A critical analysis of undergraduate students' cultural immersion experiences

PURPOSE

This paper is concerned with the impact of an international health promotion experience on the understanding of culture among university students. Such immersion experiences are often cited as a strategy to prepare nurses for culturally appropriate practice. We describe students' epistemic movements over time with respect to cultural perspectives prior to, during and after a field study in Malawi.

DESIGN

Data were collected at three time points from students in undergraduate nursing (n = 14) and non-nursing (n = 8) programs at a Canadian university. Two essays narrating participants' understanding of culture were submitted by consenting class members. A subgroup of nine participants (four nursing students, five from other disciplines) completed a third narrative following a subsequent field study course in Malawi.

METHOD

Using narrative analysis, themes and structures in the participants' writing were identified and located within a constructivist or essentialist paradigm of cultural understanding.

FINDINGS

Overwhelmingly, students' narratives were initially portrayed and informed by an essentialist understanding of culture. Later narratives demonstrated varying degrees of epistemic movement towards more constructivist viewpoints. Narratives that initially exhibited constructivist characteristics tended to display strengthened convictions in that paradigm.

CONCLUSION

We challenge the claim that an international immersion experience immediately transforms participants into cultural experts; our evidence suggests that students experienced existential growth, but their understanding of culture did not change as a result of their brief stay in a different cultural context. Cultural immersion is a phenomenon that requires more critical analysis and systematic investigation to determine how such experiences contribute to learning about culture among nursing students.

Twelve tips for facilitating successful teleconferences

BACKGROUND

The work of medical education is increasingly collaborative across geographical sites, sometimes spanning international borders. The success of projects depends more strongly on how meetings are led and run than variables about the task itself; therefore, excellent communication using teleconferencing technology is required. However, we found no medical literature to assist with developing best practices in telecommunication.

AIM

Using the organization and management literature, which has examined the use of telecommunication in optimizing work outcomes, we provide a guide for initiating and facilitating teleconferences.

METHODS

We used Tuckman's framework for group development as a means of organizing guidelines that address practical issues in approaching communication on teleconferences and discuss important aspects of forming work groups using telecommunication, setting ground rules and norms, addressing conflict, and enhancing accountability and outcomes.

RESULTS

We identified 12 tips for optimal teleconferencing and divided them into phases of formation, setting ground rules, managing conflict, and enhancing group performance.

CONCLUSION

Successful work on teleconferences requires excellent attention to the group process, especially since full engagement by participants is not always assured.

Characteristics of success in mentoring and research productivity - a case-control study of academic centers

OBJECTIVES

While mentoring has been associated with research productivity, the specific characteristics of successful mentoring have not been well studied. Thus, we performed a case-control study to identify characteristics of successful mentoring programs.

METHODS

Institutions were divided based on number of plenary research presentations at an annual society meeting over 6years. Case institutions (Group A) had more presentations vs. controls (Group B). A survey of professors and research fellows assessed characteristics of their mentoring program. Chi-square and logistic regression analyses were performed.

RESULTS

Of 159 surveyed, response rates were 46% for professors and 51% for fellows. Compared to Group B, Group A was more likely to have: an additional year of protected fellowship research training (62% vs. 24%; p=0.003), an established program to connect a mentor and mentee with similar research interests (52% vs. 27%; p=0.049), methods to provide feedback to mentors (62% vs. 29%; p=0.01), require mentee research progress reports (45% vs. 21%; p=0.047), and report ease of identifying a mentor (90% vs. 69%; p=0.046). On multivariate analyses, the additional year of research training (OR=7.53, 95% CI: 2.10-27.09; p=0.002) and ease at identifying a research mentor (OR=7.45, 95% CI: 1.44-38.6; p=0.017) remained as independent factors associated with higher research productivity.

CONCLUSIONS

Our data suggest that programs can enhance research productivity with the incorporation of accountability features including formalized reports of progress and mentorship feedback in fellowship training. Facilitating the identification of a mentor and providing an additional year of research may be independent factors associated with research productivity.

Educating generalists: factors of resident continuity clinic associated with perceived impact on choosing a generalist career

BACKGROUND

Fewer residents are choosing general internal medicine (GIM) careers, and their choice 5 be influenced by the continuity clinic experience during residency. We sought to explore the relationship between resident satisfaction with the continuity clinic experience and expressed interest in pursuing a GIM career.

METHODS

We surveyed internal medicine residents by using the Veterans Health Administration Office of Academic Affiliations Learners' Perceptions Survey-a 76-item instrument with established reliability and validity that measures satisfaction with faculty interactions, and learning, working, clinical, and physical environments, and personal experience. We identified 15 reliable subscales within the survey and asked participants whether their experience would prompt them to consider future employment opportunities in GIM. We examined the association between satisfaction measures and future GIM interest with 1-way analyses of variance followed by Student-Newman-Keuls post hoc tests.

RESULTS

Of 217 residents, 90 (41%) completed the survey. Residents felt continuity clinic influenced career choice, with 22% more likely to choose a GIM career and 43% less likely. Those more likely to choose a GIM career had higher satisfaction with the learning (P  =  .001) and clinical (P  =  .002) environments and personal experience (P < .001). They also had higher satisfaction with learning processes (P  =  .002), patient diversity (P < .001), coordination of care (P  =  .009), workflow (P  =  .001), professional/personal satisfaction (P < .001), and work/life balance (P < .001).

CONCLUSIONS

The continuity clinic experience 5 influence residents' GIM career choice. Residents who indicate they are more likely to pursue GIM based on that clinical experience have higher levels of satisfaction. Further prospective data are needed to assess if changes in continuity clinic toward these particular factors can enhance career choice.

Validation of a self-efficacy instrument and its relationship to performance of crisis resource management skills

Self-efficacy is thought to be important for resuscitation proficiency in that it influences the development of and access to the associated medical knowledge, procedural skills and crisis resource management (CRM) skills. Since performance assessment of CRM skills is challenging, self-efficacy is often used as a measure of competence in this area. While self-efficacy may influence performance, the true relationship between self-efficacy and performance in this setting has not been delineated. We developed an instrument to measure pediatric residents' self-efficacy in CRM skills and assessed its content validity, internal structure, and relationship to other variables. After administering the instrument to 125 pediatric residents, critical care fellows and faculty, we performed an exploratory factor analysis within a confirmatory factor analysis as well as a known group comparison. The analyses specified four factors that we defined as: situation awareness, team management, environment management, and decision making. Pediatric residents reported lower self-efficacy than fellows and faculty in each factor. We also examined the correlation between self-efficacy and performance scores for a subset of 30 residents who led video recorded simulated resuscitations and had their performances rated by three observers. We found a significant, positive correlation between residents' self-efficacy in situation awareness and environment management and their overall performance of CRM skills. Our findings suggest that in a specific context, self-efficacy as a form of self-assessment may be informative with regards to performance.

Learning through service: student perceptions on volunteering at interprofessional hepatitis B student-run clinics

Student-run clinics (SRCs) are widespread, but studies on their educational impact are limited. We surveyed preclinical medical, nursing, and pharmacy students about their experiences in a hepatitis B elective which provided opportunities to they could volunteer at hepatitis B screening and vaccination SRCs. Student responses revealed positive perceptions of the volunteer experience. Benefits included interacting with patients, developing clinical skills, providing service to disadvantaged populations, and collaborating with health professional peers. Students who participated in clinic reported enhanced skills compared to those who did not attend. SRCs play a valuable role in instilling positive attitudes and improving skills.

Reframing research on faculty development

Research on faculty development has focused primarily on individual participants and has produced relatively little generalizable knowledge that can guide faculty development programs. In this article, the authors examine how current research on faculty development in medical education can be enriched by research in related fields such as teacher education, quality improvement, continuing medical education, and workplace learning. As a result of this analysis, the authors revise the old model for conceptualizing faculty development (preferably called professional development). This expanded model calls for research on educational process and outcomes focused on two communities of practice: the community created among participants in faculty development programs and the communities of teaching practice in the workplace (classroom or clinic) where teaching actually occurs. For the faculty development community, the key components are the participants, program, content, facilitator, and context in which the program occurs and in which the faculty teach. For the workplace community, associated components include relationships and networks of association in that environment, the organization and culture of the setting, the teaching tasks and activities, and the mentoring available to the members of that academic and/or clinical community of teaching practice. This expanded model of faculty development generates a new set of research questions, which are described along with six recommendations for enhancing research, including establishment of a national center for research in health professions education.

Comparison of traditional methods with 3D computer models in the instruction of hepatobiliary anatomy

This study was designed to determine whether an interactive three-dimensional presentation depicting liver and biliary anatomy is more effective for teaching medical students than a traditional textbook format presentation of the same material. Forty-six medical students volunteered for participation in this study. Baseline demographic information, spatial ability, and knowledge of relevant anatomy were measured. Participants were randomized into two groups and presented with a computer-based interactive learning module comprised of animations and still images to highlight various anatomical structures (3D group), or a computer-based text document containing the same images and text without animation or interactive features (2D group). Following each teaching module, students completed a satisfaction survey and nine-item anatomic knowledge post-test. The 3D group scored higher on the post-test than the 2D group, with a mean score of 74% and 64%, respectively; however, when baseline differences in pretest scores were accounted for, this difference was not statistically significant (P = 0.33). Spatial ability did not statistically significantly correlate with post-test scores for the 3D group or the 2D group. In the post-test satisfaction survey the 3D group expressed a statistically significantly higher overall satisfaction rating compared to students in the 2D control group (4.5 versus 3.7 out of 5, P = 0.02). While the interactive 3D multimedia module received higher satisfaction ratings from students, it neither enhanced nor inhibited learning of complex hepatobiliary anatomy compared to an informationally equivalent traditional textbook style approach. .

Development and pilot testing of a reflective learning guide for medical education

BACKGROUND

Reflection is increasingly incorporated into all levels of medical education but little is known about best practices for teaching and learning reflection.

AIMS

To develop a literature-based reflective learning guide for medical education and conduct a pilot study to determine whether (1) guide use enhances medical students' reflective writing skills and (2) reflective scores correlate with participant demographics and satisfaction.

METHODS

Guide development consisted of literature review, needs assessment, single institution survey, and educational leader consensus. The pilot cohort study compared professionalism reflections written with and without the guide by third-year medical students on their core obstetrics and gynecology rotation. Reflections were scored using a previously validated rubric. A demographics and satisfaction survey examined effects of gender and satisfaction, as well as qualitative analysis of optional written comments. Analyses used independent t-tests and Pearson's correlations.

RESULTS

We developed a two-page, literature-based guide in clinical Subjective-Objective-Assessment-Plan (SOAP) note format. There was a statistically significant difference, p < 0.001, in the reflection scores between groups, but no effects of gender or satisfaction. Student satisfaction with the guide varied widely.

CONCLUSIONS

A single exposure to a literature-based guide to reflective learning improved written reflections by third-year medical students.

Improving graduate education to support a branching career pipeline: recommendations based on a survey of doctoral students in the basic biomedical sciences

Today's doctoral programs continue to prepare students for a traditional academic career path despite the inadequate supply of research-focused faculty positions. We advocate for a broader doctoral curriculum that prepares trainees for a wide range of science-related career paths. In support of this argument, we describe data from our survey of doctoral students in the basic biomedical sciences at University of California, San Francisco (UCSF). Midway through graduate training, UCSF students are already considering a broad range of career options, with one-third intending to pursue a non-research career path. To better support this branching career pipeline, we recommend that national standards for training and mentoring include emphasis on career planning and professional skills development to ensure the success of PhD-level scientists as they contribute to a broadly defined global scientific enterprise.

Collaborative research in medical education: a discussion of theory and practice

CONTEXT

Medical education researchers are inherently collaborators. This paper presents a discussion of theoretical frameworks, issues and challenges around collaborative research to prepare medical education researchers to enter into successful collaborations. It gives emphasis to the conceptual issues associated with collaborative research and applies these to medical education research. Although not a systematic literature review, the paper provides a rich discussion of issues which medical education researchers might consider when undertaking collaborative studies.

METHODS

Building on the work of others, we have classified collaborative research in three dimensions according to: the number of administrative units represented; the number of academic fields present, and the manner in which knowledge is created. Although some literature on collaboration focuses on the more traditional positivist perspective and emphasises outcomes, other literature comes from the constructivist framework, in which research is not driven by hypotheses and the approaches emphasised, but by the interaction between investigator and subject.

DISCUSSION

Collaborations are more effective when participants overtly clarify their motivations, values, definitions of appropriate data and accepted methodologies. These should be agreed upon prior to commencing a study. The way we currently educate researchers should be restructured if we want them to be able to undertake interdisciplinary research. Despite calls for researchers to be educated differently, most training programmes for developing researchers have demonstrated a limited, if not contrary, response to these calls.

CONCLUSIONS

Collaborative research in medical education should be driven by the problem being investigated, by the new knowledge gained and by the interpersonal interactions that may be achieved. Success rests on recognising that many of the research problems we, as medical educators, address are fundamentally interdisciplinary in nature. This represents a transition to bridge the dichotomy often presented in medical education between theory building and addressing practical needs.

Do writing and storytelling skill influence assessment of reflective ability in medical students' written reflections?

BACKGROUND

Increasingly, students are asked to write reflections as part of their medical education, but some question the influence of other factors on the evaluation of these reflections. In this pilot study, the investigators determined whether scores from a validated rubric to measure reflective ability were affected by irrelevant variance resulting from writing or storytelling ability.

METHOD

Students in clerkships wrote reflections on professionalism. All were given identical prompts, with half receiving additional structured guidelines on reflection. Sixty reflections, 30 from each group, were randomly chosen and scored for reflection, writing, and storytelling by trained raters using validated rubrics.

RESULTS

There was no correlation between reflection and either writing (r = 0.049, P = .35) or storytelling (r = 0.14, P = .13). The guidelines increased reflection, but not writing or storytelling scores.

CONCLUSIONS

Reflection is a distinct construct unaffected by learners' writing or storytelling skills. These findings support reflective ability as a distinct skill.

Improving resident education and patient safety: a method to balance initial caseloads at academic year-end transfer

PURPOSE

In outpatient continuity clinics, incoming trainees may receive caseloads that are unbalanced in terms of the mental workload required from each resident. When significant, these imbalances may compromise resident learning and patient safety. Using data from psychiatric outpatient continuity clinics, this study tested a method for balancing initial caseloads.

METHOD

Adapting prior research on mental workload, the authors developed and implemented a workload-balancing method to balance initial caseloads regarding factors contributing to mental workload: number of patients, number of acute patients, complexity/time demands outside clinic, visits per month, and collaboration demands. For academic years 2006-2007, 2007-2008, 2008-2009, and 2009-2010, they compared these balanced caseloads with those that would have been created by the clinic's traditional method of largely preserving prior caseloads (with some redistribution to balance only the number of patients). The outcome measure was the intercaseload coefficient of variation for each of the chosen mental workload factors and for all factors combined.

RESULTS

Compared with the traditional method, the workload-balancing method generated lower intercaseload variation for each mental workload factor. Also, this method reduced overall intercaseload variation for all factors combined by 50% to 61% in each of the intervention years.

CONCLUSIONS

The workload-balancing method evenly distributes among resident panels factors known to contribute to mental workload. This method may reduce errors and stress likely to occur when residents inherit unbalanced caseloads that are overly challenging and, thus, may improve patient safety and resident learning. This model could be applicable to other caseload situations.

Categorization of unprofessional behaviours identified during administration of and remediation after a comprehensive clinical performance examination using a validated professionalism framework

BACKGROUND

Unprofessional behaviours by medical students predict future disciplinary outcomes. Comprehensive clinical performance examinations (CPXs) that are commonly employed to evaluate learners may provide an opportunity to identify unprofessional behaviours.

AIMS

To categorize the professionalism problems that occur during the CPX and subsequent remediation of students who perform poorly.

METHODS

We interviewed 33 individuals responsible for remediation after the CPX at 33 medical schools. We applied a validated framework for characterizing unprofessional behaviours to the professionalism problems described. We searched transcripts for 119 descriptors representing eight categories of unprofessional behaviour from this framework.

RESULTS

Eighteen interviewees identified professionalism as a problem during the examination and subsequent remediation. Unprofessional behaviours reported to occur in order of most to least mentioned, where a diminished capacity for self-improvement, impaired relationships with patients, irresponsibility, poor initiative and unprofessional behaviour associated with anxiety.

CONCLUSIONS

Unprofessional behaviours are exhibited during the CPX and subsequent remediation. The frequently occurring behaviours of irresponsibility and diminished capacity for self-improvement are predictive of future professionalism problems and co-occur with behaviours that preclude meaningful patient relationships. A framework for identifying unprofessional behaviours may be useful in the formal assessment of professionalism during the CPX.

Impact of an in-person versus web-based practice standardized patient examination on student performance on a subsequent high-stakes standardized patient examination

BACKGROUND

Optimal methods of preparing students for high-stakes standardized patient (SP) examinations are unknown.

PURPOSES

The purpose is to compare the impact of two formats of a formative SP examination (Web-based vs. in-person) on scores on a subsequent high-stakes SP examination and to compare students' satisfaction with each formative examination format.

METHODS

Clustered randomized trial comparing a Web-based module versus in-person formative SP examination. We compared scores on a subsequent high-stakes SP examination and satisfaction.

RESULTS

Scores on the subsequent high-stakes SP examination did not differ between the two formative formats but were higher after the formative assessment than without (p < .001). Satisfaction was higher with the in-person than Web-based formative assessment format (4.00 vs. 3.62 on a 5-point scale, p = .01).

CONCLUSIONS

Two formats of a formative SP examination led to equivalent improvement in scores on a subsequent high-stakes examination. Students preferred an in-person formative examination to online but were satisfied with both.

Transitional clerkship: an experiential course based on workplace learning theory

Starting clerkships is anxiety provoking for medical students. To ease the transition from preclerkship to clerkship curricula, schools offer classroom-based courses which may not be the best model for preparing learners. Drawing from workplace learning theory, the authors developed a seven-day transitional clerkship (TC) in 2007 at the University of California, San Francisco School of Medicine in which students spent half of the course in the hospital, learning routines and logistics of the wards along with their roles and responsibilities as members of ward teams. Twice, they admitted and followed a patient into the next day as part of a shadow team that had no patient-care responsibilities. Dedicated preceptors gave feedback on oral presentations and patient write-ups. Satisfaction with the TC was higher than with the previous year's classroom-based course. TC students felt clearer about their roles and more confident in their abilities as third-year students compared with previous students. TC students continued to rate the transitional course highly after their first clinical rotation. Preceptors were enthusiastic about the course and expressed willingness to commit to future TC preceptorships. The transitional course models an approach to translating workplace learning theory into practice and demonstrates improved satisfaction, better understanding of roles, and increased confidence among new third-year students.

Developing an educator network: the effect of a teaching scholars program in the health professions on networking and productivity

BACKGROUND

Teaching Scholars Programs are designed to enhance productivity and faculty retention. The formation of an increased network may be a facilitative mechanism.

PURPOSES

This study determined if participants increased their educational network and if the increase affected productivity.

METHODS

Researchers interviewed Teaching Scholars participants for pre- and postparticipation members of their educational network and issues related to network formation and conducted a structured vita analysis. Researchers used social network analysis (SNA) to describe the networks and regression to determine the relationship between network and productivity.

RESULTS

Educational networks increased with participation (p <.001) but showed little or no effect on productivity. SNA revealed a decrease of participants with no network, increase in connections among participants, and increase in connections to central services personnel. Researchers identified six themes from the participants' comments.

CONCLUSIONS

This relatively modest program demonstrated a small effect on productivity through the increased network.

Teaching feedback to first-year medical students: long-term skill retention and accuracy of student self-assessment

BACKGROUND

Giving and receiving feedback are critical skills and should be taught early in the process of medical education, yet few studies discuss the effect of feedback curricula for first-year medical students.

OBJECTIVES

To study short-term and long-term skills and attitudes of first-year medical students after a multidisciplinary feedback curriculum.

DESIGN

Prospective pre- vs. post-course evaluation using mixed-methods data analysis.

PARTICIPANTS

First-year students at a public university medical school.

INTERVENTIONS

We collected anonymous student feedback to faculty before, immediately after, and 8 months after the curriculum and classified comments by recommendation (reinforcing/corrective) and specificity (global/specific). Students also self-rated their comfort with and quality of feedback. We assessed changes in comments (skills) and self-rated abilities (attitudes) across the three time points.

MEASUREMENTS AND MAIN RESULTS

Across the three time points, students' evaluation contained more corrective specific comments per evaluation [pre-curriculum mean (SD) 0.48 (0.99); post-curriculum 1.20 (1.7); year-end 0.95 (1.5); p = 0.006]. Students reported increased skill and comfort in giving and receiving feedback and at providing constructive feedback (p < 0.001). However, the number of specific comments on year-end evaluations declined [pre 3.35 (2.0); post 3.49 (2.3); year-end 2.8 (2.1)]; p = 0.008], as did students' self-rated ability to give specific comments.

CONCLUSION

Teaching feedback to early medical students resulted in improved skills of delivering corrective specific feedback and enhanced comfort with feedback. However, students' overall ability to deliver specific feedback decreased over time.

Consequences within medical schools for students with poor performance on a medical school standardized patient comprehensive assessment

PURPOSE

Medical schools increasingly employ comprehensive standardized patient assessments to ensure medical students' clinical competence. The consequences of poor performance on the assessment and the institutional factors associated with imposing consequences are unknown.

METHOD

In 2006, the investigators surveyed 122 U.S. medical school curriculum deans about comprehensive assessments using standardized patients after core clerkships, with questions about exam characteristics, institutional commitment to the examination (years of experience, exam infrastructure, clerkship director involvement), academic consequences of failing the assessment, and satisfaction with remediation.

RESULTS

Ninety-three of 122 (76%) deans responded. Eighty-two (88%) conducted a comprehensive assessment in years three or four of medical school. Of those, required remediation was the only consequence of failing employed by 61 schools (74%), and only 39 (47%) required retesting for graduation. Participants were somewhat satisfied with (mean 3.45 out of maximum 5, SD 1.08) and confident in (3.37, SD 1.17) their remediation process. Satisfaction and confidence were associated with requiring remediation (P = .003) and retesting (P < .001), but experience with the exam, exam infrastructure, and clerkship director involvement were not. No school demographic characteristics or measures of institutional commitment were related to external reporting of students' comprehensive assessment scores.

CONCLUSIONS

Despite the prevalence of comprehensive assessments, schools attach few academic consequences to poor performance. Educators are only moderately satisfied with their efforts to remediate poor performers. However, schools with greater trust in their remediation process than other schools are more likely to enforce consequences of poor performance.

Remediation techniques for student performance problems after a comprehensive clinical skills assessment

PURPOSE

Poor performance on a medical school comprehensive clinical skills assessment after core clerkships requires remediation. Little is known about techniques used to remedy students' skills deficits and their effectiveness. The authors identified remediation strategies used at U.S. medical schools and determined instructors' confidence in remediation.

METHOD

In the fall of 2007, the authors surveyed persons responsible for remediation at U.S. medical schools that conduct comprehensive clinical assessments and remediation. Respondents reported their use of four types of remediation strategies: (1) clinical activities, (2) independent study, (3) precepted video review of exam recording, and (4) organized group activities for deficits in history-taking, physical examination, knowledge, clinical reasoning, professionalism, and communication. The authors assessed confidence in remediation for the six skill areas and analyzed these measures using repeated-measures analysis of variance.

RESULTS

Fifty-three of 71 (74.6%) participants responded. Educators most commonly employ the precepted video review remediation activity across the six skill areas, and they use the clinical activities least commonly. Confidence in remediating the six skill areas was below the "agree" level. Confidence was highest for remediating history-taking and physical examination problems and lowest for professionalism.

CONCLUSION

Educators express modest confidence in remediating fourth-year students' clinical skills deficiencies. The finding that schools employ primarily video review for remediation suggests a potential need to augment opportunities for mentored skills practice to address deficits more effectively. The remediation literature similarly stresses the importance of multiple approaches tailored to particular deficits.

Becoming an academic doctor: perceptions of scholarly careers

OBJECTIVES

Despite a recognised need to prepare future faculty members, little research has been conducted on how best to accomplish this task, especially among learners and faculty members within research-intensive medical schools.

METHODS

We interviewed 40 medical students, residents and faculty members from a single institution in the USA and asked questions about which careers the school does and should prepare individuals for, and the strengths of the institution for doing so. Interviews were conducted in person at a location chosen by the participant. All interviews were transcribed and coded using qualitative methods and software. The coding and themes were reviewed and discussed among members of the research team and verified by external reviewers.

RESULTS

We identified five themes related to becoming an academic doctor: early exposure to research; role models and mentoring; career pathways; interplay of personal and social factors, and career support for junior faculty members.

CONCLUSIONS

Results suggest that opportunities should be structured within undergraduate and graduate medical education to stimulate interest in careers as academic doctors and to aid junior faculty members to act as role models who can encourage learners to pursue careers in academic medicine.

Factors associated with medical students' career choices regarding internal medicine

CONTEXT

Shortfalls in the US physician workforce are anticipated as the population ages and medical students' interest in careers in internal medicine (IM) has declined (particularly general IM, the primary specialty serving older adults). The factors influencing current students' career choices regarding IM are unclear.

OBJECTIVES

To describe medical students' career decision making regarding IM and to identify modifiable factors related to this decision making.

DESIGN, SETTING, AND PARTICIPANTS

Web-based cross-sectional survey of 1177 fourth-year medical students (82% response rate) at 11 US medical schools in spring 2007.

MAIN OUTCOME MEASURES

Demographics, debt, educational experiences, and number who chose or considered IM careers were measured. Factor analysis was performed to assess influences on career chosen. Logistic regression analysis was conducted to assess independent association of variables with IM career choice.

RESULTS

Of 1177 respondents, 274 (23.2%) planned careers in IM, including 24 (2.0%) in general IM. Only 228 (19.4%) responded that their core IM clerkship made a career in general IM seem more attractive, whereas 574 (48.8%) responded that it made a career in subspecialty IM more attractive. Three factors influenced career choice regarding IM: educational experiences in IM, the nature of patient care in IM, and lifestyle. Students were more likely to pursue careers in IM if they were male (odds ratio [OR] 1.75; 95% confidence interval [CI], 1.20-2.56), were attending a private school (OR, 1.88; 95% CI, 1.26-2.83), were favorably impressed with their educational experience in IM (OR, 4.57; 95% CI, 3.01-6.93), reported favorable feelings about caring for IM patients (OR, 8.72; 95% CI, 6.03-12.62), or reported a favorable impression of internists' lifestyle (OR, 2.00; 95% CI, 1.39-2.87).

CONCLUSIONS

Medical students valued the teaching during IM clerkships but expressed serious reservations about IM as a career. Students who reported more favorable impressions of the patients cared for by internists, the IM practice environment, and internists' lifestyle were more likely to pursue a career in IM.

Effect of the use of instructional anatomy videos on student performance

Medical schools have reduced the time allotted to anatomy instruction. Consequently, schools engage students in more independent settings using information and communication technologies (ICT). There has been limited research in the use of video aids, a type of ICT, to enhance anatomy examination performance. The objective of this study is to describe the design, usage, and effect on examination performance of eight locally developed instructional anatomy videos. First-year UCSF medical students (n = 141) had access to the videos. They reported their video usage, reason for usage, and satisfaction. The prior year students (n = 141) served as a historical control group. Anatomy and radiology examination performance was compared between groups while controlling for prior performance. The students with and without access to the videos did not differ in examination performance. Sixty-one (43%) students in the experimental group responded to the survey. Of these, 79% reported using at least one video, viewing an average of 4.75 of the eight videos. They watched 3.27 (SD = 1.57, range 1-5) of the five anatomy videos and 1.48 (SD = 1.35; range 0-3) of the three radiology videos. In a regression analysis controlling for age and MCAT scores, using the anatomy videos at least once improved anatomy examination performance by 3.4% (P-value = 0.007). There was no relationship between radiology video usage and radiology exam score. Video resource availability did not enhance student performance in anatomy and radiology. However, when analyzing performance for those whom we knew level of video use, there was a statistically different and higher anatomy achievement.

Approaches to medical student remediation after a comprehensive clinical skills examination

OBJECTIVE

Most US medical schools conduct comprehensive clinical skills assessments during Years 3 and 4. This study explores strategies used to identify and remediate students who perform poorly on these assessments.

METHODS

In the academic year 2005-06, we conducted 33 semi-structured interviews with individuals responsible for standard setting in and remediation after their schools' comprehensive clinical skills assessments. We coded interviews to identify major themes.

RESULTS

Prior to remediation, some schools employed a 'verification' step to ensure the accuracy of the failing score or need for remediation. Participants described a remediation process that included some or all of 3 steps. Firstly, students' specific learning deficits were diagnosed. Next, students participated in remedial activities such as performance review sessions or practice with standardised or actual patients. Lastly, students were re-tested, usually with a shorter, more formative examination. All participants reported using a diagnostic step, most offered or required remedial activities and many re-tested, although schools varied in the emphasis placed on each step. Many participants cited the individualised attention students received from remediation faculty staff as a strength of their approach, although they raised concerns about the substantial time demands placed on remediation faculty. Most respondents reported some dissatisfaction with their school's remediation process, particularly uncertainty about efficacy or rigour.

CONCLUSIONS

Schools vary in the intensity and scope of remediation offered to students who perform poorly on clinical skills assessments. Although many schools invest significant resources in remediation, the effect of these efforts on students' subsequent clinical performance is unknown.

Teaching Residents to Teach: The Impact of a Multi-Disciplinary Longitudinal Curriculum to Improve Teaching Skills

BACKGROUND

Residents have primary responsibility for teaching medical students, yet many receive no formal teaching instruction. This study evaluated the impact of a longitudinal multidisciplinary teaching curriculum on resident participants' self-perceived teaching skills.

METHODS

Residents received instruction on teaching and leadership skills during a four-month longitudinal teaching course. Participants completed a validated pre-post self-assessment inventory for teaching and a teaching self-efficacy survey.

RESULTS

Participants' self-rated teaching skills significantly increased in all categories of the self-assessment inventory for teaching. Self-efficacy survey results revealed statistically significant increased participant confidence in all teaching skills. Residents were very satisfied with course content.

CONCLUSION

Residents are eager to improve their teaching skills and benefit from a multidisciplinary learning group. A successful teaching curriculum increases resident interest in teaching and impacts self-efficacy and self-assessed teaching skills.

Crafting Successful Relationships with the IRB

BACKGROUND

Medical educational researchers face frustration with IRBs for activities that formerly were exempt from review or were not treated as biomedical research with patients. The authors sought to identify methods for improving relationships between IRBs and medical education researchers.

METHOD

The authors conducted interviews with medical school representatives about factors leading to relationships in which all parties feel that their concerns are being met, subjects are appropriately protected, and that the progress of evaluation or research activities is not unnecessarily inhibited.

RESULTS

Successful relationships require efforts at education of the IRB and the researchers. All institutions acknowledged the need to establish and maintain good communication. Some schools developed structures or procedures that resulted in more rapid review and increased satisfaction that interests of all parties were protected.

CONCLUSIONS

A relationship must be crafted between medical education researchers and the IRB. The authors found key elements to successful approaches.

Optimal learning environments from the perspective of resident physicians and associations with accreditation length

BACKGROUND

Indicators of program quality in graduate medical education have not been thoroughly well developed or studied. This study explores resident physicians' perceptions of program quality and associations with an external quality indicator.

METHOD

Responses to two open-ended questions about program strengths and areas in need of improvement were analyzed for 392 residents from 14 specialty programs that were reaccredited between 1999 and 2005. Computerized text analysis facilitated reliable categorization of 1,502 comments. Mann-Whitney U tests and nonparametric analyses for correlated data were used to examine associations between resident perceptions and accreditation length.

RESULTS

The most frequently mentioned program strengths were related to the quality of faculty, exposure to patients, education, and the social environment. Of these core strengths, residents in programs with longer cycle lengths had significantly more comments about the quality of faculty in their program.

CONCLUSIONS

Resident feedback can provide beneficial information about dimensions of program quality and the learning environment.

Student performance problems in medical school clinical skills assessments

BACKGROUND

Though most medical schools administer comprehensive clinical skills assessments to identify students who have not achieved competence, the types of problems uncovered by these exams have not been characterized.

METHOD

The authors interviewed 33 individuals responsible for remediation after their schools' comprehensive assessments, to explore their experience with the problems students demonstrate and strategies for and success with remediation.

RESULTS

Respondents perceived that technique problems in history taking and physical examination were readily correctable, but that poor performance resulting from inadequate knowledge or poor clinical reasoning ability was more difficult to ameliorate. Interpersonal skill deficiencies, which often manifested as detachment from the patient, and professionalism problems attributed to lack of insight, were most refractory to remediation.

CONCLUSIONS

Poor performance in comprehensive assessments often indicates underlying deficiencies in cognitive ability, communication skills, or professionalism. The challenge of remediating these deficiencies late in medical school calls for earlier identification and intervention.

Defining the core competency of professionalism based on the patient's perception

BACKGROUND

To better define professionalism using a 10-question multiple-choice survey of patient preferences.

METHODS

One hundred and ninety-one adult patients (response rate: 52% +/- 5%) completed a survey over a 3-week period in resident and faculty ophthalmology clinics in a university setting in a rural portion of the southern USA. Most patients voluntarily provided information on gender, race and age. Data are reported at proportions +/- 95% confidence intervals.

RESULTS

Patients desire a degree of formality from their physicians in the form of a handshake (61% +/- 7%), greeting of family members (69% +/- 7%) and in addressing oneself as doctor. They also prefer note taking by the physician while speaking with them. However, patients do not think that the wearing of a white coat is necessary. Most patients assume (84% +/- 5%) that the physician washes his/her hands. Surprisingly, patients (60% +/- 7%) are willing to maintain a relationship with a physician despite the use of medical jargon. We found few differences related to gender and none related to race. Women (64% +/- 9%) preferred a closed door during the exam. Men (81% +/- 8%) either did not want the physician to wear a white coat or said that it made no difference. Those younger than 46 years (67% +/- 10%) preferred the door closed compared with those who were older (45% +/- 10%).

CONCLUSIONS

Our study helps to define professionalism by providing concrete examples of the expectations of patients in the southern USA during physician interaction. Minor adjustments to the patient encounter based on these findings may increase patients' perception of professionalism, creating a higher level of trust. These are teachable precepts that can be incorporated into residency training.

Impact of a teaching scholars program

BACKGROUND

Researchers employ various approaches to evaluate teaching scholars programs (TSPs). We interviewed secondary beneficiaries of the TSP.

METHOD

During an interview, TSP graduates identified individuals and/or groups whom they felt were affected as a result of their TSP participation. At least one individual from each type of these identified beneficiaries was interviewed. Quantitative results were summarized descriptively and qualitative comments coded through a consensus process.

RESULTS

Thirty-six (88%) of TSP participants were interviewed. From their responses, 50 beneficiaries were interviewed. Sixty-eight percent of beneficiaries identified that, as a result of TSP, the scholars became better teachers and educational scholars and enhanced educational scholarship, programs, teaching, mentoring, and leadership in departments. Eighty-nine percent identified educational projects emanating from their contact with the scholar.

CONCLUSION

Beneficiaries validated that the TSP produced better teachers and scholars. The impact in scholarship validated the importance of completing a project as part of the TSP. TSP also enhanced networking and educational resources for departments.

Use of health services by ninth grade adolescents in rural Mississippi

Rural Mississippi adolescents have not been surveyed regarding their use of health services. Prior to Hurricane Katrina we found that at least 43% of ninth grade students in Hancock County received healthcare in the previous three months, but a third had no regular place of care. Students (37%) did not seek health care that they needed with two-thirds of them feeling that the problem would go away. They minimally used the school clinics that varied considerably in availability. Strikingly, at that time, over 20% reported serious emotional/mental health problems for which they did not seek care and nearly 15% had problems for which they had sought professional help. This information highlights the need to encourage students to seek and have access to services.

Educational development program for residency program directors and coordinators

BACKGROUND

Residency program directors and program coordinators have increasing demands placed on them by accrediting agencies and require educational development specifically tailored to their needs.

DESCRIPTION

We created, piloted, and evaluated an educational development program consisting of 10 sessions spanning 1 year for program directors and a parallel set of sessions for program coordinators.

EVALUATION

On average, more than half the residency programs participated in the sessions. Programs improved in residency activities related to their program's handbook, interviewing, evaluations, rotation descriptions, and program evaluation. They did not improve in educational scholarly activities. Program directors and coordinators indicated that the program improved their skills, and they would recommend the program for others.

CONCLUSIONS

This 10-session program improved important elements of residency education and was favorably received.

Effect of Individualized Social Activity on Sleep in Nursing Home Residents with Dementia

OBJECTIVES

To test the efficacy of an individualized social activity intervention (ISAI) on decreasing daytime sleep, improving nighttime sleep, and lowering the day/night sleep ratio and to determine its cost.

DESIGN

Pretest/posttest randomized with an experimental and control group.

SETTING

Seven nursing homes.

PARTICIPANTS

One hundred forty-seven residents with dementia.

INTERVENTION

One to 2 hours of individualized social activities for 21 consecutive days.

MEASUREMENTS

Twenty-four-hour sleep/wake patterns using an Actigraph.

RESULTS

The ISAI group had significantly less daytime sleep (P=.001) and a lower day/night sleep ratio (P=.03) than the control group, after adjusting for baseline values. Because 40% of the sample slept 7 or more hours at night, a secondary analysis was conducted. When only those residents with a sleep efficiency of less than 50% (n=50) were included, the ISAI group (n=20) had less daytime sleep (P=.005), a lower day/night sleep ratio (P=.02), fell asleep faster (P=.03), and were awake less at night (P=.04) than the control group (n=30), after adjusting for baseline values. The weekly cost of the ISAI was roughly $70 per participant. Initial training and supply costs were $1,944.

CONCLUSION

The ISAI provides an alternative to medications, without side effects.

Demographic and sleep characteristics in cognitively impaired nursing home residents with and without severe sleep/wake pattern inefficiency

This study determined the differences in demographic and sleep characteristics in cognitively impaired nursing home residents with and without severe sleep/wake pattern inefficiency. Identification of characteristics associated with severe sleep/wake pattern inefficiency will allow health care providers to make the best cost effective use of finite resources because they can target interventions towards those most likely to need them. This article reports the baseline characteristics of the total sample, compares the demographic and sleep characteristics of the subgroups with and without severe sleep/wake pattern inefficiency, and reviews related literature.

Sustaining a Best-Care Practice in a Nursing Home

This study tested whether an action research organizational intervention fostering participatory management practices would sustain a nursing best-care practice protocol in a nursing home. An experimental nursing home (EH) and a control nursing home (CH) with similar characteristics were studied over a 4-year period. A pretest/posttest quasi-experimental design was used. Baseline data were co[lected on residents, families, and the staffs at the EH and the CH. Staff turnover rates, demographics of participant groups, and surveys concerning job stress, nursing care, family involvement, and satisfaction of residents and family members served as proximal outcomes to indicate whether organizational changes had occurred in the EH. Sustaining best practices in a nursing home requires not only significant organizational change but also changes in regulatory support for quality care, sufficient staff resources to implement and monitor the practices, and a change coordinator with sufficient formal or informal influence.

Predictors of patient education by bone densitometry technologists

OBJECTIVE

This study investigated which factors predict the likelihood of densitometry technologists counseling their patients about osteoporosis prevention.

METHOD

Predictors of osteoporosis prevention patient education by bone densitometry technologists were analyzed in a sample of 417 radiologic technologists with ARRT advanced certification in bone densitometry and 158 densitometry technologists, none of whom were ARRT certified in bone densitometry.

RESULTS

The regression model accounted for 41% of the variation in reports of bone health counseling. Densitometry technologists with high internal motivation and low personal barriers reported educating their patients about osteoporosis prevention.

CONCLUSION

Recommendations for increasing bone health promotion include increasing personal interest through sensitivity training, expanding delivery by promoting models for clinical implementation and creating educational opportunities to strengthen counseling skills.

Balance, mobility, and falls among community-dwelling elderly persons: effects of a rehabilitation exercise program

OBJECTIVE

To assess the short-term effect of an exercise-based rehabilitation intervention on balance, mobility, falls and injuries.

DESIGN

This randomized, controlled trial with repeated measures was performed at an outpatient rehabilitation center. Elderly, ambulatory, community-dwelling volunteers underwent 6 wks of supervised stretching, balance, endurance, coordination, and strengthening exercises. Controls attended seminars. Data were recorded for time and quality performance on a functional obstacle course and for self-reported falls and injuries.

RESULTS

From baseline through 6-mo follow-up, participants in the exercise group (n = 122) significantly outperformed those in the control group (n = 83). The exercise group's functional obstacle course quality improved 2.3% postintervention and 1.57% at follow-up compared with 0.3% for the control group for each time period (P = 0.001). Functional obstacle course completion time improved 7.69% at postintervention and 8.35% at follow-up for the exercise group compared with 4.0% and 3.4% for the control group. Of baseline fallers in the intervention group, 87% (compared with 34.5% for the controls) reported no falls in the subsequent 6 mos. Of those reporting injuries in the 6 mos preintervention, 89.7% in the intervention group (compared with 55.6% for controls) reported no injury at 6 mos postintervention.

CONCLUSIONS

Our intervention can improve functional performance and protect against falls and fall-related injuries.

Residents' perception of effectiveness of twelve evaluation methods for measuring competency

OBJECTIVE

The authors assessed residents' perceptions of techniques used to evaluate competency.

METHODS

Psychiatry residents from a single program rated 12 evaluation techniques for their effectiveness to measure resident competency. They rated each method for 25 selected skills reflecting the six general competencies.

RESULTS

Sixteen residents (70%) completed the survey. Responses indicated that different methods were effective for different competencies. Residents saw objective structured clinical examinations and standardized patients as equally effective. They favored the 360 degrees evaluation method for all competencies except medical knowledge. Resident perception of the effective techniques differed from preferred techniques identified by measurement experts.

CONCLUSIONS

Residency program directors using guidelines from the Accreditation Council for Graduate Medical Education (ACGME) to select preferred evaluations may find that residents do not have the same perceptions.

Can one portfolio measure the six ACGME general competencies?

OBJECTIVE

To determine that portfolios, useable by any program, can provide needed evidence of resident performance within the ACGME general competencies.

METHODS

Eighteen residents constructed portfolios with selected entries from thirteen psychiatric skills. Two raters assessed whether entries reflected resident performance within the general competencies. They indicated no (0), some (1), or definite evidence (2) for each competency. Median scores were reported by competency and psychiatric skill.

RESULTS

Eighty entries were rated: 100% of the psychiatric skills reflected some evidence for medical knowledge; 92% provided some evidence for patient care, communication and interpersonal skills, and professionalism; 77% provided some evidence for systems-based practice, and 31% provided some evidence for practice-based learning. Ten of the 13 skills reflected evidence for at least five of the competencies.

CONCLUSIONS

Any combination of five entries reflects all competencies with the exception of practice-based learning. This deficit can be corrected with revision of portfolio guidelines.

Biopsychosocial formulation: recognizing educational shortcomings

OBJECTIVE

Since Engel introduced the biopsychosocial model, it has been extensively examined. The authors expect psychiatrists to formulate cases using the biopsychosocial model. However, resident psychiatrists' ability to generate formulations using this model has received little attention.

METHODS

The authors evaluated resident biopsychosocial formulations using biopsychosocial scores from trained, blinded raters across four institutions. Second, the authors determined if an intervention could improve biopsychosocial formulation.

DESIGN

This study included non-experimental and pre-post components using resident portfolio scores to measure biopsychosocial.

PARTICIPANTS/SETTING

Residents from four postgraduate years (PGY) in four different programs participated. In one institution, faculty made a concerted effort to improve biopsychosocial formulation. There were 33 entries in 2000-2001 and 46 entries in 2001-2002.

RESULTS

Using the combined data from all institutions, no PGY level averaged a rating of 3.0 (competent) in either year. In the institution implementing an intervention, a significant improvement was noted.

CONCLUSION

This pilot study indicates that we can improve resident competency in this area.

Demonstration of portfolios to assess competency of residents

Residency educators are identifying approaches to measure resident competence. Portfolios are well suited since they require work already completed as part of patient care where competency must be demonstrated. This paper describes assessment of the reliability and validity of portfolios in a psychiatry residency program. This was a cross-sectional study across 4years of residency education. Using guidelines, 18 residents assembled portfolios containing five entries chosen from 13 skills. Trained raters scored the portfolios. Residents and faculty were interviewed about their perceptions. Generalizability results indicated five entries and two raters were sufficient for relative decisions. Six entries or a third rater would be sufficient for absolute decisions. Portfolio scores tended to improve with years of training and correlated with psychiatric knowledge but not clinical performance. Residents and faculty identified benefits to assembling a portfolio. Portfolios incorporate tasks embedded in the residency to provide evidence of resident competency. The results support that the score is reliable and valid.

Oximeter's acquisition parameter influences the profile of respiratory disturbances

STUDY OBJECTIVES

Pulse oximetry (Sp02) is a key parameter monitored during polysomnographic studies, and different acquisition settings can be employed to obtain this data. The purpose of this study was to determine if the use of different settings would significantly influence scoring of respiratory disturbance events (RDE).

DESIGN

Prospective study

SETTING

Sleep Disorders Center - community

PATIENTS

30 patients had three identical oximeters simultaneously attached to the digits during polysomnography, each placed in a different recording setting: 3, 6 and 12 seconds.

INTERVENTIONS

None.

MEASUREMENTS

RDEs were identified by changes in snoring and flow then sub-categorized as RDE0, RDE1-2 and/or RDE3 if less than 1%, greater than 1 but less than 3%, and 3% or greater oxyhemoglobin desaturation occurred. Each event was given three labels according to the level of desaturation seen on each oximetry tracing.

RESULTS

Significant differences in the mean frequency of RDE types at each recording setting were noted (p < .001). A survey of sleep practitioners revealed changes in clinical behavior when presented examples of such differences.

CONCLUSION

These data confirm the impact of different oximetric recording settings on the profile of RDEs and the importance of reporting such acquisition settings in studies of sleep disordered breathing.

Psychosocial effects of an exercise program in older persons who fall

Falling is associated with psychosocial sequelae that may influence functional performance and fall risk. Exercise can improve psychosocial factors. To address the research questions (1) Do psychosocial variables differ among persons with and without falls? and (2) Among persons who fall, can exercise improve psychosocial variables? we evaluated psychosocial and functional performance variables in older persons with and without recent falls. A pretest and posttest design with a nonequivalent control group was used. Community-residing elderly individuals participated, 66 had falls in the past year (fallers) and 77 had no falls (nonfallers). Participants completed measures of self-esteem, depression, psychological impact, and functional performance at baseline and 6 weeks. Baseline descriptive characteristics for fallers and nonfallers were similar. Fallers then completed a 6-week exercise program. Exercise benefited fallers' self-esteem, depression, mobility, social role, social activity, and anxiety. Nearly 40% of fallers were clinically depressed before exercise and 24% were depressed after (p = 0.04). Psychosocial variables correlated significantly with quality of functional performance (p < 0.019). Among fallers, moderate exercise produced a significant improvement in psychosocial variables and functional performance (p < 0.045).

Oximeter performance: the influence of acquisition parameters

STUDY OBJECTIVE

This study was designed to determine whether different desaturation indexes (DIs) would be obtained in patients with sleep-disordered breathing by systematically altering two acquisition parameters: the recording setting and the display mode.

DESIGN

Prospective clinical study.

SETTING

Community sleep-disorders center.

PATIENTS

The study included 75 patients who were suspected of having sleep-disordered breathing.

INTERVENTIONS

Each patient had simultaneous pulse oxyhemoglobin saturation (SpO2) traces at three recording settings (3 s, 6 s, and 12 s) during the diagnostic phase of split-night polysomnography. On-line and memory displays of those data at each recording setting were obtained. DIs for > or = 3% desaturation events per hour were calculated for each of the six traces.

RESULTS

The mean on-line DIs significantly differed from each other, with slower (longer) recording settings resulting in lower values than faster (shorter) settings. The memory DIs all significantly underestimated the on-line DIs. Pearson correlations ranged from 0.82 to 0.90 between the on-line/memory DI pairs, but Bland-Altman analysis detected disagreement at higher levels of disordered breathing.

CONCLUSIONS

These findings confirm that significantly different SpO2 data are obtained at various acquisition options. The recording setting and display mode parameters should be disclosed in all reports employing oximetry with the fastest recording setting and on-line display mode preferable for case finding of sleep-disordered breathing.

Predictive validity of the Medical College Admissions Test Writing Sample for the United States medical licensing examination steps 1 and 2

Despite the amount of published research on the predictive validity of the Medical College Admissions Test (MCAT) taken as a whole, few published reports separate the individual predictive validity of the Writing Sample. The purpose of this study is to provide data on the predictive validity of the Writing Sample for the national licensing exam used in the United States. Subjects consisted of 1992-1995 matriculants from a publicly owned medical school in the Southeastern United States. Independent variables were undergraduate grade point average, and four section scores on a required admissions test (Biological Sciences, Physical Sciences, Verbal Reasoning, and Writing Sample). The dependent variables were Steps 1 and 2 on the three step licensing examination. Steps 1 and 2 of the examination are taken during medical school. Multiple regression models calculated additional variance accounted for by the addition of the Writing Sample to a model containing grade point average and the other admissions test section scores. In multivariate analyses, when grade point average and all admissions test scores were considered as predictors of licensing exam scores, the Writing Sample variable did not add to the ability to predicting the Step 1 or Step 2 scores. The results of this study suggest that the Writing Sample has limited predictive validity for assessing success on a national licensing exam. However, as others suggest, the value of the Writing Sample and other surrogates of communication probably lie in predicting performance in the clinical years of medical school and beyond. Additional work should include evaluating the predictive validity of the Writing Sample and other pre-medical school measures of communication with widely acceptable measures of performance in clinical settings, including physician-patient communication.

Portfolios as a novel approach for residency evaluation

The authors describe the development process for a portfolio that programs may use for evaluating psychiatry residents. A committee carefully developed the portfolio requirements for 13 necessary skills in psychiatry. Psychiatrists were trained to rate portfolios. Review of the development and training process suggested that portfolios provided information both on individual residents and on the residency program itself. The process requires orientation of both residents and faculty, attention to time demands, and availability of examples and resources.