tools to change clinical practice. We provide an educational framework for integrating structural competency into clinical reasoning and assessment, known as structural analysis, that can be used in inpatient and outpatient clinical settings.     

Residents’ Perceptions of Faculty Behaviors and Resident Burnout: a Cross-Sectional Survey Study Across a Large Health Care Organization

BackgroundData suggests the learning environment factors influence resident well-being. The authors conducted an assessment of how residents’ perceptions of faculty-resident relationships, faculty professional behaviors, and afforded autonomy related to resident burnout.MethodsAll residents at one organization were surveyed in 2019 using two items from the Maslach Burnout Inventory and the faculty relationship subscale of the Johns Hopkins Learning Environment Scale (JHLES, range 6 to 30). Residents were also asked about faculty professional behaviors (range 0 to 30), and satisfaction with autonomy across various clinical settings.ResultsA total of 762/1146 (66.5%) residents responded to the survey. After adjusting for age, gender, postgraduate year, and specialty, lower (less favorable) JHLES-faculty relationship subscale score (parameter estimate, − 3.08, 95% CI − 3.75, − 2.41, p < 0.0001), fewer observed faculty professional behaviors (parameter estimate, − 3.34, 95% CI − 4.02, − 2.67, p < 0.0001), and lower odds of satisfaction with autonomy in the intensive care settings (OR 0.46, 95% CI 0.30, 0.70, p = 0.001), but not other care settings, were reported by residents with burnout in comparison to those without. Similar relationships were observed when emotional exhaustion and depersonalization were analyzed separately as continuous variables.ConclusionIn this cohort, resident perceptions of faculty relationships, faculty professional behaviors, and satisfaction with autonomy in the intensive care unit were associated with resident burnout. Additional longitudinal studies are needed to elucidate the direction of these relationships and determine if faculty development can reduce resident burnout.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06452-3.

There is a high prevalence of burnout among residents.^1–4 This is grounds for concern, as resident well-being impacts quality of patient care and residents’ competency, career satisfaction, specialty choice, and personal health.^1,2,4–8 A complex array of factors within the clinical learning environment influence resident well-being.^4,9,10 Conceptually, burnout results when job demands (e.g., excessive workload, administrative burdens, inadequate technology usability) exceed job resources (e.g., professional relationships, autonomy, meaning and purpose in work, professional development, organizational culture).¹¹ Specifically within the learning environment, high faculty demands, inadequate emotional support from faculty, stressful faculty relationships, hostile faculty behaviors, poor mentorship relationships, and insufficient autonomy are associated with higher risk of burnout among residents.^3,4,12,13 On the other hand, residents who report greater opportunities for learning, better teaching quality, and more frequent direct observation and feedback—all of which increase “job resources”—are less likely to have burnout.^1,13–15 Although previous studies are informative, most included small numbers of learners, involved one specialty, were conducted outside the USA, or did not control for potential confounders.The Accreditation Council for Graduate Medical Education (ACGME) common program requirements state that clinical settings where graduate medical education occurs must ensure learning environments promote resident well-being and that the health of learning environments must be monitored.¹⁶ Additionally, the ACGME common program requirements specify that faculty have a direct role in creating and sustaining an effective learning environment, and faculty development must occur to equip the faculty with the capacity to do so.¹⁶ To guide such efforts, we surveyed residents in all specialty training programs across a large health system to identify faculty behaviors associated with resident burnout. We hypothesized that poor faculty-resident relationships, suboptimal faculty professional behaviors, and dissatisfaction with autonomy would be associated with resident burnout.     

Mentorship in academic general internal medicine

BACKGROUND: Effective mentorship is crucial to career development. Strategies to improve the availability of mentors include mentoring multiple mentees at once, compensating mentors, comentoring, and long-distance mentoring. OBJECTIVE: To describe current trends in mentorship in general Internal Medicine (GIM). METHODS: We conducted a national cross-sectional web-based survey of GIM mentors, GIM fellowship directors, and GIM National Institutes of Health K24 grant awardees to capture their experiences with mentoring, including compensation for mentorship, multiple mentees, comentorship, and long-distance mentorship. We compared experiences by mentorship funding status, faculty type, academic rank, and sex. RESULTS: We collected data from 111 mentors (77% male, 54% full professors, and 68% clinician-investigators). Fifty-two (47%) received funding for mentorship. Mentors supervised a median (25th percentile, 75th percentile) of 5 (3, 8) mentees each, and would be willing to supervise a maximum of 6 (4, 10) mentees at once. Compared with mentors without funding, mentors with funding had more current mentees (mean of 8.3 vs 5.1, respectively; P<.001). Full professors had more current mentees than associate or assistant professors (8.0 vs 5.9 vs 2.4, respectively; P=.005). Ninety-four (85%) mentors had experience comentoring, and two-thirds of mentors had experience mentoring from a distance. Although most mentors found long-distance mentoring to be less demanding, most also said it is less effective for the mentee and is personally less fulfilling. CONCLUSIONS: Mentors in GIM appear to be close to their mentorship capacity, and the majority lack funding for mentorship. Comentoring and long-distance mentoring are common.     

Medical humanities education in China: an exploratory cross-sectional study

Background

Governmental policies in China have strengthened education in the medical humanities. Previous publications have highlighted the inadequacy of medical humanities education in China and have promoted their advancement and evaluation. Medical disputes and mistrust between doctors and patients in China have been ascribed to a paucity of proper medical humanities education at the medical student level. However, no studies to date have specifically examined the frequency, structure, and characteristics of the medical humanities curricula at all Chinese medical schools, making it difficult to draw a comprehensive understanding of its current state. We therefore aim to provide such an understanding of the current role of the medical humanities at Chinese medical schools.

Association Between Study Quality and Publication Rates of Medical Education Abstracts Presented at the Society of General Internal Medicine Annual Meeting

Background

Studies reveal that 44.5 % of abstracts presented at national meetings are subsequently published in indexed journals, with lower rates for abstracts of medical education scholarship.

Objective

We sought to determine whether the quality of medical education abstracts is associated with subsequent publication in indexed journals, and to compare the quality of medical education abstracts presented as scientific abstracts versus innovations in medical education (IME).

Design

Retrospective cohort study.

Participants

Medical education abstracts presented at the Society of General Internal Medicine (SGIM) 2009 annual meeting.

Main Measures

Publication rates were measured using database searches for full-text publications through December 2013. Quality was assessed using the validated Medical Education Research Study Quality Instrument (MERSQI).

Key Results

Overall, 64 (44 %) medical education abstracts presented at the 2009 SGIM annual meeting were subsequently published in indexed medical journals. The MERSQI demonstrated good inter-rater reliability (intraclass correlation range, 0.77–1.00) for grading the quality of medical education abstracts. MERSQI scores were higher for published versus unpublished abstracts (9.59 vs. 8.81, p = 0.03). Abstracts with a MERSQI score of 10 or greater were more likely to be published (OR 3.18, 95 % CI 1.47–6.89, p = 0.003). ). MERSQI scores were higher for scientific versus IME abstracts (9.88 vs. 8.31, p < 0.001). Publication rates were higher for scientific abstracts (42 [66 %] vs. 37 [46 %], p = 0.02) and oral presentations (15 [23 %] vs. 6 [8 %], p = 0.01).

Conclusions

The publication rate of medical education abstracts presented at the 2009 SGIM annual meeting was similar to reported publication rates for biomedical research abstracts, but higher than publication rates reported for medical education abstracts. MERSQI scores were associated with higher abstract publication rates, suggesting that attention to measures of quality—such as sampling, instrument validity, and data analysis—may improve the likelihood that medical education abstracts will be published.KEY WORDS: medical education, medical education research, quality, publication     

Teaching Telemedicine in the COVID-19 Era: a National Survey of Internal Medicine Clerkship Directors

BackgroundPrior to the COVID-19 pandemic, telemedicine (TM) experiences in undergraduate medical education were uncommon. When students’ clinical experiences were interrupted due to the pandemic, TM education provided opportunities for students to participate in clinical care while adhering to social distancing guidelines.ObjectiveTo assess the prevalence of TM experiences in the internal medicine (IM) core clerkship experience prior to the COVID-19 pandemic, during interruption in clinical clerkships, and following the return to in-person activities at US medical schools.DesignThe Clerkship Directors in Internal Medicine (CDIM) survey is a national, annually recurring thematic survey of IM core clerkship directors. The 2020 survey focused on effects of the COVID-19 pandemic, including a section about TM. The survey was fielded online from August through October 2020.ParticipantsA total of 137 core clinical medicine clerkship directors at Liaison Committee on Medical Education fully accredited US/US territory–based medical schools.Main MeasuresA 10-item thematic survey section assessing student participation in TM and assessment of TM-related competencies.Key ResultsThe response rate was 73.7% (101/137 medical schools). No respondents reported TM curricular experiences prior to the pandemic. During clinical interruption, 39.3% of respondents reported TM experiences in the IM clerkship, whereas 24.7% reported such experiences occurring at the time they completed the survey. A higher percentage of clerkships with an ambulatory component reported TM to be an important competency compared to those without an ambulatory component.ConclusionsThe extent to which TM was used in the IM clinical clerkship, and across clinical clerkships, increased substantially when medical students were removed from in-person clinical duties as a response to COVID-19. When students returned to in-person clinical duties, experiences in TM continued, suggesting the continued value of TM as part of the formal education of students during the medicine clerkship. Curricula and faculty development will be needed to support TM education.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07061-4.

The use of telemedicine (TM) grew substantially in response to the COVID-19 pandemic.^1,2 In March 2020 alone, the number of telehealth visits increased by 154% compared to the same period in 2019.³ That rise in TM coincided with a contraction of in-person experiences for medical students in the USA.⁴ When medical students throughout the country were removed from clinical rotations to reduce the spread of COVID-19, medical schools responded in a variety of ways, with some suspending clinical clerkships entirely while others developed alternative experiences.⁵ Some healthcare organizations incorporated trainees into TM-related patient outreach programs and other ways that students could contribute to patient care remotely.^6,7 Overall, the COVID-19 pandemic highlighted the need for medical trainees to become proficient in TM as part of holistic medical education.⁸Even prior to the pandemic, leading medical organizations called for medical students to gain experience in TM.⁹ In 2019, some US medical schools offered didactic learning experiences, exercises with standardized patients, and opportunities for telemedicine patient encounters, though these experiences varied based on location.¹⁰ Most formal TM training experiences described in the literature focus on students in clinical clerkships.^10–12 For example, Jonas et al. described a TM-focused curriculum embedded into clinical clerkships, including didactic content and interactive patient contact. Students reported improvement in TM-related competencies and 80% reported future plans to practice TM.¹³ Additionally, national organizations have made online modules available to medical trainees and clinicians on TM competencies.¹⁴ However, there is great variability in the prevalence of TM curricula and experiences, with several states in 2019 reporting that no medical schools offered formal TM training.¹⁰In response to COVID-19, many regulatory requirements governing the use of TM were relaxed, providing new opportunities for TM in medical education.¹⁵ Jumreornvong et al. proposed a framework for incorporating TM education into medical schools, highlighting the importance of formal training to provide future physicians with the competencies to implement safe, ethical, and legal TM practices.⁸ However, the number of medical students who received formal education or experiences in TM during the COVID-19 pandemic has not been quantified.This study is based on a nationally representative survey of internal medicine (IM) clerkship directors (CDs), conducted to understand the prevalence of TM education and clinical experiences for clinical clerkships in relation to the COVID-19 pandemic. We assessed what training was provided to students and how TM competencies are assessed, if at all; and described the challenges and best practices in TM education following the onset of the COVID-19 pandemic.     

Mentorship in the Context of Interdisciplinary Geriatric Research: Lessons Learned from the RAND/Hartford Program for Building Interdisciplinary Geriatric Research Centers

In light of the growing trend toward formalized research mentorship for effectively transmitting the values, standards, and practices of science from one generation of researchers to the next, this article provides the results of an exploratory study. It reports on research mentorship in the context of interdisciplinary geriatric research based on experiences with the RAND/Hartford Program for Building Interdisciplinary Geriatric Research Centers. At the end of the 2-year funding period, staff from the RAND Coordinating Center conducted 60- to 90-minute open-ended telephone interviews with the co-directors of the seven centers. Questions focused on interdisciplinary mentorship activities, barriers to implementing these activities, and strategies for overcoming them, as well as a self-assessment tool with regard to programs, policies, and structures across five domains, developed to encourage research mentorship. In addition, the mentees at the centers were surveyed to assess their experiences with interdisciplinary mentoring and the center. According to the interviewees, some barriers to successful interdisciplinary mentoring included the mentor's lack of time, structural support, and the lack of a clear definition of interdisciplinary research. Most centers had formal policies in place for mentor identification and limited policies on mentor incentives. Mentees uniformly reported their relationships with their mentors as positive. More than 50% of mentees reported having a primary mentor from within their discipline and had more contact with their primary mentor than their secondary mentors. Further research is needed to understand the complexity of institutional levers that emerging programs might employ to encourage and support research mentorship.     

A Randomized Controlled Effectiveness Trial for PSA Screening Decision Support Interventions in Two Primary Care Settings

BACKGROUND

Decision support interventions (DESIs) provide a mechanism to translate comparative effectiveness research results into clinical care so that patients are able to make informed decisions. Patient decision support interventions for prostate-specific antigen (PSA) have been shown to promote informed decision making and reduce PSA testing in efficacy trials, but their impact in real world settings is not clear.

OBJECTIVE

We performed an effectiveness trial of PSA decision support interventions in primary care.

DESIGN

A randomized controlled trial of three distribution strategies was compared to a control.

PARTICIPANTS

Participants included 2,550 men eligible for PSA testing (76.6 % of the eligible population) and 2001 survey respondents (60.1 % survey response rate).

INTERVENTIONS

The intervention groups were: 1) mailed the DESI in DVD format, 2) offered a shared medical appointment (SMA) to view the DESI with other men and discuss, and 3) both options.

MAIN MEASURES

We measured PSA testing identified via electronic medical record at 12 months and DESI use by self-report 4 months after the intervention mailing.

KEY RESULTS

We found no differences in PSA testing across the three distribution strategies over a year-long follow-up period: 21 %, 24 %, 22 % in the DESI, SMA, and combined group respectively, compared to 21 % in the control group (p = 0.51). Self-reported DESI use was low across all strategies at 4 months: 16 % in the mailed DESI group, 6 % in the SMA group, and 15 % in the combined group (p = < 0.0001).

CONCLUSIONS

Mailing PSA decision support interventions or inviting men to shared medical appointments unrelated to a primary care office visit do not appear to promote informed decision making, or change PSA testing behavior.KEY WORDS: cancer prevention, prostate cancer, medical decision making, prostate-specific antigen, early detection of cancerDecision support interventions (DESIs) provide a mechanism to translate comparative effectiveness research results into clinical care, so that patients are able to make informed decisions. In efficacy trials, DESIs have been shown to increase knowledge, activate patients to participate in shared decision making, resulting in decisions that are more informed and consistent with patient values.¹ These tools have been developed for many medical decisions; however, prostate cancer screening with prostate specific antigen (PSA) is a decision where informed decision making has been strongly endorsed.^2–5Patient DESIs for PSA screening have been shown to promote informed decision making and reduce prostate-specific antigen (PSA) screening in efficacy trials.^6,7 However, the evidence supporting the use of decision support comes primarily from randomized controlled trials performed in ideal conditions—ensuring exposure to the intervention—with select populations of research volunteers. Several well-conducted studies of these PSA-DESIs are available but have been limited, either because participation required active consent,⁸ limiting generalizability, or the studies were performed at single sites and not randomized.^9,10 Several other studies have explored using PSA DESIs in conjunction with counseling or shared medical appointments, but these have also been limited by select samples.^11,12 Therefore, little is known about the effectiveness of PSA-DESIs in an unselected population of men in “real world” primary care settings, despite recommendations that they be used to facilitate decisions about PSA screening.To address this gap, we conducted an effectiveness trial to determine the impact of several distribution methods in two primary care settings. We designed the trial to maximize reach and generalizability, to mimic conditions in primary care where distribution of PSA-DESIs has been recommended. Specifically, we conducted a randomized controlled trial comparing three distribution methods (mailing the DESI, offering a shared medical appointment for DESI viewing, or both options) to a control group. We hypothesized that providing men with access to PSA-DESIs would result in uptake of the DESIs by men in the intervention groups and a decrease in PSA screening, as has been found in some efficacy trials.^1,7 We also hypothesized that the use of DESIs would differ by distribution strategy; specifically, we hypothesized men offered both options would be more likely to use the DESIs.     

Funding of Graduate Medical Education in a Market-Based Healthcare System

The graduate medical education (GME) process in the United States is considered the most respected model for high-quality education of graduate physicians in the world. With substantial funding through government and private insurers and through structured educational accreditation standards, the American Board of Medical Specialists–certified physicians are recognized for their expertise in delivering high-quality medical care. However, under fiscal constraints and changing social expectations, questions are continually posed about the process of funding and whether the “physician outcomes” are sufficient to continue with the investment. This article reviews the history of postgraduate physician education, the multiple funding pathways, disruptions to a placid educational system and changing social expectations. The ultimate issues involve the core goals of GME and how much GME should shoulder responsibility for changing the healthcare system.     

Trauma of Hospitalization Is Common in Medical Inpatients But Is Not Associated with Post-Discharge Outcomes

BackgroundTrauma of hospitalization is characterized by patient-reported disturbances in sleep, mobility, nutrition, and/or mood and one study suggested it was associated with more 30-day readmissions.ObjectiveTo define the trauma of hospitalization in medical inpatients and determine whether higher rates of disturbance correlate with adverse post-discharge outcomes.DesignA prospective cohort study was conducted between June 2018 and August 2019 with patients reporting disturbances in sleep, mobility, nutrition, and/or mood. High trauma of hospitalization was defined as disturbance in 3 or 4 domains.ParticipantsGeneral medicine inpatients at an academic hospital in Edmonton, Canada.Main Measures7-day, 30-day, and 90-day rates of death, unplanned hospital readmission, or emergency department (ED) visit.Key ResultsOf 299 patients (mean age 65.9 years, 47.8% female, mean Charlson score 3.6, and mean length of stay 8.2 days), 260 (87.0%) reported disturbance in at least one domain (most commonly nutrition or mobility) during their hospitalization, 179 (59.9%) reported disturbances in multiple domains, and 87 (29.1%) met the criteria for high trauma of hospitalization. Patients who reported a high trauma of hospitalization did not differ from those reporting less hospitalization disturbances in terms of demographics, burden of comorbidities, or length of stay, but did report higher rates of pre-hospital disturbances in sleep (32.3% vs. 14.4%, p = 0.03), nutrition (77.4% vs. 54.4%, p = 0.02), and mood (41.9% vs. 13.3%, p = 0.0007). High trauma of hospitalization was not significantly associated with death, readmission, or ED visit at 7 days (12.6% vs. 11.3%, aOR 1.13 [95% CI 0.52–2.46]), 30 days (31.0% vs. 32.1%, aOR 1.03 [95% CI 0.59–1.79]), or 90 days (52.9% vs. 50.9%, aOR 1.16 [95% CI 0.69–1.94]) after discharge.ConclusionsIn-hospital disturbances in sleep, mobility, nutrition, and mood are common in medical inpatients but were not associated with post-discharge outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06427-4.KEY WORDS: hospitalization, patient experiences, post-discharge outcomes

While it has long been known that hospitalization exposes patients to risk of iatrogenic illnesses, nosocomial infections, and deconditioning, there is emerging evidence that patient subjective experiences during their hospitalization may also influence their post-discharge outcomes.^1–3 Detsky and Krumholz described the stressful and depersonalizing effects of the hospital environment as the “trauma of hospitalization” and hypothesized that the cumulative effect of hospital-related disturbances in sleep, mobility, nutrition, and mood (even when not recognized by their care team) may cause physiologic disruptions that worsen patient outcomes, potentially increasing their probability of unplanned readmissions or emergency department (ED) visits.^4–6A recently published prospective cohort study used a 10-item patient-reported “in-hospital disturbance survey” (see Box 1) to examine the trauma of hospitalization in medical inpatients and post-discharge outcomes.⁷ The survey evaluated the 4 domains of sleep, nutrition, mobility, and mood: the 29.5% of patients who reported disturbance in 3 or 4 domains in hospital were considered to have high trauma of hospitalization and they exhibited a substantial and statistically significant increase in risk of 30-day readmission or ED visit (37.7% vs. 21.9% in those patients who reported lower trauma of hospitalization, adjusted Odds Ratio 2.52, 95% CI 1.24 to 5.17).⁷ While this result highlighted a potentially important novel opportunity for future interventions to improve both patient experience and clinical outcomes, their findings must be validated in other settings. Thus, we designed this study to examine the trauma of hospitalization in medical inpatients and to explore whether high scores on the in-hospital disturbance survey are associated with higher rates of readmissions or repeat ED visits or death at 7 days (our primary outcome), 30 days, and 3 months in a different geographic setting.Box 1 Disturbance survey (adapted from Rawal et al.⁷)     

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.