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Eidtson WH, Konopasky A, Fong J, Schmitt KE, Foster-Johnson L, Lyons VT. Are Pre-clerkship Remediation, Grading, and Reporting Practices Equitable in the U.S.? A National Survey. TEACHING AND LEARNING IN MEDICINE 2024:1-10. [PMID: 38946530 DOI: 10.1080/10401334.2024.2366938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 05/24/2024] [Indexed: 07/02/2024]
Abstract
Phenomenon: With the proliferation of pass/fail grading practices in the pre-clerkship phase of undergraduate medical education, questions arise about the transparency and variability of grading and grade reporting practices, raising issues of equity in assessment, particularly regarding residency matching. The purpose of this survey was to determine the remediation and academic performance reporting practices of United States (U.S.) allopathic medical schools in the pre-clerkship phase of their curricula. Approach: After an extensive literature search and feedback from curriculum deans and learning experts, we developed a survey that we sent in the Spring of 2022 to pre-clerkship curriculum officials at all 154 accredited U.S. allopathic medical schools. It addressed curriculum content and structure; pre-clerkship remediation (e.g., course retakes) and reporting (e.g., permanency of transcript notation) practices; documentation and reporting of nonacademic competencies; and participant opinions and recommendations regarding reporting, transparency, and equity. We generated descriptive statistics and did manifest coding of open-ended responses. Findings: We had a response rate of 40% (62/155), with over 71% indicating mainly organ systems-based curricula. Depending on the situation, there were a wide range of remediation approaches for single- and multiple-course failures, including tutoring or learning support, re-exams, and referrals to a promotion board. Professionalism concerns were a top priority to report to residency directors, with significant variability in respondent opinions and practices in reporting remedial activities. Respondents were concerned about equity, both in terms of flexible grading practices and transparency of reporting practices. Insights: The variability in reporting practices across schools, while allowing holistic and individualized approaches to academic support, also creates potential inequities. More work is needed to understand how different reporting practices across institutions may disadvantage marginalized and minoritized student groups at different points in their preparation.
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Affiliation(s)
- William H Eidtson
- Department of Medical Education, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Abigail Konopasky
- Department of Medical Education, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Justin Fong
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Kerry E Schmitt
- Department of Medical Education, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Lynn Foster-Johnson
- Department of Medical Education, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Dermatology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Virginia T Lyons
- Department of Medical Education, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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Kelleher M, Kinnear B, Weber DE, Knopp MI, Schumacher D, Warm E. Point/Counterpoint: Should we stop writing and reading letters of recommendation for residency selection? J Hosp Med 2024. [PMID: 38923809 DOI: 10.1002/jhm.13440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 06/11/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Matthew Kelleher
- Department of Pediatrics, Division of Hospital Medicine, Internal Medicine and Pediatrics Hospital Medicine, University of Cincinnati College of Medicine/Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Benjamin Kinnear
- Department of Pediatrics, Division of Hospital Medicine, University of Cincinnati College of Medicine/Cincinnati Childrens Medical Center, Cincinnati, Ohio, USA
| | - Danielle E Weber
- Department of Pediatrics, Division of Hospital Medicine, University of Cincinnati College of Medicine/Cincinnati Childrens Medical Center, Cincinnati, Ohio, USA
| | - Michelle I Knopp
- Department of Pediatrics, Division of Hospital Medicine, University of Cincinnati College of Medicine/Cincinnati Childrens Medical Center, Cincinnati, Ohio, USA
| | - Daniel Schumacher
- Department of Pediatrics, Division of Emergency Medicine, University of Cincinnati College of Medicine/Cincinnati Childrens Medical Center, Cincinnati, Ohio, USA
| | - Eric Warm
- Department of Internal Medicine and Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Hsu D, Rassbach C, Leaming-Van Zandt K, Morrow A, Rubenstein J, Tatem A, Turner DA, Poitevien P, Barone MA. Competency based medical education and trust in the learning environment. Curr Probl Pediatr Adolesc Health Care 2024:101640. [PMID: 38876832 DOI: 10.1016/j.cppeds.2024.101640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/16/2024]
Affiliation(s)
- Deborah Hsu
- Stanford University School of Medicine, Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Palo Alto CA, United States.
| | - Carrie Rassbach
- Stanford University School of Medicine, Department of Pediatrics, Division of Hospital Medicine, Palo Alto CA, United States
| | - Katherine Leaming-Van Zandt
- Penn State College of Medicine, Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Hershey PA, United States
| | - Asha Morrow
- Baylor College of Medicine, Department of Pediatrics, Division of Pediatric Emergency Medicine, Houston TX, United States
| | - Jared Rubenstein
- Baylor College of Medicine, Department of Pediatrics, Division of Palliative Care, Houston TX, United States
| | - Andria Tatem
- Eastern Virginia Medical School and Children's Hospital of the King's Daughters, Department of Pediatrics, Norfolk VA, United States
| | - David A Turner
- American Board of Pediatrics, Chapel Hill NC, United States
| | - Patricia Poitevien
- Brown University Warren Alpert Medical School and Hasbro Children's Hospital, Department of Pediatrics, Division of Pediatric Hospital Medicine, Providence RI, United States
| | - Michael A Barone
- Brown University Warren Alpert Medical School and Hasbro Children's Hospital, Department of Pediatrics, Division of Pediatric Hospital Medicine, Providence RI, United States
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Cottrell SA, Hedrick JS, Lama A, Sofka S, Ferrari ND. The Urgent Need for Reporting Accurate and Fair Student Comparisons in the Medical Student Performance Evaluation. J Grad Med Educ 2024; 16:257-260. [PMID: 38882437 PMCID: PMC11173022 DOI: 10.4300/jgme-d-23-00862.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2024] Open
Affiliation(s)
- Scott A Cottrell
- is Professor, Department of Medical Education, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Jason S Hedrick
- is Assistant Professor, Department of Medical Education, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Anna Lama
- is Assistant Professor, Department of Medical Education, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Sarah Sofka
- is Professor and Vice Chair of Education, Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, West Virginia, USA; and
| | - Norman D Ferrari
- is Professor and Chair, Department of Medical Education, West Virginia University School of Medicine, Morgantown, West Virginia, USA
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Raikhel AV, Starks H, Berger G, Redinger J. Through the Looking Glass: Comparing Hospitalists' and Internal Medicine Residents' Perceptions of Feedback. Cureus 2024; 16:e63459. [PMID: 39077307 PMCID: PMC11285250 DOI: 10.7759/cureus.63459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2024] [Indexed: 07/31/2024] Open
Abstract
INTRODUCTION Feedback is critical for resident growth and is most effective when the relationship between residents and attendings is collaborative, with shared expectations for the purpose, timing, and manner of communication for feedback. Within internal medicine, there is limited work exploring the resident and hospitalist perspectives on whether key elements are included in feedback sessions. METHODS We surveyed internal medicine residents and supervising hospitalists at a large urban training program about their perspectives on four components of effective feedback: specificity,timeliness, respectful communication, and actionability. RESULTS We received surveys from 130/184 internal medicine residents and 74/129 hospitalists (71% and 57% response rate, respectively). Residents and hospitalists differed in their perspectives about specificity and timeliness: 54% (70/129) of residents reported they did not receive specific feedback while 90% (65/72) of hospitalists reported they delivered specific feedback (p<0.01), and 33% (43/129) of residents compared with 82% (59/72) of hospitalists perceived feedback as timely (p<0.01). Internal medicine residents and hospitalists reported concordant rates of feedback sessions consisting of a two-way conversation (84%, 109/129; 89%, 64/72, respectively, p=0.82) and that communication was delivered in a respectful manner (95%, 122/129; 97%, 70/72, respectively, p=0.57). CONCLUSIONS We observed discordance between internal medicine residents and supervising hospitalist perspectives on the inclusion of two critical components of feedback: specificity and timing. The hospitalist cohort reported delivering more components of effective feedback than the resident cohort reported receiving. The etiology of this discordance is likely multifactorial and requires further investigation.
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Affiliation(s)
- Andrew V Raikhel
- Department of Hospital Medicine, VA (Veteran's Affairs) Puget Sound Healthcare System, Seattle Division, Seattle, USA
- Department of General Internal Medicine, University of Washington, Seattle, USA
| | - Helene Starks
- Department of Bioethics and Humanities, University of Washington, Seattle, USA
| | - Gabrielle Berger
- Department of General Internal Medicine, University of Washington, Seattle, USA
| | - Jeffrey Redinger
- Department of Medicine, University of Washington School of Medicine, Seattle, USA
- Department of Hospital Medicine, VA (Veteran's Affairs) Puget Sound Healthcare System, Seattle Division, Seattle, USA
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Tackett S, Steinert Y, Mirabal S, Reed DA, Whitehead CR, Wright SM. Blind spots in medical education - International perspectives. MEDICAL TEACHER 2024:1-7. [PMID: 38688493 DOI: 10.1080/0142159x.2024.2345271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/16/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND All individuals and groups have blind spots that can create problems if unaddressed. The goal of this study was to examine blind spots in medical education from international perspectives. METHODS From December 2022 to March 2023, we distributed an electronic survey through international networks of medical students, postgraduate trainees, and medical educators. Respondents named blind spots affecting their medical education system and then rated nine blind spot domains from a study of U.S. medical education along five-point Likert-type scales (1 = much less attention needed; 5 = much more attention needed). We tested for differences between blind spot ratings by respondent groups. We also analyzed the blind spots that respondents identified to determine those not previously described and performed content analysis on open-ended responses about blind spot domains. RESULTS There were 356 respondents from 88 countries, including 127 (44%) educators, 80 (28%) medical students, and 33 (11%) postgraduate trainees. At least 80% of respondents rated each blind spot domain as needing 'more' or 'much more' attention; the highest was 88% for 'Patient perspectives and voices that are not heard, valued, or understood.' In analyses by gender, role in medical education, World Bank country income level, and region, a mean difference of 0.5 was seen in only five of the possible 279 statistical comparisons. Of 885 blind spots documented, new blind spot areas related to issues that crossed national boundaries (e.g. international standards) and the sufficiency of resources to support medical education. Comments about the nine blind spot domains illustrated that cultural, health system, and governmental elements influenced how blind spots are manifested across different settings. DISCUSSION There may be general agreement throughout the world about blind spots in medical education that deserve more attention. This could establish a basis for coordinated international effort to allocate resources and tailor interventions that advance medical education.
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Affiliation(s)
- Sean Tackett
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Yvonne Steinert
- Faculty of Medicine and Health Sciences, Richard and Sylvia Cruess Chair in Medical Education, McGill University, Montreal, Canada
| | - Susan Mirabal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Darcy A Reed
- Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
- Division of Community Internal Medicine, Geriatrics and Palliative Care, Mayo Clinic, Rochester, MN, USA
| | - Cynthia R Whitehead
- Department of Family and Community Medicine, Wilson Centre for Research in Education, University Health Network & University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Scott M Wright
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Caretta-Weyer HA, Schumacher DJ, Kinnear B. Lessons From Organic Chemistry: The Case for Considering Both High Standards and Equity in Assessment. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2024; 99:243-246. [PMID: 38011041 DOI: 10.1097/acm.0000000000005578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
ABSTRACT In this commentary, the authors explore the tension of balancing high performance standards in medical education with the acceptability of those standards to stakeholders (e.g., learners and patients). The authors then offer a lens through which this tension might be considered and ways forward that focus on both patient outcomes and learner needs.In examining this phenomenon, the authors argue that high performance standards are often necessary. Societal accountability is key to medical education, with the public demanding that training programs prepare physicians to provide high-quality care. Medical schools and residency programs, therefore, require rigorous standards to ensure graduates are ready to care for patients. At the same time, learners' experience is important to consider. Making sure that performance standards are acceptable to stakeholders supports the validity of assessment decisions.Equity should also be central to program evaluation and validity arguments when considering performance standards. Currently, learners across the continuum are variably prepared for the next phase in training and often face inequities in resource availability to meet high passing standards, which may lead to learner attrition. Many students who face these inequities come from underrepresented or disadvantaged backgrounds and are essential to ensuring a diverse medical workforce to meet the needs of patients and society. When these students struggle, it contributes to the leaky pipeline of more socioeconomically and racially diverse applicants.The authors posit that 4 key factors can balance the tension between high performance standards and stakeholder acceptability: standards that are acceptable and defensible, progression that is time variable, requisite support structures that are uniquely tailored for each learner, and assessment systems that are equitably designed.
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Bullock JL, Sukhera J, Del Pino-Jones A, Dyster TG, Ilgen JS, Lockspeiser TM, Teunissen PW, Hauer KE. 'Yourself in all your forms': A grounded theory exploration of identity safety in medical students. MEDICAL EDUCATION 2024; 58:327-337. [PMID: 37517809 DOI: 10.1111/medu.15174] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/30/2023] [Accepted: 07/05/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION Identity threats, such as stereotype threat and microaggressions, impair learning and erode well-being. In contrast to identity threat, less is known about how learners experience feelings of safety regarding their identity. This exploratory study aims to develop a theory of identity safety in the clinical learning environment. METHODS This multi-institutional, qualitative interview study was informed by constructivist grounded theory and critical pedagogy. Participants were clinical students at three public medical schools in the United States in 2022. Investigators purposively sampled participants for interviews based on their responses to an 11-item survey with an open-ended question soliciting students' personal identities and responses to both the racial/ethnic and gender Stereotype Vulnerability Scales. The investigators interviewed, coded, constantly compared and continued sampling until the codes could be developed into categories, then concepts and finally into a theory. The team engaged in critical reflexivity throughout the analytic process to enrich data interpretations. RESULTS Sixteen diverse students were interviewed. We organised their identity-salient experiences into identity threat, threat mitigation and identity safety. Participants experienced identity threat through unwelcoming learning environments, feeling compelled to change their behaviour in inauthentic ways or sociopolitical threat. Threat mitigation occurred when a participant or supervisor intervened against an identity threat, dampening but not eliminating the threat impact. Participants characterised identity safety as the ability to exist as their authentic selves without feeling the need to monitor how others perceive their identities. Identity safety manifested when participants demonstrated agency to leverage their identities for patient care, when others upheld their personhood and saw them as unique individuals and when they felt they belonged in the learning environment. DISCUSSION Attending to identity safety may lead to educational practices that sustain and leverage team members' diverse identities. Identity safety and threat mitigation may work together to combat identity threats in the learning environment.
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Affiliation(s)
- Justin L Bullock
- Division of Nephrology, University of Washington School of Medicine, Seattle, Washington, USA
- School of Health Professions Education, Maastricht University, Maastricht, Netherlands
| | - Javeed Sukhera
- Department of Psychiatry at Hartford Hospital, Institute of Living, Hartford, Connecticut, USA
| | - Amira Del Pino-Jones
- Department of Medicine, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Timothy G Dyster
- School of Medicine, Division of Pulmonary, and Critical Care Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jonathan S Ilgen
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Tai M Lockspeiser
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Pim W Teunissen
- School of Health Professions Education, Maastricht University, Maastricht, Netherlands
- Maastricht University Medical Centre, Maastricht, Netherlands
| | - Karen E Hauer
- University of California, San Francisco, San Francisco, California, USA
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Anderson HL, Abdulla L, Balmer DF, Govaerts M, Busari JO. Inequity is woven into the fabric: a discourse analysis of assessment in pediatric residency training. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2024; 29:199-216. [PMID: 37351698 DOI: 10.1007/s10459-023-10260-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 06/18/2023] [Indexed: 06/24/2023]
Abstract
Intrinsic inequity in assessment refers to sources of harmful discrimination inherent in the design of assessment tools and systems. This study seeks to understand intrinsic inequity in assessment systems by studying assessment policies and associated procedures in residency training, using general pediatrics as a discourse case study. Foucauldian discourse analysis (FDA) was conducted on assessment policy and procedure documents. Two authors independently prepared structured analytic notes using guiding questions. Documents and respective analytic notes were subsequently reviewed independently by all authors. Each author prepared further unstructured analytic notes on the documents' discourse. The authors then compared notes and constructed truth statements (i.e., interpretations of what the discourse establishes as true about the construct under study) and sub-strands (i.e., themes) that were repeated and legitimized across the documents via iterative discussion. Based on analysis, the authors constructed two truth statements. These truth statements, "good assessment is equitable assessment," and "everyone is responsible for inequity," conceptualized inequity in assessment as an isolated or individual-level aberration in an otherwise effective or neutral system. Closer examination of the truth statements and sub-strands in the discourse presented an alternative view, suggesting that inequity may in fact not be an aberration but rather an inherent feature of assessment systems.
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Affiliation(s)
- Hannah L Anderson
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, USA.
- School of Health Professions Education (SHE), Maastricht University, Maastricht, The Netherlands.
| | - Layla Abdulla
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dorene F Balmer
- Director of Research On Education, Perelman School of Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Marjan Govaerts
- Department of Educational Development, School of Health Professions Education (SHE), Maastricht University, Maastricht, The Netherlands
| | - Jamiu O Busari
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Kinnear B, Schumacher DJ. What the hell is water? Changing medical education's ideology through validity. MEDICAL EDUCATION 2024; 58:274-276. [PMID: 37792578 DOI: 10.1111/medu.15243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 09/15/2023] [Indexed: 10/06/2023]
Abstract
@Midwest_MedPeds and @DrDanSchumacher call for a "What the hell is water?" reckoning with #MedEd using academic excellence as a central selection metric
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Affiliation(s)
- Benjamin Kinnear
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Daniel J Schumacher
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Gin BC, Ten Cate O, O'Sullivan PS, Boscardin C. Assessing supervisor versus trainee viewpoints of entrustment through cognitive and affective lenses: an artificial intelligence investigation of bias in feedback. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2024:10.1007/s10459-024-10311-9. [PMID: 38388855 DOI: 10.1007/s10459-024-10311-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/21/2024] [Indexed: 02/24/2024]
Abstract
The entrustment framework redirects assessment from considering only trainees' competence to decision-making about their readiness to perform clinical tasks independently. Since trainees and supervisors both contribute to entrustment decisions, we examined the cognitive and affective factors that underly their negotiation of trust, and whether trainee demographic characteristics may bias them. Using a document analysis approach, we adapted large language models (LLMs) to examine feedback dialogs (N = 24,187, each with an associated entrustment rating) between medical student trainees and their clinical supervisors. We compared how trainees and supervisors differentially documented feedback dialogs about similar tasks by identifying qualitative themes and quantitatively assessing their correlation with entrustment ratings. Supervisors' themes predominantly reflected skills related to patient presentations, while trainees' themes were broader-including clinical performance and personal qualities. To examine affect, we trained an LLM to measure feedback sentiment. On average, trainees used more negative language (5.3% lower probability of positive sentiment, p < 0.05) compared to supervisors, while documenting higher entrustment ratings (+ 0.08 on a 1-4 scale, p < 0.05). We also found biases tied to demographic characteristics: trainees' documentation reflected more positive sentiment in the case of male trainees (+ 1.3%, p < 0.05) and of trainees underrepresented in medicine (UIM) (+ 1.3%, p < 0.05). Entrustment ratings did not appear to reflect these biases, neither when documented by trainee nor supervisor. As such, bias appeared to influence the emotive language trainees used to document entrustment more than the degree of entrustment they experienced. Mitigating these biases is nonetheless important because they may affect trainees' assimilation into their roles and formation of trusting relationships.
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Affiliation(s)
- Brian C Gin
- Department of Pediatrics, University of California San Francisco, 550 16th St Floor 4, UCSF Box 0110, San Francisco, CA, 94158, USA.
| | - Olle Ten Cate
- Utrecht Center for Research and Development of Health Professions Education, University Medical Center, Utrecht, the Netherlands
- Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Patricia S O'Sullivan
- Department of Medicine, University of California San Francisco, San Francisco, USA
- Department of Surgery, University of California San Francisco, San Francisco, USA
| | - Christy Boscardin
- Department of Medicine, University of California San Francisco, San Francisco, USA
- Department of Anesthesia, University of California San Francisco, San Francisco, USA
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Arno K, Bradby C, Shappell E, Mannix A, Fix M, Jordan J, Cooney R, Krzyzaniak SM, Gottlieb M. Differences in emergency medicine resident procedural reporting by race and ethnicity. AEM EDUCATION AND TRAINING 2024; 8:e10930. [PMID: 38235392 PMCID: PMC10790187 DOI: 10.1002/aet2.10930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/10/2023] [Accepted: 10/22/2023] [Indexed: 01/19/2024]
Abstract
Background The recruitment, retention, and training of physicians from groups underrepresented in medicine (UiM) is critically important to the practice of emergency medicine (EM). Studies across specialties have demonstrated disparities in operative experiences among UiM resident learners who are UiM; however, there are limited data on procedural disparities in EM. Objective We sought to quantify the association between racial and ethnic identities that are UiM and the number of procedures reported among EM residents. Methods We conducted a retrospective review of procedural differences by UiM status (using self-identified race and ethnicity) among graduating EM residents at nine training programs over a 10-year period. Sites were selected to ensure diversity of program length, program type, and geography. Data from residents in combined training programs, those who did not complete their full training at that institution, and those with missing data or electing not to report race/ethnicity were excluded. We calculated median and interquartile ranges for each procedure by UiM status. We conducted multivariable regression analyses accounting for UiM status, gender, and site as well as a sensitivity analysis excluding values >3 standard deviations from the mean for each procedure. Results We collected data from 988 total residents, with 718 (73%) being non-UiM, 204 (21%) being UiM, 48 (5%) electing not to specific race/ethnicity, and 18 (2%) missing race/ethnicity data. While unadjusted data demonstrated a difference between UiM and non-UiM resident numbers across several procedures, there were no significant differences in procedures reported after accounting for gender and site in the primary or sensitivity analyses. Conclusions We did not identify a statistically significant difference in reported procedures between UiM and non-UiM residents in EM. Future work should include qualitative investigations of UiM resident experience surrounding procedures as well as mixed-methods studies to examine how these data interact.
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Affiliation(s)
- Kimbia Arno
- Department of Emergency MedicineMaimonides Medical CenterBrooklynNew YorkUSA
| | - Cassandra Bradby
- Department of Emergency MedicineThe Brody School of Medicine at East Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Eric Shappell
- Department of Emergency MedicineMassachusetts General Hospital/Harvard Medical SchoolBostonMassachusettsUSA
| | - Alexandra Mannix
- Department of Emergency MedicineUniversity of Florida College of Medicine–JacksonvilleJacksonvilleFloridaUSA
| | - Megan Fix
- Department of Emergency MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Jaime Jordan
- Department of Emergency MedicineDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
| | - Robert Cooney
- Emergency MedicineGeisinger Medical CenterDanvillePennsylvaniaUSA
| | - Sara M. Krzyzaniak
- Department of Emergency MedicineStanford UniversityPalo AltoCaliforniaUSA
| | - Michael Gottlieb
- Department of Emergency MedicineRush University Medical CenterChicagoIllinoisUSA
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Howard TF, Pike J, Grobman WA. Racial disparities in the selection of chief resident: A cross-sectional analysis of a national sample of senior residents in the United States. J Natl Med Assoc 2024; 116:6-12. [PMID: 38052698 DOI: 10.1016/j.jnma.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/18/2023] [Accepted: 09/25/2023] [Indexed: 12/07/2023]
Abstract
INTRODUCTION Part of the difficulty in recruiting and retaining a diverse physician workforce, as well as within medical leadership, is due to racial disparities in medical education. We investigated whether self-identified race-ethnicity is associated with the likelihood of selection as chief resident (CR). MATERIALS AND METHODS We performed a cross sectional analysis using de-identified person-level data from the GME Track, a national resident database and tracking system, from 2015 through 2018. The exposure variable, self-identified race-ethnicity, was categorized as African American or Black, American Indian or Alaskan Native, Asian, Hispanic, Latino or of Spanish Origin, Native Hawaiian or Pacific Islander, White, and Multi-racial. The primary study outcome was CR selection among respondents in their final program year. Logistic regression was used to estimate the adjusted odds ratios (aOR) and 95% confidence intervals (CI) of CR selection for each racial group, as compared to the White referent group. RESULTS Among the study population (N=121,247), Black, Asian and Hispanic race-ethnicity was associated with a significantly decreased odds of being selected as CR in unadjusted and adjusted analyses. Black, Asian and Hispanic residents had a 26% (aOR=0.74, 95% CI 0.66-0.83), 29% (aOR=0.71, 95% CI 0.66-0.76) and 28% (aOR=0.72, 95% CI 0.66-0.94) decreased likelihood of becoming CR, respectively. Multi-racial residents also had a decreased likelihood, but to a lesser degree (aOR=0.92, 95% CI 0.89-0.95). CONCLUSIONS In as much as CR is an honor that sets one up for future opportunity, our findings suggest that residents of color are disproportionately disadvantaged compared to their White peers.
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Affiliation(s)
- Tera Frederick Howard
- Department of Women's Health, University of Texas at Austin Dell Medical School, Austin Tx
| | - Jordyn Pike
- Texas Advanced Computing Center, University of Texas at Austin Dell Medical School, Austin, TX, United States
| | - William A Grobman
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, United States.
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Busari JO, Diffey L, Hauer KE, Lomis KD, Amiel JM, Barone MA, Schultz K, Chen HC, Damodaran A, Turner DA, Jones B, Oandasan I, Chan MK. Advancing anti-oppression and social justice in healthcare through competency-based medical education (CBME). MEDICAL TEACHER 2024:1-8. [PMID: 38215046 DOI: 10.1080/0142159x.2023.2298763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/20/2023] [Indexed: 01/14/2024]
Abstract
Competency-based medical education (CBME) focuses on preparing physicians to improve the health of patients and populations. In the context of ongoing health disparities worldwide, medical educators must implement CBME in ways that advance social justice and anti-oppression. In this article, authors describe how CBME can be implemented to promote equity pedagogy, an approach to education in which curricular design, teaching, assessment strategies, and learning environments support learners from diverse groups to be successful. The five core components of CBME programs - outcomes competency framework, progressive sequencing of competencies, learning experiences tailored to learners' needs, teaching focused on competencies, and programmatic assessment - enable individualization of learning experiences and teaching and encourage learners to partner with their teachers in driving their learning. These educational approaches appreciate each learner's background, experiences, and strengths. Using an exemplar case study, the authors illustrate how CBME can afford opportunities to enhance anti-oppression and social justice in medical education and promote each learner's success in meeting the expected outcomes of training. The authors provide recommendations for individuals and institutions implementing CBME to enact equity pedagogy.
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Affiliation(s)
- Jamiu O Busari
- Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Pediatrics, Dr. Horacio Oduber Hospital, Oranjestad, Aruba
| | - Linda Diffey
- Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Karen E Hauer
- University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | | | - Jonathan M Amiel
- Office of Innovation in Health Professions Education and Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Michael A Barone
- NBME, Philadelphia, PA, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Schultz
- PGME Queen's University, Kingston, Canada
- Department of Family Medicine, Queen's University, Kingston, Canada
| | - H Carrie Chen
- Georgetown University School of Medicine, Washington, DC, USA
| | - Arvin Damodaran
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - David A Turner
- Department of Pediatrics, Division of Pediatric Critical Care, Duke Health System, Durham, NC, USA
- Competency-Based Medical Education, American Board of Pediatrics, Chapel Hill, NC, USA
| | - Benjamin Jones
- Health Systems Collaborative, Nuffield Department of Medicine, Oxford, UK
| | - Ivy Oandasan
- Toronto General Hospital Research Institute (TGHRI), Toronto, Canada
| | - Ming-Ka Chan
- Department of Pediatrics & Child Health, Office of Leadership Education, Rady Faculty of Health Sciences and Equity, Diversity, Inclusivity and Social Justice Lead, University of Manitoba and The Children's Hospital of Winnipeg, Winnipeg, Canada
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15
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Anderson A, Onumah C. Does Racial Bias Play a Role in Internal Medicine Resident Knowledge Evaluations? Ann Intern Med 2024; 177:95-96. [PMID: 38145567 DOI: 10.7326/m23-3141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Affiliation(s)
- Andrea Anderson
- Department of Emergency Medicine, Division of Family Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Chavon Onumah
- Department of Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC
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Schumacher DJ, Kinnear B, Carraccio C, Holmboe E, Busari JO, van der Vleuten C, Lingard L. Competency-based medical education: The spark to ignite healthcare's escape fire. MEDICAL TEACHER 2024; 46:140-146. [PMID: 37463405 DOI: 10.1080/0142159x.2023.2232097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
High-value care is what patients deserve and what healthcare professionals should deliver. However, it is not what happens much of the time. Quality improvement master Dr. Don Berwick argued more than two decades ago that American healthcare needs an escape fire, which is a new way of seeing and acting in a crisis situation. While coined in the U.S. context, the analogy applies in other Western healthcare contexts as well. Therefore, in this paper, the authors revisit Berwick's analogy, arguing that medical education can, and should, provide the spark for such an escape fire across the globe. They assert that medical education can achieve this by fully embracing competency-based medical education (CBME) as a way to place medicine's focus on the patient. CBME targets training outcomes that prepare graduates to optimize patient care. The authors use the escape fire analogy to argue that medical educators must drop long-held approaches and tools; treat CBME implementation as an adaptive challenge rather than a technical fix; demand genuine, rich discussions and engagement about the path forward; and, above all, center the patient in all they do.
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Affiliation(s)
- Daniel J Schumacher
- Pediatrics, Cincinnati Children's Hospital Medical Center and, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Benjamin Kinnear
- Pediatrics and Internal Medicine, Cincinnati Children's Hospital Medical Center and, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Carol Carraccio
- Vice President of Competency-Based Medical Education, American Board of Pediatrics, Chapel Hill, North Carolina, USA
| | - Eric Holmboe
- Milestones Development and Evaluation Officer, Accreditation Council for Graduate Medical Education, Chicago, Illinois, USA
| | - Jamiu O Busari
- Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Cees van der Vleuten
- Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
| | - Lorelei Lingard
- Department of Medicine, and Center for Education Research & Innovation, Schulich School of Medicine and Dentistry at Western University, London, Ontario, Canada
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Gray BM, Lipner RS, Roswell RO, Fernandez A, Vandergrift JL, Alsan M. Adoption of Internal Medicine Milestone Ratings and Changes in Bias Against Black, Latino, and Asian Internal Medicine Residents. Ann Intern Med 2024; 177:70-82. [PMID: 38145569 DOI: 10.7326/m23-1588] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND The 2014 adoption of the Milestone ratings system may have affected evaluation bias against minoritized groups. OBJECTIVE To assess bias in internal medicine (IM) residency knowledge ratings against Black or Latino residents-who are underrepresented in medicine (URiM)-and Asian residents before versus after Milestone adoption in 2014. DESIGN Cross-sectional and interrupted time-series comparisons. SETTING U.S. IM residencies. PARTICIPANTS 59 835 IM residents completing residencies during 2008 to 2013 and 2015 to 2020. INTERVENTION Adoption of the Milestone ratings system. MEASUREMENTS Pre-Milestone (2008 to 2013) and post-Milestone (2015 to 2020) bias was estimated as differences in standardized knowledge ratings between U.S.-born and non-U.S.-born minoritized groups versus non-Latino U.S.-born White (NLW) residents, with adjustment for performance on the American Board of Internal Medicine IM certification examination and other physician characteristics. Interrupted time-series analysis measured deviations from pre-Milestone linear bias trends. RESULTS During the pre-Milestone period, ratings biases against minoritized groups were large (-0.40 SDs [95% CI, -0.48 to -0.31 SDs; P < 0.001] for URiM residents, -0.24 SDs [CI, -0.30 to -0.18 SDs; P < 0.001] for U.S.-born Asian residents, and -0.36 SDs [CI, -0.45 to -0.27 SDs; P < 0.001] for non-U.S.-born Asian residents). These estimates decreased to less than -0.15 SDs after adoption of Milestone ratings for all groups except U.S.-born Black residents, among whom substantial (though lower) bias persisted (-0.26 SDs [CI, -0.36 to -0.17 SDs; P < 0.001]). Substantial deviations from pre-Milestone linear bias trends coincident with adoption of Milestone ratings were also observed. LIMITATIONS Unobserved variables correlated with ratings bias and Milestone ratings adoption, changes in identification of race/ethnicity, and generalizability to Milestones 2.0. CONCLUSION Knowledge ratings bias against URiM and Asian residents was ameliorated with the adoption of the Milestone ratings system. However, substantial ratings bias against U.S.-born Black residents persisted. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Bradley M Gray
- American Board of Internal Medicine, Philadelphia, Pennsylvania (B.M.G., R.S.L., J.L.V.)
| | - Rebecca S Lipner
- American Board of Internal Medicine, Philadelphia, Pennsylvania (B.M.G., R.S.L., J.L.V.)
| | - Robert O Roswell
- Zucker School of Medicine at Hofstra Northwell, Hempstead, New York (R.O.R.)
| | - Alicia Fernandez
- Department of Medicine, University of California, San Francisco, San Francisco, California (A.F.)
| | - Jonathan L Vandergrift
- American Board of Internal Medicine, Philadelphia, Pennsylvania (B.M.G., R.S.L., J.L.V.)
| | - Marcella Alsan
- John F. Kennedy School of Government, Harvard University, Cambridge, Massachusetts (M.A.)
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Tavares W, Kinnear B, Schumacher DJ, Forte M. "Rater training" re-imagined for work-based assessment in medical education. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2023; 28:1697-1709. [PMID: 37140661 DOI: 10.1007/s10459-023-10237-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/30/2023] [Indexed: 05/05/2023]
Abstract
In this perspective, the authors critically examine "rater training" as it has been conceptualized and used in medical education. By "rater training," they mean the educational events intended to improve rater performance and contributions during assessment events. Historically, rater training programs have focused on modifying faculty behaviours to achieve psychometric ideals (e.g., reliability, inter-rater reliability, accuracy). The authors argue these ideals may now be poorly aligned with contemporary research informing work-based assessment, introducing a compatibility threat, with no clear direction on how to proceed. To address this issue, the authors provide a brief historical review of "rater training" and provide an analysis of the literature examining the effectiveness of rater training programs. They focus mainly on what has served to define effectiveness or improvements. They then draw on philosophical and conceptual shifts in assessment to demonstrate why the function, effectiveness aims, and structure of rater training requires reimagining. These include shifting competencies for assessors, viewing assessment as a complex cognitive task enacted in a social context, evolving views on biases, and reprioritizing which validity evidence should be most sought in medical education. The authors aim to advance the discussion on rater training by challenging implicit incompatibility issues and stimulating ways to overcome them. They propose that "rater training" (a moniker they suggest be reserved for strong psychometric aims) be augmented with "assessor readiness" programs that link to contemporary assessment science and enact the principle of compatibility between that science and ways of engaging with advances in real-world faculty-learner contexts.
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Affiliation(s)
- Walter Tavares
- Department of Health and Society, Wilson Centre, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Benjamin Kinnear
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel J Schumacher
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Milena Forte
- Department of Family and Community Medicine, Temerty Faculty of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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Lee MC, Melcer EF, Merrell SB, Wong LY, Shields S, Eddington H, Trickey AW, Tsai J, Korndorffer JR, Lin DT, Liebert CA. Usability of ENTRUST as an Assessment Tool for Entrustable Professional Activities (EPAs): A Mixed Methods Analysis. JOURNAL OF SURGICAL EDUCATION 2023; 80:1693-1702. [PMID: 37821350 DOI: 10.1016/j.jsurg.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 06/19/2023] [Accepted: 09/08/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE As the American Board of Surgery transitions to a competency-based model of surgical education centered upon entrustable professional activities (EPAs), there is a growing need for objective tools to determine readiness for entrustment. This study evaluates the usability of ENTRUST, an innovative virtual patient simulation platform to assess surgical trainees' decision-making skills in preoperative, intra-operative, and post-operative settings. DESIGN This is a mixed-methods analysis of the usability of the ENTRUST platform. Quantitative data was collected using the system usability scale (SUS) and Likert responses. Analysis was performed with descriptive statistics, bivariate analysis, and multivariable linear regression. Qualitative analysis of open-ended responses was performed using the Nielsen-Shneiderman Heuristics framework. SETTING This study was conducted at an academic institution in a proctored exam setting. PARTICIPANTS The analysis includes n = 47 (PGY 1-5) surgical residents who completed an online usability survey following the ENTRUST Inguinal Hernia EPA Assessment. RESULTS The ENTRUST platform had a median SUS score of 82.5. On bivariate and multivariate analyses, there were no significant differences between usability based on demographic characteristics (all p > 0.05), and SUS score was independent of ENTRUST performance (r = 0.198, p = 0.18). Most participants agreed that the clinical workup of the patient was engaging (91.5%) and felt realistic (85.1%). The most frequent heuristics represented in the qualitative analysis included feedback, visibility, match, and control. Additional themes of educational value, enjoyment, and ease-of-use highlighted participants' perspectives on the usability of ENTRUST. CONCLUSIONS ENTRUST demonstrates high usability in this population. Usability was independent of ENTRUST score performance and there were no differences in usability identified in this analysis based on demographic subgroups. Qualitative analysis highlighted the acceptability of ENTRUST and will inform ongoing development of the platform. The ENTRUST platform holds potential as a tool for the assessment of EPAs in surgical residency programs.
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Affiliation(s)
- Melissa C Lee
- Stanford University School of Medicine, Stanford, California
| | - Edward F Melcer
- Department of Computational Media, University of California-Santa Cruz, Baskin School of Engineering, Santa Cruz, California
| | | | - Lye-Yeng Wong
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Samuel Shields
- Department of Computational Media, University of California-Santa Cruz, Baskin School of Engineering, Santa Cruz, California
| | - Hyrum Eddington
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Palo Alto, California
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Palo Alto, California
| | - Jason Tsai
- Department of Computational Media, University of California-Santa Cruz, Baskin School of Engineering, Santa Cruz, California; Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - James R Korndorffer
- Department of Surgery, Stanford University School of Medicine, Stanford, California; VA Palo Alto Health Care System, Surgical Services, Palo Alto, California
| | - Dana T Lin
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Cara A Liebert
- Department of Surgery, Stanford University School of Medicine, Stanford, California; VA Palo Alto Health Care System, Surgical Services, Palo Alto, California.
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Fancher TL, Brenner J, Baker PL, Turner L, Bragg D, Booker M, Awolope A, Green C, Santen SA. So You Found Inequities in Clerkship Grades? How to Talk With Students and Community Members About Your Findings. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:S172-S173. [PMID: 37983531 DOI: 10.1097/acm.0000000000005382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Affiliation(s)
- Tonya L Fancher
- Author affiliations: T.L. Fancher, M. Booker, A. Awolope, C. Green, University of California Davis School of Medicine; J. Brenner, NYU Long Island School of Medicine; P.L. Baker, L. Turner, D. Bragg, S. Santen, University of Cincinnati College of Medicine
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Edwell A, Van Schaik S, Teherani A. URM: Underrepresented or Underrecognized? A Case Study of Black Pediatric Critical Care Physicians. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:S50-S57. [PMID: 37983396 DOI: 10.1097/acm.0000000000005370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
PURPOSE This study explored Black physicians' experience via an antideficit lens to gain new ideas for advancing minoritized physicians in academic medicine more broadly. Increasingly, systemic racism in academic medicine is intentionally acknowledged and named. However, many solutions to tackle racism and the overall paucity of Black physicians use a deficit framing, painting Black physicians and trainees as lacking preparation, interest, or experience and qualifications. Such solutions aim to help Black people assimilate into the "White Space" of academic medicine, rather than focusing on Black people's strengths. METHOD This qualitative study included 15 Black physicians and trainees in pediatric critical care medicine (PCCM) from across the country who participated in semistructured interviews. Through an antideficit lens, the researchers examined the social, cultural, and structural contexts influencing the participants' individual experiences. They analyzed the data combining thematic and narrative qualitative analysis approaches, including restorying. RESULTS The data help promote understanding of the landscape and context in which Black PCCM physicians become successful. Achievement took on different forms for the participants. Participants described enablers of achievement that supported them through their individual journeys spanning 3 general domains-intrinsic, interpersonal, and systemic. Three additional enablers were tied specifically to participants' Black identities-harnessing Blackness as a superpower, leaning in to lead, and successfully navigating the "unwritten rules." CONCLUSIONS By using an antideficit framework, this study delineates and centers participants' ingenuity in cultivating repertoires of practice that enabled them to succeed, despite challenges rooted in systemic racism. Going forward, rather than focus solely on what is missing, academic medicine should try to shift systems and regularly recognize and value the knowledge, expertise, and merit Black that physicians bring. Perhaps an appropriate framing is not that Black physicians are underrepresented in medicine; maybe instead, it is that they are underrecognized.
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Affiliation(s)
- April Edwell
- A. Edwell is assistant professor of pediatrics, Department of Pediatrics, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California
| | - Sandrijn Van Schaik
- S. Van Schaik is professor of pediatrics, Department of Pediatrics, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California
| | - Arianne Teherani
- A. Teherani is professor of medicine, University of California, San Francisco School of Medicine, San Francisco, California; ORCID: http://orcid.org/0000-0003-2936-983
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Perez S, Schwartz A, Hauer KE, Karani R, Hirshfield LE, McNamara M, Henry D, Lupton KL, Woods M, Teherani A. Developing Evidence for Equitable Assessment Characteristics Based on Clinical Learner Preferences Using Discrete Choice Experiments. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:S108-S115. [PMID: 37983403 DOI: 10.1097/acm.0000000000005360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
PURPOSE Medical education is only beginning to explore the factors that contribute to equitable assessment in clinical settings. Increasing knowledge about equitable assessment ensures a quality medical education experience that produces an excellent, diverse physician workforce equipped to address the health care disparities facing patients and communities. Through the lens of the Anti-Deficit Achievement framework, the authors aimed to obtain evidence for a model for equitable assessment in clinical training. METHOD A discrete choice experiment approach was used which included an instrument with 6 attributes each at 2 levels to reveal learner preferences for the inclusion of each attribute in equitable assessment. Self-identified underrepresented in medicine (UIM) and not underrepresented in medicine (non-UIM) (N = 306) fourth-year medical students and senior residents in medicine, pediatrics, and surgery at 9 institutions across the United States completed the instrument. A mixed-effects logit model was used to determine attributes learners valued most. RESULTS Participants valued the inclusion of all assessment attributes provided except for peer comparison. The most valued attribute of an equitable assessment was how learner identity, background, and trajectory were appreciated by clinical supervisors. The next most valued attributes were assessment of growth, supervisor bias training, narrative assessments, and assessment of learner's patient care, with participants willing to trade off any of the attributes to get several others. There were no significant differences in value placed on assessment attributes between UIM and non-UIM learners. Residents valued clinical supervisors valuing learner identity, background, and trajectory and clinical supervisor bias training more so than medical students. CONCLUSIONS This study offers support for the components of an antideficit-focused model for equity in assessment and informs efforts to promote UIM learner success and guide equity, diversity, and inclusion initiatives in medical education.
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Affiliation(s)
- Sandra Perez
- S. Perez is a resident, Department of Pathology, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Alan Schwartz
- A. Schwartz is the Michael Reese Endowed Professor of Medical Education, Department of Medical Education, and research professor, Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, and director, Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network (APPD LEARN), McLean, Virginia; ORCID: http://orcid.org/0000-0003-3809-6637
| | - Karen E Hauer
- K.E. Hauer is professor, Department of Medicine, and associate dean for competency assessment and professional standards, University of California, San Francisco, School of Medicine, San Francisco, California; ORCID: https://orcid.org/0000-0002-8812-4045
| | - Reena Karani
- R. Karani is professor, Departments of Medicine, Medical Education, and Geriatrics and Palliative Medicine, and director, Institute for Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Laura E Hirshfield
- L.E. Hirshfield is the Dr. Georges Bordage Medical Education Faculty Scholar, associate professor, PhD program codirector, and associate director of graduate studies, Department of Medical Education, University of Illinois College of Medicine, Chicago, Illinois; ORCID: https://orcid.org/0000-0003-0894-2994
| | - Margaret McNamara
- M. McNamara is professor, Department of Pediatrics, and pediatric residency program director, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Duncan Henry
- D. Henry is associate professor, Department of Pediatrics, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Katherine L Lupton
- K.L. Lupton is professor, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Majka Woods
- M. Woods holds the Dibrell Family Professorship in the Art of Medicine, and is assistant professor, Department of Surgery, and vice dean for academic affairs, John Sealy School of Medicine at the University of Texas Medical Branch, Galveston, Texas
| | - Arianne Teherani
- A. Teherani is professor, Department of Medicine, education scientist, Center for Faculty Educators, director of program evaluation and education continuous quality improvement, and founding codirector, University of California Center for Climate Health and Equity, University of California, San Francisco, School of Medicine, San Francisco, California; ORCID: http://orcid.org/0000-0003-2936-9832
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Tackett S, Steinert Y, Mirabal S, Reed DA, Wright SM. Using Group Concept Mapping to Explore Medical Education's Blind Spots. TEACHING AND LEARNING IN MEDICINE 2023:1-11. [PMID: 37886902 DOI: 10.1080/10401334.2023.2274991] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/11/2023] [Indexed: 10/28/2023]
Abstract
PHENOMENON All individuals and groups have blind spots that can lead to mistakes, perpetuate biases, and limit innovations. The goal of this study was to better understand how blind spots manifest in medical education by seeking them out in the U.S. APPROACH We conducted group concept mapping (GCM), a research method that involves brainstorming ideas, sorting them according to conceptual similarity, generating a point map that represents consensus among sorters, and interpreting the cluster maps to arrive at a final concept map. Participants in this study were stakeholders from the U.S. medical education system (i.e., learners, educators, administrators, regulators, researchers, and commercial resource producers) and those from the broader U.S. health system (i.e., patients, nurses, public health professionals, and health system administrators). All participants brainstormed ideas to the focus prompt: "To educate physicians who can meet the health needs of patients in the U.S. health system, medical education should become less blind to (or pay more attention to) …" Responses to this prompt were reviewed and synthesized by our study team to prepare them for sorting, which was done by a subset of participants from the medical education system. GCM software combined sorting solutions using a multidimensional scaling analysis to produce a point map and performed cluster analyses to generate cluster solution options. Our study team reviewed and interpreted all cluster solutions from five to 25 clusters to decide upon the final concept map. FINDINGS Twenty-seven stakeholders shared 298 blind spots during brainstorming. To decrease redundancy, we reduced these to 208 in preparation for sorting. Ten stakeholders independently sorted the blind spots, and the final concept map included 9 domains and 72 subdomains of blind spots that related to (1) admissions processes; (2) teaching practices; (3) assessment and curricular designs; (4) inequities in education and health; (5) professional growth and identity formation; (6) patient perspectives; (7) teamwork and leadership; (8) health systems care models and financial practices; and (9) government and business policies. INSIGHTS Soliciting perspectives from diverse stakeholders to identify blind spots in medical education uncovered a wide array of issues that deserve more attention. The concept map may also be used to help prioritize resources and direct interventions that can stimulate change and bring medical education into better alignment with the health needs of patients and communities.
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Affiliation(s)
- Sean Tackett
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Yvonne Steinert
- Family Medicine and Health Sciences Education, McGill University, Montreal, Québec, Canada
| | - Susan Mirabal
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Darcy A Reed
- Division of Community Internal Medicine, Geriatrics and Palliative Care, Mayo Clinic, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Scott M Wright
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
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Austin Z, Andriole DA, Rhoney DH. Is it Time for Competency-Based Education to Move Forward in Pharmacy Education? AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2023; 87:100550. [PMID: 37331516 DOI: 10.1016/j.ajpe.2023.100550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 06/07/2023] [Accepted: 06/15/2023] [Indexed: 06/20/2023]
Abstract
Competency-based education is rapidly emerging as a paradigmatic shift in health professions education, as we grapple with the realities of ever-changing and increasing demands of society and health systems. While pharmacy educators are becoming more familiar with this paradigm, colleagues in medical education have been exploring models and methods of competency-based education for many years, and their experiences can be illuminating for us. The persistent question that drives continuous quality improvement in pharmacy education and the development of initiatives within American Association of Colleges of Pharmacy might be stated as "Is there a better (more effective, more efficient) way to prepare pharmacists (future and current) to meet the medication-related needs of the public?"
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Affiliation(s)
- Zubin Austin
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | | | - Denise H Rhoney
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Zaidi Z, Rockich-Winston N, Chow C, Martin PC, Onumah C, Wyatt T. Whiteness theory and the (in)visible hierarchy in medical education. MEDICAL EDUCATION 2023; 57:903-909. [PMID: 37199083 DOI: 10.1111/medu.15124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 04/13/2023] [Accepted: 04/29/2023] [Indexed: 05/19/2023]
Abstract
CONTEXT The theory of whiteness in medical education has largely been ignored, yet its power continues to influence learners within our medical curricula and our patients and trainees within our health systems. Its influence is even more powerful given the fact that society maintains a 'possessive investment' in its presence. In combination, these (in)visible forces create environments that favour White individuals at the exclusion of all others, and as health professions educators and researchers, we have the responsibility to uncover how and why these influences continue to pervade medical education. PROPOSAL To better understand how whiteness and the possessive investment in its presence create (in)visible hierarchies, we define and explore the origin of whiteness by examining whiteness studies and how we have come to have a possessive investment in its presence. Next, we provide ways in which whiteness can be studied in medical education so that it can be disruptive. CONCLUSION We encourage health profession educators and researchers to collectively 'make strange' our current hierarchical system by not just recognising the privileges afforded to those who are White but also recognising how these privileges are invested in and maintained. As a community, we must develop and resist established power structures to transform the current hierarchy into a more equitable system that supports everyone, not just those who are White.
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Affiliation(s)
- Zareen Zaidi
- George Washington School of Medicine & Health Sciences, George Washington University, Washington, District of Columbia, USA
| | | | - Candace Chow
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Paolo C Martin
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Chavon Onumah
- George Washington School of Medicine & Health Sciences, George Washington University, Washington, District of Columbia, USA
| | - Tasha Wyatt
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Vanstone M, Cavanagh A, Molinaro M, Connelly CE, Bell A, Mountjoy M, Whyte R, Grierson L. How medical learners and educators decide what counts as mistreatment: A qualitative study. MEDICAL EDUCATION 2023; 57:910-920. [PMID: 36815430 DOI: 10.1111/medu.15065] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 01/18/2023] [Accepted: 02/20/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION The mistreatment or abuse (maltreatment) of medical learners by their peers and supervisors has been documented globally for decades, and there is significant research about the prevalence, sequelae and strategies for intervention. However, there is evidence that learners experience maltreatment as being less clear cut than do researchers, educators and administrators. This definitional ambiguity creates problems for understanding and addressing this issue. The objective of this study was to understand how medical learners and educators make sense of less-than-ideal interactions in the clinical learning environment, and to describe which factors influenced their perception that the encounter constituted maltreatment. METHODS Using constructivist grounded theory, we interviewed 16 medical students, 15 residents or fellows, and 18 educators associated with a single medical school (n = 49). Data collection began with the most junior learners, iterating with analysis as we progressed through the project. Constant comparative analysis was used to gather and compare stories of 'definitely', 'maybe' and 'definitely not' maltreatment across a variety of axes including experience level, clinical setting and type of interaction. RESULTS Our data show that learners and educators have difficulty classifying their experiences of negative interpersonal interaction, except in the most severe and concrete cases. While there was tremendous variation in the way they categorised similar experiences, there was consistency in the elements drawn upon to make sense of those experiences. Participants interpreted negative interpersonal interactions on an individual basis by considering factors related to the interaction, initiator and recipient. CONCLUSIONS Only the most negative behaviour is consistently understood as maltreatment; a complex process of individual sense-making is required to determine the acceptability of each interaction. The differences between how individuals judge these interactions highlight an opportunity for administrative, research and faculty development intervention.
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Affiliation(s)
- Meredith Vanstone
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alice Cavanagh
- McMaster Program for Education Research, Innovation and Theory, Hamilton, Ontario, Canada
- MD/PhD Program, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Monica Molinaro
- McMaster Program for Education Research, Innovation and Theory, Hamilton, Ontario, Canada
| | - Catherine E Connelly
- Michael G. DeGroote School of Business, McMaster University, Hamilton, Ontario, Canada
| | - Amanda Bell
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Program for Education Research, Innovation and Theory, Hamilton, Ontario, Canada
- Undergraduate MD Program, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Margo Mountjoy
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- Undergraduate MD Program, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Robert Whyte
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Grierson
- McMaster Program for Education Research, Innovation and Theory, Hamilton, Ontario, Canada
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Lusk P. Emotion, ethics, epistemology: What can shame 'do' in medical education? J Eval Clin Pract 2023; 29:1135-1142. [PMID: 36317709 DOI: 10.1111/jep.13782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/22/2022] [Accepted: 10/04/2022] [Indexed: 03/21/2023]
Abstract
BACKGROUND Recent empirical studies have described and theorized a culture of shame within medical education in the Anglo-American context (Bynum). Shame is universal and highly social human emotion characterized by a sense of feeling objectified and judged negatively, in contrast to one's own self-concept. Shame has both an embodied and a relational dimension. Shame is considered especially relevant in healthcare settings (Dolezal and Lyons), and the tenets of patient care within the medical profession include respecting the dignity and upholding the safety of patients. However, shame is frequently deployed as a teaching tool within medical training. METHOD Here I ask, what can shame do in medical education (Ahmed)? What epistemic and relational conditions does it construct? I draw from philosophical voices in higher education to illuminate how shaming practices in medical education can undermine dignity safety (Callan), preclude inclusivity, and in the context of the hierarchical and marginalizing medical system, propagate epistemic injustice (Fricker). DISCUSSION This argument shows how shame in education can be both phenomenologically and normatively problematic and may act differently upon students who experience marginalization and those who are majoritized. I further suggest that a medical education system which upholds the epistemological and relational frameworks of power, shame, and epistemic injustice, underscores those frameworks in the medical system at large, disserving individual patients who are already at risk of suffering epistemic injustice (Carel), and society at large. CONCLUSION This analysis of shame in medical education focuses on the highly relational and interpersonal elements of learning to live and work in the medical system, highlighting the need for respect, trust, and resistance to reorient the relational learning environment toward individual and systemic forms of justice.
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Affiliation(s)
- Penelope Lusk
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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28
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Maggio LA, Costello JA, Ninkov AB, Frank JR, Artino AR. Expanding Interdisciplinarity: A Bibliometric Study of Medical Education Using the Medical Education Journal List-24 (MEJ-24). PERSPECTIVES ON MEDICAL EDUCATION 2023; 12:327-337. [PMID: 37636330 PMCID: PMC10453959 DOI: 10.5334/pme.984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 08/02/2023] [Indexed: 08/29/2023]
Abstract
Introduction Interdisciplinary research, which integrates input (e.g., data, techniques, theories) from two or more disciplines, is critical for solving wicked problems. Medical education research is assumed to be interdisciplinary. However, researchers have questioned this assumption. The present study, a conceptual replication, clarifies the nature of medical education interdisciplinarity by analyzing the citations of medical education journal articles. Method The authors retrieved the cited references of all articles in 22 medical education journals between 2001-2020 from Web of Science (WoS). We then identified the WoS classifications for the journals of each cited reference. Results We analyzed 31,283 articles referencing 723,683 publications. We identified 493,973 (68.3%) of those cited references in 6,618 journals representing 242 categories, which represents 94% of all WoS categories. Close to half of all citations were categorized as "education, scientific disciplines" and "healthcare sciences and services". Over the study period, the number of references consistently increased as did the representation of categories to include a diversity of topics such as business, management, and linguistics. Discussion Our study aligns with previous research, suggesting that medical education research could be described as inwardly focused. However, the observed growth of categories and their increasing diversity over time indicates that medical education displays increasing interdisciplinarity. Now visible, the field can raise awareness of and promote interdisciplinarity, if desired, by seeking and highlighting opportunities for future growth.
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Affiliation(s)
- Lauren A. Maggio
- Uniformed Services University of the Health Sciences in Bethesda, Maryland, USA
| | - Joseph A. Costello
- Uniformed Services University of the Health Sciences in Bethesda, Maryland, USA
| | - Anton B. Ninkov
- Université de Montréal, École de bibliothéconomie et des sciences de l’information in Montréal, Québec Canada, Canada
| | - Jason R. Frank
- Department of Emergency Medicine, and Director, Centre for Innovation in Medical Education, University of Ottawa, Canada
| | - Anthony R. Artino
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Boatright D, Edje L, Gruppen LD, Hauer KE, Humphrey HJ, Marcotte K. Ensuring Fairness in Medical Education Assessment. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:S1-S2. [PMID: 37073970 DOI: 10.1097/acm.0000000000005244] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Affiliation(s)
- Dowin Boatright
- D. Boatright is vice chair of research, Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York
| | - Louito Edje
- L. Edje is associate dean of graduate medical education, designated institutional official, and professor of medical education and family and community medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Larry D Gruppen
- L.D. Gruppen is professor, Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan
| | - Karen E Hauer
- K.E. Hauer is associate dean for competency assessment and professional standards, and professor, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
| | - Holly J Humphrey
- H.J. Humphrey is president, Josiah Macy Jr. Foundation, New York, New York
| | - Kayla Marcotte
- K. Marcotte is an MD-PhD student, University of Michigan Medical School, Ann Arbor, Michigan
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Holmboe ES, Osman NY, Murphy CM, Kogan JR. The Urgency of Now: Rethinking and Improving Assessment Practices in Medical Education Programs. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:S37-S49. [PMID: 37071705 DOI: 10.1097/acm.0000000000005251] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Assessment is essential to professional development. Assessment provides the information needed to give feedback, support coaching and the creation of individualized learning plans, inform progress decisions, determine appropriate supervision levels, and, most importantly, help ensure patients and families receive high-quality, safe care in the training environment. While the introduction of competency-based medical education has catalyzed advances in assessment, much work remains to be done. First, becoming a physician (or other health professional) is primarily a developmental process, and assessment programs must be designed using a developmental and growth mindset. Second, medical education programs must have integrated programs of assessment that address the interconnected domains of implicit, explicit and structural bias. Third, improving programs of assessment will require a systems-thinking approach. In this paper, the authors first address these overarching issues as key principles that must be embraced so that training programs may optimize assessment to ensure all learners achieve desired medical education outcomes. The authors then explore specific needs in assessment and provide suggestions to improve assessment practices. This paper is by no means inclusive of all medical education assessment challenges or possible solutions. However, there is a wealth of current assessment research and practice that medical education programs can use to improve educational outcomes and help reduce the harmful effects of bias. The authors' goal is to help improve and guide innovation in assessment by catalyzing further conversations.
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Affiliation(s)
- Eric S Holmboe
- E.S. Holmboe is chief, Research, Milestones Development and Evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois; ORCID: https://orcid.org/0000-0003-0108-6021
| | - Nora Y Osman
- N.Y. Osman is associate professor of medicine, Harvard Medical School, and director of undergraduate medical education, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts; ORCID: https://orcid.org/0000-0003-3542-1262
| | - Christina M Murphy
- C.M. Murphy is a fourth-year medical student and president, Medical Student Government at Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0003-3966-5264
| | - Jennifer R Kogan
- J.R. Kogan is associate dean, Student Success and Professional Development, and professor of medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0001-8426-9506
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Hauer KE, Park YS, Bullock JL, Tekian A. "My Assessments Are Biased!" Measurement and Sociocultural Approaches to Achieve Fairness in Assessment in Medical Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:S16-S27. [PMID: 37094278 DOI: 10.1097/acm.0000000000005245] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Assessing learners is foundational to their training and developmental growth throughout the medical education continuum. However, growing evidence shows the prevalence and impact of harmful bias in assessments in medical education, accelerating the urgency to identify solutions. Assessment bias presents a critical problem for all stages of learning and the broader educational system. Bias poses significant challenges to learners, disrupts the learning environment, and threatens the pathway and transition of learners into health professionals. While the topic of assessment bias has been examined within the context of measurement literature, limited guidance and solutions exist for learners in medical education, particularly in the clinical environment. This article presents an overview of assessment bias, focusing on clinical learners. A definition of bias and its manifestations in assessments are presented. Consequences of assessment bias are discussed within the contexts of validity and fairness and their impact on learners, patients/caregivers, and the broader field of medicine. Messick's unified validity framework is used to contextualize assessment bias; in addition, perspectives from sociocultural contexts are incorporated into the discussion to elaborate the nuanced implications in the clinical training environment. Discussions of these topics are conceptualized within the literature and the interventions used to date. The article concludes with practical recommendations to overcome bias and to develop an ideal assessment system. Recommendations address articulating values to guide assessment, designing assessment to foster learning and outcomes, attending to assessment procedures, promoting continuous quality improvement of assessment, and fostering equitable learning and assessment environments.
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Affiliation(s)
- Karen E Hauer
- K.E. Hauer is associate dean for competency assessment and professional standards, and professor, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California; ORCID: http://orcid.org/0000-0002-8812-4045
| | - Yoon Soo Park
- Y.S. Park is associate professor and associate head, Department of Medical Education, University of Illinois at Chicago College of Medicine, Chicago, Illinois; ORCID: http://orcid.org/0000-0001-8583-4335
| | - Justin L Bullock
- J.L. Bullock is a fellow, Department of Medicine, Division of Nephrology, University of Washington School of Medicine, Seattle, Washington; ORCID: http://orcid.org/0000-0003-4240-9798
| | - Ara Tekian
- A. Tekian is professor and associate dean for international education, Department of Medical Education, University of Illinois at Chicago College of Medicine, Chicago, Illinois; ORCID: http://orcid.org/0000-0002-9252-1588
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Onumah CM, Pincavage AT, Lai CJ, Levine DL, Ismail NJ, Alexandraki I, Osman NY. Strategies for Advancing Equity in Frontline Clinical Assessment. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:S57-S63. [PMID: 37071692 DOI: 10.1097/acm.0000000000005246] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Educational equity in medicine cannot be achieved without addressing assessment bias. Assessment bias in health professions education is prevalent and has extensive implications for learners and, ultimately, the health care system. Medical schools and educators desire to minimize assessment bias, but there is no current consensus on effective approaches. Frontline teaching faculty have the opportunity to mitigate bias in clinical assessment in real time. Based on their experiences as educators, the authors created a case study about a student to illustrate ways bias affects learner assessment. In this paper, the authors use their case study to provide faculty with evidence-based approaches to mitigate bias and promote equity in clinical assessment. They focus on 3 components of equity in assessment: contextual equity, intrinsic equity, and instrumental equity. To address contextual equity, or the environment in which learners are assessed, the authors recommend building a learning environment that promotes equity and psychological safety, understanding the learners' contexts, and undertaking implicit bias training. Intrinsic equity, centered on the tools and practices used during assessment, can be promoted by using competency-based, structured assessment methods and employing frequent, direct observation to assess multiple domains. Instrumental equity, focused on communication and how assessments are used, includes specific, actionable feedback to support growth and use of competency-based narrative descriptors in assessments. Using these strategies, frontline clinical faculty members can actively promote equity in assessment and support the growth of a diverse health care workforce.
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Affiliation(s)
- Chavon M Onumah
- C.M. Onumah is associate professor, Department of Medicine, George Washington School of Medicine and Health Sciences, Washington, DC
| | - Amber T Pincavage
- A.T. Pincavage is professor, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Cindy J Lai
- C.J. Lai is professor and director of medical student clinical education, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
| | - Diane L Levine
- D.L. Levine is professor and vice chair for education, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan
| | - Nadia J Ismail
- N.J. Ismail is professor, Department of Medicine and Department of Education, Innovation and Technology, and vice dean, Baylor College of Medicine, Houston, Texas
| | - Irene Alexandraki
- I. Alexandraki is professor and senior associate dean, academic affairs, Office of Academic Affairs, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Nora Y Osman
- N.Y. Osman is associate professor, Harvard Medical School, and director of undergraduate medical education, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Josiah Macy Jr. Foundation Conference on Ensuring Fairness in Medical Education Assessment: Conference Recommendations Report. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:S3-S15. [PMID: 37070828 DOI: 10.1097/acm.0000000000005243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
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Smith JF, Piemonte NM. The Problematic Persistence of Tiered Grading in Medical School. TEACHING AND LEARNING IN MEDICINE 2023; 35:467-476. [PMID: 35619232 DOI: 10.1080/10401334.2022.2074423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 04/01/2022] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
Issue: The evaluation of medical students is a critical, complex, and controversial process. It is tightly woven into the medical school curriculum, beginning at the inception of the medical student's professional journey. In this respect, medical student evaluation is among the first in a series of ongoing, lifelong assessments that influence the interpersonal, ethical, and socioeconomic dimensions necessary for an effective physician workforce. Yet, tiered grading has a questionable historic pedagogic basis in American medical education, and evidence suggests that tiered grading itself is a source of student burnout, anxiety, depression, increased competitiveness, reduced group cohesion, and racial biases. Evidence: In its most basic form, medical student evaluation is an assessment of the initial cognitive and technical competencies ultimately needed for the safe and effective practice of contemporary medicine. At many American medical schools, such evaluation relies largely on norm-based comparisons, such as tiered grading. Yet, tiered grading can cause student distress, is considered unfair by most students, is associated with biases against under-represented minorities, and demonstrates inconsistent correlation with residency performance. While arguments that tiered grading motivates student performance have enjoyed historic precedence in academia, such arguments are not supported by robust data or theories of motivation. Implications: Given the evolving recognition of the deleterious effects on medical student mental health, cohesiveness, and diversity, the use of tiered grading in medical schools to measure or stimulate academic performance, or by residency program directors to distinguish residency applicants, remains questionable. Examination of tiered grading in its historical, psychometric, psychosocial, and moral dimensions and the various arguments used to maintain it reveals a need for investigation of, if not transition to, alternative and non-tiered assessments of our medical students.
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Affiliation(s)
- James F Smith
- Departments of Medical Education and Medical Humanities, Creighton University, Omaha, Nebraska, USA
| | - Nicole M Piemonte
- Departments of Medical Humanities and Student Affairs, Creighton University, Phoenix, Arizona, USA
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Anderson N, Nguyen M, Marcotte K, Ramos M, Gruppen LD, Boatright D. The Long Shadow: A Historical Perspective on Racism in Medical Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:S28-S36. [PMID: 37071703 PMCID: PMC10584990 DOI: 10.1097/acm.0000000000005253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
To dismantle racism in U.S. medical education, people must understand how the history of Christian Europe, Enlightenment-era racial science, colonization, slavery, and racism shaped modern American medicine. Beginning with the coalescence of Christian European identity and empire, the authors trace European racial reasoning through the racial science of the Enlightenment into the White supremacist and anti-Black ideology behind Europe's global system of racialized colonization and enslavement. The authors then follow this racist ideology as it becomes an organizing principle of Euro-American medicine and examine how it manifests in medical education in the United States today. Within this historical context, the authors expose the histories of violence underlying contemporary terms such as implicit bias and microaggressions. Through this history, they also gain a deeper appreciation of why racism is so prevalent in medical education and how it affects admissions, assessments, faculty and trainee diversity, retention, racial climate, and the physical environment. The authors then recommend 6 historically informed steps for confronting racism in medical education: (1) incorporate the history of racism into medical education and unmask institutional histories of racism, (2) create centralized reporting mechanisms and implement systematic reviews of bias in educational and clinical activities, (3) adopt mastery-based assessment in medical education, (4) embrace holistic review and expand its possibilities in admissions, (5) increase faculty diversity by using holistic review principles in hiring and promotions, and (6) leverage accreditation to combat bias in medical education. These strategies will help academic medicine begin to acknowledge the harms propagated throughout the history of racism in medicine and start taking meaningful steps to address them. Although the authors have focused on racism in this paper, they recognize there are many forms of bias that impact medical education and intersect with racism, each with its particular history, that deserve their own telling and redress.
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Affiliation(s)
- Nientara Anderson
- N. Anderson is a resident, Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Mytien Nguyen
- M. Nguyen is an MD-PhD student, Yale School of Medicine, New Haven, Connecticut
| | - Kayla Marcotte
- K. Marcotte is an MD-PhD student, University of Michigan Medical School, Ann Arbor, Michigan
| | - Marco Ramos
- M. Ramos is assistant professor, Section of History of Science and Medicine and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Larry D Gruppen
- L.D. Gruppen is professor, Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan
| | - Dowin Boatright
- D. Boatright is vice chair of research, Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York
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Kinnear B, Weber DE, Schumacher DJ, Edje L, Warm EJ, Anderson HL. Reconstructing Neurath's Ship: A Case Study in Reevaluating Equity in a Program of Assessment. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:S50-S56. [PMID: 37071695 DOI: 10.1097/acm.0000000000005249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Inequity in assessment has been described as a "wicked problem"-an issue with complex roots, inherent tensions, and unclear solutions. To address inequity, health professions educators must critically examine their implicit understandings of truth and knowledge (i.e., their epistemologies) with regard to educational assessment before jumping to solutions. The authors use the analogy of a ship (program of assessment) sailing on different seas (epistemologies) to describe their journey in seeking to improve equity in assessment. Should the education community repair the ship of assessment while sailing or should the ship be scrapped and built anew? The authors share a case study of a well-developed internal medicine residency program of assessment and describe efforts to evaluate and enable equity using various epistemological lenses. They first used a postpositivist lens to evaluate if the systems and strategies aligned with best practices, but found they did not capture important nuances of what equitable assessment entails. Next, they used a constructivist approach to improve stakeholder engagement, but found they still failed to question the inequitable assumptions inherent to their systems and strategies. Finally, they describe a shift to critical epistemologies, seeking to understand who experiences inequity and harm to dismantle inequitable systems and create better ones. The authors describe how each unique sea promoted different adaptations to their ship, and challenge programs to sail through new epistemological waters as a starting point for making their own ships more equitable.
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Affiliation(s)
- Benjamin Kinnear
- B. Kinnear is associate professor of internal medicine and pediatrics, Departments of Pediatrics and Internal Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0003-0052-4130
| | - Danielle E Weber
- D.E. Weber is assistant professor of internal medicine and pediatrics, Departments of Pediatrics and Internal Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0002-4857-6936
| | - Daniel J Schumacher
- D.J. Schumacher is tenured professor of pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0001-5507-8452
| | - Louito Edje
- L. Edje is professor of family and community medicine, Department of Medical Education and Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eric J Warm
- E.J. Warm is professor of internal medicine and program director, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0002-6088-2434
| | - Hannah L Anderson
- H.L. Anderson is clinical research associate, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0002-9435-1535
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Schafer KR, Sood L, King CJ, Alexandraki I, Aronowitz P, Cohen M, Chretien K, Pahwa A, Shen E, Williams D, Hauer KE. The Grade Debate: Evidence, Knowledge Gaps, and Perspectives on Clerkship Assessment Across the UME to GME Continuum. Am J Med 2023; 136:394-398. [PMID: 36632923 DOI: 10.1016/j.amjmed.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/03/2023] [Indexed: 01/10/2023]
Affiliation(s)
- Katherine R Schafer
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC.
| | - Lonika Sood
- Elson S. Floyd College of Medicine, Washington State University, Spokane
| | - Christopher J King
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | | | | | - Margot Cohen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Amit Pahwa
- Johns Hopkins University School of Medicine, Baltimore, Md
| | - E Shen
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Donna Williams
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
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Ambardekar AP, Furukawa L, Eriksen W, McNaull PP, Greeley WJ, Lockman JL. A Consensus-Driven Revision of the Accreditation Council for Graduate Medical Education Case Log System: Pediatric Anesthesiology Fellowship Education. Anesth Analg 2023; 136:446-454. [PMID: 35773224 DOI: 10.1213/ane.0000000000006129] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Clinical experiences, quantified by case logs, are an integral part of pediatric anesthesiology fellowship programs. Accreditation of pediatric anesthesiology fellowships by the Accreditation Council of Graduate Medical Education (ACGME) and establishment of case log reporting occurred in 1997 and 2009, respectively. The specialty has evolved since then, but the case log system remains largely unchanged. The Pediatric Anesthesiology Program Directors Association (PAPDA) embarked on the development of an evidence-based case log proposal through the efforts of a case log task force (CLTF). This proposal was part of a larger consensus-building process of the Society for Pediatric Anesthesia (SPA) Task Force for Pediatric Anesthesiology Graduate Medical Education. The primary aim of case log revision was to propose an evidence-based, consensus-driven update to the pediatric anesthesiology case log system. METHODS This study was executed in 2 phases. The CLTF, composed of 10 program directors representing diverse pediatric anesthesiology fellowship programs across the country, utilized evidence-based literature to develop proposed new categories. After an approval vote by PAPDA membership, this proposal was included in the nationally representative, stakeholder-based Delphi process executed by the SPA Task Force on Graduate Medical Education. Thirty-seven participants engaged in this Delphi process, during which iterative rounds of surveys were used to select elements of the old and newly proposed case logs to create a final revision of categories and minimums for updated case logs. The Delphi methodology was used, with a two-thirds agreement as the threshold for inclusion. RESULTS Participation in the Delphi process was robust, and consensus was almost completely achieved by round 2 of 3 survey rounds. Participants suggested that total case minimums should increase from 240 to 300 (300-370). Participants agreed (75.86%) that the current case logs targeted the right types of cases, but requirements were too low (82.75%). They also agreed (85.19%) that the case log system and minimums deserved an update, and that this should be used as part of a competency-based assessment in pediatric anesthesia fellowships (96%). Participants supported new categories and provided recommended minimum numbers. CONCLUSIONS The pediatric anesthesiology case log system continues to have a place in the assessment of fellowship programs, but it requires an update. This Delphi process established broad support for new categories and benchmarked minimums to ensure the robustness of fellowship programs and to better prepare the pediatric anesthesiology workforce of the future for independent clinical practice.
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Affiliation(s)
- Aditee P Ambardekar
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Louise Furukawa
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Whitney Eriksen
- Mixed Methods Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peggy P McNaull
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - William J Greeley
- Departments of Anesthesiology and Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Justin L Lockman
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennyslvania, Philadelphia, Pennsylvania
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Boyd C, Myers P, Gray MM, Johnston LC. Illuminating the path towards inclusivity: strategies to improve workforce diversity in neonatal-perinatal medicine. J Perinatol 2023; 43:415-416. [PMID: 36624305 DOI: 10.1038/s41372-023-01599-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 12/21/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Affiliation(s)
- Cameron Boyd
- Department of Pediatrics, Northwestern University School of Medicine, Chicago, IL, USA
| | - Patrick Myers
- Department of Pediatrics, Northwestern University School of Medicine, Chicago, IL, USA
| | - Megan M Gray
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Lindsay C Johnston
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA.
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Zubiaurre Bitzer LA, Dathatri S, Fine JB, Swan Sein A. Building a student learning-focused assessment and grading system in dental school: One school's experience. J Dent Educ 2023; 87:614-624. [PMID: 36607618 DOI: 10.1002/jdd.13158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/21/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE/OBJECTIVES As health professions education moves toward competency-based education, there has been increased focus on the structure of assessment systems that support student competency development and learning. This has been buoyed by a growing body of research supporting assessment for learning processes to promote student growth and learning rather than relying on assessment systems primarily to measure performance. This paper presents the rationale and evidence for moving to an assessment for learning system and the results of a quasi-experimental interrupted time series study using data from 2015 to 2022 to evaluate the impacts of these changes. METHODS Columbia University College of Dental Medicine faculty voted to implement assessment for learning system changes beginning in 2017 with the graduating class of 2021. These changes included moving from using a grading system for didactic courses with Honors, Pass, and Fail as available grades to a grading system with only Pass and Fail as available grades, as well as creating synthesis and assessment weeks, weekly problem sets, post-exam review sessions, exam remediation opportunities, and formative progress exams throughout the curriculum. The revised assessment and grading system changes were communicated to residency program directors, and programmatic competency data about student performance across the curriculum were shared with programs in Dean's Letters. RESULTS Once assessment system changes were implemented, it was found that student exam failure rates were lower, course exam scores were the same or higher, and performance on board exams improved compared to the national average. Students reported positive perceptions with regard to well-being and learning climate that they associated with the adoption of Pass/Fail grading. Match outcomes, including student satisfaction and program director ratings, have remained consistently positive. CONCLUSION As dental educators, our goal is to nurture students to become life-long learners. Adopting a grading structure that is Pass/Fail and an assessment system that fosters learning allows students to shape learning practices that favor long-term retention and application of information, also enhancing the learning environment and student well-being. These system changes may also facilitate the inclusion and support of students whose backgrounds are underrepresented in dentistry.
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Affiliation(s)
| | - Shubha Dathatri
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - James B Fine
- College of Dental Medicine, Columbia University, New York, New York, USA
| | - Aubrie Swan Sein
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
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Royce CS, Morgan HK, Baecher-Lind L, Cox S, Everett EN, Fleming A, Graziano SC, Sims SM, Morosky C, Sutton J, Sonn T. The time is now: addressing implicit bias in obstetrics and gynecology education. Am J Obstet Gynecol 2022; 228:369-381. [PMID: 36549568 DOI: 10.1016/j.ajog.2022.12.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/29/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
Obstetrician-gynecologists can improve the learning environment and patient care by addressing implicit bias. Accumulating evidence demonstrates that racial and gender-based discrimination is woven into medical education, formal curricula, patient-provider-trainee interactions in the clinical workspace, and all aspects of learner assessment. Implicit bias negatively affects learners in every space. Strategies to address implicit bias at the individual, interpersonal, institutional, and structural level to improve the well-being of learners and patients are needed. The authors review an approach to addressing implicit bias in obstetrics and gynecology education, which includes: (1) curricular design using an educational framework of antiracism and social justice theories, (2) bias awareness and management pedagogy throughout the curriculum, (3) elimination of stereotypical patient descriptions from syllabi and examination questions, and (4) critical review of epidemiology and evidence-based medicine for underlying assumptions based on discriminatory practices or structural racism that unintentionally reinforce stereotypes and bias. The movement toward competency-based medical education and holistic evaluations may result in decreased bias in learner assessment. Educators may wish to monitor grades and narratives for bias as a form of continuous educational equity improvement. Given that practicing physicians may have little training in this area, faculty development efforts in bias awareness and mitigation strategies may have significant impact on learner well-being.
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Affiliation(s)
- Celeste S Royce
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA.
| | - Helen Kang Morgan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Laura Baecher-Lind
- Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA
| | - Susan Cox
- Department of Medical Education, The University of Texas at Tyler School of Medicine, Tyler, TX
| | - Elise N Everett
- Department of Obstetrics, Gynecology and Reproductive Sciences, Robert Larner College of Medicine, The University of Vermont, Burlington, VT
| | - Angela Fleming
- Department of Obstetrics and Gynecology, Michigan State University College of Osteopathic Medicine, East Lansing, MI
| | - Scott C Graziano
- Department of Obstetrics and Gynecology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Shireen Madani Sims
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL
| | - Christopher Morosky
- Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington, CT
| | - Jill Sutton
- Department of Obstetrics and Gynecology, Brody School of Medicine, East Carolina University, Greenville, NC
| | - Tammy Sonn
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
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Mowchun JJ, Davila CH. How Am I Doing in Small Group? Student Perceptions of Feedback in Case-Based Learning Sessions. MEDICAL SCIENCE EDUCATOR 2022; 32:1487-1493. [PMID: 36532402 PMCID: PMC9755430 DOI: 10.1007/s40670-022-01677-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/28/2022] [Indexed: 06/17/2023]
Abstract
Introduction Small group case-based learning (CBL) facilitators are content experts that may provide feedback to students on cognitive reasoning skills and knowledge acquisition. However, student feedback-seeking behavior and response toward faculty feedback in CBL sessions are not known, and it is essential to maximize feedback in this setting where it can be a challenge to observe student performance while groups may have varied emphasis on individual versus team performance. We explored student perceptions of the effectiveness of faculty feedback processes during CBL sessions. Methods This qualitative study used semi-structured interviews with ten second year medical students enrolled in the Geisel School of Medicine preclinical neurology course. Investigator triangulation was used with interpretation comparisons that included independent content analysis. The constructed themes were discussed and final theme consensus was reached. Results Three major themes arose: (1) students value frequent feedback on their understanding of key clinical case concepts; (2) the CBL learning environment is not conducive to individual feedback; and (3) student feedback-seeking behavior and response are influenced by self-perceived level of preparedness for the sessions and overall comfort with the CBL facilitator and learning environment. Conclusions Students value content-based feedback from CBL sessions and need more individualized feedback. The style of the facilitator and overall learning environment can vary widely in the small group setting and has direct impact on feedback opportunities and student feedback-seeking behavior.
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Affiliation(s)
- Justin J. Mowchun
- Departments of Neurology and Medical Education, Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH USA
| | - Claire Hogue Davila
- Departments of Neurology and Medical Education, Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH USA
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Gingell G, Wilkerson L. Mitigating Bias in Clinical Assessment: A Mixed-Methods Analysis of Clerkship Grading Committees. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:S163. [PMID: 37838892 DOI: 10.1097/acm.0000000000004812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- Gareth Gingell
- Author affiliations: G. Gingell, L. Wilkerson, Dell Medical School at The University of Texas at Austin
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Arora VM, Carter K, Babcock C. Bias in Assessment Needs Urgent Attention-No Rest for the "Wicked". JAMA Netw Open 2022; 5:e2243143. [PMID: 36409501 DOI: 10.1001/jamanetworkopen.2022.43143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Vineet M Arora
- University of Chicago Pritzker School of Medicine, Biological Sciences Division, University of Chicago, Chicago, Illinois
| | - Keme Carter
- University of Chicago Pritzker School of Medicine, Biological Sciences Division, University of Chicago, Chicago, Illinois
- Section of Emergency Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Christine Babcock
- Section of Emergency Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
- Graduate Medical Education, University of Chicago Medicine, Chicago, Illinois
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Kukulski P, Schwartz A, Hirshfield LE, Ahn J, Carter K. Racial Bias on the Emergency Medicine Standardized Letter of Evaluation. J Grad Med Educ 2022; 14:542-548. [PMID: 36274765 PMCID: PMC9580305 DOI: 10.4300/jgme-d-21-01144.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/03/2022] [Accepted: 07/07/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Studies on components of residency applications have shown evidence of racial bias. The Standardized Letter of Evaluation (SLOE) is an assessment measure for emergency medicine (EM) residency applications and, as more specialties opt to use SLOEs in place of narrative letters of recommendation, understanding bias on standardized assessments is essential. OBJECTIVE To determine whether there is a difference in rankings on the EM SLOE between underrepresented in medicine (UIM) and non-UIM applicants, White and non-White applicants, and to examine whether differences persist after controlling for other characteristics. METHODS The sample was drawn from medical students who applied to EM residency at the study institution in 2019. We compared rankings between UIM and non-UIM students and between students of each individual race/ethnicity and White students, after controlling for United States Medical Licensing Examination Step scores, Alpha Omega Alpha status, type of school (US MD, US DO, internation medical graduate), Medical Student Performance Evaluation class percentile, affiliated program vs visiting clerkship SLOE, gender and the interaction of race/ethnicity and gender, and adjusted for students submitting multiple SLOEs, using ordinal regression. RESULTS There were 1555 applicants to the study institution in 2019; 1418 (91.2%) had a SLOE and self-identified race/ethnicity. After controlling for applicant characteristics, non-UIM students were significantly more likely to be ranked higher than UIM students on "Rank Against Peers," (OR 1.46, 95% CI 1.03-2.07) and Grade (OR 1.46, 95% CI 1.05-2.04). CONCLUSIONS Analysis of EM SLOEs submitted to our institution demonstrates racial bias on this standardized assessment tool, which persists after controlling for other performance predictors.
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Affiliation(s)
- Paul Kukulski
- Paul Kukulski, MD, MPHE, is Assistant Professor and Assistant Program Director, Section of Emergency Medicine, Department of Medicine, University of Chicago
| | - Alan Schwartz
- Alan Schwartz, PhD, is Professor and Interim Head, The Michael Reese Endowed Professor of Medical Education, Department of Medical Education, University of Illinois at Chicago
| | - Laura E. Hirshfield
- Laura E. Hirshfield, PhD, is The Dr. Georges Bordage Medical Education Faculty Scholar and Associate Professor of Medical Education and Sociology, Department of Medical Education, University of Illinois at Chicago
| | - James Ahn
- James Ahn, MD, MHPE, is Associate Professor and Program Director, Section of Emergency Medicine Department of Medicine, University of Chicago
| | - Keme Carter
- Keme Carter, MD, is Associate Professor, Associate Dean for Admissions, and Clerkship Director, Section of Emergency Medicine, Department of Medicine, University of Chicago
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Klein R, Ufere NN, Schaeffer S, Julian KA, Rao SR, Koch J, Volerman A, Snyder ED, Thompson V, Ganguli I, Burnett-Bowie SAM, Palamara K. Association Between Resident Race and Ethnicity and Clinical Performance Assessment Scores in Graduate Medical Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1351-1359. [PMID: 35583954 PMCID: PMC9910786 DOI: 10.1097/acm.0000000000004743] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
PURPOSE To assess the association between internal medicine (IM) residents' race/ethnicity and clinical performance assessments. METHOD The authors conducted a cross-sectional analysis of clinical performance assessment scores at 6 U.S. IM residency programs from 2016 to 2017. Residents underrepresented in medicine (URiM) were identified using self-reported race/ethnicity. Standardized scores were calculated for Accreditation Council for Graduate Medical Education core competencies. Cross-classified mixed-effects regression assessed the association between race/ethnicity and competency scores, adjusting for rotation time of year and setting; resident gender, postgraduate year, and IM In-Training Examination percentile rank; and faculty gender, rank, and specialty. RESULTS Data included 3,600 evaluations by 605 faculty of 703 residents, including 94 (13.4%) URiM residents. Resident race/ethnicity was associated with competency scores, with lower scores for URiM residents (difference in adjusted standardized scores between URiM and non-URiM residents, mean [standard error]) in medical knowledge (-0.123 [0.05], P = .021), systems-based practice (-0.179 [0.05], P = .005), practice-based learning and improvement (-0.112 [0.05], P = .032), professionalism (-0.116 [0.06], P = .036), and interpersonal and communication skills (-0.113 [0.06], P = .044). Translating this to a 1 to 5 scale in 0.5 increments, URiM resident ratings were 0.07 to 0.12 points lower than non-URiM resident ratings in these 5 competencies. The interaction with faculty gender was notable in professionalism (difference between URiM and non-URiM for men faculty -0.199 [0.06] vs women faculty -0.014 [0.07], P = .01) with men more than women faculty rating URiM residents lower than non-URiM residents. Using the 1 to 5 scale, men faculty rated URiM residents 0.13 points lower than non-URiM residents in professionalism. CONCLUSIONS Resident race/ethnicity was associated with assessment scores to the disadvantage of URiM residents. This may reflect bias in faculty assessment, effects of a noninclusive learning environment, or structural inequities in assessment.
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Affiliation(s)
- Robin Klein
- R. Klein is associate professor, Department of Medicine, Division of General Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nneka N Ufere
- N.N. Ufere is instructor of medicine, Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sarah Schaeffer
- S. Schaeffer is associate professor, Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California
| | - Katherine A Julian
- K.A. Julian is professor, Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, San Francisco, California
| | - Sowmya R Rao
- S.R. Rao is statistician, Department of Global Health, Boston University School of Public Health and Massachusetts General Hospital Biostatistics Center, Boston, Massachusetts
| | - Jennifer Koch
- J. Koch is professor, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Anna Volerman
- A. Volerman is associate professor, Departments of Medicine and Pediatrics, University of Chicago, Chicago, Illinois
| | - Erin D Snyder
- E.D. Snyder is professor, Department of Medicine, Division of General Internal Medicine, University of Alabama Birmingham School of Medicine, Birmingham, Alabama
| | - Vanessa Thompson
- V. Thompson is associate professor, Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, San Francisco, California
| | - Ishani Ganguli
- I. Ganguli is assistant professor, Department of Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sherri-Ann M Burnett-Bowie
- S.-A.M. Burnett-Bowie is assistant professor, Department of Medicine, Division of Endocrinology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kerri Palamara
- K. Palamara is associate professor, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Warm EJ, Carraccio C, Kelleher M, Kinnear B, Schumacher DJ, Santen S. The education passport: connecting programmatic assessment across learning and practice. CANADIAN MEDICAL EDUCATION JOURNAL 2022; 13:82-91. [PMID: 36091737 PMCID: PMC9441115 DOI: 10.36834/cmej.73871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Competency-based medical education (CBME) shifts us from static assessment of learning to developmental assessment for learning. However, implementation challenges associated with CBME remain a major hurdle, especially after training and into practice. The full benefit of developmental assessment for learning over time requires collaboration, cooperation, and trust among learners, regulators, and the public that transcends each individual phase. The authors introduce the concept of an "Education Passport" that provides evidence of readiness to travel across the boundaries between undergraduate medical education, graduate medical education, and the expanse of practice. The Education Passport uses programmatic assessment, a process of collecting numerous low stakes assessments from multiple sources over time, judging these data using criterion-referencing, and enhancing this with coaching and competency committees to understand, process, and accelerate growth without end. Information in the Passport is housed on a cloud-based server controlled by the student/physician over the course of training and practice. These data are mapped to various educational frameworks such Entrustable Professional Activities or milestones for ease of longitudinal performance tracking. At each stage of education and practice the student/physician grants Passport access to all entities that can provide data on performance. Database managers use learning analytics to connect and display information over time that are then used by the student/physician, their assigned or chosen coaches, and review committees to maintain or improve performance. Global information is also collected and analyzed to improve the entire system of learning and care. Developing a true continuum that embraces performance and growth will be a long-term adaptive challenge across many organizations and jurisdictions and will require coordination from regulatory and national agencies. An Education Passport could also serve as an organizing tool and will require research and high-value communication strategies to maximize public trust in the work.
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Affiliation(s)
- Eric J Warm
- Department of Internal Medicine, University of Cincinnati College of Medicine, Ohio, USA
- Correspondence to: Eric J. Warm,
| | | | - Matthew Kelleher
- Department of Internal Medicine, University of Cincinnati College of Medicine, Ohio, USA
| | - Benjamin Kinnear
- Department of Pediatrics, University of Cincinnati College of Medicine, Ohio, USA
| | - Daniel J Schumacher
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Ohio, USA
| | - Sally Santen
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Ohio, USA
- Virginia Commonwealth University, Ohio, USA
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Pincavage AT, Osman NY, Alexandraki I, Ismail NJ, Levine DL, Onumah CM, Lai CJ. AAIM Recommendations to Promote Equity in the Clerkship Clinical Learning Environment. Am J Med 2022; 135:1021-1028. [PMID: 35504324 DOI: 10.1016/j.amjmed.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 11/17/2022]
Affiliation(s)
| | - Nora Y Osman
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Irene Alexandraki
- Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso
| | - Nadia J Ismail
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Diane L Levine
- Department of Medicine, Wayne State University School of Medicine, Detroit, Mich
| | - Chavon M Onumah
- Department of Medicine, George Washington School of Medicine and Health Sciences, Washington, DC
| | - Cindy J Lai
- Department of Medicine, University of California, San Francisco, School of Medicine
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McClintock AH, Fainstad T. Growth, Engagement, and Belonging in the Clinical Learning Environment: the Role of Psychological Safety and the Work Ahead. J Gen Intern Med 2022; 37:2291-2296. [PMID: 35710656 PMCID: PMC9296742 DOI: 10.1007/s11606-022-07493-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 03/22/2022] [Indexed: 10/18/2022]
Abstract
Psychological safety is the perception that an environment is safe for interpersonal risk taking, exposing vulnerability, and contributing perspectives without fear of being shamed, blamed, or ignored. The presence of psychological safety has been associated with improved team learning and innovation, leader inclusivity, and team members' sense of belonging. In medical education, psychological safety has additional benefits: it allows learners to be present in the moment and to focus on the tasks at hand, and reduces trainee focus on image. Several key features of psychologically safe environments have already been described, including the presence of high-quality relationships, the absence of social positioning, a learner-driven and flexible learning agenda, the lack of formal assessment, and time for debriefing. However, many of the structures and cultural traditions in medical education are in clear opposition to these features. This paper describes the current barriers to psychological safety in medical education, and sets out an agenda for change. In accordance with benefits seen in other sectors, we anticipate that an emphasis on relationships and psychological safety will support the learning, inclusion, and success of medical trainees.
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Affiliation(s)
- Adelaide H McClintock
- Department of Medicine, Division of General Internal Medicine, University of Washington School of Medicine, 4245 Roosevelt Way NE, Box 354765, Seattle, WA, 98107, USA.
| | - Tyra Fainstad
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Wyatt TR, Rockich-Winston N, Crandall S, Wooten R, Gillette C. A comparison of professional identity experiences among minoritized medical professionals. J Natl Med Assoc 2022; 114:456-464. [PMID: 35728993 DOI: 10.1016/j.jnma.2022.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 05/24/2022] [Accepted: 05/30/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Professional identity formation (PIF) is considered a fundamental process in the development of healthcare providers. In medical education, the PIF literature has historically centered on medicine's socialization practices involving white male physicians. However, recently researchers have begun to reveal how larger socio-historical contexts influence PIF in minoritized physicians. To better understand what influences Black/African American physicians' PIF, this study compares their PIF experiences to a group of minoritized physician assistants (PAs). In comparing Black physicians' experiences to another provider, this study explored what PIF experiences may be attributed to participants' minoritized status and what might be attributed to the culture of medicine. METHODS In this cross-case analysis, 45 minoritized PA students and practicing PAs were recruited from several Southeastern universities. The PA participants included 23 Black/African Americans, 12 Latinx, 4 Indigenous/Native, and 6 of mixed races/ethnicities. Interview data were then compared to previously collected data from 41 Black/African American medical trainees and physicians. Using constant comparative method, similarities and differences in PIF were explored. RESULTS Similarities between the two groups included the importance of participants' racial/ethnic identity to patient care, experiences on-going microaggressions from patients and peers, and a desire to engage in racial uplift. However, one marked difference was found, namely that PAs felt they could bring their entire selves to the profession, whereas physicians described feeling splintered early in their training. CONCLUSIONS Several possibilities that might explain why Black physicians and minoritized PAs have this one marked difference in their PIF experience, including identity threat, internalization of different discourses, and length of training for physicians. While this study was not designed to answer this question, it is clear that there is something in the culture of medicine and the training of physicians that signals to Black physicians that they cannot bring their whole selves to the profession.
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Affiliation(s)
- T R Wyatt
- Uniformed Services University of the Health Sciences, Department of Medicine, Bethesda, Maryland, United States
| | - N Rockich-Winston
- Medical College of Georgia at Augusta University, Department of Pharmacology and Toxicology, 1120 15th Street, Augusta, Georgia 30912, United States.
| | - S Crandall
- Wake Forest School of Medicine, Department of PA Studies, Winston-Salem, NC, United States
| | - R Wooten
- Wake Forest School of Medicine, Department of PA Studies, Winston-Salem, NC, United States
| | - C Gillette
- Wake Forest School of Medicine, Department of PA Studies, Winston-Salem, NC, United States
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