Future: new strategies for hospitalists to overcome challenges in teaching on today's wards

The Hospitalist Movement 25 Years Later

Hospitalists are generalists who specialize in the care of hospitalized patients. In the 25 years since the term hospitalist was coined, the field of hospital medicine has grown exponentially and established a substantial footprint in the medical community. There are now more hospitalists than practicing physicians in any other internal medicine subspecialty. Several key forces catalyzed the growth in the field of hospital medicine, including the quality, safety, and value movements; residency duty hour restrictions; the emergence of electronic health records; and the COVID-19 pandemic. Looking ahead, we see new opportunities in the realms of technology and telemedicine, and challenges persist in regard to balancing financial considerations with increasing workload and burnout. Hospitalists must remain nimble and seize emerging opportunities to continue supporting the field's prominence and growth.

Kontinuierliche medizinische Fortbildung in der Dermatologie für Ärzte und Studierende während der Coronavirus‐Pandemie – eine große Herausforderung

Kontinuierliche medizinische Fortbildung (Continuing Medical Education, CME) ist die wesentliche Grundlage der studentischen Lehre sowie der Aus- und Weiterbildung von Ärzten. Eine moderne und adäquate Patientenversorgung ist ohne sie nicht denkbar. Vor kurzem zwang die durch das schwere akute respiratorische Syndrom-Coronavirus 2 (SARS-CoV-2) verursachte Pandemie die gesamte medizinische Gemeinschaft, ihre Gewohnheiten bezüglich der medizinischen Fortbildung und Lehre sowie des Lernens in der Medizin zu ändern. Infolgedessen rückten über soziale Medien (Social Media) verbreitete digitale Aus-, Fortbildungs- und Lehrformate, medizinische Online-Enzyklopädien, webbasierte medizinische Lernportale und medizinische Podcasts in den Vordergrund. In diesem Beitrag geben wir einen Überblick zu aktuelle Konzepten in der medizinischen Online-Fortbildung, unter besonderer Berücksichtigung der Dermatologie.

The Case for Writing Critical Thinking Reports as a Teaching Strategy on Today's Hospital Wards

I review some of the challenges in teaching medical students and housestaff on today's hospital medicine wards, including increasingly limited time for dedicated teaching. Tapping into the extensive literature of "writing to learn" or "writing-across-the curriculum" in non-medical educational settings ranging from elementary school to college classes, I urge consideration of writing concise critical thinking reports (CTRs) by medical students and housestaff in response to questions raised during patient rounds as a means of enhancing their ward-based learning experience. Several potential reasons for writing CTRs are offered: (1) Nurtures curiosity; (2) Demands self-directed search for and encoding of new knowledge; (3) Emphasizes metacognition and conceptualization crucial to meaningful learning; (4) Provides opportunity for learners to teach and share newly-assimilated material with a broader web-based audience; (5) Encourages the concept of narrow but more in-depth learning related to a specific clinically relevant subject matter; (6) Nudges learners toward clear and succinct writing as an important general skill to develop in their everyday professional activities, including electronic medical record documentation; and (7) Reduces work-related burnout. Barriers to writing CTRs, including lack of general appreciation for explanatory writing as a potential teaching strategy in medical education and allowing sufficient time for medical students and housestaff to engage in this activity among other competing demands, are discussed. Writing CTRs is a potentially powerful pedagogical tool in ward-based learning that deserves consideration and formal evaluation by properly designed studies.

Asking a Variety of Questions on Walk Rounds: a Pilot Study

BACKGROUND

Morning walk rounds have lost some of their engagement while remaining a useful and valued practice.

AIM

We created a pilot study to evaluate the impact on rounds of learning to asking a variety of different questions.

SETTING

One-hour intervention sessions were voluntarily offered to members of the Department of Medicine and taught by an expert in the question, listen, and respond method.

PARTICIPANTS

Participants included attendings and residents in Internal Medicine on medical teams.

PROGRAM DESCRIPTION

Questionnaires were collected on six pre-intervention and six post-intervention days. Nine months later, an anonymous online survey was sent to participants asking about their use of a wider variety of questions.

PROGRAM EVALUATION

Two hundred eight physicians (residents 175 (45.5%), attending physicians 25 (27.7%)) filled out pre-intervention surveys. One hundred eighty-one physicians (residents 155 (40.3%), attending physicians 18 (20%)) filled out post-intervention surveys. When survey responses from the attendings and residents on the medical teams were combined, post-intervention rounds were perceived as more worthwhile (1.99 pre-intervention and 1.55 post-intervention, [95% confidence interval 1.831-2.143]) (p < 0.001) and more engaging (1.68 pre-intervention and 1.30 post-intervention, [95% confidence interval 1.407-1.688]) (p < 0.001).Non-medical teams' survey responses did not change. Patient census data indicated no significant difference in the hospital's census on the pre- and post-intervention dates. Spontaneous suggestions for improving rounds came largely from the residents and included teaching points, clinical pearls, patient focus, more interactive, increased dedicated time for teaching, inclusive/multidisciplinary, questions, and evidence-based teaching. Of the participants who answered the online survey 9 months later, 75% (6/8) reported that they "actually asked a wider variety of types of questions."

DISCUSSION

This pilot study indicates that the 1-h intervention of learning to ask a variety of different questions is associated with rounds that are rated as more worthwhile and engaging by the medical teams.

Integration of Mobile Devices to Facilitate Patient Care and Teaching During Family-Centered Rounds

OBJECTIVES

The increasing prevalence of mobile devices in clinical settings has the potential to improve both patient care and education. The benefits are particularly promising in the context of family-centered rounds in inpatient pediatric settings. We aimed to increase mobile device usage by inpatient rounding teams by 50% in 6 months. We hoped to demonstrate that use of mobile devices would improve access to patient care and educational information and to determine if use would improve efficiency and perceptions of clinical teaching.

METHODS

We designed a mixed-methods study involving pre- and post-implementation surveys to residents, families, and faculty as well as direct observations of family-centered rounds. We conducted rapid cycles of continual quality improvement by using the Plan-Do-Study-Act framework involving 3 interventions.

RESULTS

Pre-intervention, the mobile computing cart was used for resident education on average 3.3 times per rounding session. After cycle 3, teaching through the use of mobile devices increased by ∼79% to 5.9 times per rounding session. On the basis of survey data, we determined there was a statistically significant increase in residents' perception of feeling prepared for rounds, receiving teaching on clinical care, and ability to teach families. Additionally, average time spent per patient on rounds decreased after implementation of mobile devices.

CONCLUSIONS

Integration of mobile devices into a pediatric hospital medicine teaching service can facilitate patient care and perception of resident teaching by extending the utility of electronic medical records in care decisions and by improving access to knowledge resources.

More Learning in Less Time: Optimizing the Resident Educational Experience with Limited Clinical and Educational Work Hours

OBJECTIVE

Resident education in the United States and elsewhere has undergone significant changes in recent years owing to work hour restrictions, requiring didactics to fit within a limited schedule, while being increasingly effective at accomplishing educational goals.

METHODS

A single small program experience in improving the didactic experience of residents is described.

RESULTS

Focused mentorship, curricula for intangibles, asynchronous education, and independent curricula all are useful tools in resident education.

CONCLUSIONS

Residents can be exposed to both clinical material and specialty-specific mores using focused and intentional educational techniques.

Results of a Flipped Classroom Teaching Approach in Anesthesiology Residents

BACKGROUND

In a flipped classroom approach, learners view educational content prior to class and engage in active learning during didactic sessions.

OBJECTIVE

We hypothesized that a flipped classroom improves knowledge acquisition and retention for residents compared to traditional lecture, and that residents prefer this approach.

METHODS

We completed 2 iterations of a study in 2014 and 2015. Institutions were assigned to either flipped classroom or traditional lecture for 4 weekly sessions. The flipped classroom consisted of reviewing a 15-minute video, followed by 45-minute in-class interactive sessions with audience response questions, think-pair-share questions, and case discussions. The traditional lecture approach consisted of a 55-minute lecture given by faculty with 5 minutes for questions. Residents completed 3 knowledge tests (pretest, posttest, and 4-month retention) and surveys of their perceptions of the didactic sessions. A linear mixed model was used to compare the effect of both formats on knowledge acquisition and retention.

RESULTS

Of 182 eligible postgraduate year 2 anesthesiology residents, 155 (85%) participated in the entire intervention, and 142 (78%) completed all tests. The flipped classroom approach improved knowledge retention after 4 months (adjusted mean = 6%; P = .014; d = 0.56), and residents preferred the flipped classroom (pre = 46%; post = 82%; P < .001).

CONCLUSIONS

The flipped classroom approach to didactic education resulted in a small improvement in knowledge retention and was preferred by anesthesiology residents.

Texting preferences in a Paediatric residency

PURPOSE

Text messaging is ubiquitous among residents, but remains an underused educational tool. Though feasibility has been demonstrated, evidence of its ability to improve standardised test scores and provide insight on resident texting preferences is lacking. The authors set out to evaluate: (1) satisfaction with a hybrid question-and-answer (Q&A) texting format; and (2) pre-/post-paediatric in-training exam (ITE) performance.

METHODS

A prospective study with paediatrics and internal medicine-paediatrics residents. Residents were divided into subgroups: adolescent medicine (AM) and developmental medicine (DM). Messages were derived from ITE questions and sent Monday-Friday with a 20 per cent variance in messages specific to the sub-group. Residents completed surveys gauging perceptions of the programme, and pre- and post-programme ITE scores were analysed.

RESULTS

Forty-one residents enrolled and 32 (78%) completed a post-programme survey. Of those, 21 (66%) preferred a Q&A format with an immediate text response versus information-only texts. The percentage change in ITE scores between 2013 and 2014 was significant. Comparing subgroups, there was no significant difference between the percentage change in ITE scores. Neither group performed significantly better on either the adolescent or developmental sections of the ITE. Text messaging… remains an underused educational tool CONCLUSIONS: Overall, participants improved their ITE scores, but no improvement was seen in the targeted subgroups on the exam. Although Q&A texts are preferred by residents, further assessment is required to assess the effect on educational outcomes.

Flipping the Quality Improvement Classroom in Residency Education

PURPOSE

The flipped classroom (FC), in which instructional content is delivered before class with class time devoted to knowledge application, has the potential to engage residents. A Mayo Clinic Internal Medicine Residency Program study was conducted to validate an FC perception instrument (FCPI); determine whether participation improved FC perceptions; and determine associations between resident characteristics, change in quality improvement (QI) knowledge, and FC perception scores.

METHOD

All 143 internal medicine residents at Mayo Clinic, Rochester participated from 2014 to 2015; some experienced a flipped QI curriculum and others completed the traditional nonflipped course. The FCPI was developed, and factor analysis revealed an intuitive two-factor structure: preclass activity and in-class application. Residents were surveyed before and after the monthlong curriculum to measure changes in perception, and the QI Knowledge Assessment Tool was employed to measure knowledge improvement.

RESULTS

Postcourse FCPI scores significantly increased for three of the eight items. QI knowledge increased significantly among residents who experienced the FC compared with residents who completed the non-FC curriculum. Those without prior FC exposure demonstrated a significant increase in QI knowledge compared with those with previous FC experience. The FCPI had compelling validity evidence with improved scores after curriculum exposure and associations with greater engagement in online modules.

CONCLUSIONS

Residents who participated in the FC demonstrated improved QI knowledge compared with the control group. Residents valued the in-class application sessions more than the online component. These findings have important implications for graduate medical education as residency training programs increasingly use FC models.

Introduction to Curriculum Development and Medical Education Scholarship for Resident Trainees: A Webinar Series

INTRODUCTION

A common career aspiration among residents is to become a clinician-educator, though standard postgraduate training may not prepare trainees for the academic and scholarly requirements of this career. To address this need, we designed and implemented an asynchronous, interactive webinar series detailing a systematic approach to medical education research and scholarship. The series was piloted as part of a new track at the University of Chicago for residents interested in additional training and completing an educational learning project in medical education.

METHODS

We aimed to use this series to introduce relevant frameworks in curriculum development, program evaluation, and learning theory. Materials associated with this publication include six webinars and corresponding summary reference handouts, discussion assignments, and answer keys. Additional materials include a faculty course director packet and sample feedback for discussion assignments. Each webinar is an 8- to 20-minute narrated presentation with goals and objectives, an overview of each session's content, and example vignettes. Residents viewed presentations and completed a two-part discussion assignment for each webinar, which included reflection on the educational material and vignettes, faculty feedback on this reflection, and application of webinar material and faculty feedback to their own experiences in medical education.

RESULTS

All residents in the pilot completed the webinars and assignments. Residents' reactions to the webinar series have been positive, and residents have commented that self-paced learning with directed faculty feedback is a desirable instructional method for this material.

DISCUSSION

This series is well suited to introduce fundamental concepts in medical education scholarship and inspire self-directed study for motivated learners.

What's in a learning environment? Recognizing teachers' roles in shaping a learning environment to support competency

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Maintaining a Twitter Feed to Advance an Internal Medicine Residency Program's Educational Mission

BACKGROUND

Residency programs face many challenges in educating learners. The millennial generation's learning preferences also force us to reconsider how to reach physicians in training. Social media is emerging as a viable tool for advancing curricula in graduate medical education.

OBJECTIVE

The authors sought to understand how social media enhances a residency program's educational mission.

METHODS

While chief residents in the 2013-2014 academic year, two of the authors (PB, AN) maintained a Twitter feed for their academic internal medicine residency program. Participants included the chief residents and categorical internal medicine house staff.

RESULTS

At the year's end, the authors surveyed residents about uses and attitudes toward this initiative. Residents generally found the chief residents' tweets informative, and most residents (42/61, 69%) agreed that Twitter enhanced their overall education in residency.

CONCLUSIONS

Data from this single-site intervention corroborate that Twitter can strengthen a residency program's educational mission. The program's robust following on Twitter outside of the home program also suggests a need for wider adoption of social media in graduate medical education. Improved use of data analytics and dissemination of these practices to other programs would lend additional insight into social media's role in improving residents' educational experiences.

A pilot study of team learning on in-patient rounds

BACKGROUND

Medical trainees often do not receive structured teaching during in-patient rounds.

OBJECTIVE

To assess whether the addition of a collaborative team learning technique would improve the learning experience on a general medicine in-patient team.

METHODS

Eight learners participated in this pilot study. Learning teams consisted of internal medicine residents and third-year medical students on a general medicine in-patient rotation. The experimental curriculum covered four common topics: cardiac stress testing; syncope; pneumonia; and valvular heart disease. Sessions had the following format: (1) each learner answered five self-assessment questions using an immediate feedback technique; (2) learners were divided into groups of two or three to discuss their answers; (3) the teaching doctor led a discussion to clarify and summarise, and also distributed a handout delineating key learning points. Control sessions consisted of the usual teaching rounds. Learners were e-mailed a daily online survey asking them to rate the rounds and handouts on a Likert scale. Medical trainees often do not receive structured teaching during in-patient rounds

RESULTS

All of the learners rated the collaborative team learning intervention as either 'excellent' or 'very good'. Learners also indicated that they found the take-away handout valuable, and positive responses were also noted in the survey comments.

DISCUSSION

A novel collaborative team learning technique resulted in high ratings of teaching rounds by medical residents and medical students. Learners found the sessions engaging, high yield, and educationally valuable. This interactive discussion-based teaching method could be used to enhance the learning experience during teaching rounds on medical, surgical and subspecialty services.

Text4Peds: Feasibility of an Educational Text-Messaging Program for Pediatrics Residents

BACKGROUND

There is an ongoing effort to maximize educational material provided to residents who are in a time-constrained work environment. Mobile technology, principally smartphone applications and online modules, has shown educational promise.

INTERVENTION

We developed a text-messaging program, Text4Peds, to assist residents with preparation for their pediatric board examinations. Goals were to assess (1) the feasibility of texting educational messages to residents, and (2) resident satisfaction and perceived usefulness of a texting program.

METHODS

We conducted a prospective study of pediatrics and combined internal medicine-pediatrics residents. Messages derived from the most missed pediatric in-training examination questions were sent daily to residents. After 3 months, residents completed surveys that gauged their perception on the educational value of the text messages and the effect on their pediatric board preparation. Feasibility of the system was assessed as a total percentage of messages successfully received by residents.

RESULTS

Of 55 residents, 35 (64%) participated in the program. Of 2534 messages sent out to participants, 2437 (96.2%) were delivered successfully. Positive comments cited the texting of board facts as a quick, helpful, daily study tool. Residents liked that messages were sent at 2:00 pm, and most felt that 1 to 5 messages per week was appropriate. Drawbacks included character restrictions of messages, content limitations, and the lack of a question-answer format.

CONCLUSIONS

An educational text message-based program was successfully implemented in our residency program. Messages were delivered with a high success rate, and residents found educational value in the messages.

The development of an internet-based knowledge exchange platform for pediatric critical care clinicians worldwide*

OBJECTIVES

Advances in Internet technology now enable unprecedented global collaboration and collective knowledge exchange. Up to this time, there have been limited efforts to use these technologies to actively promote knowledge exchange across the global pediatric critical care community. To develop an open-access, peer-reviewed, not-for-profit Internet-based learning application, OPENPediatrics, a collaborative effort with the World Federation of Pediatric Intensive and Critical Care Societies, was designed to promote postgraduate educational knowledge exchange for physicians, nurses, and others caring for critically ill children worldwide.

DESIGN

Description of program development.

SETTING

International multicenter tertiary pediatric critical care units across six continents.

SUBJECTS

Multidisciplinary pediatric critical care providers.

INTERVENTIONS

A software application, providing information on demand, curricular pathways, and videoconferencing, downloaded to a local computer.

MEASUREMENTS AND MAIN RESULTS

In 2010, a survey assessing postgraduate educational needs was distributed through World Federation of Pediatric Intensive and Critical Care Societies to constituent societies. Four hundred and twenty-nine critical care providers from 49 countries responded to the single e-mail survey request. Respondents included 68% physicians and 28% nurses who care for critically ill children. Fifty-two percent of respondents reported accessing the Internet at least weekly to obtain professional educational information. The five highest requests were for educational content on respiratory care [mechanical ventilation] (48% [38%]), sepsis (28%), neurology (25%), cardiology (14%), extracorporeal membrane oxygenation (10%), and ethics (8%). Based on these findings, and in collaboration with researchers in adult learning and online courseware, an application was developed and is currently being used by 770 registered users in 60 countries.

CONCLUSIONS

We describe here the development and implementation of an Internet-based application which is among the first efforts designed to promote global knowledge exchange for physicians and nurses caring for critically ill children. This application has the potential to evolve new methods in postgraduate education. Ongoing assessment of the efficacy of Internet-based learning platforms will be necessary.