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Failure to elicit patients' values, goals, and priorities can result in missed opportunities to provide patient-centered care. Little is known about resident physicians' direct experience of eliciting patients' values, goals, and priorities and integrating them into routine hospital care.In 2017, we asked resident physicians on general internal medicine wards rotations to elicit and document a "Personal History" from patients upon hospital admission, in addition to a traditional social history. We defined a Personal History as documenting "what matters most to the patient and why." The purpose of the Personal History was to understand and consider patients' values, goals, and priorities. We then conducted qualitative interviews of the resident physicians to understand their experiences eliciting and integrating patients' values, goals, and priorities in routine hospital care.We performed this exploratory intervention at a large high-volume urban hospital. Two teams from general medicine wards participated in the Personal History intervention. We conducted voluntary interviews of eligible residents (n = 14/15; 93%) about their experience after they completed their general wards rotations. Using the coproduction model, our aim was to explore how patients' self-expertise can be combined with physicians' medical expertise to achieve patient-centered care.Four major themes were identified: 1) Taking a Personal History had value, and eliciting patients' self-expertise had the potential to change medical decision making, 2) Situational and relational factors created barriers to obtaining a Personal History, 3) Variability in buy-in with the proposed intervention affected effort, and 4) Meaningful Personal History taking could be an adaptive and longitudinal process. Perceived benefits included improved rapport with patients, helpful for patients with complex medical history, and improved physician-patient communication. Barriers included patient distress, lack of rapport, and responses from patients which did not add new insights. Accountability from attending physicians affected resident effort. Suggested future applications were for patients with serious illness, integration into electronic health records, and skills taught in medical education.Resident physicians had generally positive views of eliciting a Personal History from patients upon admission to the hospital. Overall, many residents conveyed the perceived ability to elicit and consider patient's values, goals, and priorities in certain situations (e.g., patient not in distress, adequate rapport, lack of competing priorities such as medical emergencies or overwhelming workloads). External factors, such as electronic health record design and accountability from attending physicians, may further promote residents' efforts to routinely incorporate patients' values, goals, and priorities in clinical care. Increasing familiarity among both resident physicians and patients in routinely discussing patients' values, goals, and priorities may facilitate patient-centered practice.

Our annual summer shadowing program for preclinical medical students faced significant challenges due to COVID-19-related safety and resource concerns during Summer 2020. We created a pilot 7-week virtual shadowing program with the goal of providing virtual observational clinical experiences to increase students’ clinical exposure and understanding of medical specialties. Faculty and preclinical medical students were matched via student preference selection and mentor availability. A practice guide was developed that outlined suggested virtual shadowing procedures. Afterward, participating faculty and students were surveyed on their experience. Overall, both faculty and students found the program effective and experienced limited technological difficulty.

YouTube is a popular source of health care information for consumers. The use of "Dr" or "Doctor" in a channel name is a way contributors establish expertise. The current study sought to understand the degree by which popular YouTube channels belonging to individuals who self-identify as doctors disclose their credentials and the nature of their disclosures.Two raters extracted descriptive characteristics from the most viewed public YouTube channel names meeting keyword search criteria of "Doctor" and "Dr". Channel-level disclosure was captured by examining a channel's "About" section. Video-level disclosure was captured by watching the first 2 minutes of the five most viewed videos from each channel.Forty-eight channels (45.7%; 48/105) disclosed degree, 60 channels (57.1%; 60/105) disclosed specialty, and 26 channels (24.8%; 26/105) disclosed the level of training. Two hundred thirty-six videos (46.6%; 236/506) disclosed degree, 201 videos (39.7%; 201/506) disclosed specialty, and 81 videos (16%; 81/506) disclosed the level of training.Our findings suggest that the most viewed YouTube health channels and videos demonstrate inconsistent credential disclosure, occurring less than half of the time. Current professional guidance from licensing boards on social media encourages transparency around expertise and credential sharing. In addition, it remains unclear what guidance other health care professionals receive about disclosure practices online. Future recommendations and training to health care professionals should include explicit language for transparent disclosure of credentials.

Purpose To describe the prevalence and scope of wellness programs at U.S. and Canadian medical schools. Method In July 2019, the authors surveyed 159 U.S. and Canadian medical schools regarding the prevalence, structure, and scope of their wellness programs. They inquired about the scope of programming, mental health initiatives, and evaluation strategies. Results Of the 159 schools, 104 responded (65%). Ninety schools (93%, 90/97) had a formal wellness program, and across 75 schools, the mean full-time equivalent (FTE) support for leadership was 0.77 (standard deviation [SD] 0.76). The wellness budget did not correlate with school type or size (respectively, P = .24 and P = .88). Most schools reported adequate preventative programming (62%, 53/85), reactive programming (86%, 73/85), and cultural programming (52%, 44/85), but most reported too little focus on structural programming (56%, 48/85). The most commonly reported barrier was lack of financial support (52%, 45/86), followed by lack of administrative support (35%, 30/86). Most schools (65%, 55/84) reported in-house mental health professionals with dedicated time to see medical students; across 43 schools, overall mean FTE for mental health professions was 1.62 (SD 1.41) and mean FTE per student enrolled was 0.0024 (SD 0.0019). Most schools (62%, 52/84) evaluated their wellness programs; they used the Association of American Medical Colleges Graduation Questionnaire (83%, 43/52) and/or annual student surveys (62%, 32/52). The most commonly reported barrier to evaluation was lack of time (54%, 45/84), followed by lack of administrative support (43%, 36/84). Conclusions Wellness programs are widely established at U.S. and Canadian medical schools, and most focus on preventative and reactive programming, as opposed to structural programming. Rigorous evaluation of the effectiveness of programs on student well-being is needed to inform resource allocation and program development. Schools should ensure adequate financial and administrative support to promote students' well-being and success.

Websites are important tools for programs to provide future residency applicants with freely accessible information regarding their program, including diversity, equity, and inclusion (DEI) initiatives.To describe the variability of DEI content in residency programs and compare DEI website content by specialty.Using the 2021 Accreditation Council for Graduate Medical Education (ACGME) list of residency programs, residency training websites were identified and evaluated. Information was extracted from program websites as indicators of DEI content. Chi-square analysis and one-way ANOVA were chosen to assess for statistical differences.In total, 4644 program websites representing 26 specialties were assessed. Among all the programs, the average DEI completeness of a program website was 6.1±14.6% (range 0-100%). While 6.2% of all programs had a diversity webpage, only 13.3% included a commitment to DEI, and few programs (2.7%) provided information about underrepresented in medicine (URiM) faculty.Graduate medical education programs can enhance information for current and prospective applicants about DEI initiatives on their websites. Including DEI initiatives on residency websites may improve diversity recruitment efforts.

Introduction: Institutions have developed professionalism policies to help guide physician social media behavior in light of professionalism lapses that have resulted in serious consequences. Prior...

Problem Sociodemographic identities, including race, culture, ethnicity, gender, and sexual orientation (race and culture), are recognized as important determinants of health, with significant impacts on patients' health outcomes, but teaching medical students about this is challenging. The authors sought to identify areas for improvement in delivery of critical content about race, culture, structural inequalities, and health disparities within a set of virtual patient cases used by U.S. medical schools and develop revision guidelines. Approach A workgroup (medical students and faculty) conducted a literature review in 2017 to identify challenges and best practices for teaching and learning about race and culture in medicine. Using an analytic framework informed by this review, they analyzed 63 Aquifer virtual patient teaching cases for effectiveness of the presentation of race and culture, resulting in six main themes describing common mistakes or pitfalls. They then developed an evidence-based guide for systematic case revision. Outcomes The authors present a novel, practical guide for medical educators to use to revise existing teaching cases and improve the delivery of critical concepts surrounding race and culture. This guide includes fundamental definitions and six sections to guide structured case revision based on the main themes. It includes examples of language, suggested edits, and the rationale and evidence for recommendations. Next steps Feedback from faculty and students regarding implementation of the guide and delivery of revised content in Aquifer cases will be critical in determining the guide's effectiveness. This structured guide may be adapted to a variety of teaching modalities in medicine.

Objectives: As the coronavirus disease 2019 (COVID-19) vaccine is introduced, it is critical to recognize that public opinion on vaccines is largely influenced by health communications, with YouTube being a major source of information and misinformation. This analysis graded the accuracy, quality, and reliability of the most viewed YouTube videos depicting COVID-19 and vaccinations over a 6-mo period. Methods: We collected hyperlinks for the 150 most viewed YouTube videos discussing COVID-19 from January through June 2020. Closed captioning data were searched for the term “vaccine,” yielding 32 videos. This sample was evaluated for quality, accuracy, and reliability using a rubric that incorporated existing instruments: Global Quality Scale (GQS), JAMA Benchmark Criteria, and DISCERN. Results: These 32 videos had 139,764,188 views at the time of data collection. The majority of videos received low scores, with network news sources receiving the lowest scores overall. Conclusions: The overall quality of COVID-19 YouTube videos related to vaccines may be low and raises a precautionary alert for the public consuming these videos and for health-care providers working to provide the best information to their patients. Existing scoring tools may not capture the complexities of social media. New tools could allow for a better understanding of the modern landscape of health communications.

The COVID-19 pandemic drastically impacted medical student experiences. Little is known about the impact of the pandemic on student well-being and protective factors for burnout.Assess US medical student burnout, stress, and loneliness during the initial phase of the pandemic, compare results to pre-pandemic data, and identify risk factors for distress and protective factors to inform support interventions.Cross-sectional survey of medical students conducted between May and July 2020.3826 students from 22 medical schools.Burnout (MBI-HSS), stress (PSS-10), loneliness (UCLA scale), and student experiences. Compared burnout and stress to pre-pandemic studies (2010-2020).Of 12,389 students, 3826 responded (31%). Compared to pre-pandemic studies, burnout was lower (50% vs. 52%, P = 0.03) while mean stress was higher (18.9 vs. 16.0, P0.001). Half (1609/3247) reported high (≥ 6/9) loneliness scores. Significant differences were found in burnout and stress by class year (P = 0.002 and P0.001) and race (P = 0.004 and P0.001), with the highest levels in second- and third-year students and Black, Asian, or other racial minority students. Students experiencing financial strain or racism had higher burnout and stress (P0.001 for all). Respondents with COVID-19 diagnoses in themselves or family members had higher stress (P0.001). Nearly half (1756/3569) volunteered during the pandemic, with volunteers reporting lower burnout [48% (782/1639) vs. 52% (853/1656), P = 0.03].While stress was higher compared to pre-pandemic data, burnout was significantly lower. Higher burnout and stress among Black, Asian, and other racial minority students and those who experienced financial strain, racism, or COVID-19 diagnoses likely reflect underlying racial and socioeconomic inequalities exacerbated by the pandemic and concurrent national racial injustice events. Volunteer engagement may be protective against burnout. Schools should proactively support vulnerable students during periods of stress.

To describe the prevalence and scope of wellness programs at U.S. and Canadian medical schools.In July 2019, the authors surveyed 159 U.S. and Canadian medical schools regarding the prevalence, structure, and scope of their wellness programs. They inquired about the scope of programming, mental health initiatives, and evaluation strategies.Of the 159 schools, 104 responded (65%). Ninety schools (93%, 90/97) had a formal wellness program, and across 75 schools, the mean full-time equivalent (FTE) support for leadership was 0.77 (standard deviation [SD] 0.76). The wellness budget did not correlate with school type or size (respectively, P = .24 and P = .88). Most schools reported adequate preventative programming (62%, 53/85), reactive programming (86%, 73/85), and cultural programming (52%, 44/85), but most reported too little focus on structural programming (56%, 48/85). The most commonly reported barrier was lack of financial support (52%, 45/86), followed by lack of administrative support (35%, 30/86). Most schools (65%, 55/84) reported in-house mental health professionals with dedicated time to see medical students; across 43 schools, overall mean FTE for mental health professions was 1.62 (SD 1.41) and mean FTE per student enrolled was 0.0024 (SD 0.0019). Most schools (62%, 52/84) evaluated their wellness programs; they used the Association of American Medical Colleges Graduation Questionnaire (83%, 43/52) and/or annual student surveys (62%, 32/52). The most commonly reported barrier to evaluation was lack of time (54%, 45/84), followed by lack of administrative support (43%, 36/84).Wellness programs are widely established at U.S. and Canadian medical schools, and most focus on preventative and reactive programming, as opposed to structural programming. Rigorous evaluation of the effectiveness of programs on student well-being is needed to inform resource allocation and program development. Schools should ensure adequate financial and administrative support to promote students' well-being and success.

Several decades of work have detailed the value and goals of interprofessional education (IPE) within the health professions, defining IPE competencies and best practices. In 2013, the Liaison Committee for Medical Education (LCME) elevated IPE to a U.S. medical school accreditation standard. To examine the status of IPE within internal medicine (IM) clerkships including perspectives, curricular content, barriers, and assessment a year after the LCME standard issuance. Anonymous online survey. IM clerkship directors from each of the Clerkship Directors in Internal Medicine’s 121 U.S. and Canadian member medical schools in 2014. In 2014, a section on IPE (18 items) was included in the Clerkship Directors in Internal Medicine annual survey of its 121 U.S. and Canadian member medical schools. Items (18) assessed clerkship director (CD) perspectives, status of IPE curricula in IM clerkships, and barriers to IPE implementation. Data were analyzed using descriptive statistics and qualitative analysis of free-text responses to one of the survey questions. The overall survey response rate was 78% (94/121). The majority (88%) agreed that IPE is important to the practice of IM, and 71% believed IPE should be part of the IM clerkship. Most (76%) CDs agreed there is need for faculty development programs in IPE; 27% had such a program at their institution. Lack of curricular time, scheduling conflicts, and lack of faculty trained in IPE were the most frequently cited barriers. Twenty-nine percent had formal IPE activities within their IM clerkships, and 38% were planning to make changes. Of those with formal IPE activities, over a third (37%) did not involve student assessment. Since LCME standard issuance, only a minority of IM clerkships have included formal IPE activities, with lectures as the predominant method. Opportunities exist for enhancing educational methods as well as IPE faculty development.

Inappropriate social media behavior can have detrimental effects on students' future opportunities, but medical students are given little opportunity to reflect upon ways of integrating their social media identities with their newly forming professional identities.In 2012, a required educational session was developed for 1st-year medical students on social media and professional identity. Objectives include identifying professionalism issues and recognizing positive social media use. The 2-hour large-group session uses student-generated social media examples to stimulate discussion and concludes with an expert panel. Students complete a postsession reflection assignment.The required social media session occurs early in the 1st year and is part of the Professionalism curriculum in The George Washington University School of Medicine. Reflection papers are graded for completion.The study began in 2012 and ran through 2014; a total of 313/505 participants (62%) volunteered for the study. Assessment occurred through qualitative analysis of students' reflection assignments. Most students (65%, 203/313) reported considering changes in their social media presence due to the session. The analysis revealed themes relating to a broader understanding of online identity and opportunities to enhance careers. In a 6-month follow-up survey of 76 students in the 2014 cohort who completed the entire survey, 73 (94%) reported some increase in awareness, and 48 (64%) made changes to their social media behavior due to the session (response rate = 76/165; 46%), reflecting the longer term impact.Opportunities for discussion and reflection are essential for transformational learning to occur, enabling understanding of other perspectives. Incorporating student-submitted social media examples heightened student interest and engagement. The social media environment is continually changing, so curricular approaches should remain adaptable to ensure timeliness and relevance. Including online professionalism curricula focused on implications and best practices helps medical students develop an awareness of their electronic professional identities.

Criticism, scathing comments, and harassment are becoming more common elements of social media discourse. Recent coordinated public attacks directed at higher education faculty illustrate these troubling trends. In several cases, these attacks have been politically motivated by participants who disagree with a faculty member's statements regarding sensitive subjects. Whereas most high-profile cases have included faculty teaching at the undergraduate level who use social media to promote scholarly discussion, medical school faculty may also be at risk, especially if their scholarly pursuits pertain to politically charged issues (e.g., race and diversity, firearms, vaccinations, the health of transgender populations). In today's digital environment of cellphone recordings, forwarded e-mails, and open-access manuscripts, any faculty member who discusses or engages in scholarship of politically sensitive issues on- or offline may be at risk. In this Invited Commentary, the authors discuss the multifaceted problem of cyberbullying of medical school faculty and provide recommendations to faculty and administrators about how to mitigate and manage these situations.

While researchers have studied negative professional consequences of medical trainee social media use, little is known about how medical students informally use social media for education and career development. This knowledge may help future and current physicians succeed in the digital age.We aimed to explore how and why medical students use Twitter for professional development.This was a digital ethnography.Medical student "superusers" of Twitter participated in the studyThe postings ("tweets") of 31 medical student superusers were observed for 8 months (May-December 2013), and structured field notes recorded. Through purposive sampling, individual key informant interviews were conducted to explore Twitter use and values until thematic saturation was reached (ten students). Three faculty key informant interviews were also conducted. Ego network and subnetwork analysis of student key informants was performed. Qualitative analysis included inductive coding of field notes and interviews, triangulation of data, and analytic memos in an iterative process.Twitter served as a professional tool that supplemented the traditional medical school experience. Superusers approached their use of Twitter with purpose and were mindful of online professionalism as well as of being good Twitter citizens. Their tweets reflected a mix of personal and professional content. Student key informants had a high number of followers. The subnetwork of key informants was well-connected, showing evidence of a social network versus information network. Twitter provided value in two major domains: access and voice. Students gained access to information, to experts, to a variety of perspectives including patient and public perspectives, and to communities of support. They also gained a platform for advocacy, control of their digital footprint, and a sense of equalization within the medical hierarchy.Twitter can serve as a professional tool that supplements traditional education. Students' practices and guiding principles can serve as best practices for other students as well as faculty.

Narrative medicine educational interventions may enhance patient-centered care, yet most educational interventions do not involve actual patient-provider interactions, nor do they assess narrative competence, a key skill for its practice. An experiential narrative medicine curriculum for medical students was developed and piloted.The purpose of the study was to develop narrative competence, practice attentive listening, and stimulate reflection.Participants were third-year medicine clerkship students.The curriculum involved 1) an introductory session, 2) a patient storytelling activity, and 3) a group reflection session. For the storytelling activity, students elicited illness narratives in storytelling form from patients, listened attentively, wrote their versions of the story, and then read them back to patients.Five student focus groups were conducted between July 2011 and March 2012 (n = 31; 66%) to explore students' experiences, student-patient dynamics, challenges, and what they learned. Patient interviews (n = 17) on their experience were conducted in January 2013. Thematic analysis of the audiotaped stories of ten patients and corresponding student-written stories helped gauge narrative competence.The curriculum was found to be feasible and acceptable to both patients and students. Some patients and students were profoundly moved. Ongoing focus groups resulted in continual process improvement. Students' stories showed attainment of narrative competence.

Objective. To describe the experience of medical students volunteering at a camp for children with a variety of medical conditions. Methods. Rising second-year medical students who had served as counselors for 1 week at a medical specialty camp were invited to participate. We conducted a 2-part qualitative study using on-site focus groups and follow-up individual interviews. Results. Nine medical students participated. Students described their experience as motivating and career reinforcing. It helped them “move beyond the textbook” and deepened their commitment to serving future patients with compassion. One theme that emerged was the idea that their camp experience fostered the development of their professional identities. Conclusions. A 1-week, immersive community service experience at a medical specialty camp played a role in influencing the early formative professional identities of rising second-year medical students. Medical schools could use camps as a promising community service-learning experiences to foster professional identity.

This journal watch is sponsored by the Alliance for Clinical Education (ACE). The purpose of this article is to summarize medical education manuscripts from specialty journals that are important and relevant to educators across specialties. Specialties included in our review were cardiology, gastroenterology, general internal medicine, pulmonology, nephrology, hematology and oncology, endocrinology, rheumatology, infectious disease, and neurology. We are grateful to Teaching and Learning in Medicine and ACE for giving us the opportunity to publish this review. The Clerkship Directors in Internal Medicine Research Committee conducted this review. Included are English articles published from September 2006 through September 2007. PubMed was searched for peer-reviewed research publications reporting primary data on medical education. Medical subject heading terms included combinations of medical education, medical student, residency training, practice, undergraduate medical education, graduate medical educat...

Purpose: End-of-life and palliative care (EOL/PC) education is a necessary component of undergraduate medical education. The extent of EOL/PC education in internal medicine (IM) clerkships is unknown. The purpose of this national study was to investigate the presence of formal EOL/PC curricula within IM clerkships; the value placed by IM clerkship directors on this type of curricula; curricular design and implementation strategies; and related barriers and resources. Method: The Clerkship Directors in Internal Medicine conducted its annual survey of its institutional members in April 2012. The authors analyzed responses to survey items pertaining to formal EOL/PC curriculum and content using descriptive statistics. The authors used qualitative techniques to analyze free-text responses. Results: The response rate was 77.0% (94/122). Of those responding, 75.8% (69/91) believed such training should occur in the IM clerkship, and 43.6% (41/94) reported formal curricula in EOL/PC. Multiple instructional modalities were used to deliver this content, with the majority of programs dedicating four or more hours to the curriculum. Curricula covered a wide range of topics, and student assessment tools were varied. Most felt that students valued this education. The qualitative analysis revealed differences in the values clerkship directors placed on teaching EOL/PC within the IM clerkship. Conclusions: Although many IM clerkship directors have implemented formal curricula in EOL/PC, a substantial gap remains between those who have implemented and those who believe it belongs in the clerkship. Time, faculty, cost, and competing demands are the main barriers to implementation.

A 57-year old man presenting with frequent and painful urination and negative initial urinalysis for infection was given a diagnosis of benign prostate hypertrophy, which was never revised by subsequent providers. Instead, the patient continued to be treated for urinary retention and pain. A potent NSAID, Toradol (ketorolac), was included in his regimen. One day prior to his demise, the patient was diagnosed with prostatic abscess and admitted for treatment with intravenous antibiotics. However the patient died on hospital day one from massive GI bleeding. Autopsy revealed an underlying peptic ulcer. This case shines a light on diagnostic error: missed, wrong, or delayed diagnosis. It also uncovers the multifaceted nature of diagnostic errors and highlights the importance of system- related interventions, in particular, better communication between health care providers. Based on malpractice claims data, diagnostic error is the most frequent and costly of all medical mistakes, yet it remains one of the least studied areas of patient safety. While the field has some barriers to study, many opportunities exist for impact in the field of diagnostic errors

Purpose A case of probable carvedilol-induced thrombocytopenia is reported. Summary A 64-year-old African-American woman with a history of hypertension, diastolic dysfunction, mild left-ventricular hypertrophy, and pulmonary embolism was hospitalized with a platelet count of 94,000 platelets/mm[3][1]. Dalteparin, warfarin, and carvedilol had recently been added to her medication regimen. Beta-2-glycoprotein immunoglobulin G (IgG) antibody, anticardiolipin IgG, and anticardiolipin immunoglobulin M tests, conducted to rule out antiphospholipid syndrome, revealed values within the normal range. After the exclusion of dalteparin, hydrochlorothiazide, and other causes of drug- and non-drug-related thrombocytopenia, carvedilol was discontinued and replaced with metoprolol tartrate. After this substitution, the patient’s platelet count continued to rise. On hospital day 10, the patient was discharged to home on low-molecular-weight heparin bridging therapy, warfarin sodium 5 mg orally daily, ranitidine 150 mg orally daily, metoprolol tartrate 75 mg orally twice daily, lisinopril 20 mg orally daily, amlodipine 10 mg orally daily, cyanocobalamin 1000 mg orally daily, and two tablets of hydrochlorothiazide 25 mg–triamterene 37.5 mg orally daily. Her platelet count was 319,000 platelets/mm[3][1] on the day of discharge and remained stable thereafter. The recovery time of the platelets coincided with the elimination half-life of carvedilol. Conclusion A woman developed thrombocytopenia, first noticed as a reduction in the platelet count to a low-normal value, 17 days after treatment with carvedilol was begun. Other possible culprit drugs were withdrawn, but the platelet count continued to drop until carvedilol was discontinued. The platelet count rose on the day of carvedilol removal and was within the normal range within another day. [1]: #ref-3

Many American military personnel who served in the Iraq and Afghanistan wars will need long-term management of war-related conditions. There is pressing need for expertise in veterans’ care outside of the Military Health System (MHS) and Department of Veterans Affairs (VA), as many will seek care elsewhere: Veterans receive free MHS care only while on active duty; enhanced eligibility for VA healthcare ends 5 years after military discharge; many veterans eligible for VA healthcare use non-VA services instead; and the Affordable Care Act will expand Medicaid coverage for uninsured veterans. Families of veterans also may need care for conditions related to war service. Most medical schools lack veteran-focused curricula beyond VA clerkships, which often do not provide specific training on service-related conditions. The VA, Department of Defense (DoD), veterans groups, and medical professional organizations should partner to develop technical competencies in veteran and family health care for clinicians at all career stages, and cultural competencies to ensure contextually appropriate care. National and state licensing boards should assess these competencies formally. Partnerships between VA, DoD, and the community for care delivery can improve transitions and the quality of veterans’ post-deployment care.

Objective The use of social networking sites (SNS) is increasing among all ages, with implications for medical education faculty and trainee interactions. Our objective was to understand pediatric medical educators' use of SNS and perspectives on professional boundaries and posted content. Methods From September through December 2010, the Council on Medical Student Education in Pediatrics conducted its annual online survey. This survey included 11 questions regarding members' own SNS use, interactions with trainees, and perceptions about online behaviors by students. In addition, 3 open-ended questions about reasons for SNS use/nonuse and interactions with trainees were included. Bivariate and multivariable analyses were conducted with the use of logistic regression for predictors of clerkship directors' SNS use and views about behaviors. Open-ended questions were analyzed qualitatively to identify themes. Results Of the 65% (94/144) of clerkship directors responding to the survey, 34% (32/94) currently use SNS, 54% (51/94) never used SNS, and 12% (11/94) previously used SNS. Lack of time was the main reason for non-use. Female respondents were more likely to perceive it as never/rarely acceptable to accept students' friend requests (odds ratio=2.96, P = .03). Most felt hypothetical student online behaviors were rarely/never acceptable, such as photos of students holding alcohol (68/92, 74%), using discriminatory language (89/91, 98%), and sexually explicit posts (87/90, 97%). Conclusions Approximately one-third of pediatric clerkship directors currently use SNS, with use less likely with increasing age. Fewer have SNS relationships with students than with residents. Perceptions of appropriateness of faculty SNS behaviors and students' postings varied. These perceptions by medical education leaders can stimulate discussion to inform consensus guidelines on professional SNS use.

This journal watch feature sponsored by the Alliance for Clinical Education provides brief summaries of selected medical education articles that were published in internal medicine specialty journa...

A young doctor questions what appeared to be a predetermined route to dialysis—and wonders why the full range of options wasn’t laid out.

Background U.S. medical schools have reported unprofessional online content by medical students. To inform institutional policies and curricula, we conducted a qualitative study exploring medical student perspectives on online posting. Method Six focus groups were conducted with students from a single institution in November 2009. Interviews were recorded, transcribed, and analyzed using qualitative methods. Results Sixty-four students participated. Besides HIPAA violations and illegal activities, students disagreed as to what was inappropriate to post. They experienced online identity conflicts and described ambivalence toward Facebook. Students were concerned about online activity risks and lack of personal control. Their postings were guided by common sense and what they believed was expected from medical students. Students desired recommendations for appropriate content and suggested raising awareness through discussion. Conclusions Medical students viewed online postings through a lens of personal risk. They desired recommendations but were sensitive to feeling controlled by their school.

Physical examination teaching using actual patients is an important part of medical training. The patient experience undergoing this type of teaching is not well-understood.To understand the meaning of physical examination teaching for patients.Phenomenological qualitative study using semi-structured interviews.Patients who underwent a physical examination-based teaching session at an urban Veterans Affairs Medical Center.A purposive sampling strategy was used to include a diversity of patient teaching experiences. Multiple interviewers triangulated data collection. Interviews continued until new themes were no longer heard (total of 12 interviews). Interviews were recorded and transcribed verbatim. Coding was performed by two investigators and peer-checked. Themes were identified and meanings extracted from themes.Seven themes emerged from the data: positive impression of students; participation considered part of the program; expect students to do their job: hands-on learning; interaction with students is positive; some aspects of encounter unexpected; range of benefits to participation; improve convenience and interaction. Physical examination teaching had four possible meanings for patients: Tolerance, Helping, Social, and Learning. We found it possible for a patient to move from one meaning to another, based on the teaching session experience.Physical examination teaching can benefit patients. Patients have the potential to gain more value from the experience based on the group interaction.

Background Little is known about the advice fourth-year medical students receive from their advisors as they prepare to apply for residency training. Objective We collected information on recommendations given to medical students preparing to apply to internal medicine residencies regarding fourth-year schedules and application strategies. Methods Clerkship Directors in Internal Medicine conducted its annual member survey in June 2013. We analyzed responses on student advising using descriptive and comparative statistics, and free-text responses using content analysis. Results Of 124 members, 94 (76%) responded, and 83 (88%) advised fourth-year medical students. Nearly half (45%) advised an average of more than 20 students a year. Advisors encouraged students to take a medicine subinternship (Likert scale mean 4.84 [1, strongly discourage, to 5, strongly encourage], SD = 0.61); a critical care rotation (4.38, SD = 0.79); and a medicine specialty clinical rotation (4.01, SD = 0.80). Advisors reported they thought fourth-year students should spend a mean of 6.5 months doing clinical rotations (range 1–10, SD = 1.91). They recommended highest academic quartile students apply to a median of 10 programs (range 1–30) and lowest quartile students apply to 15 programs (range 3–100). Top recommendations involved maximizing student competitiveness, valuing program fit over reputation, and recognizing key decision points in the application process. Conclusions Undergraduate medical advisors recommended specific strategies to enhance students' competitiveness in the Match and to prepare them for residency. The results can inform program directors and encourage dialogue between undergraduate medical education and graduate medical education on how to best utilize the fourth year.

The rise of social media has increased connectivity and blurred personal and professional boundaries, bringing new challenges for medical professionalism. Whether traditional professionalism principles apply to the online social media space remains unknown. The purpose of this synthetic literature review was to characterize the original peer-reviewed research studies published between 1 January 2000-1 November 2014 on online professionalism, to assess methodologies and approaches used, and to provide insights to guide future studies in this area. The investigators searched three databases and performed manual searches of bibliographies to identify the 32 studies included. Most studies originated in the USA. Cross-sectional surveys and analyses of publicly available online content were the most common methodologies employed. Studies covered the general areas of use and privacy, assessment of unprofessional online behaviours, consensus-gathering of what constitutes unprofessional or inappropriate online behaviours, and education and policies. Studies were of variable quality; only around half of survey studies had response rates of 50% or greater. Medical trainees were the most common population studied. Future directions for research include public perspectives of online professionalism, impact on patient trust, and how to use social media productively as medical professionals.

The field of emergency research has come a long way. Once stymied by the difficulties in obtaining informed consent from patients with catastrophic injury or illness, the Food and Drug Administration (FDA) and the Department of Health and Human Services published regulations 21 CFR 50.24 in 1996 to guide the ethical and legal conduct of emergency research using exception from informed consent.1 For studies to qualify, subjects must have a life-threatening condition, available treatments are unproven or unsatisfactory, valid scientific evidence is needed to determine the safety and efficacy of the intervention, and obtaining informed consent is not feasible.2 Because these critically ill patients are quintessentially vulnerable subjects, 21 CFR 50.24 incurred extra responsibilities for parties involved in such research including consultation with communities from which subjects would be drawn and public disclosure of information before study commencement and after study completion (Table).1 These guidelines are used in studies evaluating FDA-approved therapies and devices and other interventions not under the direct purview of FDA, as well. Local institutional review boards (IRBs) have the responsibility to review a study’s plans for community consultation and public disclosure (CC/PD) and to ensure their adequacy. The FDA recommends that IRB members attend community consultation activities to hear community views and inform their decision as to a study’s disposition.2 View this table: Table. Key Elements of the Community Consultation and Public Disclosure Process Article see p 267 Traditional approaches to CC/PD have not been particularly successful in eliciting community attitudes toward research or informing communities of planned research. Commonly used methods include community meetings (town halls), random-digit telephone dialing, traditional media (print, television, radio), and Web sites. Among emergency department patients, awareness of an ongoing study involving the exception from informed consent that had used 5 community meetings, local newspaper, television, and radio spots, …

Background : Many different components factor into the final grade assigned for the internal medicine clerkship. Failure of one or more of these requires consideration of remedial measures. Purpose : To determine which assessment components are used to assign students a passing grade for the clerkship and what remediation measures are required when students do not pass a component. Methods : A national cross-sectional survey of Clerkship Directors in Internal Medicine (CDIM) institutional members was conducted in April 2011. The survey included sections on remediation, grading practices, and demographics. The authors analyzed responses using descriptive and comparative statistics. Results : Response rate was 73% (86/113). Medicine clerkships required students to pass the following components: clinical evaluations 83 (97%), NBME subject exam 76 (88%), written assignments 40 (46%), OSCE 35 (41%), in-house written exam 23 (27%), and mini-CEX 19 (22%). When students failed a component of the clerkship for the first time, 55 schools (64%) simply allowed students to make up the component, while only 16 (18%) allowed a simple make-up for a second failure. Additional ward time was required by 24 schools (28%) for a first-time failure of one component of the clerkship and by 49 (57%) for a second failure. The presence or absence of true remedial measures in a school was not associated with clerkship director academic rank, grading scheme, or percent of students who failed the clerkship in the previous year. Conclusions : Most schools required passing clinical evaluations and NBME subject exam components to pass the medicine clerkship, but there was variability in other requirements. Most schools allowed students to simply re-take the component for a first-time failure. This study raises the question of whether true remediation is being undertaken before students are asked to re-demonstrate competence in a failed area of the clerkship to be ready for the subinternship level. Keywords: remediation; failure; clerkship; clerkship failure; grade; clinical competence; medical knowledge; evaluation (Published: 10 December 2014) Citation: Med Educ Online 2014, 19 : 25991 - http://dx.doi.org/10.3402/meo.v19.25991

The social media and medicine landscape is evolving rapidly. Early research, social media policies, and educational efforts focused on risk avoidance, while more current efforts have encouraged reflection and explored opportunities. This trajectory has affirmed physicians' professional commitment to maintaining public trust in the face of new challenges in the digital age. In this Commentary, the authors propose viewing physicians' social media use as a hierarchy of needs, similar to Maslow's psychological theory which posits that more basic levels of needs must be met before higher, aspirational levels can be fully attained. The three levels in the social media in medicine's hierarchy of needs are Security, Reflection, and Discovery. Critical to this model is respecting the essential need for Security in order to move towards Reflection and into Discovery. The social media in medicine hierarchy of needs pyramid rests on a foundation of Public Trust. How physicians as a profession have responded to past--and continue to respond to present and future--social media challenges to professionalism reveals what matters most: maintaining public trust and honoring the physicians' contract with society. A victory for online professionalism would be providing trainees with the tools and guidance needed to ascend to Discovery, while ensuring that their basic social media needs are first met. To do this, physician educators need to continue increasing trainees' awareness through designing relevant curricula, encouraging reflection, and providing positive role modeling and effective mentorship.

Picture this: You are giving an invited talk at a medical conference. You look out at the audience only to see many people with their heads down, buried in their smartphones or tablets, fingers flying furiously. What is your reaction? For some, it may be annoyance. Why are they here if they are not interested in listening? But for others, it might be satisfaction in realizing that their talk is interesting enough to be “live-Tweeted” (key points distilled into 140-character–limited messages, shared with the Twitter world). Here, a shift in paradigm highlights the contrast between the challenges and the opportunities afforded by technology. In this issue of the Journal of Graduate Medical Education, 2 articles address emerging uses of technology in graduate medical education (GME). In “Smartphones, Trainees, and Mobile Education: Implications for Graduate Medical Education,” Short et al1 review the many ways that mobile phone applications (apps) can be used for education and bedside care to complement traditional in-classroom teaching approaches. Although the initial impulse of some educators may be to equate trainee smartphone or tablet use on rounds with distraction, the myriad educational uses for mobile devices highlighted by Short and colleagues should prompt us to consider the benefits of a paradigm shift. Are we taking full advantage of teaching through mobile platforms? Are we missing out on critical opportunities to reach our learners? We propose that the “teachable moment” has expanded. Medical educators have historically sought to harness teachable moments—or opportunities for learner-educator interaction inspired by notable patient care scenarios—as anchors for teaching content in a way that is engaging and memorable to learners. Now, every time a learner gets onto a smartphone device is an opportunity for a teachable moment about finding and accessing information to help us provide care and learn more effectively. In the second technology-related paper in this issue, “Use of a Secure Social Media Platform to Facilitate Reflection in a Residency Program,” Bernard et al2 describe the use of a secure social media platform with similarities to popular social networks, such as Facebook, to facilitate reflection among residents. Although social media, specifically blogs, have been shown to facilitate reflection in undergraduate medical education,3,4 with trainees achieving similar levels of reflection as a comparison group who reflected in small groups,3 this study extended the application of using social media for reflection to GME. These studies show that reflection, traditionally done privately or among small groups, can be translated to a larger group in an asynchronous fashion through technology and can extend the reach of faculty. These social platforms can also allow faculty to monitor and address the “hidden curriculum” (the unwritten and unintended learning that occurs during training) as sentinel events are documented and discussed with faculty and peers, such as, “My team was making jokes about a patient, and I felt guilty for laughing along.”4 The strengths of social media—to promote asynchronous interaction and sharing among members near and far—can be used to achieve specific learning objectives. These 2 highlighted articles contribute to a growing body of literature that suggests that technology uses in GME, and medical education in general, are not a fad but part of the future of teaching and learning.5–,7 A few medical schools have transitioned to an all-digital learning platform. Incoming students at the University of California, Irvine are given iPads preloaded with digital resources, including textbooks and podcasts of lectures; the iPads also have the ability to interface with digital stethoscopes, portable ultrasound technology, and encrypted electronic health records. University of California, Irvine reported its first cohort of students scored an average of 23% higher on the United States Medical Licensing Examination Step 1 compared with previous classes despite similar baseline academic performance.8 Another example is the application of wikis, which are websites that allow collaborative editing of content and structure by its users, in medical education. Wikis have been used to organize administrative and educational information in an internal medicine residency with improved resident perception of workflow.9 A wiki-based journal club, created and managed by residents, provides open, user-reviewed summaries of landmark trials.10 With this rapid growth of novel technologies, scholarly educators should view these innovations as merely tools. Deciding on the best-fit tool to match an educational purpose requires a thoughtful pedagogic approach to achieve desired learning outcomes. Educational need should drive technology use, and not vice versa. As these technologies become more mainstream in medical education, a broad research agenda should move beyond research that simply compares instructional methods and instead should delve into the complexities of a field that involves cognitive science, principles of multimedia design, and learning theories. The 2007 Association of American Medical Colleges' expert consensus white paper on the “Effective Use of Educational Technology in Medical Education” provides additional research agenda questions within a framework: “Simple answers are unlikely. Rather, solutions will be contingent upon multiple factors including learner attributes, desired learning outcomes, institutional characteristics, and other factors in the learning environment.”7 We add the following questions that should be considered by the GME community: What are the most effective models of new technology to promote lifelong learning? Can targeted learning be individualized using new technology? Are there metrics to determine the quality and validity of open access, online content in medical education? Can technologies be harnessed to assess competencies and Milestones? How do we use technology to facilitate patient-centered care (eg, communication, patient education, shared decision making)? How can the electronic health record serve as a learning tool for residents? What are the standards of professionalism and how does one teach them to learners in this new age of open, collaborative social media? Can we establish standards for sharing patient information via technology and social media? From the perspective of a “digital educator,” how can one demonstrate scholarship for faculty promotion and tenure considerations? As technology and GME continue to evolve in tandem, educators and scholars are challenged with discovering best practices for teaching and learning through creativity, shifting the “teachable moment” paradigm, and conducting rigorous scholarly inquiry. Furthermore, there is a need for faculty development to learn the foundational aspects of different technological tools and to share best practice models. As educators, we should be asking ourselves: How can we seize the opportunities to reach our learners and expand our traditional definitions of “the teachable moment?” How can we harness technology to meet our needs? How can we advance the field of educational technologies? We invite JGME readers to contribute to this discussion by sharing your thoughts and reactions to these questions by sending your Letters to the Editor (limited to 500 words) to gro.emgca@emgj, or by sending a Tweet to @JournalofGME. We will collate those answers and responses in an upcoming issue.

The rise of social media--content created by Internet users and hosted by popular sites such as Facebook, Twitter, YouTube, and Wikipedia, and blogs--has brought several new hazards for medical professionalism. First, many physicians may find applying principles for medical professionalism to the online environment challenging in certain contexts. Second, physicians may not consider the potential impact of their online content on their patients and the public. Third, a momentary lapse in judgment by an individual physician to create unprofessional content online can reflect poorly on the entire profession. To overcome these challenges, we encourage individual physicians to realize that as they "tread" through the World Wide Web, they leave behind a "footprint" that may have unintended negative consequences for them and for the profession at large. We also recommend that institutions take a proactive approach to engage users of social media in setting consensus-based standards for "online professionalism." Finally, given that professionalism encompasses more than the avoidance of negative behaviors, we conclude with examples of more positive applications for this technology. Much like a mirror, social media can reflect the best and worst aspects of the content placed before it for all to see.