Factors affecting resident performance: development of a theoretical model and a focused literature review

Interventions for undergraduate and postgraduate medical learners with academic difficulties: A BEME systematic review update: BEME Guide No. 85

BACKGROUND

Clinical teachers often struggle to record trainee underperformance due to lacking evidence-based remediation options.

OBJECTIVES

To provide updated evidence-based recommendations for addressing academic difficulties among undergraduate and postgraduate medical learners.

METHODS

A systematic review searched databases including MEDLINE, CINAHL, EMBASE, ERIC, Education Source, and PsycINFO (2016-2021), replicating the original Best Evidence Medical Education 56 review strategy. Original research/innovation reports describing intervention(s) for medical learners with academic difficulties were included. Data extraction used Michie's Behaviour Change Techniques (BCT) Taxonomy and program evaluation models from Stufflebeam and Kirkpatrick. Quality appraised used the Mixed Methods Appraisal Tool (MMAT). Authors synthesized extracted evidence by adapting GRADE approach to formulate recommendations.

RESULTS

Eighteen articles met the inclusion criteria, primarily addressing knowledge (66.7%), skills (66.7%), attitudinal problems (50%) and learner's personal challenges (27.8%). Feedback and monitoring was the most frequently employed BCT. Study quality varied (MMAT 0-100%). We identified nineteen interventions (UG: n = 9, PG: n = 12), introducing twelve new thematic content. Newly thematic content addressed contemporary learning challenges such as academic procrastination, and use of technology-enhanced learning resources. Combined with previous interventions, the review offers a total dataset of 121 interventions.

CONCLUSION

This review offers additional evidence-based interventions for learners with academic difficulties, supporting teaching, learning, faculty development, and research efforts.

The mediating role of work-related perceptions in the relationship between empathy and self-perceived clinical performance of residents in China: A multi-center cross-sectional study

OBJECTIVE

This study aimed to describe the association between empathy and residents' clinical performance and investigate whether work-related perception mediates this relationship.

METHODS

A multi-center cross-sectional study was conducted, including 1160 residents from 10 cities in Liaoning Province between March and October 2020. The participants completed various self-reported questionnaires regarding demographic characteristics, work-related perceptions, self-perceived clinical performance, and empathy. The relationships among empathy, work-related perception, and self-perceived clinical performance were examined using a structural equation model (SEM).

RESULTS

Of the 1160 residents, 961 (82.8 %) completed the questionnaires. The SEM path analysis showed that the direct effect of empathy on self-perceived clinical performance was significant and positive (β = 0.34, P < 0.001). There existed significant effects of empathy on work-related perception (β = 0.26, P < 0.001) and work-related perception on performance (β = 0.31, P < 0.001). The path coefficients of empathy concerning self-perceived clinical performance decreased significantly (β = 0.26, P < 0.001) when work-related perception was modeled as a mediator. The bias-corrected and accelerated bootstrap test revealed that work-related perception significantly mediated the relationship between empathy and self-perceived clinical performance (a*b = 0.08, BCa 95 % CI: 0.05-0.13). However, the correlation between the sub-scales of empathy and the items of self-perceived clinical performance was not substantial, even if most of them were statistically significant. The final SEM produced a good fit to the sample data, with CMIN/DF = 2.07 (P < 0.001), CFI = 0.99, GFI = 0.99, AGFI = 0.98, TLI = 0.98, NFI = 0.97, RMSEA (90 % CI) = 0.033 (0.017, 0.049), and SRMR = 0.024.

CONCLUSION

Empathy might significantly affect self-perceived clinical performance both directly and indirectly through the mediating role of work-related perception.

PRACTICE IMPLICATIONS

Efforts to improve clinical performance among residents might benefit from interventions for cultivating empathy and practices for improving work-related perceptions of residents.

Academic Faculty Demonstrate Weak Agreement in Evaluating Orthopaedic Surgery Residents

Background

As objective metrics fade, subjective elements of orthopaedic surgery applicants carry increasing importance during recruitment. Academic orthopaedic surgeons believe they can select for high-performing orthopaedic residents. However, can they agree? The purpose of this study was (1) to analyze an academic orthopaedic surgery department to determine whether they agree on which residents performed best during residency and; (2) to correlate preresidency and intraresidency factors with postresidency evaluations of resident performance.

Methods

With Institutional Review Board [IRB] approval, an orthopaedic surgery department completed surveys to evaluate residency performance for 10 years of graduated residents (2012-2022). Faculty determined (1) Post-Residency Class Rank (PRCR)-ranked from the highest (1) to lowest performing resident (5) relative to their class based on faculty perspective of performance-and (2) Rank List Score (RLS)-ranked based off the 5-point AOA SLOR used during recruitment interviews. RLS assessed how likely the department would have graduates in the program again based on residency performance. Free marginal Cohen's kappa statistics assessed faculty inter-rater agreement. Preresidency metrics (United States Medical Licensing Exam [USMLE] 1 and 2 scores, research publications, etc) were correlated with Orthopaedic In-Training Exam (OITE) scores, research productivity, American Board of Orthopaedic Surgery (ABOS) scores, and faculty-derived rankings. Linear regressions with forward variable entry (p < 0.05) were used to determine factors associated with excellent resident performance.

Results

Eighteen of 25 faculty members (72%) provided survey responses evaluating 46 residents. Faculty agreed 37% and 38% of the time for PRCR (kappa 0.26) and RLS (kappa 0.23), respectively. Step 2 score was the only preresidency factor significantly associated with PRCR (p = 0.03, r2 = 0.15) and RLS (p = 0.02, r2 = 0.3). The only intraresidency factor significantly correlated with PRCR (p = 0.002, r2 = 0.50) and RLS (p = 0.01, r2 = 0.39) was PGY-4 OITE score.

Conclusions

An academic orthopaedic surgery department is able to come to a consensus on evaluations of residency performance relative to peers in the same year of training (PRCR) and an objective standard (RLS). Step 2 and Post-Graduate Year (PGY)-4 OITE scores were the only preresidency and intraresidency factors with significant association to higher postresidency, faculty-derived performance scores.

Level of Evidence

III.

A framework for residents' pursuit of excellence based upon non-cognitive and cognitive attributes

PURPOSE

Excellence, although variably conceptualized, is commonly used in medicine and the resident excellence literature is limited. Both cognitive attributes (CAs) and non-cognitive attributes (NCAs) are essential for academic and clinical performance; however, the latter are difficult to evaluate. Undergirded by an inclusive and non-competitive approach and utilizing CAs and NCAs, we propose a criterion-referenced behavioral framework of resident excellence.

METHODS

Perceptions of multiple stakeholders (educational administrators, faculty, and residents), gathered by survey (n = 218), document analysis (n = 52), and focus group (n = 23), were analyzed. Inductive thematic analysis was followed by deductive interpretation and categorization using sensitizing concepts for excellence, NCAs, and CAs. Chi-squared tests were used to determine stakeholder perception differences.

RESULTS

All stakeholders had similar perceptions (P > .05) and 13 behavioral attributes in 6 themes undergirded by insight and conscientiousness were identified. The NCAs included: interpersonal skills (works with others, available, humble), professional (compassionate, trustworthy), commitment to profession (visible, volunteers), commitment to learn (proactively seeks feedback, creates learning opportunities), and work-life balance/integration (calm demeanor, inspirational). The CA (medical knowledge and intellect) included: applies knowledge to gain expertise and improves program's caliber.

CONCLUSION

Resident excellence is posited as a pursuit. The attributes are non-competitive, inclusionary, potentially achievable by all, and do not negatively affect freedom of choice. However, contextual and cultural differences are likely and these need validation across societal equity segments. There are implications for learners (adaptive reflection and learning goal orientation), faculty (reduced bias and whole-person feedback), and system leaders (enhancing culture and learning environments) to foster excellence.

Can a Situational Judgment Test Identify Trainees at Risk of Professionalism Issues? A Multi-Institutional, Prospective Cohort Study

PURPOSE

To determine whether overall situational judgment test (SJT) scores are associated with programs' clinical competency committee (CCC) ratings of trainee professionalism, any concerning behavior, and concerning behavior requiring active remediation at 2 time periods.

METHOD

In fall 2019, trainees from 17 U.S. programs (16 residency, 1 fellowship) took an online 15-scenario SJT developed to measure 7 dimensions of professionalism. CCC midyear and year-end (6 months and 1 year following SJT completion, respectively) professionalism scores and concern ratings were gathered for academic year 2019-2020. Analyses were conducted to determine whether overall SJT scores related to overall professionalism ratings, trainees displaying any concerns, and trainees requiring active remediation at both time periods.

RESULTS

Overall SJT scores correlated positively with midyear and year-end overall professionalism ratings ( r = .21 and .14, P &lt; .001 and = .03, respectively). Holding gender and race/ethnicity constant, a 1 standard deviation (SD) increase in overall SJT score was associated with a .20 SD increase in overall professionalism ratings at midyear ( P = .005) and a .22 SD increase at year-end ( P = .001). Holding gender and race/ethnicity constant, a 1 SD increase in overall SJT score decreased the odds of a trainee displaying any concerns by 37% (odds ratio [OR] 95% confidence interval [CI]: [.44, .87], P = .006) at midyear and 34% (OR 95% CI: [.46, .95], P = .025) at year-end and decreased the odds of a trainee requiring active remediation by 51% (OR 95% CI: [.25, .90], P = .02) at midyear.

CONCLUSIONS

Overall SJT scores correlated positively with midyear and year-end overall professionalism ratings and were associated with whether trainees exhibited any concerning behavior at midyear and year-end and whether trainees needed active remediation at midyear. Future research should investigate whether other potential professionalism measures are associated with concerning trainee behavior.

Who can do this procedure? Using entrustable professional activities to determine curriculum and entrustment in anesthesiology - An international survey

INTRODUCTION

As competency-based curricula get increasing attention in postgraduate medical education, Entrustable Professional Activities (EPAs) are gaining in popularity. The aim of this survey was to determine the use of EPAs in anesthesiology training programs across Europe and North America.

METHODS

A survey was developed and distributed to anesthesiology residency training program directors in Switzerland, Germany, Austria, Netherlands, USA and Canada. A convergent design mixed-methods approach was used to analyze both quantitative and qualitative data.

RESULTS

The survey response rate was 38% (108 of 284). Seven percent of respondents used EPAs for making entrustment decisions. Fifty-three percent of institutions have not implemented any specific system to make such decisions. The majority of respondents agree that EPAs should become an integral part of the training of residents in anesthesiology as they are universal and easy to use.

CONCLUSION

Although recommended by several national societies, EPAs are used in few anesthesiology training programs. Over half of responding programs have no specific system for making entrustment decisions. Although several countries are adopting or planning to adopt EPAs and national societies are recommending the use of EPAs as a framework in their competency-based programs, few are yet using these to make "competence" decisions.

Once in the Door, Grit May Matter More: An Evaluation of Grit in Medical Students

INTRODUCTION

Health professions educators seek understanding of the process of learner performance and achievement. Grit, defined as passion and perseverance for long-term goals, has been implicated in this process. Research suggests that effort counts twice in achievement: skill times effort equals skill and, subsequently, skill times effort equals achievement. Research also suggests that an individual's interest influences job performance and satisfaction. Grit, composed of Perseverance of Effort and Consistency of Interest, has been shown to positively correlate with performance and achievement in various disciplines. Limited research reveals Grit negatively correlates with resident attrition and physician burnout. This study evaluates relationships between Grit and medical student performance measures. We gather validity evidence for Grit scale use among medical students and, subsequently, use this data to evaluate for differences in Grit score by gender and assess whether there is a relationship between Grit and standardized exam scores. We hypothesize that Grit will not vary with gender and that it will be positively associated with standardized examination scores.

METHODS

Enrolled students receive the 12-item Grit survey. An exploratory factor analysis evaluates validity evidence of Grit. Descriptive statistical analysis, Pearson correlation, and moderation analysis evaluate if Grit score differs by gender and if there are relationships with standardized exams.

RESULTS

The survey response rate is 59% (412/698) and exploratory factor analysis replicates the two-factor structure of Grit found in other fields-Perseverance of Effort and Consistency of Interest. Average Grit scores do not significantly differ by gender. Grit weakly correlates with United States Medical Licensing Exam Step 1 (r = 0.10,  = 0.36) and United States Medical Licensing Exam Step 2 Clinical Knowledge (r = 0.12, P=0.29). Grit weakly and negatively correlates with Medical College Admission Test score (r = - 0.18, P<0.05). Grit is not a significant moderator of the relationship between Medical College Admission score and Step exams scores.

CONCLUSION

Exploratory factor analysis results provide preliminary validity evidence for Grit scale use in medical students. Grit does not significantly moderate the Medical College Admission Test-Step score relationship. Grit correlates negatively with Medical College Admission Test scores. Though the correlations in this study were not significant, the results showed that Grit may tend to positively correlate with Step 1 and Step 2 Clinical Knowledge examinations. Given that these three exams are taken at different levels of training, the stepwise progression towards positive correlation may suggest that the theory "effort counts twice" applies to medical training.

Assessment of operative competency for thyroidectomy: Comparison of resident self-assessment vs attending surgeon assessment

BACKGROUND

Self-awareness of skill, essential for progression as a surgeon, has direct bearing on postresidency practice; however, studies have supported that residents achieve self-perceived competence later than believed by program directors. This study compares residents' self-perception of operative competency to attending surgeon's evaluation using Computer Enhanced Visual Learning, a validated online hemithyroidectomy-specific assessment tool.

METHODS

Eleven otolaryngology-Head and Neck Surgery (HNS) residents completed a preoperative module and postoperative survey, later reviewed by an attending surgeon. Eighty-three performances were assessed for inter-rater reliabilities of key surgical steps.

RESULTS

Almost perfect agreement (Kappa = 0.81-1.00) was shown in 11 of 18 parameters. Substantial agreement (Kappa = 0.61-0.80) was demonstrated in the remaining seven parameters.

CONCLUSIONS

Otolaryngology-HNS trainees have high self-awareness of their performance at each step in a hemithyroidectomy. Standardized assessment tools can allow for documentation of procedural performance and serve as guides for improvement. This is the only study to examine otolaryngology-HNS trainees' self-perceived skill compared to an attending surgeon's assessment for hemithyroidectomy.

Interventions for undergraduate and postgraduate medical learners with academic difficulties: A BEME systematic review: BEME Guide No. 56

Background: Clinical teachers often struggle to report unsatisfactory trainee performance, partly because of a lack of evidence-based remediation options. Objectives: To identify interventions for undergraduate (UG) and postgraduate (PG) medical learners experiencing academic difficulties, link them to a theory-based framework and provide literature-based recommendations around their use. Methods: This systematic review searched MEDLINE, CINAHL, EMBASE, ERIC, Education Source and PsycINFO (1990-2016) combining these concepts: medical education, professional competence/difficulty and educational support. Original research/innovation reports describing intervention(s) for UG/PG medical learners with academic difficulties were included. Data extraction employed Michie's Behavior Change Techniques (BCT) Taxonomy and program evaluation models from Stufflebeam and Kirkpatrick. Quality appraisal used the Mixed Methods Appraisal Tool (MMAT). The authors synthesized extracted evidence by adapting the GRADE approach to formulate recommendations. Results: Sixty-eight articles met the inclusion criteria, most commonly addressing knowledge (66.2%), skills (53.9%) and attitudinal problems (26.2%), or learner personal issues (41.5%). The most common BCTs were Shaping knowledge, Feedback/monitoring, and Repetition/substitution. Quality appraisal was variable (MMAT 0-100%). A thematic content analysis identified 109 interventions (UG: n = 84, PG: n = 58), providing 24 strong, 48 moderate, 26 weak and 11 very weak recommendations. Conclusion: This review provides a repertoire of literature-based interventions for teaching/learning, faculty development, and research purposes.

Association Between Endoscopist Personality and Rate of Adenoma Detection

BACKGROUND & AIMS

There is significant variation among endoscopists in their adenoma detection rates (ADRs). We explored associations between ADR and characteristics of endoscopists, including personality traits and financial incentives.

METHODS

We collected electronic health record data from October 2013 through September 2015 and calculated ADRs for physicians from 4 health systems. ADRs were risk-adjusted for differences in patient populations. Physicians were surveyed to assess financial motivations, knowledge and perceptions about colonoscopy quality, and personality traits. Of 140 physicians sent the survey, 117 responded.

RESULTS

The median risk-adjusted ADR for all surveyed physicians was 29.3% (interquartile range, 24.1%-35.5%). We found no significant association between ADR and financial incentives, malpractice concerns, or physicians' perceptions of ADR as a quality metric. ADR was associated with the degree of self-reported compulsiveness relative to peers: among endoscopists who described themselves as much more compulsive, the ADR was 33.1%; among those who described themselves as somewhat more compulsive, the ADR was 32.9%; among those who described themselves as about the same as others, the ADR was 26.4%; and among those who described themselves as somewhat less compulsive, the ADR was 27.3%) (P = .0019). ADR was also associated with perceived thoroughness (much more thorough than peers, ADR = 31.5%; somewhat more, 31.9%; same/somewhat less, 27.1%; P = .0173). Physicians who reported feeling rushed, having difficulty pacing themselves, or having difficulty in accomplishing goals had higher ADRs. A secondary analysis found the same associations between personality and adenomas per colonoscopy.

CONCLUSIONS

We found no significant association between ADR and financial incentives, malpractice concerns, or perceptions of ADR as a quality metric. However, ADRs were higher among physicians who described themselves as more compulsive or thorough, and among those who reported feeling rushed or having difficulty accomplishing goals.

Use of a Novel Measure of Nontechnical Skills in Surgical Trainees: Is There an Association With Technical Skills Performance?

OBJECTIVE

To investigate whether scores on a psychological measure of concentration and interpersonal characteristics, The Attentional and Interpersonal Style Inventory (TAIS), are associated with performance of surgical skills.

DESIGN

Postgraduate surgical trainees completed an operative surgical skills assessment in the simulation laboratory and the psychological measure (TAIS). The surgical skills assessment consisted of 6 tasks (3 per trainee): laceration suturing; lipoma excision; incision and closure of a laparotomy wound; bowel anastomosis; saphenofemoral junction ligation and basic laparoscopic skills. The association between operative surgical skill performance and TAIS factors was investigated.

SETTING

The TAIS assessments and surgical skills assessments were conducted at the National Surgical Training Centre at the Royal College of Surgeons in Ireland (RCSI).

PARTICIPANTS

One hundred and two surgical trainees in years one and two (PGY 2-3 equivalent) participated in the study.

RESULTS

Performance on 2 of the 6 tasks assessed (bowel anastomosis and lipoma excision) were positively associated with multiple TAIS factors (energy, confidence, competitiveness, extroversion, self-criticism and performing under pressure). Another factor, focus over time, was significantly associated with scores on the lipoma excision task.

CONCLUSIONS

Trainees with high levels of energy, confidence, competitiveness, extroversion, and focus over time and low levels of self-criticism demonstrated better performance on specific technical skills tasks.

Contextualizing Work-Based Assessments of Faculty and Residents: Is There a Relationship Between the Clinical Practice Environment and Assessments of Learners and Teachers?

PURPOSE

Competence is bound to context, yet seldom is environment explicitly considered in work-based assessments. This study explored faculty and residents' perspectives of the environment during internal medicine clinical teaching unit (CTU) rotations, the extent that each group accounts for environmental factors in assessments, and relationships between environmental factors and assessments.

METHOD

From July 2014 to June 2015, 212 residents and 54 faculty across 5 teaching hospitals at University of Toronto rated their CTU environment using a novel Practice Environment Rating Scale (PERS) matched by block and hospital. Faculty-PERS data were paired to In-Training Evaluation Reports (ITERs) of residents supervised during each block, and Resident-PERS data to Resident Assessment of Teaching Effectiveness (RATE) scores of the same faculty. Differences between perceptions and assessments were tested using repeated-measures MANOVAs, ANOVAs, and correlations.

RESULTS

One-hundred sixty-four residents completed the PERS; residents rated the CTU environment more positively than faculty (3.91/5 vs. 3.29, P < .001). Residents were less likely to report considering environmental factors when assessing faculty (2.70/5) compared with faculty assessing residents (3.40, P < .0001), d = 1.2. Whereas Faculty-PERS ratings did not correlate with ITER scores, Resident-PERS ratings had weak to moderate correlations with RATE scores (overall r = 0.27, P = .001).

CONCLUSIONS

Residents' perceptions of the environment had small but significant correlations with assessments of faculty. Faculty's perceptions did not affect assessments of residents, potentially because they reported accounting for environmental factors. Understanding the interplay between environment and assessment is essential to developing valid competency judgments.

Emotional Distress Among Physician Residents and Fellows: An Observational Study of Trainees Seeking Counseling Visits

OBJECTIVE

Emotional distress, burnout, and depression occur frequently among graduate medical education (GME) trainees and may negatively affect patient care, education, and well-being. The authors aimed to characterize the causes and severity of distress among GME trainees seeking on-site counseling services at a large, multi-site, university-based training program in the USA.

METHODS

The authors analyzed visits of all GME trainees seeking counseling from 2009 to 2012 and described trainee characteristics, level of distress, chief and secondary complaints, and initial visit outcomes.

RESULTS

GME trainees (n = 332; 14.1% of total population) attended 2017 counseling visits. Women comprised over half (60.7%) of the clients. Referrals originated from trainees themselves (79.8%), program leadership (16.6%), or partners (1.8%). Mean counselor-assessed distress level at intake was 4.1 (range 1-5). Mental health was the most frequent concern (46.1%), particularly depression (19.3%) or anxiety (11.5%). Other chief complaints included personal relationship (28.6%), career (21.7%), and physical health concerns (2.7%). Counselors referred nearly a quarter (22.7%) of trainees to additional services such as psychiatry, primary care provider, or career mentor. Most trainees (75.3%) returned for ≥1 follow-up counseling visits.

CONCLUSION

GME trainees seen in counseling report significant emotional distress from a broad range of sources. Further research should identify effective preventative and therapeutic interventions to reduce trainee emotional distress.

Medical students' views of clinical environments

BACKGROUND

Monitoring the quality of clinical learning environments (CLEs) is immensely important in medical education. Objective indicators of the quality of the CLE can be used to measure learner perceptions and to inform educational improvements; however, many established tools were not designed for use in clinical settings and are not theoretically grounded. Our aim was to apply a new tool to the new context of a UK setting to explore the perceptions of senior medical students in a number of different CLEs. Monitoring the quality of clinical learning environments is immensely important in medical education METHODS: The four-factor Undergraduate Clinical Education Environment Measure (UCEEM) was translated into English, and used to gather final-year medical students' perceptions of four different specialties they had rotated through: Emergency Medicine (EM), General Surgery (GS), Medicine for the Elderly (ME), and Obstetrics and Gynaecology (O&G). The UCEEM was distributed in paper form. Students were asked to complete it in relation to two of the four specialties.

RESULTS/FINDINGS

Year-5 medical students (n = 132) returned a completed UCEEM. For opportunities to learn in and through work experience EM was reported the most positively. ME was perceived to be the most prepared for student entry. Students reported being well received by staff and made to feel part of the team within GS, EM and ME, but less so in O&G.

DISCUSSION

UCEEM appears to be a useful tool for evaluating medical student perceptions of CLEs. Theoretically robust, UCEEM is straightforward to administer and to score. It has the potential to be used by time-pressured educators to collect baseline and comparative data for evaluation and improvement purposes.

Anesthesiology residents' perception of educational environment: comparison between different years of training

STUDY OBJECTIVES

To assess whether the year of residency in anesthesiology is associated with residents' overall perceptions of the learning environment and to evaluate the association between year of residency and each of the five domains of the Dundee Ready Education Environment Measure (DREEM) survey.

DESIGN

Cross-sectional study.

SETTING

Residency program of anesthesiology at the Cleveland Clinic.

SUBJECTS AND INTERVENTION

Residents of anesthesiology at the Cleveland Clinic were invited to complete the DREEM questionnaire and a demographic survey.

MEASUREMENTS

We assessed whether year of residency was associated with the overall standardized DREEM questionnaire score using linear regression. We also assessed the associations between year of residency and each of the 5 DREEM questionnaire domains using separate linear regression models.

RESULTS

Of the 60 residents invited to complete the DREEM questionnaire, 49 (82%) completed it. There was no association between year of residency and overall DREEM score (P = .21), students' perception of teaching (P = .38), students' perceptions of teachers (P = .28), students' academic self-perceptions (P = .03), students' perceptions of atmosphere (P = .65), or students' social self-perceptions (P = .08). The primary outcome was assessed using a significance criterion of 0.05, whereas each secondary outcome was assessed using a significance criterion of 0.01 for secondary analyses (ie, 0.05/5, Bonferroni).

CONCLUSION

Resident's perception of the learning environment in the anesthesiology residency program of the Cleveland Clinic is on the positive side, as measured by the DREEM questionnaire. We found no association between the year of training and the DREEM questionnaire overall score. Furthermore, we found no association between year of residency and any of the subscores for the 5 DREEM domains. There is room for improvement, especially in the area of self-perception.

Institution and Specialty Contribute to Resident Satisfaction With Their Learning Environment and Workload

BACKGROUND

This large, multi-institutional study examines the relative contribution of residency specialty and institution to resident satisfaction with their learning environment and workload.

METHOD

Survey responses from 798 residents were linked to institution (N = 20) and specialty (N = 10) and to characteristics of individual residency programs (N = 126) derived from the FREIDA Online database. Hierar chical linear modeling was used to estimate relative contributions of these factors to resident satisfaction with workload and learning environment.

RESULTS

Institution had greater influence than specialty on resident ratings of satisfaction with their workload and learning environment. Institution and specialty accounted for more variance in satisfaction with workload than with the learning environment. There is evidence that characteristics of a given residency program in a given institution have additional impact beyond these main effects. However, characteristics of institutions or programs, such as program selectivity, off-duty periods, or number of faculty, did not explain statistically significant amounts of variance in resident satisfaction ratings.

CONCLUSIONS

This study is the first to quantify the degree to which institution and specialty contribute to differences in resident perceptions of their learning environment and workload. Although organizational and institutional cultures are presumed to influence the learning environment, estimating the size of these influences requires a multi-institutional and multispecialty dataset, such as this one. These results suggest that there is empirical justification for institutional interventions to improve the learning environment.

Clinical learning during night call versus day work: Perceptions of interns

Introduction:

Clinical learning during night call has been shown to be less efficient and effective than during the day among residents. Strategies are needed to address the gap between night-time and daytime learning. We conducted a survey study to examine perceptions of night-time compared with daytime learning among Internal Medicine interns, and asked for suggestions to address this gap.

Method:

This is a cross-sectional survey study conducted on a single class of 47 interns from Singapore General Hospital in December 2013. Interns anonymously completed a modified previously published 25-item survey. A total of 23 items asked for ratings of learning during the day versus the night using a 5-point Likert scale. The remaining two open-ended questions invited respondents to suggest improvements for teaching and learning. Analysis was done by descriptive statistics for the Likert-scale items, and thematic coding by two coders for narrative responses.

Results:

Response rate was 70% (33/47). Interns rated learning during the day more positively than during night call for 23 of 23 (100%) items, with 22 out of 23 items showing significant difference. Among the 33 respondents, 20 provided narrative responses. Three major themes emerged: increasing manpower, allowing patient follow-up after night call, and more time for bedside teaching in the daytime.

Conclusion:

Our study confirms that learning during night call is perceived as less effective than during the day. We further extended this finding to offer alternate strategies to enhance clinical learning among interns.

Personality assessments and outcomes in medical education and the practice of medicine: AMEE Guide No. 79

In a paradigm of physician performance we propose that both "cognitive" and "noncognitive" components contribute to the performance of physicians-in-training and in-practice. Our review of the relevant literature indicates that personality, as an important factor of the "noncognitive" component, plays a significant role in academic and professional performances. We describe findings on 14 selected personality instruments in predicting academic and professional performances. We question the contention that personality can be validly and reliably assessed from admission interviews, letters of recommendation, essays, and personal statements. Based on conceptual relevance and currently available empirical evidence, we propose that personality attributes such as conscientiousness and empathy should be considered among the measures of choice for the assessment of pertinent aspects of personality in academic and professional performance. Further exploration is needed to search for additional personality attributes pertinent to medical education and patient care. Implications for career counseling, assessments of professional development and medical education outcomes, and potential use as supplementary information for admission decisions are discussed.

The "problem" learner: whose problem is it? AMEE Guide No. 76

Clinical teachers often work with students or residents whom they perceive as a "problem". For some, it is a knowledge deficit that first alerts them to a problem; for others it is an attitudinal problem or distressing behaviour . And in some cases, it is difficult to know if the learner is, indeed, presenting with a problem. The goal of this Guide is to outline a framework for working with "problem" learners. This includes strategies for identifying and defining learners' problems, designing and implementing appropriate interventions, and assuring due process. The potential stress of medical school and residency training will also be addressed, as will a number of prevention strategies. Identifying learners' problems early - and providing guidance from the outset - can be an important investment in the training and development of future health professionals. It is hoped that this Guide will be of help to clinical teachers, program directors and faculty developers.

The role of role: learning in longitudinal integrated and traditional block clerkships

CONTEXT

Traditional block clerkship (BC) structures may not optimally support medical student participation in the workplace, whereas longitudinal integrated clerkship (LIC) structures seem more conducive to students' active engagement in patient care over time. Understanding the ways in which these two clerkship models influence students' roles and responsibilities can inform clinical learning programme design.

METHODS

This was a multicentre qualitative study. We conducted semi-structured interviews with LIC and BC medical students at three institutions early and late in the core clinical year to explore their experiences with patients and the roles they served. Using the framework of 'workplace affordances', qualitative coding focused on students' roles and qualities of the learning environment that invited or inhibited student participation. We compared transcripts of early- and late-year interviews to assess students' changing roles and conducted discrepant case analysis to ensure that coding fit the data.

RESULTS

Fifty-four students participated in interviews. They described serving three major roles in clinical care that respectively involved: providing support to patients; sharing information about patients across health care settings, and functioning in a doctor-like role. Both LIC and BC students served in the providing support and transmitting information roles both early and late in the year. By contrast, LIC students commonly served in the doctor-like role in managing their patients' care, particularly late in the year, whereas BC students rarely served in this role. Continuity in settings and in supervisors, and preceptors' endorsement of students' legitimate role afforded opportunities for students to participate actively in patient care.

CONCLUSIONS

Although both LIC and BC students reported serving in important roles in supporting their patients and sharing information about their care, only LIC students consistently described opportunities to grow into a doctor role with patients. The high level of integration of LIC students into care systems and their deeper relationships with preceptors and patients enhanced their motivation and feelings of competence to provide patient-centred care.

Associations of medical student personality and health/wellness characteristics with their medical school performance across the curriculum

PURPOSE

To assess the relationships of cognitive and noncognitive performance predictors to medical student preclinical and clinical performance indicators across medical school years 1 to 3 and to evaluate the association of psychological health/wellness factors with performance.

METHOD

In 2010, the authors conducted a cross-sectional, correlational, retrospective study of all 175 students at the Saint Louis University School of Medicine who had just completed their third (first clinical) year. Students were asked to complete assessments of personality, stress, anxiety, depression, social support, and community cohesion. Performance measures included total Medical College Admission Test (MCAT) score, preclinical academic grades, National Board of Medical Examiners subject exam scores, United States Medical Licensing Examination Step 1 score, clinical evaluations, and Humanism in Medicine Honor Society nominations.

RESULTS

A total of 152 students (87%) participated. MCAT scores predicted cognitive performance indicators (academic tests), whereas personality variables (conscientiousness, extraversion, empathy) predicted noncognitive indicators (clinical evaluations, humanism nominations). Conscientiousness predicted all clinical skills, extraversion predicted clinical skills reflecting interpersonal behavior, and empathy predicted motivation. Health/wellness variables had limited associations with performance. In multivariate analyses that included control for shelf exam scores, conscientiousness predicted clinical evaluations, and extraversion and empathy predicted humanism nominations.

CONCLUSIONS

This study identified two sets of skills (cognitive, noncognitive) used during medical school, with minimal overlap across the types of performance (e.g., exam performance versus clinical interpersonal skills) they predict. Medical school admission and evaluation efforts may need to be modified to reflect the importance of personality and other noncognitive factors.

Resident physician well-being and assessments of their knowledge and clinical performance

BACKGROUND

Medical knowledge and clinical performance ratings are major criteria for assessing the competence of resident physicians. However, these assessments may be influenced by residents' mental health. The relationship between residents' well-being and empathy and assessments of their global performance remains unclear.

OBJECTIVE

To determine whether resident well-being and empathy are associated with assessments of their medical knowledge and clinical performance.

DESIGN, SETTING, AND PARTICIPANTS

We studied 730 clinical performance assessments completed by peers, supervising residents, and allied health professionals; 193 mini-clinical evaluation exercise (mini-CEX) evaluations; and 260 in-training examinations (ITE) of Mayo Clinic internal medicine residents between January 2009 and August 2010. Multivariate generalized estimating equations were used to evaluate associations between residents' well-being and empathy and assessments of their knowledge and clinical performance.

MEASUREMENTS

Independent variables were empathy using the Interpersonal Reactivity Index (IRI), burnout using the Maslach Burnout Inventory, depression using a standardized two-question screening instrument, and quality of life using a Linear Analog Self-Assessment item and the Medical Outcomes Study Short Form (SF-8). Dependent variables were mini-CEX, ITE, and the validated six-item Mayo clinical performance assessment.

RESULTS

202 residents (64.7%) provided both well-being and at least one category of assessment data. In multivariate models, residents' scores on the IRI empathy measure of "the tendency to adopt the psychological view of others" were associated with higher peer ratings on "desirability as a physician for a family member" (beta = 0.023, 95% CI = 0.007-0.039, p = 0.004). Additionally, burnout was associated with higher supervisor ratings of communication (beta = 0.309, 95% CI = 0.100-0.517, p = 0.004). There were no observed associations between ITE or mini-CEX scores and resident quality of life, burnout, fatigue, depression, or empathy.

CONCLUSIONS

Most dimensions of resident well-being were not associated with residents' knowledge scores and assessments of their clinical performance by other members of the health care team, which supports the trustworthiness of these measures. Nonetheless, correlations of resident empathy and burnout with assessments completed by peers and supervising residents suggest that some ratings of residents may be influenced by interpersonal factors.

Stress and burnout in postgraduate dental education

INTRODUCTION

High levels of stress and burnout have been documented among dental students and practicing dentists, but evidence among dental residents and postgraduate students is lacking.

MATERIALS AND METHODS

Ninety-nine postgraduate students enrolled in clinical, non-clinical and PhD programmes in the Athens University School of Dentistry completed the Graduate Dental Environment Stress (GDES) questionnaire and the Maslach Burnout Inventory. Perceived stress was measured in two domains, academic (GDES-A) and clinical (GDES-C) and burnout was measured using the scales of emotional exhaustion (EE), depersonalisation (DP) and personal accomplishment (PA). Analyses relied on descriptive, univariate and multivariate methods based on ANOVA and generalised linear models.

RESULTS

Participants' mean age was 30 years; two-thirds were women and practised dentistry independently of their graduate studies. Residents in clinical programmes reported significantly higher levels of perceived stress compared to non-clinical and PhD students (P<0.05). There were no gender differences in perceived stress. Forty per cent of respondents were burnout 'cases' on the EE scale, while this proportion was 38% for reduced PA and smaller, 13% for DP. Perceived stress was positively correlated with all burnout dimensions, whereas independent dental practice and higher age had a protective effect.

CONCLUSIONS

High rates of burnout manifestations were detected among this sample of Greek postgraduate dental students. Perceived stress correlated with burnout and was more pronounced among those enrolled in clinical residency compared to non-clinical and PhD programmes.

[Reasons residents choose to specialize in anesthesiology and postoperative critical care in the autonomous community of Madrid]

OBJECTIVES

Our main objective was to determine the reasons why residents chose to specialize in anesthesiology and postoperative critical care in the autonomous community of Madrid. We also wished to know if prior contact with this specialty influenced their choice, if those who chose it as a second specialization differed from those who were doing a first residency, what expectations the residents had and if they had been met, and if they were satisfied with their training.

MATERIAL AND METHODS

Survey of all residents in anesthesiology and postoperative critical care medicine in the community of Madrid between November 2008 and February 2010. The questionnaire items covered demographic data, prior specialty training, undergraduate contact with the specialty, reasons for choosing this specialty (technical, social, or employment-related interests), satisfaction, and expectations met.

RESULTS

We received 89 valid questionnaires, a sample that represented 35% of the residents. The reasons expressed most often were learning and performing techniques (97.8%); that the specialty was dynamic, with broad theoretical and practical content (98.9%), and an interest in providing critical care (93.3%). These 3 reasons were considered important or very important by most of the respondents; 55.8% considered that learning and carrying out techniques was the most important reason. All the respondents who had previously done specialty training said they were dissatisfied. Prior contact with the specialty was associated with having different reasons and interests, such as an interest in pain (F = .037) or emulating a role model (P = .014).

CONCLUSIONS

The specialty's mix of theoretical and practical content and the chance to perform techniques and provide critical care are the features the residents find most attractive. Residents who already have another specialty are less satisfied and their expectations are not as well met.

Evidence based post graduate training. A systematic review of reviews based on the WFME quality framework

BACKGROUND

A framework for high quality in post graduate training has been defined by the World Federation of Medical Education (WFME). The objective of this paper is to perform a systematic review of reviews to find current evidence regarding aspects of quality of post graduate training and to organise the results following the 9 areas of the WFME framework.

METHODS

The systematic literature review was conducted in 2009 in Medline Ovid, EMBASE, ERIC and RDRB databases from 1995 onward. The reviews were selected by two independent researchers and a quality appraisal was based on the SIGN tool.

RESULTS

31 reviews met inclusion criteria. The majority of the reviews provided information about the training process (WFME area 2), the assessment of trainees (WFME area 3) and the trainees (WFME area 4). One review covered the area 8 'governance and administration'. No review was found in relation to the mission and outcomes, the evaluation of the training process and the continuous renewal (respectively areas 1, 7 and 9 of the WFME framework).

CONCLUSIONS

The majority of the reviews provided information about the training process, the assessment of trainees and the trainees. Indicators used for quality assessment purposes of post graduate training should be based on this evidence but further research is needed for some areas in particular to assess the quality of the training process.

Personality factors and medical training: a review of the literature

CONTEXT

it has been acknowledged that certain personality characteristics influence both medical students' and doctors' performance. With regard to medical students, studies have been concerned with the role of personality, and performance indicators such as academic results and clinical competence. In addition, the link between personality and vulnerability to stress, which has implications for performance, has been investigated at both undergraduate and postgraduate levels. Most of the studies cited in the literature were published before the year 2000. The authors therefore undertook a literature search to determine whether any prospective systematic studies have been published since 2000.

METHODS

a review of the literature for 2000-2009 was performed, using the databases MEDLINE, PsycINFO and CINAHL. The search terms used were 'personality', 'performance', 'stress' and 'medical student'. Specific inclusion criteria required studies to be cohort studies carried out over a minimum period of 2 years, which measured medical student scores on valid and reliable personality tests, and used objective measures of performance and stress.

RESULTS

the authors identified seven suitable studies. Four of these looked at personality factors and academic success, one looked at personality factors and clinical competence, and two looked at personality factors and stress. The main personality characteristic repeatedly identified in the literature was conscientiousness.

CONCLUSIONS

the personality trait known as conscientiousness has been found to be a significant predictor of performance in medical school. The relationship between personality and performance becomes increasingly significant as learners advance through medical training. Additional traits concerning sociability (i.e. extraversion, openness, self-esteem and neuroticism) have also been identified as relevant, particularly in the applied medical environment. A prospective national study with the collaboration of all medical schools would make it possible to further investigate these important but initial findings.

Alienation and engagement in postgraduate training at a South African medical school

BACKGROUND

The importance of contextual factors, such as the learning environment and sociocultural characteristics of the student, are becoming increasingly evident. Mann [2001. Alternative perspectives on the student experience: Alienation and engagement. Stud High Educ 26(1):7-19.] proposed that all learning experiences can be viewed as either alienating or engaging and Case expanded on this work.

AIM

The purpose of this study was to explore perceptions of alienation or engagement as experienced by residents in anatomical pathology at one South African university.

METHOD

A cross-sectional case study, with 16 semi-structured interviews was conducted. Residents were categorised as either alienated or engaged, based mainly on workplace experiences.

RESULTS

Four relevant dimensions were identified; individual, home, workplace and institution. The personal attributes, strategies for coping and reasons for choosing pathology of alienated residents differed from those with engaged experiences. Poor socioeconomic background and schooling did not lead to predominantly alienating experiences, but this group still lacked some generic skills. In the workplace, two main factors resulting in alienated experiences were the interaction between residents and consultants and residents' comprehension of workplace-based learning.

CONCLUSIONS

We present a simple model which may be used to identify factors that engage and alienate students in the learning experience in the workplace-based setting. Addressing these factors can contribute towards a more engaging experience for all residents.

Lack of association between resident doctors' well-being and medical knowledge

OBJECTIVES

Resident doctors' (residents) well-being impacts on the medical care they provide. Despite the high prevalence of resident doctors' distress, the relationship between their well-being and the specific competencies defined by the Accreditation Council for Graduate Medical Education is poorly understood. We evaluated the association of resident well-being with medical knowledge as assessed on both a standardised test of general medical knowledge and at the end of web-based courses on a series of focused topics.

METHODS

We conducted a repeated cross-sectional study of associations between well-being and medical knowledge scores over time for internal medicine residents from July 2004 to June 2007. Well-being measures included linear analogue self-assessment (LASA) scales measuring quality of life (including overall quality of life, mental, physical and emotional well-being, and fatigue), the Medical Outcome Study Eight-Item Short Form Health Survey (SF-8) assessment of mental and physical well-being, the Maslach Burnout Inventory and the PRIME-MD two-item depression screen. We also measured empathy using the perspective taking and empathic concern subscales of the Interpersonal Reactivity Index. Medical knowledge measures included scores on web-based learning module post-tests and scores on the national Internal Medicine In-Training Examination (IM-ITE). As data for each association were available for at least 126 residents, this study was powered to detect a small-to-moderate effect size of 0.3 standard deviations.

RESULTS

No statistically significant associations were observed between well-being and either web-based learning module post-test score or IM-ITE score. Parameter estimates of the association of well-being variables with knowledge scores were uniformly small. For all well-being metrics, meaningful differences were associated with knowledge score difference estimates of < 1 percentage point.

CONCLUSIONS

Resident well-being appears to have limited association with competence in medical knowledge as assessed following web-based courses on specific topics or using standardised general medical examinations.

Validation and implementation of surgical simulators: a critical review of present, past, and future

BACKGROUND

In the past 20 years the surgical simulator market has seen substantial growth. Simulators are useful for teaching surgical skills effectively and with minimal harm and discomfort to patients. Before a simulator can be integrated into an educational program, it is recommended that its validity be determined. This study aims to provide a critical review of the literature and the main experiences and efforts relating to the validation of simulators during the last two decades.

METHODS

Subjective and objective validity studies between 1980 and 2008 were identified by searches in Pubmed, Cochrane, and Web of Science.

RESULTS

Although several papers have described definitions of various subjective types of validity, the literature does not offer any general guidelines concerning methods, settings, and data interpretation. Objective validation studies on endourological simulators were mainly characterized by a large variety of methods and parameters used to assess validity and in the definition and identification of expert and novice levels of performance.

CONCLUSION

Validity research is hampered by a paucity of widely accepted definitions and measurement methods of validity. It would be helpful to those considering the use of simulators in training programs if there were consensus on guidelines for validating surgical simulators and the development of training programs. Before undertaking a study to validate a simulator, researchers would be well advised to conduct a training needs analysis (TNA) to evaluate the existing need for training and to determine program requirements in a training program design (TPD), methods that are also used by designers of military simulation programs. Development and validation of training models should be based on a multidisciplinary approach involving specialists (teachers), residents (learners), educationalists (teaching the teachers), and industrial designers (providers of teaching facilities). In addition to technical skills, attention should be paid to contextual, interpersonal, and task-related factors.

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.

Can hospital rankings measure clinical and educational quality?

BACKGROUND

A relative dearth of relevant data hampers efforts to demonstrate a link between educational and clinical quality and may preclude residency applicants from identifying programs with the best clinical outcomes. Existing clinical rankings could fill this gap if they are based on sound judgments about quality.

METHOD

To explore the potential of the U.S. News & World Report "America's Best Hospitals" clinical rankings in measuring the quality of clinical and learning environments, the author systematically reviewed the U.S. and Canadian literature for 1975 through 2007 regarding quality indicators and teaching hospitals. Individual data elements of the rankings were examined to assess the extent to which they included accepted measures of clinical performance.

RESULTS

A total of 187 articles met the inclusion criteria of addressing clinical quality criteria relevant to the rankings and quality assessment in teaching hospitals. Statistical examination of the data underlying the rankings and their relationship with measures of educational and clinical quality showed the rankings are largely based on institutional "prestige." Ranked clinical programs and institutions consistently outperform counterparts on available indices, suggesting that the data elements underlying the rankings may provide valid assessments about the quality of care in educational settings.

CONCLUSIONS

Data elements in the rankings can be used to assess clinical and, to a lesser extent, educational quality, but the number of specialties and ranked institutions is too small to have a significant effect on widespread clinical or educational quality, unless ranked institutions serve as sites for the development, study, and dissemination of best practices.

The postgraduate hospital educational environment measure (PHEEM) questionnaire identifies quality of instruction as a key factor predicting academic achievement

OBJECTIVE

This study analyzes the reliability of the PHEEM questionnaire translated into Portuguese. We present the results of PHEEM following distribution to doctors in three different medical residency programs at a university hospital in Brazil.

INTRODUCTION

Efforts to understand environmental factors that foster effective learning resulted in the development of a questionnaire to measure medical residents' perceptions of the level of autonomy, teaching quality and social support in their programs.

METHODS

The questionnaire was translated using the modified Brislin back-translation technique. Cronbach's alpha test was used to ensure good reliability and ANOVA was used to compare PHEEM results among residents from the Surgery, Anesthesiology and Internal Medicine departments. The Kappa coefficient was used as a measure of agreement, and factor analysis was employed to evaluate the construct strength of the three domains suggested by the original PHEEM questionnaire.

RESULTS

The PHEEM survey was completed by 306 medical residents and the resulting Cronbach's alpha was 0.899. The weighted Kappa was showed excellent reliability. Autonomy was rated most highly by Internal Medicine residents (63.7% +/- 13.6%). Teaching was rated highest in Anesthesiology (66.7% +/- 15.4%). Residents across the three areas had similar perceptions of social support (59.0% +/- 13.3% for Surgery; 60.5% +/- 13.6% for Internal Medicine; 61.4% +/- 14.4% for Anesthesiology). Factor analysis suggested that nine factors explained 58.9% of the variance.

CONCLUSIONS

This study indicates that PHEEM is a reliable instrument for measuring the quality of medical residency programs at a Brazilian teaching hospital. The results suggest that quality of teaching was the best indicator of overall response to the questionnaire.

Qualities of the medical school dean: insights from the literature

PURPOSE

To review the literature and resources for professional development of medical school executives in order to identify the characteristics proposed as relevant to medical school deanship.

METHOD

In 2006, the authors conducted a PubMed search using the key words leadership, dean, medical school, and academic medical center to identify relevant publications since 1995. Articles were excluded that that did not address the roles and responsibilities of the North American medical school dean. Articles gleaned through review of materials from relevant executive development programs and interviews with leaders involved in these programs were added.

RESULTS

Both management skills (e.g., institutional assessment, strategic planning, financial stewardship, recruitment and retention of talent) and leadership skills (e.g., visioning, maximizing values, building constituency) are commonly cited as important deans of contemporary medical schools. Key content knowledge (e.g., academic medical center governance, expectations of clinicians and scientists, process of medical education) and certain attitudes (e.g., commitment to the success of others, appreciation of institutional culture) are also noted to be valuable qualities for medical school deans.

CONCLUSIONS

The literature review identifies a number of areas of knowledge and skill consistently affirmed by scholars as important to success for medical school deans. These characteristics can provide a basic foundation for needs assessment and professional development activities of academic medical executives preparing for and entering medical school deanships, and they can also provide insight to those charged with selecting their next dean.

Job stress in young physicians with an emphasis on the work-home interface: a nine-year, nationwide and longitudinal study of its course and predictors

Although physicians are known to experience more stress than other workers, knowledge is lacking on the course of stress from a longitudinal perspective. This study explored the course of and contributors to, different dimensions of early career job-stress among physicians by means of a nationwide mail survey, with a particular emphasis on stress relating to the work-home interference. All physicians graduating from all four Norwegian universities in 1993 / 94 (N=631), responded during their final year of medical school (N=522), during their internship (N=402), in their 4th postgraduate year (N=422), and in their 10th postgraduate year (N=390). The mean observation period was 9.2 yr (SD=0.5). The main outcomes were job stress dimensions derived from an established job stress questionnaire (Cooper / Tyssen), with emphasis placed on dimensions of the work-home interference. Stress relating to the work-home interference increased during the observation period for both genders (repeated measures: beta=0.06, p<0.05), whereas stress relating to emotional pressure, time pressure, and fear of complaints and criticism, decreased. Stress relating to the work-home interference increased during their early career, mainly due to a lack of adaptive reduction in work hours and an increased number of children. Neuroticism, conscientiousness, and lack of support from one's partner and colleagues, appeared to be predictive of this stress.

Helping Learners in Difficulty – The Incidence and Effectiveness of Remedial Programmes of the Medical Radiation Sciences Programme at University of Toronto and the Michener Institute for Applied Sciences, Toronto, Ontario, Canada

Introduction: Academic difficulty can often be a significant problem for students in health professional programmes. Students in difficulty are often identified late in their training and run the risk of dismissal if remediation is not successful. Since the inception of the Medical Radiation Sciences Program (MRSP) at the University of Toronto, Faculty of Medicine, and the Michener Institute (MI) in 1999, a number of students have required remediation due to problems in the didactic or clinical component of their training. Not all remediation was successful, and a number of students have been dismissed. There is relatively sparse evidence in the educational literature regarding the nature of academic difficulties that health professional students encounter, and what constitutes appropriate remedial education. The purpose of this research was to evaluate the incidence and prevalence of remediation in the MRSP and the nature of the academic problems. In addition, this study looked at the type of remedial instruction that the Radiation Sciences Board of Examiners (BOE) recommended for these students as well as the effectiveness of these recommendations. Materials and Methods: This study consisted of a review of the academic records of students who failed one or more courses and underwent pre-clinical or clinical remediation, and who were presented at the Medical Radiation Sciences Board of Examiners at the University of Toronto between September 1999 and December 2004. Data extraction forms were developed to obtain demographic information, the nature of the academic problems, the remedial recommendation, and their outcomes. Results: This study identified 69 students who were presented to the BOE 95 times. Forty-four students (44/69, 64%) were from the Radiation Therapy stream, 16 students (16/69, 23%) were from the Nuclear Medicine stream and 9 students (9/69, 13%) were from the Radiographic Technology stream. Most of the remediation occurred due to pre-clinical 50 (50/69, 72%), clinical 15 (15/69, 22%) and both preclinical and clinical problems 4 students (4/69, 6%). Out of 54 students who required pre-clinical remediation, 40 (74%) were promoted. Out of 19 students who required clinical remediation, 10 (10/19, 53%) passed their remediation. Six students (6/69, 9%) were dismissed from the programme due to unsuccessful remediation; 2 due to pre-clinical and 4 due to clinical problems. Based on these results, the remediation process at the MRSP was successful; however, 6 students (6/69, 9%) were dismissed from the programme during the last 4 years despite lengthy unsuccessful remediation. Conclusion: Our study provided an important perspective about the remediation process at the MRSP at the Michener Institute for Applied Health Sciences. Despite its retrospective methodology, it attempted to identify the magnitude of learning problems that lead to remediation, and identified the efficacy of the remedial programmes. Key words: Radiation oncology, Radiotherapy, Remedial teaching

The Relationship of Learning Environment, Quality of Life, and Study Strategies Measures to Anesthesiology Resident Academic Performance

BACKGROUND

We designed this study to determine the academic performance of anesthesia residents as related to their differential characteristics on some affective-motivational variables, represented by perceptions about their educational environment, subjective quality of life, and learning and study strategies.

METHODS

The study sample consisted of 63 anesthesia residents who completed the World Health Organization Quality of Life Inventory, the Dundee Ready Educational Environment Measure, the Learning and Study Strategies Inventory, and a progress test on basic sciences on two to four measurement occasions during a 2-year period. A growth curve model was fit to the academic performance. Mantel-Haenszel tests identified independent predictors of academic performance on progress tests.

RESULTS

Mean rating at the first measuring occasion was 41%. There was a statistically significant improvement over time (slope = 7% per 6-m period; P < 0.01). Analysis of the random effects showed significant individual differences in the intercept. The residents' scores improved at an equivalent rate over the course of the residency. The independent predictors of academic performance were anxiety, motivation, and ability in selecting main ideas.

CONCLUSIONS

Knowledge growth on basic sciences during anesthesia residency is significantly associated to the level of anxiety related to study and achievement, to the motivation for learning and for personal improvement, and to the ability in selecting main ideas from subject matters to which residents are exposed during learning episodes.

Psychometric properties of an instrument to measure the clinical learning environment

OBJECTIVES

The clinical learning environment is an influential factor in work-based learning. Evaluation of this environment gives insight into the educational functioning of clinical departments. The Postgraduate Hospital Educational Environment Measure (PHEEM) is an evaluation tool consisting of a validated questionnaire with 3 subscales. In this paper we further investigate the psychometric properties of the PHEEM. We set out to validate the 3 subscales and test the reliability of the PHEEM for both clerks (clinical medical students) and registrars (specialists in training).

METHODS

Clerks and registrars from different hospitals and specialties filled out the PHEEM. To investigate the construct validity of the 3 subscales, we used an exploratory factor analysis followed by varimax rotation, and a cluster analysis known as Mokken scale analysis. We estimated the reliability of the questionnaire by means of variance components according to generalisability theory.

RESULTS

A total of 256 clerks and 339 registrars filled out the questionnaire. The exploratory factor analysis plus varimax rotation suggested a 1-dimensional scale. The Mokken scale analysis confirmed this result. The reliability analysis showed a reliable outcome for 1 department with 14 clerks or 11 registrars. For multiple departments 3 respondents combined with 10 departments provide a reliable outcome for both groups.

DISCUSSION

The PHEEM is a questionnaire measuring 1 dimension instead of the hypothesised 3 dimensions. The sample size required to achieve a reliable outcome is feasible. The instrument can be used to evaluate both single and multiple departments for both clerks and registrars.