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Objectives: This study used a qualitative research approach to grounded theory to identify factors that contributed to resident distress during 2021-2022 in multiple different specialties and at different postgraduate years of residency. By better understanding these contributors to distress, the aim was to inform the design of optimal interventions to reduce burnout and other emotional distress., Methods: The residents enrolled in this study completed a demographic survey and semistructured interview. Interviews were recorded and transcribed. Data analysis included developing codes inductively, grouping codes into categories, and describing themes. Recruitment continued until data analysis indicated theoretical saturation/sufficiency had been reached. A qualitative research approach to grounded theory was used to identify themes and relationships among themes to better understand how the sources of distress affected the trainees of various specialties and postgraduate levels of training., Results: Thirty-three participants (15 medical-based, 9 hospital-based, and 9 surgical-based residents) participated in interviews between 2021 and 2022. Seven themes described sources of distress and potential ameliorating factors: workload, support and community, culture, resident outlook, institutional resources, work-life balance, and coronavirus disease 2019. The grounded theory highlights that these factors can collectively influence work-life balance and distress., Conclusions: The findings of the grounded theory qualitative analysis were used to examine ways to better mitigate the sources of distress that the residents enrolled in this study described. As institutions strive to diminish distress among residents, they can consider opportunities to assess environmental factors and design targeted interventions for their institutions or programs.

Objective: To perform a qualitative content analysis of learning and assessment strategies that pediatric subinterns describe in Individualized Learning Plans (ILPs) and to explore barriers and facilitators to their learning., Methods: We analyzed ILPs from medical students enrolled in pediatric subinternships at 10 US medical schools that utilized a standardized curriculum and were recruited to reflect diversity in geographic location, funding, and enrollment. Students used an ILP to record 3 or more selected learning objectives, rationale for selection, and reflection on learning and assessment strategies. Investigators used the constant comparative method to perform a content analysis of the ILPs, grouping codes into themes, and verifying relationships between codes within themes., Results: Two hundred and four ILPs that included student reflections on 850 learning objectives were analyzed. Content was analyzed in 5 categories: rationale for selecting objectives, learning strategies, assessment strategies, challenges to learning, and facilitators of learning. Students showed strong commitment to individualized, self-directed learning, developed a wide range of creative learning strategies, and relied heavily on self-reflection to assess their progress. The learning environment both helped and hindered students' ability to make and assess progress on their selected learning objectives., Conclusions: Through ILP-guided reflection and a formal curriculum, students can choose well-justified learning objectives and demonstrate resourcefulness and independence in developing self-directed learning and assessment strategies. The strategies that students identified in this study provide a menu of learning and assessment options for subinterns. Identified challenges and facilitators of learning provide guidance for educators who seek to enhance the clinical learning environment., Competing Interests: Declaration of Competing Interest The authors have no potential conflicts of interest or corporate sponsors to disclose. We had no funding for this study., (Copyright © 2023. Published by Elsevier Inc.)

Objective: Virtual care (VC) is an accepted modality of care delivery, and shared decision-making (SDM) benefits patients with rheumatologic and chronic conditions (RCCs). Unfortunately, research suggests reduced quality of SDM during VC. This study explores the benefits and shortcomings of SDM regarding RCCs during VC with suggestions for optimally using VC during SDM., Methods: Following Stiggelbout's framework for SDM, we conducted focus groups of patients with RCCs and providers to understand their experiences with SDM during VC, probing for facilitating and challenging factors. We conducted content analysis of the transcripts, defining themes, and inductively reasoned to identify relationships among themes. We summarized the facilitators, barriers, and opportunities for improving SDM during VC that participants proposed., Results: Virtual SDM shares several similarities with in-person practice, as both draw upon trusting patient-provider relationships, following the same general steps, and relying on effective communication. VC presents solutions for known barriers to in-person SDM, expanding time for making decisions and access to care. Technology and virtual health systems introduce new barriers to SDM, and participants list opportunities for overcoming these concerns., Conclusion: VC is a tool that can enhance and even support superior SDM compared with in-person visits when implemented successfully, a condition requiring the development of nuanced skills to correctly identify when and how to best use VC for SDM as well as technology and health care structures that integrate SDM into VC. Therefore, patients, providers, insurance carriers, and policy makers all contribute to the success of SDM among RCCs during VC., (© 2023 The Authors. ACR Open Rheumatology published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

Purpose: The authors aimed to gain a better understanding of students' and teachers' perspectives about whether clinical clerkship feedback is provided equitably irrespective of a student's race/ethnicity., Method: A secondary analysis of existing interview data was conducted, focusing on racial/ethnic disparities in clinical grading. Data had been acquired from 29 students and 30 teachers at 3 U.S. medical schools. The authors performed secondary coding on all 59 transcripts, writing memos focused on statements related to aspects of feedback equity and developing a template for coding students' and teachers' observations and descriptions specific to clinical feedback. Using the template, memos were coded, and thematic categories emerged describing perspectives on clinical feedback., Results: Forty-eight (22 teachers and 26 students) participants' transcripts provided narratives about feedback. Both student and teacher narratives described how students who are racially/ethnically underrepresented in medicine may receive less helpful formative clinical feedback needed for professional development. Thematic analysis of narratives yielded 3 themes related to feedback inequities: 1) teachers' racial/ethnic biases influence the feedback they provide students, 2) teachers have limited skill sets to provide equitable feedback, and 3) racial/ethnic inequities in the clinical learning environment shape clinical and feedback experiences., Conclusions: Narratives indicated that both students and teachers perceived racial/ethnic inequities in clinical feedback. Teacher- and learning environment-related factors influenced these racial/ethnic inequities. These results can inform medical education's efforts to mitigate biases in the learning environment and provide equitable feedback to ensure every student has what they need to develop into the competent physician they aspire to be., (Copyright © 2023 by the Association of American Medical Colleges.)

PhenomenonMoral distress, which occurs when someone's moral integrity is seriously compromised because they feel unable to act in accordance with their core values and obligations, is an increasingly important concern for physicians. Due in part to limited understanding of the root causes of moral distress, little is known about which approaches are most beneficial for mitigating physicians' distress. Our objective was to describe system-level factors in United States (U.S.) healthcare that contribute to moral distress among pediatric hospitalist attendings and pediatric residents.ApproachIn this qualitative study, we conducted one-on-one semi-structured interviews with pediatric hospitalist attendings and pediatric residents from 4 university-affiliated, freestanding children's hospitals in the U.S. between August 2019 and February 2020. Data were coded with an iteratively developed codebook, categorized into themes, and then synthesized.FindingsWe interviewed 22 hospitalists and 18 residents. Participants described in detail how the culture of medicine created a context that cultivated moral distress. Norms of medical education and the practice of medicine created conflicts between residents' strong sense of professional responsibility to serve the best interests of their patients and the expectations of a hierarchical system of decision-making. The corporatization of the U.S. healthcare system created administrative and financial pressures that conflicted with the moral responsibility felt by both residents and hospitalists to provide the care that their patients and families needed.InsightsThese findings highlight the critical role of systemic sources of moral distress. These findings suggest that system-level interventions must supplement existing interventions that target individual health care providers. Preventing and managing moral distress will require a broad approach that addresses systemic drivers, such as the corporatization of medicine, which are entrenched in the culture of medicine.

Purpose: Racial/ethnic disparities exist in clinical clerkship grading, yet little is known about medical student and faculty perspectives on why these disparities occur. This study explored what happens during clerkships that might explain grading disparities., Method: Medical students and clerkship teachers at 3 U.S. medical schools completed a demographic survey and semistructured interview. The constant comparative method was used to analyze transcripts by inductively developing codes; grouping codes in categories; and refining codes, descriptions, and group assignments to identify themes. Interpretations of and relationships among themes were iteratively discussed to develop a grounded theory., Results: Fifty-nine participants (29 medical students, 30 teachers [28 clinical faculty, 2 residents]) were interviewed in 2020. The Social Milieu of Medical Education (relationships, fit, opportunities, and judgments in the clinical-learning setting) was the organizing theme, influenced by 5 additional themes: Societal Influence (experiences in society), Students' Characteristics and Background (personal characteristics and experiences outside medical school), Assessment Processes (collection of student performance data and how data inform grades), Learning Environment (resources available and messaging within the clinical setting), and Students' Interactions and Reactions (interactions with and reactions to peers and teachers). The grounded theory highlights complex, multilayered aspects of how the social milieu of medical education is shaped by and shapes students' experiences, relationships, and clerkship assessments and promotes clerkship-grading disparities., Conclusions: Mitigating clerkship-grading disparities will require intervening on interrelated, contextual factors to provide equitable opportunities for students from diverse backgrounds and with varying styles of engagement in clinical-learning settings, along with attending to modifying assessment processes., (Copyright © 2022 by the Association of American Medical Colleges.)

Assessing competence for teamwork is a challenging task. Neverthesless, health professions training programs are asked to assure collaborative competency in their learners. Interprofessional education (IPE) programs seek tools to assess team member effectiveness and demonstrate collaborative competency. The Comprehensive Assessment of Team Member Effectiveness (CATME), originally developed for use in engineering, has been applied in various learning settings, with limited use in IPE. This paper presents validity evidence in 4 domains (content, response processes, internal structure, and relations to other variables) for the use of the CATME in a classroom-based IPE course taught with Team-Based Learning.

Objective: To explore how pediatric hospitalist attendings can recognize, prevent, and mitigate moral distress among pediatric residents., Methods: We conducted a qualitative study, utilizing a deductive approach, from August 2019 to February 2020 at 4 university-affiliated, freestanding children's hospitals in the United States using semistructured, one-on-one interviews with pediatric residents and pediatric hospitalist attendings. All transcripts were coded by pairs of research team members. Using constant comparative analysis, codes were categorized into themes and subsequently grouped into domains. We then conceptualized the relationships between the domains., Results: We interviewed 40 physicians (18 residents, 22 attendings) and identified specific strategies for attendings to help residents navigate moral distress, which were categorized into 4 proactive and 4 responsive themes. The proactive themes included strategies employed before morally distressing events to minimize impact: ensuring attendings' awareness of residency factors influencing residents' moral distress; knowing available support resources; creating a learning environment that lays the foundation for mitigating distress; and recognizing moral distress in residents. The responsive themes included strategies that help mitigate the impact of morally distressing situations after they occur: partnering with the senior resident to develop a team-specific plan; consideration of who will participate in, the timing of, and content of the debrief., Conclusions: We present multiple strategies that attendings can implement to learn to recognize, prevent, and mitigate moral distress among residents. Our findings highlight the need for both proactive and reactive strategies and offer a possible roadmap for attending physicians to help their residents navigate moral distress., (Copyright © 2021 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Background: Primary care forms a critical part of pediatricians' practices, yet the most effective ways to teach primary care during residency are not known., Objective: We established a new primary care curriculum based on Malcolm Knowles' theory of andragogy, with brief clinical content that is easily accessible and available in different formats., Methods: We used Kern's model to create a curriculum. In 2013, we implemented weekly e-mails with links to materials on our learning management system, including moderators' curricular content, resident-developed quizzes, and podcasts. After 3 years, we evaluated the curriculum with resident focus groups, retrospective pre-/post-resident surveys, faculty feedback, a review of materials accessed, and resident attendance., Results: From content analysis of focus groups we learned that residents found the curriculum beneficial, but it was not always possible to do the pre-work. The resident survey, with a response rate of 87% (71 of 82), showed that residents perceived improvement in 37 primary care clinical skills, with differences from 0.64 to 1.46 for scales 1-5 ( P < .001 for all). Faculty feedback was positive regarding curriculum organization and structure, but patient care often precluded devoting time to discussing the curriculum. In other ways, our results were disappointing: 51% of residents did not access the curriculum materials, 51% did not open their e-mails, only 37% completed any of the quizzes, and they attended a weekly conference 46% of the time., Conclusions: Although residents accessed the curriculum less than expected, their self-assessments reflect perceptions of improvement in their clinical skills after implementation., Competing Interests: Conflict of interest: The authors declare they have no competing interests., (Accreditation Council for Graduate Medical Education 2019.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Introduction: There is an increasing call for developing validity evidence in medical education assessment. The literature lacks a practical resource regarding an actual development process. Our workshop teaches how to apply principles of validity evidence to existing assessment instruments and how to develop new instruments that will yield valid data., Methods: The literature, consensus findings of curricula and content experts, and principles of adult learning guided the content and methodology of the workshop. The workshop underwent stringent peer review prior to presentation at one international and three national academic conferences. In the interactive workshop, selected domains of validity evidence were taught with sequential cycles of didactics, demonstration, and deliberate practice with facilitated feedback. An exercise guide steered participants through a stepwise approach. Using Likert-scale items and open-response questions, an evaluation form rated the workshop's effectiveness, captured details of how learners reached the objectives, and determined participants' plans for future work., Results: The workshop demonstrated generalizability with successful implementation in diverse settings. Sixty-five learners, the majority being clinician-educators, completed evaluations. Learners rated the workshop favorably for each prompt. Qualitative comments corroborated the workshop's effectiveness. The active application and facilitated feedback components allowed learners to reflect in real time as to how they were meeting a particular objective., Discussion: This feasible and practical educational intervention fills a literature gap by showing the medical educator how to apply validity evidence to both existing and in-development assessment instruments. Thus, it holds the potential to significantly impact learner and, subsequently, patient outcomes., Competing Interests: None to report.

Nutrition counseling continues to be a concern for pediatric providers. This study aimed to extend the understanding of the perceptions of pediatric providers regarding nutrition care. Individual semi-structured qualitative interviews were conducted using a purposive sampling technique. Interviews were conducted in-person or via telephone, recorded, and transcribed. Seven themes emerged from the data and these can be used as a "how to" for medical educators. Based on the experiences and perspectives of the pediatric providers in our study, we are moving forward with the systematic development of a curriculum to improve nutrition care and counseling in pediatrics., (© International Association of Medical Science Educators 2018.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Study Objective: To develop and evaluate an educational activity designed to teach the adolescent Home, Education and employment, Eating, Activities, Drugs, Sexuality, Suicide/depression, and Safety (HEADS) examination. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Participants were third-year medical students in their pediatric clerkships. Students received an article on the HEADS interview and attended an adolescent medicine educational session. The session included individualized goal-setting and coached role play. Students' skills in doing a HEADS interview were evaluated through a standardized patient encounter (SPE) with a checklist and a retrospective pre- and post-test survey. The SPE checklist was used to assess whether the students included questions in 6 key areas of a HEADS interview., Results: One hundred fifty-two students participated. During the SPE, 90% of students queried the adolescent's home life, 91% education, 82% activities, 84% drug/substance abuse, 95% sexual history, and 61% symptoms of depression. Pre- and postintervention data were compared using the Kruskal-Wallis Test and showed a statistically significant difference in the students' ability to list key topic areas of the HEADS exam (P < .001) and to use the skills needed for an adolescent interview using the HEADS exam (P < .001)., Conclusion: After an introduction to the HEADS examination, most students covered almost all of the topic areas of this screening interview during a SPE. Only three-fifths of the students, however, included questions about symptoms of depression. Coached role play with goal-setting facilitated effective learning of this approach to adolescent interviewing., (Copyright © 2017 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Management of referral and consultation is an entrustable professional activity for pediatric residents; however, few tools exist to teach these skills. We designed and implemented tools to prompt discussion, feedback, and reflection about the process of referral, notably including the family's perspective., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

A process and tool that prompts learners to think about and reflect on their clinical performance was implemented. Learner narrative reflections about their work and faculty feedback, both captured in the moment, provided data for decisions about level of performance in a competency-based assessment system., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: The Council on Medical Student Education in Pediatrics and Association of Pediatric Program Directors developed a Pediatric Subinternship (CAPS) curriculum for use with an individualized learning plan (ILP). The authors determined which learning objectives (LOs) pediatric subinterns selected when provided the CAPS curriculum, summarized students' self-reported progress, and determined feasibility of ILPs in subinternship., Methods: Students from 10 medical schools completed a standardized ILP during pediatric subinternship. Students listed ≥3 LOs using CAPS curriculum as a guide and self-assessed their progress. Students reviewed ILPs with faculty preceptors; preceptors completed questionnaires on time and effort spent. Authors mapped student LOs to CAPS curriculum objectives and grouped in Accreditation Council for Graduate Medical Education competency domains., Results: Two hundred four students documented 850 LOs. Authors mapped student LOs to 61 of the 69 CAPS objectives (88%). Students most commonly chose Patient Care LOs, with the top 3 related to oral presentations, time management, and management plans. Student LOs not in CAPS addressed nutrition, child development, test interpretation, and cost. No students chose LOs related to health disparities, shared decision making, informed consent, or patient safety. Students self-reported significant progress on most LOs (73%). Faculty met with students ≥1 time and 93% met for a total of ≤1 hour. According to faculty, students required little or no help completing ILPs., Conclusions: Students chose a wide range of LOs when provided the CAPS curriculum. Revision to include additional student-identified LOs would enhance CAPS curriculum's comprehensiveness. Using this curriculum with an ILP during subinternship is feasible, but gaps between educator-identified and student-identified objectives require further exploration., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background/objectives: Pediatricians manage skin conditions such as atopic dermatitis (AD) but report that their dermatologic training is inadequate. Online modules may enhance medical education when sufficient didactic or clinical teaching experiences are lacking. We assessed whether an online module about AD improved pediatric residents' knowledge and changed their clinical management of AD., Methods: Target and control cohorts of pediatric residents from two institutions were recruited. Target subjects took a 30-question test about AD early in their residency, reviewed the online module, and repeated the test 6 months and 1 year later. The control subjects, who had 1 year of clinical experience but had not reviewed the online module, also took the test. The mean percentage of correct answers was calculated and compared using two-sided, two-sample independent t tests and repeated-measures analysis of variance. For a subset of participants, clinical documentation from AD encounters was reviewed and 13 practice behaviors were compared using the Fisher exact test., Results: Twenty-five subjects in the target cohort and 29 subjects in the control cohort completed the study. The target cohort improved from 18.0 ± 3.2 to 23.4 ± 3.4 correctly answered questions over 1 year (P < .001). This final value was greater than that of the control cohort (20.7 ± 4.5; P = .01). Meaningful differences in practice behaviors were not seen., Conclusion: Pediatric residents who reviewed an online module about AD demonstrated statistically significant improvement in disease-specific knowledge over time and had statistically significantly higher scores than controls. Online dermatology education may effectively supplement traditional clinical teaching., (© 2017 Wiley Periodicals, Inc.)

Background: Patients with little or no health insurance are frequently readmitted to the hospital, yet few previous studies have listened to patients' explanations of why they returned to the hospital after discharge. Enhanced understanding of patient perspectives may facilitate targeted services and improve care., Methods: We enrolled 18 patients with Medicaid or no insurance during a hospital readmission within 30 days in a major metropolitan area, and conducted semi-structured qualitative interviews to explore the impact of patients' experiences around readmission using a grounded theory approach., Results: We identified five themes contributing to readmission: (1) therapeutic misalignment; (2) accountability; (3) social fragility; (4) access failures; and (5) disease behavior. Medical conditions were complicated by social influences and insufficiently addressed by our health system. Patients understood the need to manage their own health but were unable to effectively execute care plans because of competing life demands and compromised relationships with health providers., Conclusions: Our study using interviews of readmitted Medicaid and uninsured patients revealed complex illnesses complicated by social instability and health system failures. Improved patient-provider trust and shared decision-making, while addressing social determinants and expanding care coordination with community partners, provide opportunity to better meet patients' needs and decrease hospital readmission in high-risk patients.

Objective: To identify challenges primary care providers (PCPs) experience providing a Medical Home for children with autism spectrum disorders (ASDs) and to describe the role developmental behavioral pediatricians (DBPs) play in the Medical Home Neighborhood., Methods: The authors used purposeful sampling to recruit 25 PCPs from around Colorado to participate in 4 focus groups. Member checking was performed at the end of each group. Sampling continued until themes repeated and saturation was achieved. Focus groups were transcribed verbatim, and transcripts were analyzed using content analysis; an outside reviewer audited the data., Results: Qualitative analysis yielded 30 codes that fell into 7 themes: provider education, shared model of care, initial diagnostic evaluation by the DBP, communication, office factors, cost and coverage, and access. PCPs identified knowledge gaps that led to decreased comfort and desired ongoing education and a centralized resource for providers. They envisioned a shared care model with ongoing specialist collaboration and improved communication within the care team. A specific role desired of the DBP was to provide the initial diagnostic evaluation and treatment plan with specific resources. Office factors, high cost and variable coverage, and poor access to services were barriers to providing a Medical Home for children with ASD., Conclusion: Working to remove barriers to shared care as well as providing continued educational opportunities will help improve access to a Medical Home Neighborhood for children with ASD. Advocacy is needed to help remove barriers related to cost, coverage, and access to services.

Objective: To explore pediatric interns' perspectives on the educational value of general pediatric ward rounds, in particular their rounding experiences with and without an attending physician., Methods: Qualitative study using individual interviews of pediatric interns (2013-2014) rotating on 2 general pediatric inpatient services at different institutions with different rounding team structures. In accordance with grounded theory methodology, data were analyzed using the constant comparative method. Codes were built using an iterative approach and organized into themes., Results: Twenty pediatric interns participated in 25 interviews. Data analysis yielded 4 themes: what is being learned; learning environment on rounds; learning and work; and ways of learning. Senior residents generally taught practical aspects of patient care and attending physicians taught broader concepts with references to the medical literature. Rounds without an attending physician were perceived as less formal and promoted collaborative discussions with senior residents. Interns were more uncomfortable during rounds with an attending physician but appreciated how that facilitated their learning. Although patient care tasks provided opportunities for experiential learning, interns frequently perceived them to impede learning during rounds. Intern learning during ward rounds occurred via self-directed learning, interactive learning, and through caring for patients. Brief, clinically relevant teaching pearls and questioning clinical reasoning in a respectful manner were helpful., Conclusions: Interns learn different content and learn in different ways depending on the presence or absence of an attending physician at rounds. There might be educational value from rounding with teams that include and do not include an attending physician., (Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Purpose: Medical education aims to equip physicians for lifelong learning, an objective supported by the conceptual framework of self-regulated learning (SRL). Learning goals have been used to develop SRL skills in learners across the medical education continuum. This study's purpose was to elicit residents' perspectives on learning goal use and to develop explanations suggesting how aspects of the learning environment may facilitate or hinder the meaningful use of learning goals in residency., Method: Resident focus groups and program director interviews were conducted in 2012-2013, audio-recorded, and transcribed. Programs were selected to maximize diversity of size, geographic location, type of program, and current use of learning goals. Data were analyzed using the constant comparative method associated with grounded theory. Further analysis compared themes frequently occurring together to strengthen the understanding of relationships between the themes. Through iterative discussions, investigators built a grounded theory., Results: Ninety-five third-year residents and 12 program directors at 12 pediatric residency programs participated. The analysis identified 21 subthemes grouped into 5 themes: program support, faculty roles, goal characteristics and purposes, resident attributes, and accountability and goal follow-through. Review of relationships between the themes revealed a pyramid of support with program support as the foundation that facilitates the layers above it, leading to goal follow-through., Conclusions: Program support facilitates each step of the SRL process that leads to meaningful use of learning goals in residency. A strong foundation of program support should include attention to aspects of the implicit curriculum as well as the explicit curriculum.

Fathers play a critical role in children's development; similarly, fatherhood positively affects men's health. Among the larger population of fathers relatively little is known about the parenting knowledge of urban, African American fathers. Focusing on urban, African American fathers, the objectives of this study were to (1) understand the primary sources from which fathers learn about parenting, (2) determine where and how fathers prefer to receive future parenting education, and (3) explore the information perceived as most valuable to fathers and how this compares with the recommended anticipatory guidance (Bright Futures-based) delivered during well visits. Five focus groups, with a total of 21 participants, were conducted with urban fathers at a community-based organization. Study eligibility included being more than 18 years old, English speaking, and having at least one child 0 to 5 years old. During the focus groups, fathers were asked where they received parenting information, how and where they preferred to receive parenting information, and what they thought about Bright Futures parenting guidelines. Fathers most commonly described receiving parenting information from their own relatives rather than from their child's health care provider. Most fathers preferred to learn parenting from a person rather than a technology-based source and expressed interest in learning more about parenting at community-based locations. Although fathers viewed health care providers' role as primarily teaching about physical health, they valued Bright Futures anticipatory guidance about parenting. Fathers valued learning about child rearing, health, and development. Augmenting physician counseling about Bright Futures with community-based parenting education may be beneficial for fathers., (© The Author(s) 2014.)

Objective: To explore medical students' experiences working with frequently rotating pediatric inpatient attending physicians., Methods: We performed a qualitative study using focus groups and individual interviews of medical students who rotated on the general pediatric inpatient service at Children's Hospital Colorado. The majority of inpatient pediatric attending physicians worked 1-week blocks. We used a semistructured interview guide and analyzed data using the constant comparative method. In accordance with the grounded theory method, codes were developed using an iterative approach, and major themes were identified. Analysis indicated theoretical saturation was achieved. We created a theory that arose from analysis of the data., Results: Twenty-seven medical students participated. Data analysis yielded 6 themes: learning climate, continuity, student resilience, opportunity to progress, growth into a physician, and evaluation. In the learning climate, the emotional environment was often stressful, although students valued exposure to different patient care and teaching styles. Senior resident continuity promoted student function; lack of continuity with attending physicians inhibited relationship development. Students were resilient in adjusting to changing faculty with different expectations. In the context of frequently rotating faculty, students had difficulty showing improvement to a single attending physician after feedback, which limited students' opportunities to progress. Students perceived summative evaluation as less meaningful in the absence of having a relationship with their attending physicians., Conclusions: Medical students valued exposure to different patient care and teaching styles. However, frequently changing attending physicians caused students stress and limited students' perceived ability to achieve and show professional growth., (Copyright © 2014 by the American Academy of Pediatrics.)

Background: In medical education, evaluation of clinical performance is based almost universally on rating scales for defined aspects of performance and scores on examinations and checklists. Unfortunately, scores and grades do not capture progress and competence among learners in the complex tasks and roles required to practice medicine. While the literature suggests serious problems with the validity and reliability of ratings of clinical performance based on numerical scores, the critical issue is not that judgments about what is observed vary from rater to rater but that these judgments are lost when translated into numbers on a scale. As the Next Accreditation System of the Accreditation Council on Graduate Medical Education (ACGME) takes effect, medical educators have an opportunity to create new processes of evaluation to document and facilitate progress of medical learners in the required areas of competence. Proposal and initial experience: Narrative descriptions of learner performance in the clinical environment, gathered using a framework for observation that builds a shared understanding of competence among the faculty, promise to provide meaningful qualitative data closely linked to the work of physicians. With descriptions grouped in categories and matched to milestones, core faculty can place each learner along the milestones' continua of progress. This provides the foundation for meaningful feedback to facilitate the progress of each learner as well as documentation of progress toward competence., Implications: This narrative evaluation system addresses educational needs as well as the goals of the Next Accreditation System for explicitly documented progress. Educators at other levels of education and in other professions experience similar needs for authentic assessment and, with meaningful frameworks that describe roles and tasks, may also find useful a system built on descriptions of learner performance in actual work settings., Conclusions: We must place medical learning and assessment in the contexts and domains in which learners do clinical work. The approach proposed here for gathering qualitative performance data in different contexts and domains is one step along the road to moving learners toward competence and mastery.

Purpose: To provide validity evidence for use of the Learning Goal Scoring Rubric to assess the quality of written learning goals and residents' goal writing skills., Method: This two-part study used the rubric to assess University of Colorado third-year pediatric residents' written learning goals to obtain validity evidence. In study 1, five raters independently scored 48 goals written in 2010-2011 and 2011-2012 by 48 residents, who also responded to the Jefferson Scale of Physician Lifelong Learning (JeffSPLL). In study 2, two raters independently scored 48 goals written in 2011-2012 by 12 residents. Intraclass correlation coefficients (ICCs) assessed rater agreement to provide evidence for response process. Generalizability theory assessed internal structure. Independent-samples Mann-Whitney U tests and correlations assessed relationship to other variables. Content was matched to published literature and instructional methods., Results: The ICC was 0.71 for the overall rubric. In study 1, where the generalizability study's (G study's) object of measurement was learning goals, the phi coefficient was 0.867. In study 2, where the G study's object of measurement was the resident (goal writing skill), the phi coefficient was 0.751. The total mean score of residents with goal writing training was significantly higher than that of those without (7.54 versus 4.98, P < .001). Correlation between goal quality and JeffSPLL score was not significant. Investigators agreed that the content matched the published literature and instructional methods., Conclusions: Preliminary validity evidence indicates that this scoring rubric can assess learning goal quality and goal writing skill.

Objective: To determine the proportion of abstracts submitted to the 2010 Pediatric Academic Societies (PAS) meeting that were exclusively qualitative, and to examine whether these abstracts were more or less likely than all others to be designated as platform, poster, or publish only., Methods: The database of abstracts submitted to the 2010 PAS meeting was searched using qualitative terms. Authors reviewed abstracts to identify exclusively qualitative abstracts. The proportions and mean score ± standard deviation for qualitative abstracts and those designated platform, poster, or publish only were calculated. Student's t test was used to analyze mean differences; pairwise comparisons and odds ratios (ORs) were used to examine differences in the disposition of qualitative versus all other abstracts. The main outcome was the proportion of abstracts designated as platform, poster, or publish only., Results: Of 4057 abstracts, 1.6% used only qualitative methods. Scores for qualitative and all other abstracts were 4.26 ± 0.60 and 3.88 ± 0.92, respectively (P < .001). The disposition of qualitative abstracts among platform, poster, and publish only differed from all other abstracts (P = .04). Compared with all others, qualitative abstracts had lower odds of platform presentation (OR 0.36; 95% confidence interval [CI] 0.15-0.91), demonstrated a nonsignificant trend toward publish only (OR 1.6; 95% CI 0.95-2.7), and were equally likely to be posters (OR 1.1; 95% CI 0.65-1.8)., Conclusions: Compared with all other abstracts, qualitative abstracts were about 3 times less likely to be chosen for platform presentations; in addition, they demonstrated a trend toward greater odds of publish only. These findings may be the result of inferior quality or an inadequate review process., (Copyright © 2013 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Effective written communication is a core competency for medical students, but it is unclear whether or how this skill is evaluated in clinical clerkships., Purpose: This study identifies current requirements and practices regarding required written work during internal medicine clerkships., Methods: In 2010, Clerkship Directors of Internal Medicine (CDIM) surveyed its institutional members; one section asked questions about students' written work. RESULTS were compared to similar, unpublished CDIM 2001 survey questions., Results: Requirements for student-written work were nearly universal (96% in 2001 and 100% in 2010). Only 23% used structured evaluation forms and 16% reported written work was weighted as a percentage of the final grade, although 72% of respondents reported that written work was "factored" into global ratings., Conclusions: Despite near universal requirements for student written work, structured evaluation was not commonly performed, raising concern about the validity of factoring these assessments into grades.

Background: Residency work hour restrictions in 2003 changed medical student participation in overnight call., Purposes: The goal is to compare experiences, attitudes, and skills between medical students who did and did not participate in overnight call., Methods: Using a retrospective cohort design, all students at one medical school received a survey at the end of their 3rd-year internal medicine clerkship. Students at 3 clerkship sites were required to take overnight call, and students at 2 sites were not., Results: One hundred four of 167 (62%) students participated. Sixty-one of 104 (59%) took overnight call. Overnight call students reported improved team relationships and were able to evaluate more unstable "cross-cover" patients. Students who took overnight call were more likely to state it was worthwhile (58% vs. 34%; p = .034). Overnight call led to fatigue and the perception of interference with didactics., Conclusions: Overnight call within the internal medicine clerkship has positive and negative effects. With new residency work hour restrictions, schools may consider innovative ways to preserve the positive experiences while working to minimize fatigue and interference with learning.

Background: There are no empirically-grounded criteria or tools to define or benchmark the quality of outpatient clinical documentation. Outpatient clinical notes document care, communicate treatment plans and support patient safety, medical education, medico-legal investigations and reimbursement. Accurately describing and assessing quality of clinical documentation is a necessary improvement in an increasingly team-based healthcare delivery system. In this paper we describe the quality of outpatient clinical notes from the perspective of multiple stakeholders., Methods: Using purposeful sampling for maximum diversity, we conducted focus groups and individual interviews with clinicians, nursing and ancillary staff, patients, and healthcare administrators at six federal health care facilities between 2009 and 2011. All sessions were audio-recorded, transcribed and qualitatively analyzed using open, axial and selective coding., Results: The 163 participants included 61 clinicians, 52 nurse/ancillary staff, 31 patients and 19 administrative staff. Three organizing themes emerged: 1) characteristics of quality in clinical notes, 2) desired elements within the clinical notes and 3) system supports to improve the quality of clinical notes. We identified 11 codes to describe characteristics of clinical notes, 20 codes to describe desired elements in quality clinical notes and 11 codes to describe clinical system elements that support quality when writing clinical notes. While there was substantial overlap between the aspects of quality described by the four stakeholder groups, only clinicians and administrators identified ease of translation into billing codes as an important characteristic of a quality note. Only patients rated prioritization of their medical problems as an aspect of quality. Nurses included care and education delivered to the patient, information added by the patient, interdisciplinary information, and infection alerts as important content., Conclusions: Perspectives of these four stakeholder groups provide a comprehensive description of quality in outpatient clinical documentation. The resulting description of characteristics and content necessary for quality notes provides a research-based foundation for assessing the quality of clinical documentation in outpatient health care settings.

Background: A specialties' lifestyle is known to be important for specialty selection, but how medical students define this concept is unknown., Purpose: The aim of this article is to determine how 4th-year medical students perceive lifestyle of specialties., Methods: All 4th-year U.S. medical students graduating in 2009 with a military service obligation were invited to participate in an electronic survey. Responses to an open-ended question, "When someone says 'That specialty has a good lifestyle,' what does that mean to you?" were classified into themes by a consensus of the authors and then compared to the students' selected specialty., Results: Response rate for the questionnaire was 46% (369 of 797). Four themes describing lifestyle emerged: "schedule control" (67% of students), "off time" (53%), "financial aspects" (48%), and "work life" (26%)., Conclusions: Medical students' definition of a "good lifestyle" includes four themes, which should be used in future research of the lifestyle factor of specialty selection.

This paper provides a primer for qualitative research in medical education. Our aim is to equip readers with a basic understanding of qualitative research and prepare them to judge the goodness of fit between qualitative research and their own research questions. We provide an overview of the reasons for choosing a qualitative research approach and potential benefits of using these methods for systematic investigation. We discuss developing qualitative research questions, grounding research in a philosophical framework, and applying rigorous methods of data collection, sampling, and analysis. We also address methods to establish the trustworthiness of a qualitative study and introduce the reader to ethical concerns that warrant special attention when planning qualitative research. We conclude with a worksheet that readers may use for designing a qualitative study. Medical educators ask many questions that carefully designed qualitative research would address effectively. Careful attention to the design of qualitative studies will help to ensure credible answers that will illuminate many of the issues, challenges, and quandaries that arise while doing the work of medical education., (Copyright © 2011 Academic Pediatric Association. All rights reserved.)

Medical students highly value a learning environment in which they feel part of the health care team, their views are valued, and they make significant contributions to the care of patients.An orientation that includes an enthusiastic welcome, an opportunity to get to know from where the students have come and where they want to go, and setting mutually agreeable SMART objectives helps create a supportive and effective learning environment.

Background: Our novel teaching approach involved having students actively participate in an unsuccessful resuscitation of a high fidelity human patient simulator with a gun shot wound to the chest, followed immediately by breaking bad news (BBN) to a standardized patient wife (SPW) portrayed by an actress., Methods: Brief education interventions to include viewing a brief video on the SPIKES protocol on how to break bad news, a didactic lecture plus a demonstration, or both, was compared to no pretraining by dividing 553 students into four groups prior to their BBN to the SPW. The students then self-assessed their abilities, and were also evaluated by the SPW on 21 items related to appearance, communication skills, and emotional affect. All received cross-over training., Results: Groups were equal in prior training (2 h) and belief that this was an important skill to be learned. Students rated the experience highly, and demonstrated marked improvement of self-assessed skills over baseline, which was maintained for the duration of the 12-wk clerkship. Additionally, students who received any of the above training prior to BBN were rated superior to those who had no training on several communication skills, and the observation of the video seemed to offer the most efficient way of teaching this skill in a time delimited curriculum., Conclusion: This novel approach was well received and resulted in improvement over baseline. Lessons learned from this study have enhanced our curricular approach to this vital component of medical education., (Published by Elsevier Inc.)

Family physicians commonly care for older patients with disabilities. Many of these patients need help maintaining a therapeutic home environment to preserve their comfort and independence. Patients often have little time to decide how to address the limitations of newly-acquired disabilities. Physicians can provide patients with general recommendations in home modification after careful history and assessment. Universal design features, such as one-story living, no-step entries, and wide hallways and doors, are key adaptations for patients with physical disabilities. Home adaptations for patients with dementia include general safety measures such as grab bars and door alarms, and securing potentially hazardous items, such as cleaning supplies and medications. Improved lighting and color contrast, enlarged print materials, and vision aids can assist patients with limited vision. Patients with hearing impairments may benefit from interventions that provide supplemental visual and vibratory cues and alarms. Although funding sources are available, home modification is often a nonreimbursed expense. However, sufficient home modifications may allow the patient and caregivers to safely remain in the home without transitioning to a long-term care facility.

Objective: To explore how patients and physicians describe attitudes and behaviours that facilitate shared decision making. Background Studies have described physician behaviours in shared decision making, explored decision aids for informing patients and queried whether patients and physicians want to share decisions. Little attention has been paid to patients' behaviors that facilitate shared decision making or to the influence of patients and physicians on each other during this process., Methods: Qualitative analysis of data from four research work groups, each composed of patients with chronic conditions and primary care physicians., Results: Eighty-five patients and physicians identified six categories of paired physician/patient themes, including act in a relational way; explore/express patient's feelings and preferences; discuss information and options; seek information, support and advice; share control and negotiate a decision; and patients act on their own behalf and physicians act on behalf of the patient. Similar attitudes and behaviours were described for both patients and physicians. Participants described a dynamic process in which patients and physicians influence each other throughout shared decision making., Conclusions: This study is unique in that clinicians and patients collaboratively defined and described attitudes and behaviours that facilitate shared decision making and expand previous descriptions, particularly of patient attitudes and behaviours that facilitate shared decision making. Study participants described relational, contextual and affective behaviours and attitudes for both patients and physicians, and explicitly discussed sharing control and negotiation. The complementary, interactive behaviours described in the themes for both patients and physicians illustrate mutual influence of patients and physicians on each other.