Graduate Medical Education Resources
General Medical Education | Educational Innovation and Curriculum Development |
Assessment and Feedback | Life Long Learning | Web-Based Learning | Professionalism |
Practice-Based Learning and Improvement

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General Medical Education
Buchel T, Edwards F. Characteristics of effective clinical teachers. Fam Ed 2005; 37: 30-35.
Buchel & Edwards - Characteristics of effective clinical teachers

OBJECTIVES: Defining what makes an exceptional teacher is challenging. This study's objectives were to identify teaching attributes that residents and faculty value most and to determine whether the opinions of residents and faculty differed.
METHODS: A list of 15 teaching attributes was distributed to residents and faculty at eight family medicine residency programs. Respondents were asked to indicate the three most important and the three least important attributes of effective clinical educators.
RESULTS: Overall response rates were 58% for residents and 65% for faculty. Residents and faculty agreed that being enthusiastic and having clinical competence are important attributes and that scholarly activity is not as important. Residents felt it is important for an educator to respect their autonomy and independence as clinicians, whereas faculty members felt that this was among the least important traits. Faculty felt that serving as a role model worth emulating was important, but residents ranked this at the bottom of their list. Residents placed a higher premium on a faculty member's ability to answer questions clearly and explain difficult topics (labeled "clarity" in our study) and felt more strongly that it was important for quality educators to be readily available and able to provide a safe, nonjudgmental, nonthreatening learning environment.
CONCLUSIONS: There are areas of agreement and disagreement between faculty and residents about attributes of effective clinical teachers. With the implementation of competency-based assessment systems, it will become important to determine which attributes actually promote the development of competence among learners, thereby allowing the encouragement of those attributes.

Baylor College of Medicine. Team learning in medical education.
Branch WT, Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med 2002; 77: 1185-88.
Branch & Paranjape - Feedback and reflection: teaching methods for clinical settings

Feedback and reflection are two basic teaching methods used in clinical settings. In this article, the authors explore the distinctions between, and the potential impact of, feedback and reflection in clinical teaching. Feedback is the heart of medical education; different teaching encounters call for different types of feedback. Although most clinicians are familiar with the principles of giving feedback, many clinicians probably do not recognize the many opportunities presented to them for using feedback as a teaching tool. Reflection in medicine-the consideration of the larger context, the meaning, and the implications of an experience and action-allows the assimilation and reordering of concepts, skills, knowledge, and values into pre-existing knowledge structures. When used well, reflection will promote the growth of the individual. While feedback is not used often enough, reflection is probably used even less.

Cavalcanti RB, Detsky AS: The education and training of future physicians. Why coaches cant be judges. JAMA 2011; 306(9): 993-994.
Cavalcanti & Detsky - The education and training of future physicians: Why coaches cant be judges

A physician must be able to diagnose and treat patients. The clinical skills required to be successful include gathering data, differentiating important from unimportant facts, making decisions about further investigations and treatments, implementing therapy, and providing follow-up, education, and counseling. These skills cannot be learned through reading or in classrooms alone practical experience is required. The present method of exposing physicians-in-training to practical experience involves a hierarchical team approach with graded levels of responsibility whereby the decisions of the most junior members of the team are reviewed by physicians with more experience and seniority. These practical experiences impart content knowledge and also allow trainees to become comfortable with decision making and to learn the consequences of these decisions. Although there may be better ways to train future physicians, this apprenticeship method seems to work, as evidenced by the relatively low failure rate in medical schools and training programs.

Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N. Engl. J. Med. 2006 Sep 28;355(13):1339-44.
Cooke, Irby, Sullivan & Ludmerer - American medical education 100 years after the Flexner report

Medical education seems to be in a perpetual state of unrest. From the early 1900s to the present, more than a score of reports from foundations, educational bodies, and professional task forces have criticized medical education for emphasizing scientific knowledge over biologic understanding, clinical reasoning, practical skill, and the development of character, compassion, and integrity.1-4 How did this situation arise, and what can be done about it? In this article, which introduces a new series on medical education in the Journal, we summarize the changes in medical education over the past century and describe the current challenges, using as a framework the key goals of professional education: to transmit knowledge, to impart skills, and to inculcate the values of the profession.

Joyner BD. Historical review of graduate medical education and a protocol of accreditation council for graduate medical education compliance. The Journal of Urology. 2004 Jul;172(1):34-9.
Joyner - Historical review of graduate medical education and a protocol of accreditation council for graduate medical education compliance

PURPOSE: A brief history of American graduate medical education is discussed to provide a context for understanding the new standards set forth by the Accreditation Council on Graduate Medical Education (ACGME). The evaluation protocol of the University of Washington, which is structured around the 6 core competencies, is described.
MATERIALS AND METHODS: Historical events regarding American graduate medical education, national conference information and recent ACGME recommendations according to the Outcomes Project are reviewed and summarized. These materials were used to design a reasonable program that would comply with ACGME recommendations.
RESULTS: ACGME tools that represent the 6 core competencies have been incorporated into our program and should provide metrics that will demonstrate improvement in residency training and education.
CONCLUSIONS: A key factor to the success of residency training and ACGME accreditation will be the education of residents and faculty about the new ACGME regulations. The University of Washington Department of Urology is poised to engage the new model by creating new call coverage strategies, applying new metrics to old teaching models and using electronic database systems.

Ludmerer, KM. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. NY: Oxford University Press: 1999.
Ludmerer KM, Johns MME. Reforming Graduate Medical Education. JAMA. 2005 Sep 7;294(9):1083-7.
Ludmerer & Johns - Reforming Graduate Medical Education

Because of the traditional subordination of education to service, graduate medical education (GME) in the United States has never realized its full educational potential. This article suggests 4 strategies for reasserting the primacy of education in GME: limit the number of patients house officers manage at one time, relieve the resident staff of noneducational chores, improve educational content, and ease emotional stresses. Achieving these goals will require regulatory reform, adequate funding, and institutional competency in the use of educational resources. Modern medicine grows ever more complex. The need to address the deficiencies of GME is urgent.

Martenson D. Learning: current knowledge and the future. Med Teacher 2001; 23: 1292-197.
Martenson - Learning: current knowledge and the future

Some empirically based statements about learning are presented. The basic conclusion is that most of that knowledge will still be valid in the future and that some is dependent on various cultural factors that need to be further explored. Two research areas that ought to be encouraged for the future are presented. One addresses cognitive processing and professional development of physicians. The other one deals with the development of students' understanding of concepts. Examples of how students retain their wrong understanding of concepts despite training and good assessment results are presented, as well as findings by Schön, Mann, and Slotnick.

Nauta RJ. Residency Training Oversight(s) in Surgery: The History and Legacy of the Accreditation Council for Graduate Medical Education. Surgical Clinics of North America. 2012 Feb;92(1):117-23.
Nauta - Residency Training Oversight(s) in Surgery: The History and Legacy of the Accreditation Council for Graduate Medical Education

Despite a quarter century of discourse since a sentinel event in New York City raised the question of appropriate oversight for graduate medical education, many questions remain unanswered. Even with the Accreditation Council for Graduate Medical Education rules in place, some opportunity remains to examine handoff methodology, the relationship of duty hours to education, and the impact of fatigue on resident performance. Neurophysiologic adjuncts applied concomitantly to evaluation of didactic performance offer promise for data-driven definition of the optimal shift. Concurrently, the merits of specialty-specific oversight of graduate medical education remain under active consideration.

Papadakis MA, Herani A, Banach MA et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med 2005; 353(25): 2673-82.
Papadakis, Herani, Banach MA et al - Disciplinary action by medical boards and prior behavior in medical school

BACKGROUND: Evidence supporting professionalism as a critical measure of competence in medical education is limited. In this case-control study, we investigated the association of disciplinary action against practicing physicians with prior unprofessional behavior in medical school. We also examined the specific types of behavior that are most predictive of disciplinary action against practicing physicians with unprofessional behavior in medical school.
METHODS: The study included 235 graduates of three medical schools who were disciplined by one of 40 state medical boards between 1990 and 2003 (case physicians). The 469 control physicians were matched with the case physicians according to medical school and graduation year. Predictor variables from medical school included the presence or absence of narratives describing unprofessional behavior, grades, standardized-test scores, and demographic characteristics. Narratives were assigned an overall rating for unprofessional behavior. Those that met the threshold for unprofessional behavior were further classified among eight types of behavior and assigned a severity rating (moderate to severe).
RESULTS: Disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school (odds ratio, 3.0; 95 percent confidence interval, 1.9 to 4.8), for a population attributable risk of disciplinary action of 26 percent. The types of unprofessional behavior most strongly linked with disciplinary action were severe irresponsibility (odds ratio, 8.5; 95 percent confidence interval, 1.8 to 40.1) and severely diminished capacity for self-improvement (odds ratio, 3.1; 95 percent confidence interval, 1.2 to 8.2). Disciplinary action by a medical board was also associated with low scores on the Medical College Admission Test and poor grades in the first two years of medical school (1 percent and 7 percent population attributable risk, respectively), but the association with these variables was less strong than that with unprofessional behavior.
CONCLUSIONS: In this case-control study, disciplinary action among practicing physicians by medical boards was strongly associated with unprofessional behavior in medical school. Students with the strongest association were those who were described as irresponsible or as having diminished ability to improve their behavior. Professionalism should have a central role in medical academics and throughout one's medical career.

Regehr G, Norman GR. Issues in cognitive psychology: implications for professional education. Acad Med 1996; 71: 988-1001.
Regehr & Norman - Issues in cognitive psychology: implications for professional education

Education and cognitive psychology have tended to pursue parallel rather than overlapping paths. Yet there is, or should be, considerable common ground, since both have major interests in learning and memory. This paper presents a number of topics in cognitive psychology, summarizes the findings in the field, and explores the implications for teaching and learning.
THE ORGANIZATION OF LONG-TERM MEMORY: The acquisition of expertise in an area can be characterized by the development of idiosyncratic memory structures called semantic networks, which are meaningful sets of connections among abstract concepts and/or specific experiences. Information (such as the assumptions and hypotheses that are necessary to diagnose and manage cases) is retrieved through the activation of these networks. Thus, when teaching, new information must be embedded meaningfully in relevant, previously existing knowledge to ensure that it will be retrievable when necessary.
INFLUENCES ON STORAGE AND RETRIEVAL FROM MEMORY: A wide variety of variables affect the capacity to store and retrieve information from memory, including meaning, the context and manner in which information is learned, and relevant practice in retrieval. Educational strategies must, therefore, be directed at three goals--to enhance meaning, to reduce dependence on context, and to provide repeated relevant practice in retrieving information.
PROBLEM SOLVING AND TRANSFER: Much of the development of expertise involves the transition from using general problem-solving routines to using specialized knowledge that reduces the need for classic "problem solving." Two manifestations of this specialized knowledge are the use of analogy and the specialization of general routines in specific domains. To develop these specialized forms of knowledge, the learner must have extensive practice in using relevant problem-solving routines and in identifying the situations in which a particular routine is likely to be useful.
CONCEPT FORMATION: Experts possess both abstract proto-typical information about categories and an extensive set of separate, specific examples of categories, which have been obtained through individual experience. Both these sources of information are used in categorization and diagnostic classifications. Thus, it is important for educators to be aware that experience with sample cases is not just an opportunity to apply and practice the rules "at the end of the chapter." Instead, experience with cases provides an alternative method of reasoning that is independent of, but equally useful to, analytical rules.
DECISION MAKING: Experts clearly do not use classic formal decision theory, but rather make use of heuristics, or shortcuts, when making decisions. Nonetheless, experts generally make appropriate decisions. This suggests that the shortcuts are useful more often than not. Rather than teaching learners to avoid heuristics, then, it might be more reasonable to help them recognize those relatively infrequent situations where their heuristics are likely to fail.

Teunissen PW, Westerman M. Opportunity or threat: the ambiguity of the consequences of transitions in medical education. Med Educ. 2011 Jan;45(1):51-9.
Teunissen & Westerman - Opportunity or threat: the ambiguity of the consequences of transitions in medical education

OBJECTIVES: The alleged medical education continuum is interrupted by a number of major transitions. After starting medical school, the first transition students encounter is that from non-clinical to clinical training. The second transition is that of graduated student to junior doctor or specialist trainee, and the third concerns the specialist trainee's transition to medical specialist. As a first step towards a better understanding of the effects of transitions, this paper provides a critical overview of how these transitions have been conceptualised in the medical education domain. The findings are complemented with perspectives from the fields of transitional psychology and organisational socialisation. The transition into medical school is not reviewed.
METHODS: Using the term 'transition', six leading medical education journals were searched for relevant articles. A snowballing technique on the reference lists of the 44 relevant articles yielded 29 additional publications. Studies were reviewed and categorised as representing objectifying, clarifying, or descriptive and/or justifying research.
RESULTS: When students enter clinical training, they need to relearn what they thought they knew and they must learn new things in a more self-directed way. As junior doctors or specialist trainees, their main challenges involve handling the many responsibilities that accompany the delivery of patient care while simultaneously learning from the process of providing that care. As medical specialists, new non-medical tasks and decisions on how to delegate responsibilities become issues.
CONCLUSIONS: Research on transitions has objectified the challenges students and doctors face. Clarifying studies often lack conceptual frameworks that could help us to gain deeper insight into the observed phenomena. Psychology offers valuable theoretical perspectives that are applicable to medical education transitions. To transform a transition from a threat to a learning opportunity, medical education should assist students and doctors in developing the coping skills they need to effectively deal with the challenges presented by new environments.

Yedidia MJ, Schwartz MD, Hirschkorn C, Lipkin M Jr Learners as teachers: the conflicting roles of medical residents. J Gen Intern Med. 1995 Nov;10(11):615-23.
Yedidia, et al. - Learners as teachers: the conflicting roles of medical residents

OBJECTIVE: To explore the impact of internal medicine residents' roles as learners, teachers, and physicians on their performance in teaching and supervising interns; to generate insights for educational policy and research.
DESIGN: Qualitative analysis of in-depth, semistructured, recorded interviews with a cohort of second-postgraduate-year (PGY-2) residents. Questions elicited their accounts of differences in the learning process between the first and second residency years, their responses to situations in which they lacked sufficient clinical knowledge, their views of their supervisory relationship with interns, and their assessments of changes in their role in patient care since their internships. Transcripts were independently analyzed by the interdisciplinary team of authors.
SETTING: New York University/Bellevue Hospital Center's internal medicine residency (New York City), a highly competitive program in a major public hospital and a university medical center, emphasizing housestaff autonomy and self-reliance.
PARTICIPANTS: A cohort of 18 of 21 medical residents at Bellevue Hospital Center during the last rotation of PGY-2.
RESULTS: Intense conflicts confound residents' roles as teachers. These conflicts fall into three categories: 1) as learners, residents' own needs frequently coincide with those of interns in ways that may undermine their teaching--they are expected to nurture others despite their own considerable needs for emotional support, teach material that they barely grasp, and exert authority while feeling ignorant; 2) as team leaders, residents must ensure that interns get the hospital's work done, sometimes at the expense of teaching them; and 3) as clinicians, residents' first priority is to address the medical needs of patients--the learning needs of interns are secondary.
CONCLUSION: Second-year internal medicine residents experience conflicts inherent in their simultaneous commitment to learning, teaching, and service that may undermine both their effectiveness in supervising interns and their own professional development. Potential remedies are to restructure residency programs so as to equip residents with training and support for their role as teachers, reduce the tension between training and service by delegating tasks to nonphysician personnel, and provide graded responsibility to housestaff as physicians and teachers.

To Err Is Human: Building a Safer Health System (IOM). In: Corrigan J, Kohn LT, Donaldson MS, Editors. Washington, DC: National Academy Press: 2000.
Educational Innovation and Curriculum Development
Ackerly DC, Sangvai DG, Udayakumar K, Shah BR, Kalman NS, Cho AH, Schulman KA, Fulkerson WJ Jr, Dzau VJ. Training the next generation of physician-executives: an innovative residency pathway in management and leadership. Acad Med. 2011 May;86(5):575-9. doi: 10.1097/ACM.0b013e318212e51b.
Ackerly, et al. - Opportunity or threat: the ambiguity of the consequences of transitions in medical education

ABSTRACT: The rapidly changing field of medicine demands that future physician-leaders excel not only in clinical medicine but also in the management of complex health care enterprises. However, many physicians have become leaders "by accident," and the active cultivation of future leaders is required. Addressing this need will require multiple approaches, targeting trainees at various stages of their careers, such as degree-granting programs, residency and fellowship training, and career and leadership development programs. Here, the authors describe a first-of-its-kind graduate medical education pathway at Duke Medicine, the Management and Leadership Pathway for Residents (MLPR). This program was developed for residents with both a medical degree and management training. Created in 2009, with its first cohort enrolled in the summer of 2010, the MLPR is intended to help catalyze the emergence of a new generation of physician-leaders. The program will provide physicians-in-training with rigorous clinical exposure along with mentorship and rotational opportunities in management to accelerate the development of critical leadership and management skills in all facets of medicine, including care delivery, research, and education. To achieve this, the MLPR includes 15 to 18 months of project-based rotations under the guidance of senior leaders in many disciplines including finance, patient safety, health system operations, strategy, and others. Developing both clinical and management skill sets during graduate medical education holds the promise of engaging future leaders of health care at an early career stage, keeping more MD-MBA graduates within health care, and creating a bench of talented future physician-executives.

Carraccio C. The initiative for innovation in pediatric education: the next chapter. Pediatrics. 2012 Oct;130(4):601-3. doi: 10.1542/peds.2012-1808.
Croft D, Jay SJ, Meslin EM, Gaffney MM, Odell JD. Perspective: is it time for advocacy training in medical education?. Acad Med. 2012 Sep;87(9):1165-70.
Croft, et al. - Perspective: is it time for advocacy training in medical education?

ASBSTRACT: As the modern medical system becomes increasingly complex, a debate has arisen over the place of advocacy efforts within the medical profession. The authors argue that advocacy can help physicians fulfill their social contract. For physicians to become competent in patient-centered, clinical, administrative, or legislative advocacy, they require professional training. Many professional organizations have called for curricular reform to meet society's health needs during the past 30 years, and the inclusion of advocacy training in undergraduate, graduate, and continuing medical education is supported on both pragmatic and ethical grounds. Undergraduate medical education, especially, is an ideal time for this training because a standard competency can be instilled across all specialties. Although the Accreditation Council for Graduate Medical Education includes advocacy training in curricula for residency programs, few medical schools or residency programs have advocacy electives. By understanding the challenges of the health care system and how to change it for the better, physicians can experience increased professional satisfaction and effectiveness in improving patient care, systems-based practice, and public health.

Kern DE, Thomas PA, Howard DM, Bass EB. Curriculum Develop for Medical Education: A Six Step Approach. Baltimore: Johns Hopkins University Press, 1998.
Litvin CB, Davis KS, Moran WP, Iverson PJ, Zhao Y, Zapka J. The use of clinical decision-support tools to facilitate geriatric education.. Med Educ. 2011 Jan;45(1):51-9.
Litvin, et al. - The use of clinical decision-support tools to facilitate geriatric education.

ABSTRACT: Innovative methods are needed to incorporate effective geriatric education into internal medicine residency programs. The purpose of this report is to describe the development and use of clinical decision-support (CDS) tools to facilitate geriatric education and improve the care delivered to older adults in an academic internal medicine residency ambulatory care clinic. Starting in 2009, CDS tools were implemented as a major strategy of an initiative to improve resident physician clinical competencies in geriatrics and improve the quality of care and quality of life of older adults. These tools, designed to improve resident assessment and action for each of three educational modules (falls, vision, and dementia) were embedded within the ambulatory electronic medical record (EMR) and provided a method of point-of-care training to residents caring for older adults. One hundred internal medicine residents supervised by 17 general internal medicine faculty members participated. Data regarding CDS use and associated outcomes were recorded and extracted from the ambulatory clinic EMR. Residents screened between 67% and 88% of eligible patients using CDS algorithms; rates of additional assessment and referral or further examination reflected the prevalence of the condition in the patient population. Although further development may be necessary, CDS tools are a promising modality to supplement geriatric postgraduate education while simultaneously improving patient care.

Jippes E, Steinert Y, Pols J, Achterkamp MC, van Engelen JM, Brand PL.How Do Social Networks and Faculty Development Courses Affect Clinical Supervisors' Adoption of a Medical Education Innovation? An Exploratory Study.. Acad Med. 2013 Jan 23
Jippes, et al. - How Do Social Networks and Faculty Development Courses Affect Clinical Supervisors' Adoption of a Medical Education Innovation? An Exploratory Study.

PURPOSE: To examine the impact of social networks and a two-day faculty development course on clinical supervisors' adoption of an educational innovation.
METHOD: During 2007-2010, 571 residents and 613 clinical supervisors in four specialties in the Netherlands were invited to complete a Web-based questionnaire. Residents rated their clinical supervisors' adoption of an educational innovation, the use of structured and constructive (S&C) feedback. Clinical supervisors self-assessed their adoption of this innovation and rated their communication intensity with other clinical supervisors in their department. For each supervisor, a centrality score was calculated, representing the extent to which the supervisor was connected to departmental colleagues. The authors analyzed the effects of supervisor centrality and participation in a two-day Teach-the-Teacher course on the degree of innovation adoption using hierarchical linear modeling, adjusting for age, gender, and attitude toward the S&C feedback innovation.
RESULTS: Respondents included 370 (60%) supervisors and 357 (63%) residents. Although Teach-the-Teacher course participation (n = 172; 46.5%) was significantly related to supervisors' self-assessments of adoption (P = .001), it had no effect on residents' assessments of supervisors' adoption (P = .371). Supervisor centrality was significantly related to innovation adoption in both residents' assessments (P = .023) and supervisors' self-assessments (P = .024).
CONCLUSIONS: A clinical supervisor's social network may be as important as faculty development course participation in determining whether the supervisor adopts an educational innovation. Faculty development initiatives should use faculty members' social networks to improve the adoption of educational innovations and help build and maintain communities of practice.

Morrison EH, Rucker L, Boker JR, Gabbert CC, Hubbell FA, Hitchcock MA, Prislin MD. The effect of a 13-hour curriculum to improve residents' teaching skills: a randomized trial. Ann Intern Med. 2004 Aug 17;141(4):257-63.
Morrison, Rucker, Boker, Gabbert, et al - The effect of a 13-hour curriculum to improve residents' teaching skills: a randomized trial.

BACKGROUND: Although resident physicians often teach, few trials have tested interventions to improve residents' teaching skills. A pilot trial in 2001-2002 found that 13 trained resident teachers taught better than did untrained control residents.
OBJECTIVE: To determine whether a longitudinal residents-as-teachers curriculum improves residents' teaching skills.
DESIGN: Randomized, controlled trial from May 2001 to February 2002 (pilot trial) and March 2002 to April 2003.
SETTING: 4 generalist residencies affiliated with an urban academic medical center.
PARTICIPANTS: 62 second-year residents: 23 in the 2001-2002 pilot trial and 39 more in 2002-2003; 27 of the 39 participants were medicine residents required to learn teaching skills.
INTERVENTION: A 13-hour curriculum in which residents practiced teaching and received feedback during 1-hour small-group sessions taught twice monthly for 6 months.
MEASUREMENTS: A 3.5-hour, 8-station, objective structured teaching examination that was enacted and rated by 50 medical students before and after the intervention. Two trained, blinded raters independently assessed each station (inter-rater reliability, 0.75).
RESULTS: In the combined results for 2001-2003, the intervention group (n = 33) and control group (n = 29) were similar in sex, specialty, and academic performance. On a 1 to 5 Likert scale, intervention residents outscored controls on overall improvement score (post-test-pretest difference, 0.74 vs. 0.07; difference between intervention and control groups, 0.68 [95% CI, 0.55 to 0.81]; P < 0.001) by a magnitude of 2.8 standard deviations and on all 8 individual stations. The intervention residents improved 28.5% overall, whereas the scores of control residents did not increase significantly (2.7%). In 2002-2003, 19 intervention residents similarly outscored 19 controls (post-test-pretest difference, 0.83 vs. 0.14; difference between intervention and control groups, 0.69 [CI, 0.53 to 0.84]; P < 0.001). Twenty-seven medicine residents required to learn teaching skills achieved scores similar to those of volunteers.
LIMITATIONS: The study was conducted at a single institution. No "real life" assessment with which to compare the results of the objective structured teaching examination was available.
CONCLUSIONS: Generalist residents randomly assigned to receive a 13-hour longitudinal residents-as-teachers curriculum consistently showed improved teaching skills, as judged by medical student raters. Residents required to participate improved as much as volunteers did.

Assessment and Feedback

Boehler, ML, Rogers DA, Schwind CJ, Mayforth R, Quin J, Williams RG and Dunnington G. An investigation of medical student reactions to feedback: A randomized controlled trial. Med Educ 2006; 40:746-749.
Boehler, Rogers, Schwind, et al. - An investigation of medical student reactions to feedback: A randomized controlled trial >BACKGROUND: Medical educators have indicated that feedback is one of the main catalysts required for performance improvement. However, medical students appear to be persistently dissatisfied with the feedback that they receive. The purpose of this study was to evaluate learning outcomes and perceptions in students who received feedback compared to those who received general compliments.
METHODS: All subjects received identical instruction on two-handed surgical knot-tying. Group 1 received specific, constructive feedback on how to improve their knot-tying skill. Group 2 received only general compliments. Performance was videotaped before and after instruction and after feedback. Subjects completed the study by indicating their global level of satisfaction. Three faculty evaluators observed and scored blinded videotapes of each performance. Intra-observer agreement among expert ratings of performance was calculated using 2-way random effects intraclass correlation (ICC) methods. Satisfaction scores and performance scores were compared using paired samples t-tests and independent samples t-tests.
RESULTS: Performance data from 33 subjects were analysed. Inter-rater reliability exceeded 0.8 for ratings of pre-test, pre-intervention and post-intervention performances. The average performance of students who received specific feedback improved (21.98 versus 15.87, P<0.001), whereas there was no significant change in the performance score in the group who received only compliments (17.00 versus 15.39, P=0.181) The average satisfaction rating in the group that received compliments was significantly higher than the group that received feedback (6.00 versus 5.00, P=0.005).
DISCUSSION: Student satisfaction is not an accurate measure of the quality of feedback. It appears that satisfaction ratings respond to praise more than feedback, while learning is more a function of feedback.

Junod Perron N, Nendaz M, Louis-Simonet M, Sommer J, Gut A, Baroffio A, Dolmans D, van der Vleuten C. Effectiveness of a training program in supervisors' ability to provide feedback on residents' communication skills. Adv Health Sci Educ Theory Pract. 2012 Nov 30.
Junod Perron, et al. - Effectiveness of a training program in supervisors' ability to provide feedback on residents' communication skills.

ABSTRACT: Teaching communication skills (CS) to residents during clinical practice remains problematic. Direct observation followed by feedback is a powerful way to teach CS in clinical practice. However, little is known about the effect of training on feedback skills in this field. Controlled studies are scarce as well as studies that go beyond self-reported data. The aim of the study was to develop and assess the effectiveness of a training program for clinical supervisors on how to give feedback on residents' CS in clinical practice. The authors designed a pretest-posttest controlled study in which clinical supervisors working in two different medical services were invited to attend a sequenced and multifaceted program in teaching CS over a period of 6-9 months. Outcome measures were self-perceived and observed feedback skills collected during questionnaires and three videotaped objective structured teaching encounters. The videotaped feedbacks made by the supervisors were analysed using a 20-item feedback rating instrument. Forty-eight clinical supervisors participated (28 in the intervention, 20 in the control group). After training, a higher percentage of trained participants self-reported and demonstrated statistically significant improvement in making residents more active by exploring residents' needs, stimulating self-assessment, and using role playing to test strategies and checking understanding, with effect sizes ranging from 0.93 to 4.94. A training program on how to give feedback on residents' communication skills was successful in improving clinical supervisors' feedback skills and in helping them operate a shift from a teacher-centered to a more learner-centered approach.

Lacasse M, Ratnapalan S.Teaching-skills training programs for family medicine residents: systematic review of formats, content, and effects of existing programs. Can Fam Physician. 2009 Sep;55(9):902-3.e1-5.
Lacasse & Ratnapalan - Teaching-skills training programs for family medicine residents: systematic review of formats, content, and effects of existing programs.

OBJECTIVES: To review the literature on teaching-skills training programs for family medicine residents and to identify formats and content of these programs and their effects.
DATA SOURCES: Ovid MEDLINE (1950 to mid-July 2008) and the Education Resources Information Center database (pre-1966 to mid-July 2008) were searched using and combining the MeSH terms teaching, internship and residency, and family practice; and teaching, graduate medical education, and family practice.
STUDY SELECTION: The initial MEDLINE and Education Resources Information Center database searches identified 362 and 33 references, respectively. Titles and abstracts were reviewed and studies were included if they described the format or content of a teaching-skills program or if they were primary studies of the effects of a teaching-skills program for family medicine residents or family medicine and other specialty trainees. The bibliographies of those articles were reviewed for unidentified studies. A total of 8 articles were identified for systematic review. Selection was limited to articles published in English.
SYNTHESIS: Teaching-skills training programs for family medicine residents vary from half-day curricula to a few months of training. Their content includes leadership skills, effective clinical teaching skills, technical teaching skills, as well as feedback and evaluation skills. Evaluations mainly assessed the programs' effects on teaching behaviour, which was generally found to improve following participation in the programs. Evaluations of learner reactions and learning outcomes also suggested that the programs have positive effects.
CONCLUSION: Family medicine residency training programs differ from all other residency training programs in their shorter duration, usually 2 years, and the broader scope of learning within those 2 years. Few studies on teaching-skills training, however, were designed specifically for family medicine residents. Further studies assessing the effects of teaching-skills training in family medicine residents are needed to stimulate development of adapted programs for the discipline. Future research should also assess how residents' teaching-skills training can affect their learners' clinical training and eventually patient care.

Mann K, van der Vleuten C, Eva K, Armson H, Chesluk B, Dornan T, Holmboe E, Lockyer L, Loney E and Sargeant J. Tensions in informed self-assessment: How the desire for feedback and reticence to collect and use it can conflict. Acad Med 2011; 86(9): 1120-1127.
Mann, van der Vleuten, Eva, et al. - Tensions in informed self-assessment: How the desire for feedback and reticence to collect and use it can conflict

PURPOSE: Informed self-assessment describes the set of processes through which individuals use external and internal data to generate an appraisal of their own abilities. The purpose of this project was to explore the tensions described by learners and professionals when informing their self-assessments of clinical performance.
METHOD: This 2008 qualitative study was guided by principles of grounded theory. Eight programs in five countries across undergraduate, postgraduate, and continuing medical education were purposively sampled. Seventeen focus groups were held (134 participants). Detailed analyses were conducted iteratively to understand themes and relationships.
RESULTS: Participants experienced multiple tensions in informed self-assessment. Three categories of tensions emerged: within people (e.g., wanting feedback, yet fearing disconfirming feedback), between people (e.g., providing genuine feedback yet wanting to preserve relationships), and in the learning/practice environment (e.g., engaging in authentic self-assessment activities versus "playing the evaluation game"). Tensions were ongoing, contextual, and dynamic; they prevailed across participant groups, infusing all components of informed self-assessment. They also were present in varied contexts and at all levels of learners and practicing physicians.
CONCLUSIONS: Multiple tensions, requiring ongoing negotiation and renegotiation, are inherent in informed self-assessment. Tensions are both intraindividual and interindividual and they are culturally situated, reflecting both professional and institutional influences. Social learning theories (social cognitive theory) and sociocultural theories of learning (situated learning and communities of practice) may inform our understanding and interpretation of the study findings. The findings suggest that educational interventions should be directed at individual, collective, and institutional cultural levels. Implications for practice are presented.

Rose SH, Long TR, Elliott BA, Brown MJ. A Historical Perspective on Resident Evaluation, the Accreditation Council for Graduate Medical Education Outcome Project and Accreditation Council for Graduate Medical Education Duty Hour Requirement. Anesth Analg. 2009 Jul 1;109(1):190-3.
Rose, Long, Elliott & Brown. - A Historical Perspective on Resident Evaluation, the Accreditation Council for Graduate Medical Education Outcome Project and Accreditation Council for Graduate Medical Education Duty Hour Requirement

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project, endorsed at the 1999 ACGME annual meeting, was intended to shift the focus of residency program requirements and accreditation from process-oriented assessment to an assessment of outcomes. The Outcome Project established six general competencies, each of which is supported by more specific competencies.
METHODS: We compared contemporary resident evaluation based on the Outcome Project to faculty evaluation of a surgical resident at Mayo Clinic that was completed in 1917.
RESULTS: The contemporary faculty assessment of resident performance was remarkably similar to the evaluation form and criteria used in 1917. All six general competencies, and nearly all of the more specific items listed under each general competency, were included in the 1917 evaluation. Duty hour data as a component of the 1917 resident evaluation included the number of hours per week spent in "practical work," "medical library," and "research work."
CONCLUSIONS: The remarkable similarities between the qualities assessed in the 1917 evaluation and the assessment of contemporary ACGME competencies suggest that a common set of desirable physician characteristics and behaviors can be identified and measured.

Teunissen PW, Stapel DA, van der Vleuten C, Scherpbier A, Boor K, Scheele F. Who wants feedback? An investigation of the variables influencing residents’ feedback-seeking behavior in relation to night shifts. Acad Med 2009; 84(7): 910-917.
Teunissen, Stapel, van der Vleuten, et al. - Who wants feedback? An investigation of the variables influencing residents’ feedback-seeking behavior in relation to night shifts

PURPOSE: The literature on feedback in clinical medical education has predominantly treated trainees as passive recipients. Past research has focused on how clinical supervisors can use feedback to improve a trainee's performance. On the basis of research in social and organizational psychology, the authors reconceptualized residents as active seekers of feedback. They investigated what individual and situational variables influence residents' feedback-seeking behavior on night shifts.
METHOD: Early in 2008, the authors sent obstetrics-gynecology residents in the Netherlands--both those in their first two years of graduate training and those gaining experience between undergraduate and graduate training--a questionnaire that assessed four predictor variables (learning and performance goal orientation, and instrumental and supportive leadership), two mediator variables (perceived feedback benefits and costs), and two outcome variables (frequency of feedback inquiry and monitoring). They used structural equation modeling software to test a hypothesized model of relationships between variables.
RESULTS: The response rate was 76.5%. Results showed that residents who perceive more feedback benefits report a higher frequency of feedback inquiry and monitoring. More perceived feedback costs result mainly in more feedback monitoring. Residents with a higher learning goal orientation perceive more feedback benefits and fewer costs. Residents with a higher performance goal orientation perceive more feedback costs. Supportive physicians lead residents to perceive more feedback benefits and fewer costs.
CONCLUSIONS: This study showed that some residents actively seek feedback. Residents' feedback-seeking behavior partially depends on attending physicians' supervisory style. Residents' goal orientations influence their perceptions of the benefits and costs of feedback-seeking.

van der Leeuw RM, Lombarts KM, Arah OA, Heineman MJ. A systematic review of the effects of residency training on patient outcomes.. BMC Med. 2012 Jun 28;10:65. doi: 10.1186/1741-7015-10-65.
van der Leeuw, et al. - A systematic review of the effects of residency training on patient outcomes.

BACKGROUND: Residents are vital to the clinical workforce of today and tomorrow. Although in training to become specialists, they also provide much of the daily patient care. Residency training aims to prepare residents to provide a high quality of care. It is essential to assess the patient outcome aspects of residency training, to evaluate the effect or impact of global investments made in training programs. Therefore, we conducted a systematic review to evaluate the effects of relevant aspects of residency training on patient outcomes.
METHODS: The literature was searched from December 2004 to February 2011 using MEDLINE, Cochrane, Embase and the Education Resources Information Center databases with terms related to residency training and (post) graduate medical education and patient outcomes, including mortality, morbidity, complications, length of stay and patient satisfaction. Included studies evaluated the impact of residency training on patient outcomes.
RESULTS: Ninety-seven articles were included from 182 full-text articles of the initial 2,001 hits. All studies were of average or good quality and the majority had an observational study design. Ninety-six studies provided insight into the effect of 'the level of experience of residents' on patient outcomes during residency training. Within these studies, the start of the academic year was not without risk (five out of 19 studies), but individual progression of residents (seven studies) as well as progression through residency training (nine out of 10 studies) had a positive effect on patient outcomes. Compared with faculty, residents' care resulted mostly in similar patient outcomes when dedicated supervision and additional operation time were arranged for (34 out of 43 studies). After new, modified or improved training programs, patient outcomes remained unchanged or improved (16 out of 17 studies). Only one study focused on physicians' prior training site when assessing the quality of patient care. In this study, training programs were ranked by complication rates of their graduates, thus linking patient outcomes back to where physicians were trained.
CONCLUSIONS: The majority of studies included in this systematic review drew attention to the fact that patient care appears safe and of equal quality when delivered by residents. A minority of results pointed to some negative patient outcomes from the involvement of residents. Adequate supervision, room for extra operation time, and evaluation of and attention to the individual competence of residents throughout residency training could positively serve patient outcomes. Limited evidence is available on the effect of residency training on later practice. Both qualitative and quantitative research designs are needed to clarify which aspects of residency training best prepare doctors to deliver high quality care.

van de Ridder JMM, Stokking KM, McGaghie WC and ten Cate OTJ. What is feedback in clinical education? Med Educ 2008; 42:189-197.
van de Ridder, Stokking, McGaghie, et al. - What is feedback in clinical education?

OBJECTIVE: Feedback is important in clinical education. However, the medical education literature provides no consensual definition of feedback. The aim of this study is to propose a consensual, research-based, operational definition of feedback in clinical education. An operational definition is needed for educational practice and teacher training, and for research into the effectiveness of different types of feedback.
METHODS: A literature search about definitions of feedback was performed in general sources, meta-analyses and literature reviews in the social sciences and other fields. Feedback definitions given from 1995 to 2006 in the medical education literature are also reviewed.
RESULTS: Three underlying concepts were found, defining feedback as 'information'; as 'reaction', including information, and as a 'cycle', including both information and reaction. In most medical education and social science literature, feedback is usually conceptualised as information only. Comparison of feedback definitions in medical education reveals at least 9 different features. The following operational definition is proposed. Feedback is: 'Specific information about the comparison between a trainee's observed performance and a standard, given with the intent to improve the trainee's performance.'
CONCLUSIONS: Different conceptual representations and the use of different key features might be a cause for inconsistent definitions of feedback. The characteristics, strengths and weaknesses of this research-based operational definition are discussed.

Wood BP. Feedback: A key feature of medical training. Radiol 2000; 215:17-19.

Life Long Learning

Curtis MT, Diazgranados D, Feldman M. Judicious use of simulation technology in continuing medical education. J Contin Educ Health Prof. 2012 Sep;32(4):255-60. doi: 10.1002/chp.21153.
Curtis Diazgranados & Feldman - Judicious use of simulation technology in continuing medical education.

ABSTRACT: Use of simulation-based training is fast becoming a vital source of experiential learning in medical education. Although simulation is a common tool for undergraduate and graduate medical education curricula, the utilization of simulation in continuing medical education (CME) is still an area of growth. As more CME programs turn to simulation to address their training needs, it is important to highlight concepts of simulation technology that can help to optimize learning outcomes. This article discusses the role of fidelity in medical simulation. It provides support from a cross section of simulation training domains for determining the appropriate levels of fidelity, and it offers guidelines for creating an optimal balance of skill practice and realism for efficient training outcomes. After defining fidelity, 3 dimensions of fidelity, drawn from the human factors literature, are discussed in terms of their relevance to medical simulation. From this, research-based guidelines are provided to inform CME providers regarding the use of simulation in CME training.

Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing Physician Performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995; 274(9): 700-5.
Davis, Thomson, Oxman & Haynes. - Changing Physician Performance. A systematic review of the effect of continuing medical education strategies

OBJECTIVE: To review the literature relating to the effectiveness of education strategies designed to change physician performance and health care outcomes.
DATA SOURCES: We searched MEDLINE, ERIC, NTIS, the Research and Development Resource Base in Continuing Medical Education, and other relevant data sources from 1975 to 1994, using continuing medical education (CME) and related terms as keywords. We manually searched journals and the bibliographies of other review articles and called on the opinions of recognized experts.
STUDY SELECTION: We reviewed studies that met the following criteria: randomized controlled trials of education strategies or interventions that objectively assessed physician performance and/or health care outcomes. These intervention strategies included (alone and in combination) educational materials, formal CME activities, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit with feedback, and reminders. Studies were selected only if more than 50% of the subjects were either practicing physicians or medical residents.
DATA EXTRACTION: We extracted the specialty of the physicians targeted by the interventions and the clinical domain and setting of the trial. We also determined the details of the educational intervention, the extent to which needs or barriers to change had been ascertained prior to the intervention, and the main outcome measure(s).
DATA SYNTHESIS: We found 99 trials, containing 160 interventions, that met our criteria. Almost two thirds of the interventions (101 of 160) displayed an improvement in at least one major outcome measure: 70% demonstrated a change in physician performance, and 48% of interventions aimed at health care outcomes produced a positive change. Effective change strategies included reminders, patient-mediated interventions, outreach visits, opinion leaders, and multifaceted activities. Audit with feedback and educational materials were less effective, and formal CME conferences or activities, without enabling or practice-reinforcing strategies, had relatively little impact.
CONCLUSION: Widely used CME delivery methods such as conferences have little direct impact on improving professional practice. More effective methods such as systematic practice-based interventions and outreach visits are seldom used by CME providers.

Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999 Sep 1;282(9):867-74.
Davis, O'Brien, Freemantle, et al. - Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes?

Although physicians report spending a considerable amount of time in continuing medical education (CME) activities, studies have shown a sizable difference between real and ideal performance, suggesting a lack of effect of formal CME.
OBJECTIVE: To review, collate, and interpret the effect of formal CME interventions on physician performance and health care outcomes.
DATA SOURCES: Sources included searches of the complete Research and Development Resource Base in Continuing Medical Education and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group, supplemented by searches of MEDLINE from 1993 to January 1999.
STUDY SELECTION: Studies were included in the analyses if they were randomized controlled trials of formal didactic and/or interactive CME interventions (conferences, courses, rounds, meetings, symposia, lectures, and other formats) in which at least 50% of the participants were practicing physicians. Fourteen of 64 studies identified met these criteria and were included in the analyses. Articles were reviewed independently by 3 of the authors.
DATA EXTRACTION: Determinations were made about the nature of the CME intervention (didactic, interactive, or mixed), its occurrence as a 1-time or sequenced event, and other information about its educational content and format. Two of 3 reviewers independently applied all inclusion/exclusion criteria. Data were then subjected to meta-analytic techniques.
DATA SYNTHESIS: The 14 studies generated 17 interventions fitting our criteria. Nine generated positive changes in professional practice, and 3 of 4 interventions altered health care outcomes in 1 or more measures. In 7 studies, sufficient data were available for effect sizes to be calculated; overall, no significant effect of these educational methods was detected (standardized effect size, 0.34; 95% confidence interval [CI], -0.22 to 0.97). However, interactive and mixed educational sessions were associated with a significant effect on practice (standardized effect size, 0.67; 95% CI, 0.01-1.45).
CONCLUSIONS: Our data show some evidence that interactive CME sessions that enhance participant activity and provide the opportunity to practice skills can effect change in professional practice and, on occasion, health care outcomes. Based on a small number of well-conducted trials, didactic sessions do not appear to be effective in changing physician performance.

Fordis M, King JE, Ballantye CM, et al. Comparison of the Instructional Efficacy of Internet-Based CME With Live Interactive CME Workshops JAMA 2005; 294(9): 1043-51.
Fordis, King, Ballantye, et al. - Comparison of the Instructional Efficacy of Internet-Based CME With Live Interactive CME Workshops

Context: Despite evidence that a variety of continuing medical education (CME) techniques can foster physician behavioral change, there have been no randomized trials comparing performance outcomes for physicians participating in Internet-based CME with physicians participating in a live CME intervention using approaches documented to be effective.
Objective: To determine if Internet-based CME can produce changes comparable to those produced via live, small-group, interactive CME with respect to physician knowledge and behaviors that have an impact on patient care.
Design, Setting, and Participants: Randomized controlled trial conducted from August 2001 to July 2002. Participants were 97 primary care physicians drawn from 21 practice sites in Houston, Tex, including 7 community health centers and 14 private group practices. A control group of 18 physicians from these same sites received no intervention.
Interventions: Physicians were randomly assigned to an Internet-based CME intervention that could be completed in multiple sessions over 2 weeks, or to a single live, small-group, interactive CME workshop. Both incorporated similar multifaceted instructional approaches demonstrated to be effective in live settings. Content was based on the National Institutes of Health National Cholesterol Education Program—Adult Treatment Panel III guidelines.
Main Outcome Measures: Knowledge was assessed immediately before the intervention, immediately after the intervention, and 12 weeks later. The percentage of high-risk patients who had appropriate lipid panel screening and pharmacotherapeutic treatment according to guidelines was documented with chart audits conducted over a 5-month period before intervention and a 5-month period after intervention.
Results: Both interventions produced similar and significant immediate and 12-week knowledge gains, representing large increases in percentage of items correct (pretest to posttest: 31.0% [95% confidence interval (CI), 27.0%-35.0%]; pretest to 12 weeks: 36.4% [95% CI, 32.2%-40.6%]; P<.001 for all comparisons). Chart audits revealed high baseline screening rates in all study groups (>=93%) with no significant postintervention change. However, the Internet-based intervention was associated with a significant increase in the percentage of high-risk patients treated with pharmacotherapeutics according to guidelines (preintervention, 85.3%; postintervention, 90.3%; P = .04).
Conclusions: Appropriately designed, evidence-based online CME can produce objectively measured changes in behavior as well as sustained gains in knowledge that are comparable or superior to those realized from effective live activities.

Web-Based Learning

Chumley-Jones, HS, Dobbie A, Alford CL. Web-based learning: sound educational method or hype? A review of the evaluation literature. Acad Med 2002; 77(10 supple): S86-93.
Chumley-Jones, Dobbie & Alford. - Web-based learning: sound educational method or hype? A review of the evaluation literature

Reviews the medical, dental and nursing web-based learning (WBL) evaluation literature to identify which facets of WBL have been evaluated and to describe the evaluation strategies used. Four domains of evaluation were identified: kowledge of gains, learner attitudes (web- or content-specific), learning efficiency and program cost. It is concluded that WBL does not address all the challenges of medical education and does not replace traditional methods. There is no evidence seen that students learn more from web-based programs. Students may learn more efficiently, but there is minimal information about the relative costs of WBL programs. The authors recommend that medical educators tailor teaching media to learners' needs rather than assume WBL is intrinsically superior.

Cook DA, Dupras DM. A practical guide to developing effective web-based learning. J Gen Intern Med 2004; 19(6): 698-707.
Cook & Dupras - A practical guide to developing effective web-based learning

OBJECTIVE: Online learning has changed medical education, but many "educational" websites do not employ principles of effective learning. This article will assist readers in developing effective educational websites by integrating principles of active learning with the unique features of the Web.
DESIGN: Narrative review.
RESULTS: The key steps in developing an effective educational website are: Perform a needs analysis and specify goals and objectives; determine technical resources and needs; evaluate preexisting software and use it if it fully meets your needs; secure commitment from all participants and identify and address potential barriers to implementation; develop content in close coordination with website design (appropriately use multimedia, hyperlinks, and online communication) and follow a timeline; encourage active learning (self-assessment, reflection, self-directed learning, problem-based learning, learner interaction, and feedback); facilitate and plan to encourage use by the learner (make website accessible and user-friendly, provide time for learning, and motivate learners); evaluate learners and course; pilot the website before full implementation; and plan to monitor online communication and maintain the site by resolving technical problems, periodically verifying hyperlinks, and regularly updating content.
CONCLUSION: Teaching on the Web involves more than putting together a colorful webpage. By consistently employing principles of effective learning, educators will unlock the full potential of Web-based medical education.

Gonzalez NR, Dusick JR, Martin NA. Effects of mobile and digital support for a structured, competency-based curriculum in neurosurgery residency education. Neurosurgery. 2012 Jul;71(1):164-72. doi: 10.1227/NEU.0b013e318253571b.
Gonzalez, Dusick & Martin - Effects of mobile and digital support for a structured, competency-based curriculum in neurosurgery residency education.

BACKGROUND: Changes in neurosurgical practice and graduate medical education impose new challenges for training programs.
OBJECTIVE: We present our experience providing neurosurgical residents with digital and mobile educational resources in support of the departmental academic activities.
METHODS: A weekly mandatory conference program for all clinical residents based on the Accreditation Council for Graduate Medical Education competencies, held in protected time, was introduced. Topics were taught through didactic sessions and case discussions. Faculty and residents prepare high-quality presentations, equivalent to peer-review leading papers or case reports. Presentations are videorecorded, stored in a digital library, and broadcasted through our Website and iTunes U. Residents received mobile tablet devices with remote access to the digital library, applications for document/video management, and interactive teaching tools.
RESULTS: Residents responded to an anonymous survey, and performances on the Self-Assessment in Neurological Surgery examination before and after the intervention were compared. Ninety-two percent reported increased time used to study outside the hospital and attributed the habit change to the introduction of mobile devices; 67% used the electronic tablets as the primary tool to access the digital library, followed by 17% hospital computers, 8% home computers, and 8% personal laptops. Forty-two percent have submitted operative videos, cases, and documents to the library. One year after introducing the program, results of the Congress of Neurological Surgeons-Self-Assessment in Neurological Surgery examination showed a statistically significant improvement in global scoring and improvement in 16 of the 18 individual areas evaluated, 6 of which reached statistical significance.
CONCLUSION: A structured, competency-based neurosurgical education program supported with digital and mobile resources improved reading habits among residents and performance on the Congress of Neurological Surgeons-Self-Assessment in Neurological Surgery examination.

Hendee W, Bosma JL, Bresolin LB, Berlin L, Bryan RN, Gunderman RB. Web modules on professionalism and ethics. J Am Coll Radiol. 2012 Mar;9(3):170-3. doi: 10.1016/j.jacr.2011.11.014.
Hendee, et al. - Web modules on professionalism and ethics.

ABSTRACT: Health care disciplines have always held resolutely to a commitment to professionalism and high ethical standards. With the present emphasis on public accountability, professionalism and ethics are receiving enhanced attention in health care education and practice. A challenge for radiologists, radiation oncologists, and medical physicists is to define the scope and depth of knowledge about professionalism and ethics that are necessary for the practice of the disciplines. A further challenge is to develop accessible educational materials that encompass this required knowledge. About 2 years ago, the ABR Foundation decided to address these challenges through the development of an ethics and professionalism curriculum and production of a series of Web-based educational modules that follow the curriculum. Six organizations agreed initially to contribute financially to construction of the curriculum and modules and were later joined by a seventh. The curriculum was developed by the ABR Foundation and included in a request for proposals that was widely distributed. Teams of authors for each of 10 modules were selected from respondents to the request for proposals. As the modules were developed, they were reviewed in 3 successive stages, including peer review by members of the ACR Committee on Professionalism and the RSNA-ACR Task Force on an Ethics Curriculum. After revisions were prepared in response to the reviews, the modules were translated into a format compatible with the e-learning platform on which they are mounted. The modules are now available to all who wish to study them.

Kerfoot BP, Baker H, Jackson Tl, et al. A multi-institutional randomized controlled trial of adjuvant web-based teaching to medical students. Acad med 2006; 81(3): 224-30.
Kerfoot, Baker, Jackson, et al. - A multi-institutional randomized controlled trial of adjuvant web-based teaching to medical students

PURPOSE: To investigate the impact of an adjuvant Web-based teaching program on medical students' learning during clinical rotations.
METHOD: From April 2003 to May 2004, 351 students completing clinical rotations in surgery-urology at four U.S. medical schools were invited to volunteer for the study. Web-based teaching cases were developed covering four core urologic topics. Students were block randomized to receive Web-based teaching on two of the four topics. Before and after a designated duration at each institution (ranging one to three weeks), students completed a validated 28-item Web-based test (Cronbach's alpha = .76) covering all four topics. The test was also administered to a subset of students at one school at the conclusion of their third-year to measure long-term learning.
RESULTS: Eighty-one percent of all eligible students (286/351) volunteered to participate in the study, 73% of whom (210/286) completed the Web-based program. Compared to controls, Web-based teaching significantly increased test scores in the four topics at each medical school (p < .001, mixed analysis of variance), corresponding to a Cohen's d effect size of 1.52 (95% confidence interval [CI], 1.23-1.80). Learning efficiency was increased three-fold by Web-based teaching (Cohen's d effect size 1.16; 95% CI 1.13-1.19). Students who were tested a median of 4.8 months later demonstrated significantly higher scores for Web-based teaching compared to non-Web-based teaching (p = .007, paired t-test). Limited learning was noted in the absence of Web-based teaching.
CONCLUSIONS: This randomized controlled trial provides Class I evidence that Web-based teaching as an adjunct to clinical experiences can significantly and durably improve medical students' learning.

Kerfoot BP, Baker HE, Koch MO, Connelly D, Joseph DB, Ritchey ML. Randomized controlled trials of spaced education to urology residents in the United States and Canada. J Urol 2007; 1007(4): 1481-7.
Kerfoot, Baker, Koch, et al. - Randomized controlled trials of spaced education to urology residents in the United States and Canada

PURPOSE: We investigated whether an online educational program based on spacing effect principles could significantly improve the acquisition and retention of medical knowledge.
MATERIALS AND METHODS: In this randomized, controlled trial involving urology residents in the United States and Canada participants randomized to cohort 1 (bolus education) were e-mailed a validated set of 96 study questions on 4 urology topic areas in June 2005. Residents in cohort 2 (spaced education) were sent daily educational e-mails during 27 weeks (June to December 2005), each of which contained 1 or 2 study questions presented in a repeating, spaced pattern. In November 2005 participants completed the Urology In-Service Examination. Participants were also randomized to 1 of 5 outcome cohorts, which completed a 32-item online test at staggered time points (1 to 14 weeks) after completion of the spaced education program.
RESULTS: Of 537 participants 400 (74%) completed the online staggered tests and 515 (96%) completed the In-Service Examination. Residents in the spaced education cohort demonstrated significantly greater online test scores than those in the bolus cohort (ANOVA p <0.001). One-way ANOVA with trend analysis revealed that online test scores for the spaced education cohort remained stable with no significant differences with time, while test scores in the bolus cohort demonstrated a significant linear decrease (p = 0.007). The specific learning gains attributable to Spaced Education were robust when controlling for use of the study materials but they did not generalize to higher scores on the In-Service Examination.
CONCLUSIONS: Online spaced education improves the acquisition and retention of clinical knowledge.

Palan J, Roberts V, Bloch B, Kulkarni A, Bhowal B, Dias J. The use of a virtual learning environment in promoting virtual journal clubs and case-based discussions in trauma and orthopaedic postgraduate medical education: the Leicester experience. Med Educ. 2011 Jan;45(1):51-9.
Palan, et al. - The use of a virtual learning environment in promoting virtual journal clubs and case-based discussions in trauma and orthopaedic postgraduate medical education: the Leicester experience.

ABSTRACT: The use of journal clubs and, more recently, case-based discussions in order to stimulate debate among orthopaedic surgeons lies at the heart of orthopaedic training and education. A virtual learning environment can be used as a platform to host virtual journal clubs and case-based discussions. This has many advantages in the current climate of constrained time and diminishing trainee and consultant participation in such activities. The virtual environment model opens up participation and improves access to journal clubs and case-based discussions, provides reusable educational content, establishes an electronic record of participation for individuals, makes use of multimedia material (including clinical imaging and photographs) for discussion, and finally, allows participants to link case-based discussions with relevant papers in the journal club. The Leicester experience highlights the many advantages and some of the potential difficulties in setting up such a virtual system and provides useful guidance for those considering such a system in their own training programme. As a result of the virtual learning environment, trainee participation has increased and there is a trend for increased consultant input in the virtual journal club and case-based discussions. It is likely that the use of virtual environments will expand to encompass newer technological approaches to personal learning and professional development.


Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002; 287: 226-35.
Epstein & Hundert EM. - Defining and assessing professional competence

CONTEXT: Current assessment formats for physicians and trainees reliably test core knowledge and basic skills. However, they may underemphasize some important domains of professional medical practice, including interpersonal skills, lifelong learning, professionalism, and integration of core knowledge into clinical practice.
OBJECTIVES: To propose a definition of professional competence, to review current means for assessing it, and to suggest new approaches to assessment.
DATA SOURCES: We searched the MEDLINE database from 1966 to 2001 and reference lists of relevant articles for English-language studies of reliability or validity of measures of competence of physicians, medical students, and residents.
STUDY SELECTION: We excluded articles of a purely descriptive nature, duplicate reports, reviews, and opinions and position statements, which yielded 195 relevant citations.
DATA EXTRACTION: Data were abstracted by 1 of us (R.M.E.). Quality criteria for inclusion were broad, given the heterogeneity of interventions, complexity of outcome measures, and paucity of randomized or longitudinal study designs.
DATA SYNTHESIS: We generated an inclusive definition of competence: the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served. Aside from protecting the public and limiting access to advanced training, assessments should foster habits of learning and self-reflection and drive institutional change. Subjective, multiple-choice, and standardized patient assessments, although reliable, underemphasize important domains of professional competence: integration of knowledge and skills, context of care, information management, teamwork, health systems, and patient-physician relationships. Few assessments observe trainees in real-life situations, incorporate the perspectives of peers and patients, or use measures that predict clinical outcomes.
CONCLUSIONS: In addition to assessments of basic skills, new formats that assess clinical reasoning, expert judgment, management of ambiguity, professionalism, time management, learning strategies, and teamwork promise a multidimensional assessment while maintaining adequate reliability and validity. Institutional support, reflection, and mentoring must accompany the development of assessment programs.

Goldstein EA, Maestas RR, Fryer-Edwards K, Wenrich MD, Oelschlager A-MA, Baernstein A, et al. Professionalism in medical education: an institutional challenge. Acad Med. 2006 Oct;81(10):871-6.
Goldstein, Maestas, Fryer-Edwards, et al. - Professionalism in medical education: an institutional challenge

Despite considerable attention to professionalism in medical education nationwide, the majority of attention has focused on training medical students, and less on residents and faculty. Curricular formats are often didactic, removed from the clinical setting, and frequently focus on abstract concepts. As a result of a recent curricular innovation at the University of Washington School of Medicine (UWSOM) in which role-model faculty work with medical students in teaching and modeling clinical skills and professionalism, a new professionalism curriculum was developed for preclinical medical students. Through student feedback, that curriculum has changed over time, and has become more focused on the clinical encounter. This new and evolving curriculum has raised awareness of the existence of an "ecology of professionalism." In this ecological model, changes in the understanding of and attention to professionalism at one institutional level lead to changes at other levels. At the UWSOM, heightened attention to professionalism at the medical student level led to awareness of the need for increased attention to teaching and modeling professionalism among faculty, residents, and staff. This new understanding of professionalism as an institutional responsibility has helped UWSOM teachers and administrators recognize and promote mechanisms that create a "safe" environment for fostering professionalism. In such an institutional culture, students, residents, faculty, staff, and the institution itself are all held accountable for professional behavior, and improvement must be addressed at all levels.

Jantausch BA, Marcdante K. Enhanced professionalism in pediatric practice.. Pediatr Ann. 2011 Sep;40(9):442-6. doi: 10.3928/00904481-20110815-07.
Jantausch & Marcdante - Enhanced professionalism in pediatric practice.

ABSTRACT: Patients trust that physicians act in their best interest. Today, patients are able to rate and publicly share impressions of physician performance with others. At the same time, social organizations highlight expectations for physicians as their role has moved from one of supporting patients through an illness with few medications and limited interventions to a role of managing constantly changing information and technology to create, in collaboration with the patient, a care plan designed to optimize health and function. These changing expectations affect how patients and others view the professionalism of physicians.

McKenna J, Rosen HD. Competency-based professionalism in anesthesiology: continuing professional development. Can J Anaesth. 2012 Sep;59(9):889-908. doi: 10.1007/s12630-012-9747-z.
McKenna & Rosen - Competency-based professionalism in anesthesiology: continuing professional development

PURPOSE: Fulfilling the current societal expectations for professionalism in medicine requires a clear understanding of the specific skills, attitudes, and behaviours expected of practitioners. This Continuing Professional Development (CPD) module discusses professionalism as it relates to the practice of anesthesiology.
PRINCIPAL FINDINGS: While many of the attributes of the professional are generic, performance expectations must be interpreted in a specialty-specific context. Anesthesiologists face challenges to their professionalism in the time-constrained, highly technical and stressful operating room environment. Ongoing shifts in the models of health care delivery require the adaptation of anesthesiology practice to meet changing demands. Consequently, anesthesiologists' practice environment has extended into preoperative assessment units, acute pain services, and perioperative medicine. Application of principles of biomedical ethics, understanding of medico-legal and regulatory aspects of practice, and attention to personal health and career sustainability are intrinsic aspects of professional practice. More recently, focus on adverse event management and continuous quality improvement has created the need for specific skill sets, which must be included in training and continuing professional development programs. The medical education literature suggests teaching and evaluation methods suited to the development of competence in all aspects of professionalism. Finally, professionalism requires the availability of remediation programs for learners and practitioners in difficulty.
CONCLUSION: The attitudes, skills, and behaviours that define professionalism in anesthesiology must be taught and evaluated to establish a basic level of competence by the completion of specialty training. Throughout their careers, anesthesiologists must continue their professional development to meet current and future societal expectations and shifting norms of health care delivery.

McLaren K, Lord J, Murray S. Perspective: delivering effective and engaging continuing medical education on physicians' disruptive behavior. Med Educ. 2011 Jan;45(1):51-9.
McLaren, Lord & Murray - Perspective: delivering effective and engaging continuing medical education on physicians' disruptive behavior.

ABSTRACT: Education about physicians' disruptive behavior is relevant for practicing physicians, who must demonstrate competence in professionalism for maintenance of certification. In addition, physicians need to know about newer regulatory standards that define disruptive behavior and mandated processes for dealing with such behavior, as health care organizations are now charged with having formal policies addressing this issue. There is a growing literature about dealing with disruptive behavior, but it has not addressed education, including continuing medical education (CME), aimed at reducing or preventing disruptive behavior. The authors suggest specific strategies for such CME educational programs, including knowing the audience before the presentation, avoiding potential pitfalls, defusing defensiveness, and increasing audience "buy-in." They present two viewpoints from which to approach the topic of disruptive behavior, depending on the audience: "rekindling of values" and "risk reduction." The authors also recommend interactive teaching methods designed to maximize audience participation and foster self-awareness and reflection.

Plochg T, Klazinga NS, Starfield B. Transforming medical professionalism to fit changing health needs. BMC Med. 2009 Oct 26;7:64. doi: 10.1186/1741-7015-7-64.
Plochg, Klazinga & Starfield - Transforming medical professionalism to fit changing health needs

BACKGROUND: The professional organization of medical work no longer reflects the changing health needs caused by the growing number of complex and chronically ill patients. Key stakeholders enforce coordination and remove power from the medical professions in order allow for these changes. However, it may also be necessary to initiate basic changes to way in which the medical professionals work in order to adapt to the changing health needs.
DISCUSSION: Medical leaders, supported by health policy makers, can consciously activate the self-regulatory capacity of medical professionalism in order to transform the medical profession and the related professional processes of care so that it can adapt to the changing health needs. In doing so, they would open up additional routes to the improvement of the health services system and to health improvement. This involves three consecutive steps: (1) defining and categorizing the health needs of the population; (2) reorganizing the specialty domains around the needs of population groups; (3) reorganizing the specialty domains by eliminating work that could be done by less educated personnel or by the patients themselves. We suggest seven strategies that are required in order to achieve this transformation.
SUMMARY: Changing medical professionalism to fit the changing health needs will not be easy. It will need strong leadership. But, if the medical world does not embark on this endeavour, good doctoring will become merely a bureaucratic and/or marketing exercise that obscures the ultimate goal of medicine which is to optimize the health of both individuals and the entire population.

Practice-Based Learning and Improvement

Mudumbai SC, Gaba DM, Boulet JR, Howard SK, Davies MF. External validation of simulation-based assessments with other performance measures of third-year anesthesiology residents. Simul Healthc. 2012 Apr;7(2):73-80. doi: 10.1097/SIH.0b013e31823d018a.
Mudumbai, et al. - External validation of simulation-based assessments with other performance measures of third-year anesthesiology residents

INTRODUCTION: There has been interest in the use of high-fidelity medical simulation to evaluate performance. We hypothesized that technical and nontechnical performance in the simulated environment is related to other various criterion measures, providing evidence to support the validity of the scores from the performance-based assessment.
METHODS: Twelve third-year anesthesia residents participated in a series of 6 short 5-minute scenarios and 1 longer 30-minute scenario. The short scenarios measured technical skills, whereas the longer one focused on nontechnical skills. Two independent raters scored subjects using analytic and holistic ratings. Short scenarios involved acute hemorrhage, blocked endotracheal tube, bronchospasm, hyperkalemia, tension pneumothorax, and unstable ventricular tachycardia. The long scenario concerned management of myocardial ischemia/infarction leading to cardiac arrest. Scores from the simulations were correlated with (a) rankings generated from an Internet-based global ranking instrument that categorized residents based on overall clinical ability and (b) residency board scores.
RESULTS: There were moderate correlations between various participant scores from the simulation-based assessment and aggregate rankings based on the global ranking instrument and residency examination scores.
CONCLUSIONS: The associations between simulator performance, both for technical and nontechnical skills, and other markers of ability provide some evidence to support the validity of simulation-based assessment scores. Replication studies with larger numbers of residents are warranted.

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