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Clinical supervisors play key roles in facilitating trainee learning. Yet combining that role with patient care complicates both roles. So, we need to know how both roles can effectively co-occur. When facilitating their trainees' learning through practice, supervisors draw on their skills - clinical and supervisory - and available opportunities in their practice. This process can be conceptualised as supervisory knowing in practice (or contextual knowing) and offers ways to elaborate on how facilitating trainees' learning can be optimised. The practice-based study presented and discussed here examined clinical supervisors' knowing in practice related to facilitating trainee learning, across three medical specialities. Nineteen clinical supervisors from emergency medicine, internal medicine and surgery, were interviewed about their roles and engagement with trainees. Interview transcripts were analysed in two stages. Firstly, a framework analysis, informed by interdependent learning theory was conducted, focussing on affordances and individual engagement. Secondly, drawing on practice theory, a further layer of analysis was undertaken interrogating supervisors' knowing in practice. We identified two common domains of supervisor practice used to facilitate trainee learning: (1) orientating and assessing trainees' readiness (or capabilities), (2) sequencing and enriching pedagogic practices. Yet across the speciality groups the supervisors' knowing in practice differed and were shaped by a trio of: (i) disciplinary practices, (ii) situational requirements and (iii) clinician preference. Overall, we offer a new reading of clinical supervision as practice differences generated distinct supervisory knowing in practice. These findings emphasise clinical supervision as fundamentally entwined in the speciality's practice; and reinforce alignments with patient care.

A random-effects model is often applied in meta-analysis when considerable heterogeneity among studies is observed due to the differences in patient characteristics, timeframe, treatment regimens, and other study characteristics. Since 2014, the journals "Research Synthesis Methods" and the "Annals of Internal Medicine" have published a few noteworthy papers that explained why the most widely used method for pooling heterogeneous studies--the DerSimonian-Laird (DL) estimator--can produce biased estimates with falsely high precision and recommended to use other several alternative methods. Nevertheless, more than half of studies (55.7%) published in top oncology-specific journals during 2015-2022 did not report any detailed method in the random-effects meta-analysis. Of the studies that did report the methodology used, the DL method was still the dominant one reported. Thus, while the authors recommend that "Research Synthesis Methods" and the "Annals of Internal Medicine" continue to increase the publication of its articles that report on specific methods for handling heterogeneity and use random-effects estimates that provide more accurate confidence limits than the DL estimator, other journals that publish meta-analyses in oncology (and presumably in other disease areas) are urged to do the same on a much larger scale than currently documented.

Some educators have described clinical documentation as "scut". Research in medicine has focused on documentation's communicative value and not its function in learning. With time being an important commodity and electronic health records changing how we document, understanding the learning value of documentation is essential. The purpose of this study was to explore how trainee composing practices shape learning. Qualitative methods employing Rhetorical Genre Theory were used to explore clinical documentation practices among medical trainees. Data collection and analysis occurred in iterative cycles. Data included field notes and field interviews from 110 h of observing junior trainees and senior internal medicine residents participating in patient admission and follow-up visits. Analysis was focused on Paré and Smart's framework for studying documentation as composing. From a composing lens, documentation plays a vital role in learning in clinical settings. Junior trainees were observed to be reliant on using writing to support their thinking around patient care. Before patient encounters, writing helped trainees focus on what was already known and develop a preliminary understanding of the patient's problem(s). After encounters, writing helped trainees synthesize the data and develop an assessment and plan. Before and after the encounter, through writing, trainees also identified knowledge and data collection gaps. Our findings highlight clinical documentation as more than a communication task. Rather, the writing process itself appeared to play a pivotal role in supporting thinking. While some have proposed strategies for reducing trainee involvement, we argue that writing can be time well spent.

Curricular development and modification involve first identifying a problem and then performing a needs assessment, which can guide the design of curricular components. Pedagogical changes, coupled with reductions in curricular time for gross anatomy, pose challenges and impose restrictions within medical school curricula. In order to make anatomy education effective and efficient, it is important to determine the anatomy considered essential for medical education through a targeted needs assessment. In this study, 50 adult primary care resident physicians in family medicine (FM) and internal medicine (IM) were surveyed to assess the importance of 907 anatomical structures, or groups of structures, across all anatomical regions from a curated list based on the boldface terms in four primary anatomy texts. There were no statistically significant differences in the ratings of structures between the two groups for any anatomical region. In total, 17.0% of structures, or groups of structures, were classified as "essential," 58.0% as "more important," 24.4% as "less important," and 0.7% as "not important." FM residents rated tissues classified as skeleton, nerves, fasciae, anatomical spaces, blood vessels, lymphatics, and surface anatomy (p < 0.0001) significantly higher than IM residents, but there were no differences in the rating of muscles or organs (p > 0.0056). It was notable that 100.0% of cranial nerves were classified as essential, and 94.5% of surface anatomy structures were classified as "essential" or "more important." It is proposed that results of this study can serve to inform curricular development and revision.

Clerkships are defining experiences for medical students in which students integrate basic science knowledge with clinical information as they gain experience in diagnosing and treating patients in a variety of clinical settings. Among the basic sciences, there is broad agreement that anatomy is foundational for medical practice. Unfortunately, there are longstanding concerns that student knowledge of anatomy is below the expectations of clerkship directors and clinical faculty. Most allopathic medical schools require eight "core" clerkships: internal medicine (IM), pediatrics (PD), general surgery (GS), obstetrics and gynecology (OB), psychiatry (PS), family medicine (FM), neurology (NU), and emergency medicine (EM). A targeted needs assessment was conducted to determine the anatomy considered important for each core clerkship based on the perspective of clinicians teaching in those clerkships. A total of 525 clinical faculty were surveyed at 24 United States allopathic medical schools. Participants rated 97 anatomical structure groups across all body regions on a 1-4 Likert-type scale (1 = not important, 4 = essential). Non-parametric ANOVAs determined if differences existed between clerkships. Combining all responses, 91% of anatomical structure groups were classified as "essential" or "more important." Clinicians in FM, EM, and GS rated anatomical structures in most body regions significantly higher than at least one other clerkship (p = 0.006). This study provides an evidence-base of anatomy content that should be considered important for each core clerkship and may assist in the development and/or revision of preclinical curricula to support the clinical training of medical students.

We analyse interactions between teachers and students during video-recorded bedside teaching sessions in internal medicine, orthopaedics and neurology. Multiple raters used a high-inference categorical scheme on 36 sessions. Our research questions concern the types of student mistakes, clinical teachers' reactions to them and if they use different strategies to address different types of mistakes. We used a Poisson model and generalized mixed models to analyse these research questions. Most frequently, students made reproduction mistakes. Relatively high rates of rejection and a similar prevalence of low and high levels of elaboration and correction time for students were observed. Reproduction mistakes were associated with the highest level of rejection and the lowest level of elaboration. High levels of elaboration were observed when students were applying skills in new situations. Students were most often allowed time to correct when mistakes in the areas of analysis or application of skills and knowledge had occurred. There is a decrease in the rate of making mistakes for neurology and orthopaedics compared to internal medicine. Reproduction mistakes influence significantly the outcome feedback compared to application mistakes. Analytic and reproduction mistakes influence elaboration significantly compared to application mistakes. We found a significant effect whether the lecturer allows time for correction of reproduction mistakes compared to application mistakes. These results contribute to the understanding of interactive, patient-centred clinical teaching as well as student mistakes and how teachers are reacting to them. Our descriptive findings provide an empirical basis for clinical teachers to react to student mistakes in didactically fruitful ways.

Introduction: Residents' learning and performance depends on program structures, clinical setting and faculty mentors; however, performance differences between and community based vs. university based residents have not been explored systematically. Objectives: To systematically review the performance differences between internal medicine residents trained in community-based programs [CBPs] versus university-based programs [UBPs] in the US. Methods: Eligible studies were identified in Medline and Embase databases from 1990- June 2018. Eligible studies compared learning and performance differences between UBP and CBP internal medicine residency programs aligned with ACGME recommendations. Results: Out of 4916 titles, 14 cross-sectional studies were included in the analysis. Diverse reporting among the included studies precluded meta-analysis. Significant differences were found in specific practice areas, such as knowledge about HIV, nutrition training, and program accreditation cycle. Residents in UBPs participated more often in hypothesis driven research and had higher publication rates than residents in CBPs. Residents trained in CBPs experienced more burnt out than those in UBPs and had higher prevalence of residents with problematic behaviors and deficiencies. Nonsignificant differences were found among residents regarding ABIM pass rate, medical procedures, and public health training. Conclusion: Our review reports inconsistent trends in residents' learning and performances following RRC-IM and ACGME recommendations. Significant differences were noted in areas that required more practice and system based learning, non-procedural skills and patient care. Future studies with larger sample sizes and adjusted analyses are needed to evaluate the difference between residents' performance and learning in UBPs versus CBPs.

Health care continuity during the transition from pediatric to adult care is critical to helping individuals with autism spectrum disorders manage complex medical and psychiatric co-morbidities that start in childhood and evolve with age. We conducted a brief online survey of pediatric and adult providers at Kaiser Permanente Northern California, a large integrated health care delivery system, to assess departmental policies and personal approaches to transitioning patients with special health care needs, including autism spectrum disorders. A total of 354 pediatric (43% response rate) and 715 adult providers (30% response rate) completed the survey. A large majority of departments did not have transition policies in place. Many providers in both primary care and mental health did not provide transition resources, review legal changes, use standardized assessment tools, or communicate with the next/previous provider. Transition planning was usually delayed until age 17 or later. Most providers did not have consistent approaches to the transition of care for youth with special health care needs and may be inadequately prepared to handle the process for patients with autism spectrum disorders. As the population of transition-age youth with autism spectrum disorders continues to grow, there is urgent need to understand how to best implement transition policies that promote early communication between providers and families and track outcomes among transitioning patients with special health care needs.

Most geriatric care is provided in non-hospital settings. Internal Medicine and Family Medicine residents should therefore learn about these different clinical sites and acuity levels of care. To help facilitate this learning, a geriatrics training curriculum for internal medicine residents was developed that focused on cognition, function, goals of care and medication management in both in-hospital and non-hospital settings. Residents rotated through both in-hospital and non-hospital settings as one block rotation. They took a test of geriatric learning before the rotation and then took the same test at the end of the rotation. Residents showed an improvement in several geriatric domains on completion of a combined in-hospital and non-hospital rotation curriculum. We concluded that the development and implementation of a combined rotation curriculum has practical application to resident learning and the potential to improve geriatrics care outside of hospital settings.

Background: Balint seminars are widely used educational activities in family medicine residency programs. However, their impact on measurable outcomes is uneven and controversial. The discussions in Balint seminars deal with perceiving and understanding the emotions of the participants. Objective: This study measures the effect of Balint seminars on the emotional intelligence (EI) and burnout of internal medicine residents at the American University of Beirut. Design: Quasi-experimental observational pretest--posttest study. Setting: In all, 27 internal medicine residents at the American University of Beirut. Methods: Bi-weekly Balint seminars were delivered to internal medicine residents throughout the academic year. EI using Mayer Salovey and Caruso Emotional Intelligence Test (MSCEIT) and burnout level using Maslach Burnout Inventory (MBI) were measured at the beginning and end of the academic year. Results: A total of 20 Balint seminars were delivered. On average, residents attended six sessions with standard deviation (SD) of 2. Using paired t-tests to compare post- and pre-total EI scores, there was no significant difference between the two scores (mean difference post-pre = -0.6 [plus or minus] 9.7, p = 0.738). Gender was the most important predictor of the difference between pre- and post-total EI scores (women are the reference, [beta] = -8.403, p = 0.007) as compared to understanding emotions baseline score ([beta] = -0.263, p = 0.003). A significant proportion of residents (22.2%-29.6%) showed severe burnout levels on at least one of the three domains of burnout at baseline; however, Balint seminars did not have any effect on any of the burnout domains. Conclusions: Balint seminars may have the beneficial effect of improving emotional intelligence among women. Balint seminars did not improve the burnout levels of internal medicine residents. Optimizing attendance of the Balint sessions may affect the outcomes attributable to Balint seminars.

Competency-based medical education and programmatic assessment intend to increase the opportunities for meaningful feedback, yet these conversations remain elusive. By comparing resident and faculty perceptions of feedback opportunities within one internal medicine residency training program, we sought to understand whether and how principles underlying meaningful feedback could be supported or constrained across a variety of feedback opportunities. Using case-study qualitative methodology, interviews and focus groups were conducted to explore 19 internal medicine residents' and 7 faculty members' perceptions of feedback across a variety of feedback opportunities: coaching, mini-CEXs, in-training evaluation reports and routine clinical supervision. Our data analysis moved iteratively between developing conceptual understandings and fine-grained analyses, while attending to both deductive and inductive analysis. Our results suggest that all feedback opportunities, including those created through formalized assessments, can foster meaningful feedback if faculty establish a trusting relationship with the resident, base their feedback on direct observation and support resident learning. However, formalized assessments were often perceived as inhibiting the conditions for meaningful feedback. A coaching program provided a context in which meaningful feedback could arise, in part because faculty were supported in shifting their focus from patient to resident. Meaningful feedback in clinical education may be fostered across a variety of feedback opportunities, however, it is often constrained by assessment. We must consider whether increasing the frequency of formative assessments may inhibit efforts to improve our feedback cultures while, in contrast, freeing up faculty to focus on supporting resident learning could improve these cultures.

The standardized residency training in China is continuous medical education for postgraduates, which is designed to master basic knowledge, theory, and clinical skills. Case-based discussion (CBD) is one of the main formative curricula used in standardized residency training. The aim of this study was to assess the impact of a novel CBD curriculum on residents' participation, satisfaction, and confidence in clinical skills. This was a prospective study that included 28 internal medicine residents. The traditional CBD contents were adjusted. The innovative approach let residents at different stages prepare and organize the CBD cases by themselves according to different levels of complexity. The surveys were designed to measure conference occurrence and residents' attendance, participation, and satisfaction, as well as their confidence in their clinical skills. Faculty could further engage the residents at any point to deepen the discussion and learning. The surveys indicated that the residents had a high satisfaction rate with the novel-staged CBD teaching method. Our curriculum improved conference occurrence, attendance, and participation; increased residents' self-report of participation in learning; and raised their confidence in their clinical skills, so the CBD was well received by residents and faculty preceptors. In addition, this study demonstrated that the staged CBD increased the knowledge and evidence usage of internal medicine residents. We expect wider application of this kind of CBD in clinical practice, medical education, residency training, and patient education in the future.

This article utilizes one counselor education program's experience as a framework for exploring how to prepare counselors to work in interdisciplinary teams. Based on an interdisciplinary training program that involves faculty and graduate students from counseling, social work, nursing, internal medicine and family medicine, the article explores the role discipline-specific orientations play in the outcome of interdisciplinary training programs. Using practical examples grounded by the program's experiences and literature on interdisciplinary training, understanding of the dynamics of interdisciplinary training programs is explored. Implications for preparing counselors for interdisciplinary work and future research are provided.

Changes to the American Board of Internal Medicine's Maintenance of Certification Program: Preserving Core Assessment Values As Maintenance of Certification (MoC) for practicing physicians has evolved into more continuous programs, controversy has arisen over how physicians should self-regulate their profession and serve the public trust in doing so. As a result, the American Board of Internal Medicine (ABIM) has focused on making substantial changes to its MoC program by inviting physician members of the internal medicine community to play critical roles in shaping the program's processes through innovation. Much of the recent focus has been on changing the high-stakes assessment to one that is more relevant and authentic to practice, less burdensome and anxiety provoking for physicians, and more continuous over the course of their career. However, at the same time, ABIM has been careful to preserve the core values of integrity and fairness that are central to testing programs especially when making consequential decisions about test-takers in order to ensure that public expectations are met. This paper lays out the case for a continuous certification program with consequences and the story of how substantial changes were made using an evidence-based approach involving the physician community.

In an effort to meet the needs of adults with autism spectrum disorder (ASD) while hospitalized, a team of experts and providers from Massachusetts General Hospital (MGH), MGH for Children as well as parents of individuals with ASD was sparked in 2013. This became a multidisciplinary collaborative, the MGH Autism Care Collaborative, to improve adult care for inpatients with ASD. The collaborative was created with three goals in mind: (1) to educate internal medicine adult inpatient providers and staff on the unique needs of adults with ASD when hospitalized; (2) to create ASD specific resources for internal medicine adult inpatient providers; and (3) to optimize patient care from admission to discharge among adults with ASD admitted to internal medicine services.

Most training programs use learners' subjective ratings of their teachers as the primary measure of teaching effectiveness. In a recent study we found that preclinical medical students' ratings of classroom teachers were associated with perceived charisma and physical attractiveness of the teacher, but not intellect. Here we explored whether the relationship between these variables and teaching effectiveness ratings holds in the clinical setting. We asked 27 Internal Medicine residents to rate teaching effectiveness of ten teachers with whom they had worked on a clinical rotation, in addition to rating each teacher's "clinical skills," "physical attractiveness," and "charisma." We used linear regression to study the association between these explanatory variables and teaching effectiveness ratings. We found no association between rating of physical attractiveness and teaching effectiveness. Clinical skill and charisma were independently associated with rating of teaching effectiveness (regression coefficients [95% confidence interval] 0.73 [0.60, 0.85], p < 0.001 and 0.12 [0.01, 0.23], p = 0.03, respectively). The variables associated with effectiveness of classroom and clinical teachers differ, suggesting context specificity in teaching effectiveness ratings. Context specificity may be explained by differences in the exposure that learners have to teachers in the classroom versus clinical setting--so that raters in the clinical setting may base ratings upon observed behaviours rather than stereotype data. Alternatively, since subjective ratings of teaching effectiveness inevitably incorporate learners' context-specific needs, the attributes that make a teacher effective in one context may not meet the needs of learners in a different context.

Physician burnout and empathy erosion are common during training and clinical practice. Museums can effectively partner with health professional schools and hospitals to address these challenges through reflective practice and a focus on physician wellness. We describe a partnership between the Brigham and Women's Hospital Department of Medicine and the Boston Museum of Fine Arts created to meet these needs. Since 2010, internal medicine residents have spent an evening of reflection and community-building at the museum as part of their Humanistic Curriculum. Residents participate in a visual thinking exercise, metaphor-making with contemporary art, group drawing, a discussion of death and dying, and a brief meditation. Residents report that the program has led them to renew commitments to family and friends, to spend time in daily reflection, and to connect more with patients. In this article we report perspectives from physician and museum stakeholders highlighting the value of this unique collaboration.

Context specificity and the impact that contextual factors have on the complex process of clinical reasoning is poorly understood. Using situated cognition as the theoretical framework, our aim was to evaluate the verbalized clinical reasoning processes of resident physicians in order to describe what impact the presence of contextual factors have on their clinical reasoning. Participants viewed three video recorded clinical encounters portraying straightforward diagnoses in internal medicine with select patient contextual factors modified. After watching each video recording, participants completed a think-aloud protocol. Transcripts from the think-aloud protocols were analyzed using a constant comparative approach. After iterative coding, utterances were analyzed for emergent themes with utterances grouped into categories, themes and subthemes. Ten residents participated in the study with saturation reached during analysis. Participants universally acknowledged the presence of contextual factors in the video recordings. Four categories emerged as a consequence of the contextual factors: (1) emotional reactions (2) behavioral inferences (3) optimizing the doctor patient relationship and (4) difficulty with closure of the clinical encounter. The presence of contextual factors may impact clinical reasoning performance in resident physicians. When confronted with the presence of contextual factors in a clinical scenario, residents experienced difficulty with closure of the encounter, exhibited as diagnostic uncertainty. This finding raises important questions about the relationship between contextual factors and clinical reasoning activities and how this relationship might influence the cost effectiveness of care. This study also provides insight into how the phenomena of context specificity may be explained using situated cognition theory.

Internists are required to perform a number of procedures that require mastery of technical and non-technical skills, however, formal assessment of these skills is often lacking. The purpose of this study was to develop, implement, and gather validity evidence for a procedural skills objective structured clinical examination (PS-OSCE) for internal medicine (IM) residents to assess their technical and non-technical skills when performing procedures. Thirty-five first to third-year IM residents participated in a 5-station PS-OSCE, which combined partial task models, standardized patients, and allied health professionals. Formal blueprinting was performed and content experts were used to develop the cases and rating instruments. Examiners underwent a frame-of-reference training session to prepare them for their rater role. Scores were compared by levels of training, experience, and to evaluation data from a non-procedural OSCE (IM-OSCE). Reliability was calculated using Generalizability analyses. Reliabilities for the technical and non-technical scores were 0.68 and 0.76, respectively. Third-year residents scored significantly higher than first-year residents on the technical (73.5 vs. 62.2%) and non-technical (83.2 vs. 75.1%) components of the PS-OSCE (p < 0.05). Residents who had performed the procedures more frequently scored higher on three of the five stations (p < 0.05). There was a moderate disattenuated correlation (r = 0.77) between the IM-OSCE and the technical component of the PS-OSCE scores. The PS-OSCE is a feasible method for assessing multiple competencies related to performing procedures and this study provides validity evidence to support its use as an in-training examination.

Resident physicians' clinical training poses unique challenges for the delivery of safe patient care. Residents face special risks of involvement in medical errors since they have tremendous responsibility for patient care, yet they are novice practitioners in the process of learning and mastering their profession. The present study explores the relationships between residents' error rates and three clinical training methods (1) progressive independence or level of autonomy, (2) consulting the physician on call, and (3) familiarity with up-to-date medical literature, and whether these relationships vary among the specialties of surgery and internal medicine and between novice and experienced residents. 142 Residents in 22 medical departments from two hospitals participated in the study. Results of hierarchical linear model analysis indicated that lower levels of autonomy, higher levels of consultation with the physician on call, and higher levels of familiarity with up-to-date medical literature were associated with lower levels of resident's error rates. The associations varied between internal and surgery specializations and novice and experienced residents. In conclusion, the study results suggested that the implicit curriculum that residents should be afforded autonomy and progressive independence with nominal supervision in accordance with their relevant skills and experience must be applied cautiously depending on specialization and experience. In addition, it is necessary to create a supportive and judgment free climate within the department that may reduce a resident's hesitation to consult the attending physician.

Spatial abilities have been related in previous studies to three-dimensional (3D) anatomy knowledge and the performance in technical skills. The objective of this study was to relate spatial abilities to residency programs with different levels of content of 3D anatomy knowledge and technical skills. The hypothesis was that the choice of residency program is related to spatial abilities. A cohort of 210 medical graduates was enrolled in a prospective study in a 5-year experiment. Spatial abilities were measured with a redrawn Vandenberg and Kuse Mental Rotations Test (MRT) in two (MRTA) and three (MRTC) dimensions. Medical graduates were enrolled in Family Medicine (n?=?76, 36.2%), Internal Medicine (64, 30.5%), Surgery (52, 24.8%), and Anesthesia (18, 8.6%). The assumption was that the level of 3D anatomy knowledge and technical skills content was higher in Surgery and Anesthesia compared to Family Medicine and Internal Medicine. Mean MRTA score of 12.4 (±SD 4.6), 12.0 (±4.3), 14.1 (±4.3), and 14.6 (±4.0) was obtained in Family Medicine, Internal Medicine, Surgery, and Anesthesia, respectively (P =?0.0176). Similarly, mean MRTC score of 8.0 (±4.4), 7.5 (±3.6), 8.5 (±3.9), and 7.9 (±4.1) was obtained (P =?0.5647). Although there was a tendency for lower MRTA score in Family Medicine and Internal Medicine compared to Surgery and Anesthesia, no statistically significant main effect of residency, year, sex, or the interactions were observed for the MRTA and MRTC. Studied sample of medical graduates was not found to choose their residency programs based on their innate spatial abilities.

A growing group of inpatients on acute clinical teaching units have non-acute needs, yet require attention by the team. While anecdotally, these patients have inspired frustration and resource pressures in clinical settings, little is known about the ways in which they influence physician perceptions of the learning environment. This qualitative study explored residents' and attending physicians' perceptions of caring for these patients, including their educational value. Using constructivist grounded theory, we conducted seven homogeneous focus groups and three interviews with residents and attending physicians from neurology and general internal medicine. A constant comparative analytical approach was employed alongside data collection, using theoretical sampling to explore emergent themes. Residents consistently described non-acute patients as non-educational, uninteresting, but still in need of care. Some attending physicians echoed this view, while others described multiple learning opportunities presented by non-acute patients. Both groups described residents as engaging with non-acute patients in a professional capacity, but not as learners. This engagement in a professional capacity could be considered diligent disinterest, or resigned professionalism. A constructivist understanding of the dynamics which influence learning in the workplace was used to explore the reasons why the residents in our study did not recognize the learning opportunities presented by non-acute patients. Our results resonate with Billett's theory of workplace affordances, which offers an explanation as to why learners may not identify or take advantage of potential learning opportunities. Overall, our study assists our understanding of the sociocultural factors that influence learners' choices to engage with particular clinical learning opportunities.

Objective structured clinical examinations (OSCEs) are used worldwide for summative examinations but often lack acceptable reliability. Research has shown that reliability of scores increases if OSCE checklists for medical students include only clinically relevant items. Also, checklists are often missing evidence-based items that high-achieving learners are more likely to use. The purpose of this study was to determine if limiting checklist items to clinically discriminating items and/or adding missing evidence-based items improved score reliability in an Internal Medicine residency OSCE. Six internists reviewed the traditional checklists of four OSCE stations classifying items as clinically discriminating or non-discriminating. Two independent reviewers augmented checklists with missing evidence-based items. We used generalizability theory to calculate overall reliability of faculty observer checklist scores from 45 first and second-year residents and predict how many 10-item stations would be required to reach a Phi coefficient of 0.8. Removing clinically non-discriminating items from the traditional checklist did not affect the number of stations (15) required to reach a Phi of 0.8 with 10 items. Focusing the checklist on only evidence-based clinically discriminating items increased test score reliability, needing 11 stations instead of 15 to reach 0.8; adding missing evidence-based clinically discriminating items to the traditional checklist modestly improved reliability (needing 14 instead of 15 stations). Checklists composed of evidence-based clinically discriminating items improved the reliability of checklist scores and reduced the number of stations needed for acceptable reliability. Educators should give preference to evidence-based items over non-evidence-based items when developing OSCE checklists.

Mismatches between the needs of public health systems and student interests have led to renewed study on the factors predicting career specializations among medical students. While most work examines career and lifestyle values, emotional proclivities may be important; disgust sensitivity may help explain preferences for careers with greater and lesser degrees of procedural content. In the study, 294 students completed measures assessing: (1) demographics, (2) career interest or intention regarding emergency medicine, internal medicine, obstetrics/gynecology, and pediatric medicine, (3) traditional determinants of career intention/interest, and (4) core/bodily product, animal reminder, contamination, and sexual/moral disgust sensitivity. As predicted, logistic regressions controlling for demographics and traditional career predictors, showed that greater animal reminder disgust predicted reduced interest in emergency medicine but greater interest in pediatric medicine. Conversely, greater core/bodily product disgust predicted lower interest in obstetrics/gynecology and pediatric medicine; greater contamination and sexual/moral disgust both predicted increased odds of interest in internal medicine. Overall, specific disgust sensitivities were the best predictors of specialization intention in multivariate models. Specific disgust sensitivities appear to differentially deter and/or predispose self-selection into specific trajectories varying in procedural content. Such findings may permit the early identification of specialty fit and provide guidance in career counseling.

Changes in certification requirements and examinee characteristics are likely to influence the validity of the evidence associated with interpretations made based on test data. We examined whether changes in Educational Commission for Foreign Medical Graduates (ECFMG) certification requirements over time were associated with changes in internal medicine (IM) residency program director ratings and certification examination scores. Comparisons were made between physicians who were ECFMG-certified before and after the Clinical Skills Assessment (CSA) requirement. A multivariate analysis of covariance was conducted to examine the differences in program director ratings based on CSA cohort and whether the examinees emigrated for undergraduate medical education (national vs. international students). A univariate analysis of covariance was conducted to examine differences in scores from the American Board of Internal Medicine (ABIM) Internal Medicine Certification Examination. For both analyses, United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores were used as covariates. Results indicate that, of those certified by ECFMG between 1993 and 1997, 17 % (n = 1,775) left their country of citizenship for undergraduate medical education. In contrast, 38 % (n = 1,874) of those certified between 1999 and 2003 were international students. After adjustment by covariates, the main effect of cohort membership on the program director ratings was statistically significant (Wilks' ? = 0.99, F[subscript 5, 15391] = 19.9, P < 0.001). However, the strength of the relationship between cohort group and the ratings was weak (? = 0.01). The main effect of migration status was statistically significant and weak (Wilks' ? = 0.98, F[subscript 5,15391] = 45.3, P < 0.01; ? = 0.02). Differences in ABIM Internal Medicine Certification Examination scores based on whether or not CSA were required was statistically significant, although the magnitude of the association between these variables was very small. The findings suggest that the implementation of an additional evaluation of skills (e.g., history-taking, physical examination) as a prerequisite to postgraduate medical education (residency) provides some additional, relevant data to those who select ECFMG-certified residents.

The high attrition rate of female physicians pursuing an academic medicine research career has not been examined in the context of career development theory. We explored how internal medicine residents and faculty experience their work within the context of their broader life domain in order to identify strategies for facilitating career advancement. Semi-structured interviews were conducted with a purposeful sample of 18 residents and 34 faculty members representing male and female physicians at different career stages. Using thematic analysis, three themes emerged: (1) the love of being a physician ("Raison d'être"), (2) family obligations ("2nd Shift"), and (3) balancing work demands with non-work life ("Negotiating Academic Medicine"). Female researchers and educators reported more strategies for multiple role planning and management than female practitioners. Interventions aimed at enhancing academic internists' planning and self-efficacy for multiple role management should be investigated as a potential means for increasing participation and facilitate advancement.

Background: Due to significant medical improvements, persons with Down syndrome now live well into adulthood. Consequently, primary care for adults with Down syndrome needs to incorporate routine care with screening for condition-specific comorbidities. This study seeks to evaluate the adherence of primary care physicians to age- and condition-specific preventive care in a cohort of adults with Down syndrome. Methods: In this retrospective observational cohort study, preventive screening was evaluated in patients with Down syndrome aged 18-45 years who received primary care in an academic medical centre from 2000 to 2008. Comparisons were made based on the field of patients' primary care providers (Family or Internal Medicine). Results: This cohort included 62 patients, median index age = 33 years. Forty per cent of patients received primary care by Family Physicians, with 60% seen by Internal Medicine practices. Patient demographics, comorbidities and overall screening patterns were similar between provider groups. Despite near universal screening for obesity and hypothyroidism, adherence to preventive care recommendations was otherwise inconsistent. Screening was "moderate" (50-80%) for cardiac anomalies, reproductive health, dentition, and the combined measure of behaviour, psychological, or memory abnormalities. Less than 50% of patients were evaluated for obstructive sleep apnea, atlanto-axial instability, hearing loss or vision loss. Conclusions: We observed inconsistent preventive care in adults with Down syndrome over this 8.5-year study. This is concerning, given that the adverse effects of many of these conditions can be ameliorated if discovered in a timely fashion. Further studies must evaluate the implications of screening practices and more timely identification of comorbidities on clinical outcomes. (Contains 3 figures and 5 tables.)

Objectives: Resident physicians report insufficient experience caring for patients with substance use disorders (SUDs). Resident training in Screening, Brief Intervention, and Referral to Treatment (SBIRT) has been recommended. We describe the development of a standardized patient (SP) assessment to measure SBIRT skills, resident perceptions of the exercise, and confidence in SBIRT skills. Methods: Fifteen Internal Medicine residents participated in the pre-curriculum SP assessment and 12 participated in the post-curriculum assessment. Results: Residents reported that SP encounters were similar to patients seen, and resident satisfaction was high. Residents felt confident screening for alcohol abuse, but less confident developing SUD treatment plans. Conclusion: An SP assessment can evaluate SBIRT skills and is well received. Residents may need additional practice to improve confidence in making SUD treatment plans. (Contains 5 tables.)

This study examined physicians' motivation to engage in work-related learning and its contribution to expertise development beyond work experience. Based on deliberate practice theory, semi-structured interviews were conducted with 17 residents and 28 experienced physicians in internal medicine, focusing on the activities they engaged in during work that might contribute to professional development and the goals underlying this behavior. Learning motivation was also measured using a goal orientation questionnaire. Expertise was measured by a case test derived from the Medical Knowledge Self Assessment Program (MKSAP). The interviews showed that participants' learning was largely embedded in everyday work; most of their learning activities were inherent to the job rather than motivated by competence improvement goals. The problems encountered in patient care played a key role in prompting learning. Role, work experience and work situation affected the type of activities engaged in, as well as the intensity of practice. Deliberate engagement in work-related learning activities was related neither to goal orientations nor to case test performance, except activities by the experienced physicians to keep up-to-date. Work experience, in contrast, showed a clear positive relationship with the performance of residents. Two main conclusions can be drawn from this study: (1) patient care induced relevant learning activities aimed at performance improvement for the patient's sake; (2) deliberate investments in learning can be enhanced to promote expertise development. Self-regulated learning by physicians needs to be strengthened and the organization for which they work should facilitate and encourage learning in daily practice.

Objective: The authors examined the effect of supervision on internal medicine residents' attitudes toward and management of depression. Method: Internal medicine residents completed a survey during preclinical conferences. The survey included a published, validated questionnaire, the Depression Attitude Questionnaire, and items developed by the researchers. Results: Of residents in attendance on the day of survey administration, 94% (51/54) agreed to participate. The study sample contained 39% of the 139-member residency program. About half (49%) reported feeling uncomfortable managing depression. Perceived training adequacy was correlated with a greater feeling of ease managing depression. Most residents reported screening [less than or equal to]20% of patients for depression, although 71% indicated they are more likely to screen if it were a priority for their supervisor. Fifty-eight percent indicated that supervisors' attitudes affect their own attitudes. However, significant correlations between supervisor and resident attitudes were not observed. Conclusion: The results of this pilot study suggest that supervision can encourage screening and promote resident preparedness to manage depression.

Studies of doctor-patient communication generally advocate a partnership communication style. However, in Southeast Asian settings, we often see a more one-way style with little input from the patient. We investigated factors underlying the use of a one-way consultation style by doctors in a Southeast Asian setting. We conducted a qualitative study based on principles of grounded theory. Twenty residents and specialists and 20 patients of a low or high educational level were interviewed in internal medicine outpatient clinics of an Indonesian teaching hospital and two affiliated hospitals. During 26 weeks we engaged in an iterative interview and coding process to identify emergent factors. Patients were generally dissatisfied with doctors' communication style. The doctors indicated that they did not deliberately use a one-way style. Communication style appeared to be associated with characteristics of Southeast Asian culture, the health care setting and medical education. Doctor-patient communication appeared to be affected by cultural characteristics which fell into two broad categories representing key features of Southeast Asian culture, "social distance" and "closeness of relationships", and to characteristics categorized as "specific clinical context". Consideration of these characteristics could be helpful in promoting the use of a partnership communication style. (Contains 2 tables.)

Introduction: Board certification has evolved from a "point-in-time" event to a process of periodic learning and reevaluation of medical competence through maintenance of certification (MOC). To better understand MOC participation, the transtheoretical model (TTM) was used to describe physicians' perceptions of MOC as a sequence of attitudinal changes. Method: Data were from a survey of internal medicine (IM) physicians' attitudes toward periodic reevaluation through MOC. An overall importance or decisional balance score was computed for each physician by summing his or her ratings across the 10 quality measures. The decisional balance score was used to classify physicians according to their acceptance of MOC, aligned with the 3 early TTM stages-of-change groups--precontemplation (PC), contemplation (C), and preparation (P)--where PC was least accepting and P was most accepting. Effect sizes assessed whether differences in attitudes toward reevaluation via MOC were of sufficient magnitude to support the TTM principles. Results: The difference in degree of acceptance of MOC between the P group and the PC and C groups was significant ("p" less than 0.001), but the effect size was lower than predicted by the "strong" principle. Resistance to MOC for the PC and C groups was significantly greater than the P group ("p" less than 0.001) and supported the "weak" principle. Physicians' beliefs about how often they should demonstrate performance on quality measures aligned well with the American Board of Internal Medicine's MOC requirements, with the P group believing in more frequent assessments than the PC and C groups ("p" less than 0.001). Conclusions: Results show that physicians in the Preparation stage had overcome resistance to MOC as predicted by the "weak" principle of the TTM, but their attitude scores about the benefits of MOC were below what was expected by theory. This suggests that the structure of MOC may have made it easier for physicians to overcome barriers to MOC participation but may have lacked adequate resources to promote the benefits of participating in the process. More effort is needed to understand the specific benefits of MOC for reevaluating competencies, how to engage physicians and other stakeholders in the design of MOC, and how to communicate the rationale and evidence to those who are less accepting of MOC. (Contains 3 tables.)

Medical residency is a period of intense socialization with a heavy workload. Previous sociological studies have identified efficiency as a practical skill necessary for success. However, many contextual features of the training environment have undergone dramatic change since these studies were conducted. What are the consequences of these changes for the socialization of residents to time management and the development of a professional identity? Based on observations of and interviews with internal medicine residents at three training programs, we find that efficiency is both a social norm and strategy that residents employ to manage a workload for which the demand for work exceeds the supply of time available to accomplish it. We found that residents struggle to be efficient in the face of seemingly intractable "systems" problems. Residents work around these problems, and in doing so develop a tolerance for organizational vulnerabilities. (Contains 3 notes and 3 tables.)

Context specificity, or the variation in a participant's performance from one case, or situation, to the next, is a recognized problem in medical education. However, studies have not explored the potential reasons for context specificity in experts using the lens of situated cognition and cognitive load theories (CLT). Using these theories, we explored the influence of selected contextual factors on clinical reasoning performance in internal medicine experts. We constructed and validated a series of videotapes portraying different chief complaints for three common diagnoses seen in internal medicine. Using the situated cognition framework, we modified selected contextual factors--patient, encounter, and/or physician--in each videotape. Following each videotape, participants completed a post-encounter form (PEF) and a think-aloud protocol. A survey estimating recent exposure from their practice to the correct videotape diagnoses was also completed. The time given to complete the PEF was randomly varied with each videotape. Qualitative utterances from the think-aloud procedure were converted to numeric measures of cognitive load. Survey and cognitive load measures were correlated with PEF performance. Pearson correlations were used to assess relations between the independent variables (cognitive load, survey of experience, contextual factors modified) and PEF performance. To further explore context specificity, analysis of covariance (ANCOVA) was used to assess differences in PEF scores, by diagnosis, after controlling for time. Low correlations between PEF sections, both across diagnoses and within each diagnosis, were observed (r values ranged from -0.63 to 0.60). Limiting the time to complete the PEF impacted PEF performance (r = 0.2 to 0.4). Context specificity was further substantiated by demonstrating significant differences on most PEF section scores with a diagnosis (ANCOVA). Cognitive load measures were negatively correlated with PEF scores. The presence of selected contextual factors appeared to influence diagnostic more than therapeutic reasoning (r = -0.2 to -0.38). Contextual factors appear to impact expert physician performance. The impact observed is consistent with situated cognition and CLT's predictions. These findings have potential implications for educational theory and clinical practice.

At our medical college many students have lower ratings in their clinical performance once they start their clinical years (third year). This is contrary to their results in other written exams. Some students demonstrate better clinical performance. We used the six-step Positive Deviance (PD) Conceptual Framework to identify and disseminate the strategies employed by the successful students to improve group clinical performance. Fifty 3rd year students (of a 5-year MBBS program) rotating through internal medicine were assessed mid-rotation with mini-CEX and 360[degrees] evaluations. Twenty students (40%) who performed well were invited for in depth interviews in order to identify positive deviant behavior in their clinical skills learning practices. The seven students (14%) who reported novel behaviors were asked to develop strategies for dissemination of their learning behavior in their peers. They decided to work in small groups with their peers, using the identified PD behaviors to encourage learning of history taking and examining skills in their peers. Group performance was assessed at the end of rotation, using mini-CEX and 360[degrees] evaluation in comparison to a subsequent group of students in the same year that did not work in PD peer learning groups. For the 360[degrees] evaluation the EP[squared] (generalizability coefficient) was 0.92 and for the mini-CEX the EP[squared] was 0.95, taking into account the variances between participants, groups, time and the interactions effects; thus indicating good reliability of both the assessment methods. A statistically significant difference (p less than 0.05) was seen for improvement in medical interviewing skills and clinical judgment on the mini-CEX exam and 360 evaluation (p less than 0.0001) in the PD group. Positive Deviance approach can help highlight behaviors among medical students, which contribute to success but may go unnoticed. Learning strategies based on the PD framework can improve student's group performance.

Context: Knowing the team physician's perspective regarding the use of evidence-based practice (EBP) for treatment of exertional heat stroke (EHS) may help increase the number of athletic trainers (ATs) implementing best practices and avoiding the use of improper assessment tools and treatment methods. Objective: To ascertain team physicians' perspectives regarding the AT's use of rectal temperature (T[subscript re]) and cold-water immersion (CWI) for recognition and treatment of EHS. Design: Exploratory study using semi-structured focus groups and follow-up telephone interviews. Setting: American College of Sports Medicine Annual meeting. Patients or Other Participants: Thirteen family or internal medicine specialists who were currently serving as the team physician for a college/university or secondary school participated. The mean age was 44 plus or minus 4 with 10 plus or minus 8 years of sports medicine specific experience. Of these, 7 participated in a focus group and 5 completed a telephone interview. Data Collection and Analysis: Data analysis included open coding procedures by a 3-member research team. Credibility was established by member checks and multiple analyst triangulations. Results: Two major themes emerged regarding how ATs could be encouraged to use T[subscript re] assessment and CWI in clinical practice: 1) "pre-certification" and 2) "post-certification." Pre-certification included two lower level themes: a) "real-life experience" and b) "skill set mandate." The post-certification theme included one lower theme: "professional development." Conclusion: Physicians, in recognition of the dichotomy between best and actual practices, believe that ATs must receive both formal skill training in a structured learning environment and field experience using these methods, and remain current through annual professional development seminars and courses. (Contains 1 table and 1 figure.)

The authors sought to evaluate the feasibility and acceptability of initiating a Screening, Brief Intervention, and Referral to Treatment (SBIRT) for alcohol and other drug use curriculum across multiple residency programs. SBIRT project faculty in the internal medicine (traditional, primary care internal medicine, medicine/pediatrics), psychiatry, obstetrics and gynecology, emergency medicine, and pediatrics programs were trained in performing and teaching SBIRT. The SBIRT project faculty trained the residents in their respective disciplines, accommodating discipline-specific implementation issues and developed a SBIRT training Web site. Post-training, residents were observed performing SBIRT with a standardized patient. Measurements included number of residents trained, performance of SBIRT in clinical practice, and training satisfaction. One hundred and ninety-nine residents were trained in SBIRT: 98 internal medicine, 35 psychiatry, 18 obstetrics and gynecology, 21 emergency medicine, and 27 pediatrics residents. To date, 338 self-reported SBIRT clinical encounters have occurred. Of the 196 satisfaction surveys completed, the mean satisfaction score for the training was 1.60 (1 = very satisfied to 5 = very dissatisfied). Standardized patient sessions with SBIRT project faculty supervision were the most positive aspect of the training and length of training was a noted weakness. Implementation of a graduate medical education SBIRT curriculum in a multispecialty format is feasible and acceptable. Future efforts focusing on evaluation of resident SBIRT performance and sustainability of SBIRT are needed. (Contains 2 figures and 3 tables.)

Introduction: Electronic knowledge resources have the potential to rapidly provide answers to clinicians' questions. We sought to determine clinicians' reasons for searching these resources, the rate of finding relevant information, and the perceived clinical impact of the information they retrieved. Methods: We asked general internists, family physicians, and clinical nurse practitioners to complete the Information Assessment Method (IAM) survey after searching 1 of 2 electronic knowledge resources linked in the electronic health record. IAM stimulates reflection on the relevance, cognitive impact, use, and potential health outcomes of retrieved clinical information. Results: Forty-two clinicians rated 502 searches (mean 12, range 1-48) and reported finding information 75% (n = 375) of the time. The most common reasons for searching were to address a clinical question (411, 82%) and for curiosity (75, 15%). In 68% of the rated searches (341), participants indicated they would use the retrieved information for at least 1 patient. In 31% (157) of rated searches, clinicians expected the retrieved information to benefit the patient by avoiding an unnecessary or inappropriate treatment, diagnostic procedure, or preventive intervention. Conclusions: Searches in electronic knowledge resources frequently yield relevant information that may benefit the patient by, for example, avoiding an inappropriate diagnostic procedure or treatment. Knowing that searches for answers to clinical questions can result in patient health benefits should intensify efforts to encourage clinicians to pursue answers to their questions.

Over the last decade a significant increase in the life expectancy of people with Down syndrome (DS) has been observed, which has caused a higher incidence of morbidity as they age. However, there is a lack of literature regarding morbidity and hospitalization of adults with DS. Analysis of 297 hospitalizations of 120 adults with DS aged 18-73 years hospitalized at Hadassah Medical Centers during the years 1988-2007 compared with data of the general population, hospitalized at the same period. At the age range 18-66 years, mean number of hospitalizations was significantly higher than the general population (P = 0.000001) with hospitalization also significantly longer (P = 0.0009). Exceptionally long hospitalizations were seen at the departments of internal medicine, dermatology and intensive care units. There was no significant difference in mortality between DS and the general population (P = 0.221). More than a fourth of the hospitalizations were caused by infectious diseases, mostly respiratory infections. Hypothyroidism was more prevalent compared with the estimated number reported by the literature (30.8% vs. 15%). Convulsive disorder was prevalent as well (15.8%). However, the prevalence of congenital heart disease, dementia, osteoporosis and obesity was found less than expected. Adults with DS are hospitalized more than the general population and for longer duration. The results of this study emphasize the need for preventive community-based medicine, awareness of co-morbidities and possible deterioration and to prepare the medical staff for a complex course of illness, expecting longer hospitalizations, arising from the complexity of this population. (Contains 7 tables.)

Effective clinical faculty are essential for disseminating substance abuse screening, brief intervention, and referral to treatment (SBIRT). The authors developed an 8-hour SBIRT training for internal medicine faculty preceptors. Trainers conducted SBIRT lectures and small-group communication practice sessions. The authors assessed participants' (n = 27) knowledge, skills, and attitudes using an enhanced Alcohol and Alcohol Problems Perceptions Questionnaire (AAPPQ). Participants self-assessed their changes in SBIRT competence and comfort. Faculty trainees did not feel competent in SBIRT, particularly in intervention and referral to treatment. AAPPQ subscale scores were highest in Role Legitimacy and Motivation and lowest in Role Adequacy and Satisfaction. After training, faculty members reported greater likelihood of performing and teaching SBIRT. In some topic areas, faculty attending an SBIRT training reported limited knowledge and competence for treating drinkers; however, their interest and motivation for doing so was high. Ongoing faculty and organizational development efforts may help close these gaps. (Contains 1 figure and 2 tables.)

Comprehensive clinical competency curricula for hazardous drinking and substance use disorders (SUDs) exists for medical students, residents, and practicing health care providers. Evaluations of these curricula typically focus on learner attitudes and knowledge, although changes in clinical skills are of greater interest and utility. The authors present a pre-post clinical skill evaluation of a 10-hour screening, brief intervention, and referral to treatment (SBIRT) curriculum for hazardous drinking and SUDs for primary care internal medicine residents using standardized patient examinations to better determine the impact of SBIRT training on clinical practice. Residents had large improvements in history taking, substance use screening skills, SUD assessment and diagnostic skills, and in SBIRT knowledge, including documentation, systems, and diversity issues. Residents made moderate improvements in brief intervention skills. Future SBIRT curricular evaluations would ideally include a controlled comparison with larger samples from multiple institutions. (Contains 2 tables.)

A major barrier to actualizing the public health impact potential of screening, brief intervention, and referral to treatment (SBIRT) is the suboptimal development and implementation of evidence-based training curricula for healthcare providers. As part of a federal grant to develop and implement SBIRT training in medical residency programs, the authors assessed 95 internal medicine residents before they received SBIRT training to identify self-reported characteristics and behaviors that would inform curriculum development. Residents' confidence in their SBIRT skills significantly predicted SBIRT practice. Lack of experience dealing with alcohol or drug problems and discomfort in dealing with these issues were significantly associated with low confidence. To target these barriers, the authors revised their SBIRT curriculum to increase residents' confidence in their skills and developed an innovative SBIRT Proficiency Checklist and Feedback Protocol for skills practice observations. Qualitative feedback suggests that, despite the discomfort residents experience in being observed, a proficiency checklist and feedback protocol appear to boost learner confidence. (Contains 3 tables.)

The Baylor College of Medicine SBIRT Medical Residency Training Program is a multilevel project that trains residents and faculty in evidenced-based screening, brief intervention, and referral to treatment (SBIRT) methods for alcohol and substance use problems. This paper describes the training program and provides initial evaluation after the first year of the project. The program was successfully incorporated into the residency curricula in family medicine, internal medicine, and psychiatry. Initial evaluations indicate a high degree of satisfaction with the program and, despite a slight decrease in satisfaction scores, participants remained satisfied with the program after 30 days. Implementation barriers, solutions, and future directions of the program are discussed. (Contains 1 figure and 4 tables.)