Generational influences in academic emergency medicine: teaching and learning, mentoring, and technology (part I)

Applying simulation learning theory to identify instructional strategies for Generation Z emergency medicine residency education

Introduction

Generation Z learners are entering emergency medicine (EM) residency training, bringing unique learning preferences that influence their engagement with residency education. To optimally teach and motivate this incoming generation of learners, EM educators must understand and adapt to the changing instructional landscape.

Methodology

The Simulation Leaders Advancing the Next Generation in Emergency Medicine (SLANG-EM) Workgroup was created to identify effective educational strategies for Generation Z learners entering EM. Members were faculty in the Society for Academic Emergency Medicine (SAEM) Simulation Academy, well versed in learning theory supporting simulation-based education (SBE) and actively involved in EM residency education.

Unique treatment/analysis

Through primary and secondary literature searches, the SLANG-EM Workgroup identified four distinctive learning preferences of Generation Z learners: (1) individualized and self-paced learning, (2) engaging and visual learning environments, (3) immediate and actionable feedback, and (4) combined personal and academic support. Workgroup members evaluated these learning preferences using a novel conceptual framework informed by the theoretical principles underpinning SBE, recommending instructional strategies for Generation Z EM residency learners across multiple educational environments.

Implications for educators

Instructional strategies were described for the didactic, simulation, and clinical learning environments. In the didactic environment, identified instructional strategies included meaningful asynchronous education, interactive small-group learning, and improved multimedia design. In the simulation environment, educational innovations particularly suitable for Generation Z learners included learner-centered debriefing, rapid-cycle deliberate practice, and virtual simulation. In the clinical environment, described instructional strategies involved setting learner-centered goals and delivering facilitative feedback in the context of an educational alliance. Overall, these instructional strategies were clustered around themes of student-centered education and the educator as facilitator, which align well with Generation Z learning preferences. These findings were synthesized and presented as an advanced workshop, "Delivering Effective Education to the Next Generation," at the 2023 SAEM Annual Meeting.

Working in fours: generational communication in the emergency department

BACKGROUND

This study examined the conflicts between different generations working in US emergency departments (ED). We sought to record generational differences involving communication preferences, perceived areas of conflict, work motivations, and attitudes regarding work-life balance.

METHODS

We developed a survey to assess the physician perspective on generational conflict in the ED. The survey was distributed to members of the American College of Emergency Physicians, a professional organization comprising emergency medicine physicians in the USA.

RESULTS

We received 696 completed responses. Men represented 60% of respondents and the largest proportion of respondents were emergency physicians working in community settings (53%); 11% were residents. Generation representation was smallest for Traditionalist (2%) and largest for Gen X (43%). Seventy percent reported observing conflict due to generational communication with the largest frequency being once a week (26%). In the associated open-ended questions, 247 (33%) provided 316 anecdotal descriptions of observed conflict. Responses clustered into seven themes (ordered by frequency): Work Ethic, Treatment Approach, Technology Application, Entitlement, Professionalism, Work Life/Balance, and Communication Style. Comparing Work Ethic responses, 52-70-year-olds reported that younger providers are less interested in "accomplishing anything" while 26-34-year-olds resented that attitude. Respondents completing the open-ended questions regarding preventing and responding to conflict provided some insight into helpful strategies including actions supportive of clear communication and standardized policies and expectations. Only 5% of respondents reported that they had discussed generational communication in department meetings with the odds of a woman reporting conflict being less than males (p = .01).

CONCLUSION

Conflicts in the ED in the USA can be attributed to how an individual views the values of someone from another generation. Understanding the frequency and areas of generational conflict in the ED can help medical leaders find strategies to mitigate negative workplace interactions.

Physicians' professionalism from the patients' perspective: a qualitative study at a single-family practice in Saudi Arabia

INTRODUCTION

Professionalism is a crucial component of medical practice. It is a culturally sensitive notion that generally consists of behaviors, values, communication, and relationships. This study is a qualitative study exploring physician professionalism from the patients' perspective.

METHODS

Focus group discussions with patients attending a family medicine center attached to a tertiary care hospital were carried out using the four gates model of Arabian medical professionalism that is appropriate to Arab culture. Discussions with patients were recorded and transcribed. Data were thematically analyzed using NVivo software.

RESULTS

Three main themes emerged from the data. (1) In dealing with patients, participants expected respect but understood delays in seeing physicians due to their busy schedules. In communication, participants expected to be informed about their health conditions and to have their questions answered. (2) In dealing with tasks, participants expected proper examination and transparency of diagnosis, but some expected the physician to know everything and did not appreciate them seeking outside opinions. They expected to see the same physician at every visit. (3) In physician characteristics preferences, participants preferred friendly smiling physicians. Some cared about the outer appearance of the physician whereas others did not.

DISCUSSION/CONCLUSIONS

The findings of the study explained only two themes of the four gates model namely dealing with patients and dealing with tasks. Cultural competence and how to benefit from patients' perceptions to be an ideal physician should be incorporated into the process of physicians' training.

Training the New Generations of Orthopaedic Surgery Residents: Understanding Generational Differences to Maximize Educational Benefit

Most of the current orthopaedic residents are considered Millennials (born between 1981 and 1996) and are often trained by attending surgeons who are from Generation X (born between 1965 and 1980) or the Baby Boomer generation (born between 1946 and 1964). The Generation X orthopaedic surgeons were largely trained by Baby Boomers who were very demanding of their trainees and expected excellence. The Baby Boomers had been inspired, mentored, and trained by the Greatest Generation (born between 1901 and 1927). Baby Boomers took nothing for granted and nothing was given to them on a silver platter. Generation X was trained under these premises and was expected to abide by similar values. Regarding the next generation of residents, current faculty hope to instill the same qualities that had been instilled in them during their training. This value transference sometimes presents a challenge because of the differences in attitudes and perspectives that may exist between Millennial residents and their predecessors regarding work-life balance, teaching styles, the regulation of duty hours, and feedback assessments. These differences require an evolution in the methods of surgical education to optimize the educational benefit and ensure good will and rapport between the generations. Trainees and faculty alike have a responsibility to understand each other's differences and come together to ensure that knowledge, experience, values, and skill sets are effectively passed on to a new generation of orthopaedic surgeons.

It's the message not the medium: Ethics in pediatric surgery communication

New communication technologies and generational differences in communication techniques create ethical challenges for pediatric surgeons. Using two hypothetical cases we explore the ethics of modern communication in pediatric surgery. The first case explores the ethics of text messaging with patients and families and of social media posts, both of which have useful ethical analogues in older communication technologies. The second case explores ways that generational experiential differences in learning can foster misunderstandings between team members at different levels of training and potentially impact important medical care decisions. The ethical rules that govern the delivery of patient care also apply to what we say and how we say it. Effective, ethical and compassionate communication will often be the aspect of therapy most appreciated by the patient and family.

Mentorship in pediatric surgery: A need for structure?

INTRODUCTION

Mentorship in surgical training is critical but differs greatly from the early apprenticeship model and often spans generations. This study evaluates the current state of and desire for structured mentorship in pediatric surgical training from the perspective of program directors (PDs) and trainees.

METHODS

A survey addressing demographics, presence of or desire for structured mentorship, and proposed mentoring topics was emailed to pediatric surgery PDs (n = 58) and trainees completing fellowship in 2018-2020 (n = 72).

RESULTS

The response rate was 38.5%. 50% of trainees were female versus 15% of PDs (p = 0.02). 19% of trainees reported having a structured mentorship program versus 26% of PDs (p = 0.72). The majority, 83%, of trainees felt a structured mentorship program is warranted versus 40% of PDs (p = 0.002). There were differing opinions between trainees and PDs regarding important components of a mentoring program. Trainees felt the following were more important: transition to practice, job negotiation, CV review, financial planning and performance review. PDs felt the following were more important: quality improvement projects and work/life balance. Both agreed academic development and job search were important.

CONCLUSIONS

The majority of pediatric surgery trainees desire structured mentorship programs; however, few institutions have them. Training programs and program directors warrant a response to this gap.

LEVEL OF EVIDENCE

IV.

The protective mutation A673T in amyloid precursor protein gene decreases Aβ peptides production for 14 forms of Familial Alzheimer's Disease in SH-SY5Y cells

The deposition of Aβ plaques in the brain leads to the onset and development of Alzheimer’s disease. The Amyloid precursor protein (APP) is cleaved by α-secretase (non-amyloidogenic processing of APP), however increased cleavage by β-secretase (BACE1) leads to the accumulation of Aβ peptides, which forms plaques. APP mutations mapping to exons 16 and 17 favor plaque accumulation and cause Familial Alzheimer Disease (FAD). However, a variant of the APP gene (A673T) originally found in an Icelandic population reduces BACE1 cleavage by 40%. A series of plasmids containing the APP gene, each with one of 29 different FAD mutations mapping to exon 16 and exon 17 was created. These plasmids were then replicated with the addition of the A673T mutation. Combined these formed the library of plasmids that was used in this study. The plasmids were transfected in neuroblastomas to assess the effect of this mutation on Aβ peptide production. The production of Aβ peptides was decreased for some FAD mutations due to the presence of the co-dominant A673T mutation. The reduction of Aβ peptide concentrations for the London mutation (V717I) even reached the same level as for A673T control in SH-SY5Y cells. These preliminary results suggest that the insertion of A673T in APP genes containing FAD mutations might confer a clinical benefit in preventing or delaying the onset of some FADs.

Communication Strategies and Our Learners

Communication is vital in healthcare to facilitate the best patient care at all times. During the COVID-19 pandemic, communication has become increasingly crucial, including devising innovative, novel, and effective ways to exchange information in graduate medical education, multidisciplinary teams, and patient care, all which affect our learners. This article will provide a comprehensive review of generational characteristics, including communication preferences. Effective communication strategies and communication challenges with learners (millennial generation) will be discussed in detail.

Prevalence and Risk Factors for Burnout in Pediatric Emergency Medicine Fellows

Burnout among emergency medicine (EM) physicians (57%) is significantly greater than among pediatricians (39%). Pediatric EM (PEM) providers are a unique population in that the majority first complete a pediatric residency and then a fellowship in pediatric emergency medicine. We sought to evaluate the prevalence and risk factors for burnout in PEM fellows.

METHODS

An e-mail survey that included the Maslach Burnout Inventory (MBI) Health Services Survey was sent to fellows in PEM programs. Anonymous surveys were scored using the MBI subscales of emotional exhaustion and depersonalization. Fellows with scores of moderate to high in both emotional exhaustion and depersonalization were considered to have burnout. The data were compared with demographic information, including fellowship year, sex, and relationship status. Participants were also asked to list items in their life they felt were burnout contributors. The burnout rate was reported as a percentage with 95% confidence intervals (95% CI), based on the Agresti-Coull method. Associations between categorical variables and burnout were tested with Fisher exact test, alpha = 0.05 (2 tails).

RESULTS

Of 463 PEM fellows, 146 responses were received (30% response rate), and 139 surveys were scored. Over half (65%) of the respondents were female. The burnout prevalence of PEM fellows was 30.9% (95% CI, 24%-39%). The burnout rate was significantly (P = 0.002) lower for men (13%) (95% CI, 6%-26%) than for women (39.8%) (95% CI, 30%-50%). Fellows who were single (50%) or divorced (66.7%) had significantly (P = 0.008) higher rates of burnout compared with married (27%) fellows. Current training year was not a significant burnout risk. Major contributors to burnout were work environment (52.5%), academic responsibilities of fellowship (36%), schedule (35.3%), work-life balance (33.8%), and career / occupational stress (33.1%).

CONCLUSIONS

Pediatric emergency medicine fellows had a 30.9% prevalence of burnout. Risk factors for burnout were similar for PEM fellows and EM physicians. Women were more likely to suffer from burnout, as well as fellows who were single or divorced.

Teaching dermatology to the millennial learner

Millennial learners have educational needs and preferences that differ from those of prior generations. They prefer learning from online resources, appreciate interactive didactic sessions, and desire frequent feedback and guidance. Understanding and adapting to these learner attributes may allow for optimization of the educational environment for members of this generation. The following recommendations were developed to advance a dermatology residency program's curriculum to accommodate the modern learner. Although the efficacy of these teaching tips has yet to be fully established, they are grounded by theory and are evidence-informed. Medical educators who are able to employ these strategies are likely to be successful in teaching and engaging the millennial learner.

Stimulating Intrinsic Motivation in Millennial Students: A New Generation, a New Approach

There has been a fundamental change in health care pedagogy to address the demands and challenges posed by the present generation of millennial students. There is also a growing recognition of the role of intrinsic motivation as a catalyst in a positive learning experience. The term intrinsic motivation refers to energizing behavior that comes from within an individual and develops due to an inherent interest in the activity at hand. However, stimulating intrinsic motivation in the present generation of millennial health care students is a daunting task, considering their diverse and disparate nature. In addition, the inherent generational differences between educators and students, and an increasing emphasis on technological tools have resulted in a dichotomy in the educational environment leading to the development of a greater incidence of burnouts among students. Hence, numerous innovative techniques have been introduced in health care education to enhance the levels of intrinsic motivation in these students. Unfortunately, most of these approaches have only been moderately successful due to their limited ability to address the unique educational expectations of millennial students. The cumulative evidence suggests that specific approaches to stimulate intrinsic motivation should aim at nurturing the learning efforts of students, bridging the generational barriers between educators and students, and ameliorating the stress associated with health care education. Hence, the specific aim of this narrative review is to suggest empirically proven curricular strategies and institutional reforms to enhance intrinsic motivation in health care students belonging to the Millennial Generation.

Assembly Line Education: A Novel Educational Technique for Today's Learners

Background

Education is undergoing a transformation. The traditional passive lectures are failing to capture and inspire the new generation of learners who value more active and collaborative learning techniques.

Objective

We sought to create a novel educational technique to integrate into our curriculum that would be more personalized, employ more active learning and collaboration, and allow for an effective assessment of resident strengths and weaknesses.

Discussion

We created a monthly assembly line education academic half-day that evolved to replace one of the typical in-classroom didactics each month. Faculty run small-group simulation rooms, procedure workshops, competitive ultrasound, and wellness stations through which residents and medical students rotate.

Conclusion

This novel education technique resulted in a more personalized approach that increased resident interest, sparked the creation of a very popular MedEd-Simulation elective, and allowed the faculty to gain a better sense of resident strengths and deficiencies.

Continuing Professional Development: Reflections on a Lifelong Learning Process

In the ever-changing fields of health care, continuing professional development (CPD) and lifelong learning are essential for patient care, regulatory requirements, personal growth, and job satisfaction. However, no specific systems in approaching CPD have been delineated, and most health professionals are left to their own devices to manage it, on top of all their other professional responsibilities. This article (1) outlines the importance of CPD, (2) describes potential systematic approaches to CPD and potential ways to assess their effectiveness, and (3) reviews resources available to incorporate into a systematic approach.

Evaluation of generational influences among 4th year pharmacy students and experiential preceptors

INTRODUCTION

The purpose of this study was to evaluate the influence generational categories may have on commonalities among pharmacy students and their pharmacist preceptors during advanced pharmacy practice experiences (APPEs).

METHODS

Multiple-choice surveys aimed at evaluating generational characteristics were sent to pharmacy students and their preceptors during the first three APPEs. Questions focused on six key areas: preferred learning/teaching style, view of career/work, communication style, view of technology, life outlook, and personal characteristics. Each response corresponded to a generational category (Veteran, Baby Boomer, Generation X, Millennial). Students and preceptors were instructed to apply each question to themselves; students then applied each question to their preceptor, while preceptors applied the questions to students.

RESULTS

Twenty-six percent of students and 35% of preceptors completed at least one generational survey. Students selected the option that corresponded to their actual generational category significantly more often compared to preceptors (2.133 ± 0.815 vs. 1.632 ± 1.132, p = 0.007). Although none of the respondents belonged to the Veteran category, responses corresponding to this generation represented the second highest number of responses selected by students and preceptors alike.

CONCLUSIONS

Students and preceptors identified with characteristics outside their actual generational category. In addition, both groups selected options such as working to make a difference that may correlate more with people who have chosen pharmacy as a profession. Pharmacist awareness of generational similarities may lead to a more successful student-preceptor relationship.

Professional competence of nurses in emergency services: evidence of content validity

OBJECTIVE

To verify the evidence of content validity of the Identifying Issues (Identification questions) elaborated from the theoretical-logical model of the Matrix and the Profile of Professional Competence of the emergency nurse.

METHOD

Descriptive and methodological study of a quantitative approach with a psychometric reference as a precursor in the elaboration of a measurement instrument for the evaluation of competencies. The study was conducted in 2013 in Brazil, with a national sample of nurses specialized in emergency services and/or with professional competence in the area. Three stages were considered: questionnaire development; data collection with Delphi, appropriate statistics for Likert; and interpretative analysis of the comments/suggestions of the analyzed issues.

RESULTS

Delphi was used in four stages. There were minor adjustments to the content and inclusion of a new Competence. They obtained 90% of Score Percentage and 98.61 of Content Validity Index.

CONCLUSION

There was consensus among the experts and the research demonstrated evidence of content validity, suggesting pertinence and adequacy to represent the constructs of competencies.

Instructors for on-the-job training of advanced paramedics - definition of competencies and development of a quality management tool for a "High Responsibility Organization"

Objective: The psychological demands placed upon the emergency medical services, assures them of their place amongst High Responsibility Organizations. A high pressure to act and an irreversibility of situations are integral features of their workplaces. After the emergency services' job profiles were restructured in Germany, the practical stage of paramedic training is now undertaken in these conditions. That is, they are trained by a supervising instructor whilst caring for critically ill patients. This paper aims to describe the requisite skills for such an instructor, formulate the associated competences as learning objectives, and develop a quality-measuring instrument for the description of training situations. Methods: The compilation of a competence catalogue was done via a two-step process: following a Delphi survey with an expert panel of practical trainers and trainees, a large cohort of parameters were validated in terms of their relevance. Those factors that formed scales together were identified. Results: After validating the results of the Delphi analysis, six scales (composed of 25 items in toto) were defined. They included the areas of "Training during times of action", "Training during periods of calm", "Background and practical relevance", "Character and personality traits", "Pedagogical competencies" and "Organizational behaviour". Conclusion: For the first time, a competency catalogue has been developed for instructors working in the emergency medical services from German-speaking countries. The catalogue focuses upon clinical training during the acute care of critically ill patients. The scales and items can be used for training-the-trainers, and also quality monitoring. Further research needs to focus on the application of the catalogue in clinical practice and evaluate the need for situational customization.

Patient's Privacy Violation on Social Media in the Surgical Area

In the new era of mobile technologies and social media, patient's privacy is at risk. Surgical patients have high visual appeal and may be vulnerable because a significant proportion of cases consist of emergency and trauma, in which patients are frequently unconscious. This study aims to identify the most vulnerable health providers to share patient's confidential data on social media in the surgical environment and their awareness of the confidentiality rules and laws. We surveyed medical graduates, surgical residents, and attending surgeons from a quaternary university hospital. Demographic data, usage and frequency of mobile apparatus, social media access, patient's data dissemination, and knowledge of laws and rules governing patient's privacy were recorded. One hundred fifty-six individuals (52 graduates, 51 residents, and 53 attending surgeons; mean age 24, 28, and 59 years, respectively) participated in the study. Patient's information was shared on social media by 53 per cent of the graduates, 86 per cent of the residents, and 32 per cent of the attending surgeons ( P < 0.05). Confidentiality preservation policies were unknown to 69 per cent of graduates, 80 per cent of residents, and 62 per cent of attending surgeons ( P = 0.124). Awareness of protocols to guide health-care professionals about safer use of social media was 0 per cent for graduates, 15 per cent for residents, and 22 per cent for attending surgeons ( P = 0.002). Residents were the most vulnerable to share patient's information on social media compared with graduates and attending surgeons. Health institutions should promote continuing education in medical ethics, focussing on residents.

Telepsychiatry and other technologies for integrated care: evidence base, best practice models and competencies

Telehealth facilitates integrated, patient-centred care. Synchronous video, telepsychiatry (TP), or telebehavioural health provide outcomes as good as in-person care. It also improves access to care, leverages expertise at a distance, and is effective for education and consultation to primary care. Other technologies on an e-behavioural health spectrum are also useful, like telephone, e-mail, text, and e-consults. This paper briefly organizes these technologies into low, mid and high intensity telehealth models and reviews the evidence base for interventions to primary care, and, specifically, for TP and integrated care (IC). Technology, mobile health, and IC competencies facilitate quality care. TP is a high intensity model and it is the best-studied option. Studies of IC are preliminary, but those with collaborative and consultative care show effectiveness. Low- and mid-intensity technology options like telephone, e-mail, text, and e-consults, may provide better access for patients and more timely provider communication and education. They are also probably more cost-effective and versatile for health system workflow. Research is needed upon all technology models related to IC for adult and paediatric primary care populations. Effective healthcare delivery matches the patients' needs with the model, emphasizes clinician competencies, standardizes interventions, and evaluates outcomes.

Physician professionalism: definition from a generation perspective

OBJECTIVES

The primary objective of this study was to determine whether consensuses on the definition of emergency physician professionalism exist within and among four different generations. Our secondary objective was to describe the most important characteristic related to emergency physician professionalism that each generation values.

METHODS

We performed a cross-sectional survey study, using a card-sorting technique, at the emergency departments of two university-based medical centers in the United States. The study was conducted with 288 participants from February to November 2017. Participants included adult emergency department patients, emergency medicine supervising physicians, emergency medicine residents, emergency department nurses, and fourth- and second-year medical students who independently ranked 39 cards that represent qualities related to emergency physician professionalism. We used descriptive statistics, quantitative cultural consensuses and Spearman's correlation coefficients to analyze the data.

RESULTS

We found cultural consensuses on emergency physician professionalism in Millennials and Generation X overall, with respect for patients named the most important quality (eigenratio 5.94, negative competency 0%; eigenratio 3.87, negative competency 1.64%, respectively). There were consensuses on emergency physician professionalism in healthcare providers throughout all generations, but no consensuses were found across generations in the patient groups.

CONCLUSIONS

While younger generations and healthcare providers had consensuses on emergency physician professionalism, we found that patients had no consensuses on this matter. Medical professionalism curricula should be designed with an understanding of each generation's values concerning professionalism. Future studies using qualitative methods across specialties, to assess definitions of medical professionalism in each generation, should be pursued.

Career Preferences and Perceptions of Cardiology Among US Internal Medicine Trainees: Factors Influencing Cardiology Career Choice

Importance

Few data exist on internal medicine trainees' selection of cardiology training, although this is important for meeting future cardiology workforce needs.

Objective

To discover trainees' professional development preferences and perceptions of cardiology, and their relationship to trainees' career choice.

Design, Setting, and Participants

We surveyed trainees to discover their professional development preferences and perceptions of cardiology and the influence of those perceptions and preferences on the trainees' career choices. Participants rated 38 professional development needs and 19 perceptions of cardiology. Data collection took place from February 2009, through January 2010. Data analysis was conducted from May 2017 to December 2017.

Main Outcomes and Measures

Multivariable models were used to determine the association of demographics and survey responses with prospective career choice.

Results

A total of 4850 trainees were contacted, and 1123 trainees (of whom 625 [55.7%] were men) in 198 residency programs completed surveys (23.1% response; mean [SD] age, 29.4 [3.5] years). Principal component analysis of survey responses resulted in 8-factor and 6-factor models. Professional development preferences in descending order of significance were stable hours, family friendliness, female friendliness, the availability of positive role models, financial benefits, professional challenges, patient focus, and the opportunity to have a stimulating career. The top perceptions of cardiology in descending order of significance were adverse job conditions, interference with family life, and a lack of diversity. Women and future noncardiologists valued work-life balance more highly and had more negative perceptions of cardiology than men or future cardiologists, who emphasized the professional advantages available in cardiology. Professional development factors and cardiology perceptions were strongly associated with a decision to pursue or avoid a career in cardiology in both men and women.

Conclusions and Relevance

Alignment of cardiology culture with trainees' preferences and perceptions may assist efforts to ensure the continued attractiveness of cardiology careers and increase the diversity of the cardiology workforce.

Scholarship by the Clinician-Educator in Emergency Medicine

Emergency medicine (EM) continues to grow as an academic specialty. Like most specialties, a large number of academic emergency physicians are focused on education of our graduate student learners. For promotion, clinician-educators (CEs) are required to produce scholarly work and disseminate knowledge. Although promotion requirements may vary by institution, scholarly work is a consistent requirement. Due to the clinical constraints of working in the emergency department, the unique interactions emergency physicians have with their learners, and early adoption of alternative teaching methods, EM CEs' scholarly work may not be adequately described in a traditional curriculum vitae. Using a rubric of established domains around the academic work of CEs, this article describes some of the ways EM educators address these domains. The aim of the article is to provide a guide for academic department leadership, CEs, and promotion committees about the unique ways EM has addressed the work of the CE.

Lifelong Learning for Clinical Practice: How to Leverage Technology for Telebehavioral Health Care and Digital Continuing Medical Education

PURPOSE OF REVIEW

Psychiatric practice continues to evolve and play an important role in patients' lives, the field of medicine, and health care delivery. Clinicians must learn a variety of clinical care systems and lifelong learning (LLL) is crucial to apply knowledge, develop skills, and adjust attitudes. Technology is rapidly becoming a key player-in delivery, lifelong learning, and education/training.

RECENT FINDINGS

The evidence base for telepsychiatry/telemental health via videoconferencing has been growing for three decades, but a greater array of technologies have emerged in the last decade (e.g., social media/networking, text, apps). Clinicians are combining telepsychiatry and these technologies frequently and they need to reflect on, learn more about, and develop skills for these technologies. The digital age has solidified the role of technology in continuing medical education and day-to-day practice. Other fields of medicine are also adapting to the digital age, as are graduate and undergraduate medical education and many allied mental health organizations. In the future, there will be more online training, simulation, and/or interactive electronic examinations, perhaps on a monthly cycle rather than a quasi-annual or 10-year cycle of recertification.

To the point: medical education, technology, and the millennial learner

This article, from the "To The Point" series that was prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, provides an overview of the characteristics of millennials and describes how medical educators can customize and reframe their curricula and teaching methods to maximize millennial learning. A literature search was performed to identify articles on generational learning. We summarize the importance of understanding the attitudes, ideas, and priorities of millennials to tailor educational methods to stimulate and enhance learning. Where relevant, a special focus on the obstetrics and gynecology curriculum is highlighted.

Heutagogy through Facebook for the Millennial learners

This article was migrated. The article was marked as recommended. Millennials are the most prevalent generation of medical learners today. These individuals have a unique outlook on education and have different preferences and expectations than their predecessors. The majority of our learners belong to the Millennial Generation, while most faculty belongs to the Baby Boomer or Generation X cohorts. Millennial learners have distinct perspectives on their learning needs that differ with their faculty's perspectives on teaching and learning. These learning differences may contribute to intergenerational conflict. In order to be successful teachers, it is important to educate ourselves on these generational differences and cater to the needs of the learners. Heutagogy is a self-determined approach of learning, which appears to suit the millennial learners. Derived from the word " Heureskein" which means to discover, the term heutagogy was coined to describe self-learning, independent of formal teaching. This adds yet another learning theory to the established fields of pedagogy (child learning) and andragogy (adult learning). Heutagogy acknowledges that learner do immensely valuable work for themselves by filling in the gaps of their formal education through discovery and reflection. Heutagogy offers models of learning that are (1) self-determined, (2) peer-led, and (3) non-linear. These characteristics map onto social media applications and the democratization of knowledge and information. Heutagogical approach is an extension of the traditional andragogical and adult learning frameworks through its emphasis on meta learning, or learning how to learn. This article presents the paradigm shift of educational strategies from pedagogy to andragogy to heutagogy and focuses on the ground principles governing heutagogy. It also describes an innovative case study where principles of heutagogy were applied to train dental students using Facebook.

Congratulations, You're Pregnant! Now About Your Shifts . . . : The State of Maternity Leave Attitudes and Culture in EM

INTRODUCTION

Increasing attention has been focused on parental leave, but little is known about early leave and parental experiences for male and female attending physicians. Our goal was to describe and quantify the parental leave experiences of a nationally representative sample of emergency physicians (EP).

METHODS

We conducted a web-based survey, distributed via emergency medicine professional organizations, discussion boards, and listservs, to address study objectives.

RESULTS

We analyzed data from 464 respondents; 56% were women. Most experienced childbirth while employed as an EP. Fifty-three percent of women and 60% of men reported working in a setting with a formal maternity leave policy; however, 36% of women and 18% of men reported dissatisfaction with these policies. Most reported that other group members cover maternity-related shift vacancies; a minority reported that pregnant partners work extra shifts prior to leave. Leave duration and compensation varied widely, ranging from no compensated leave (18%) to 12 or more weeks at 100% salary (7%). Supportive attitudes were reported during pregnancy (53%) and, to a lesser degree (43%), during leave. Policy improvement suggestions included the development of clear, formal policies; improving leave duration and compensation; adding paternity and adoption leave; providing support for physicians working extra to cover colleagues' leave; and addressing breastfeeding issues.

CONCLUSION

In this national sample of EPs, maternity leave policies varied widely. The duration and compensation during leave also had significant variation. Participants suggested formalizing policies, increasing leave duration and compensation, adding paternity leave, and changing the coverage for vacancies to relieve burden on physician colleagues.

Age Differences and the Acceptance of Infusion Pump Technology

Previous studies demonstrate that age and receptiveness to new technologies tend to be negatively correlated. Using data from a sample of 311 nurses in a large teaching hospital in the midwestern United States, this study sought to determine whether age predicted satisfaction perceptions of infusion pump technology. Hierarchical regression indicated that the relationship between age and infusion pump satisfaction was not statistically significant, but it also revealed interesting moderation effects. When perceived support for infusion pump use was low, age was negatively related to infusion pump satisfaction. However, when perceived support was high, age was positively related to infusion pump satisfaction.

Anticipated Changes in Spine Practice with Advancing Center for Medicare and Medicaid Services-Required Changes

In providing spinal care to neurosurgical patients, cost and quality metrics are areas of interest to many. The federal government has legislated changes mandated for Centers for Medicare and Medicaid Services-enrolled patient care. The ever-changing administrative and patient-care challenges and opportunities are explored in this article, highlighting the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act of 2015 (MACRA), in the context of the Affordable Care Act. Trends in contemporary spinal care, addressing bundling, patient satisfaction, and ambulatory surgical centers are featured.

How to communicate effectively in graduate advising

This paper completes a two-part series on graduate advising that integrates concepts from adult learning, leadership, and psychology into a conceptual framework for graduate advising. The companion paper discussed how to establish a learning-centered working relationship where advisor and graduate student collaborate in different roles to develop the student’s competence and confidence in all aspects of becoming a scientist. To put these ideas into practice, an advisor and a student need to communicate effectively. Here, we focus on the dynamics of day-to-day interactions and discuss (1) how to provide feedback that builds students’ competence and confidence, (2) how to choose the way we communicate and avoid a mismatch between verbal and nonverbal communication, and (3) how to prevent and resolve conflict. Miscommunication may happen out of a lack of understanding of the psychological aspects of human interactions. Therefore, we draw on concepts from Educational Transactional Analysis to provide advisors and students with an understanding of the psychological aspects of graduate advising as a basis for effective communication. Case studies illustrate the relevance of the concepts presented, and four worksheets ( Supplementary Material ) support their practical implementation.

Identifying and Addressing Problems for Student Progression in Midwifery Clinical Education

Identifying challenges to progression for a health care profession student who is not meeting expectations in a busy clinical practice can be challenging yet can lead to assisting the student toward success. Preceptor preparation includes acquiring knowledge about the student's education program, understanding federal regulations designed to protect students, gathering background information about a student, learning to provide feedback, structuring the clinical experience, and completing student evaluations. Students in health care professions may have difficulties with cognitive, affective, or psychomotor learning, and the clinical preceptor can identify problems for student progression within these learning domains. Subsequently, specific solutions that are tailored to the individual student's needs can be developed, implemented, and evaluated. A structured evaluation of the student's performance by the clinical preceptor, in accordance with the education program's parameters, is essential. Through a structured process, preceptors can assist many students to achieve success, in spite of challenges. This article describes how the preceptor can prepare, identify the type(s) of problem(s), and develop learning solutions for students who are experiencing difficulties in clinical settings.

Rapid Low-Cost Virtual Human Bootstrapping via the Crowd

Virtual human interactions provide an important avenue for training as emergent opportunities arise. In response to a new training need, we propose a framework to rapidly create experiential learning opportunities in the form of a question--answer chat interaction with virtual humans. This framework takes quickly generated case documents and breaks down the case into small tasks that can be crowdsourced by nonexperts. This framework can serve as a first step to rapidly bootstrapping new virtual humans. We have applied our framework to the task of preparing health care students and professionals to infrequent, but high-stakes, situations such as infectious diseases, cranial nerve disorders, and stroke.

Our framework was utilized by medical professionals interested in providing new training experiences to students and colleagues. Over the course of two months, these professionals created seven scenarios on a diverse range of topics that included Ebola, cancer, and neurological disorders. These scenarios were developed for multiple target audiences such as medical students, residents, and fellows. As a first step, each scenario utilized our framework and crowdsourced workers to create an initial corpus over the course of two days.

From these seven cases, we selected two to evaluate the quality of the resulting virtual-human corpuses. The two scenarios were compared to preexisting reference scenarios that have been in curricular use for several years. We found a reduction in author time commitment of at least 92% while creating a character that was at least 75% as accurate as its reference counterparts. The commitment reduction and accuracy achieved by our framework represents a first step towards rapid development of a virtual human. Our framework can then be combined with other creation processes for further virtual-human development in order to create a mature virtual human. As part of a virtual-human development process, our framework can help to rapidly develop new scenarios in response to emergent training opportunities.

Speaking the same language: Cross-sectional assessment of perceived contributors to professionalism across generations

BACKGROUND

Professionalism is integral to medical training and practice. Recent studies suggest generational differences in perceptions of professionalism, which have not been adequately explored in academic neurology.

METHODS

A cross-sectional study was performed to describe perceptions of professionalism among representative physicians across the academic training spectrum of neurology. A self-report questionnaire adapted from a published instrument was distributed to students, residents, fellows, and faculty in neurology at a single institution. Responders rated 4 domains of professionalism: Personal Characteristics, Interactions with Patients, Social Responsibility, and Interactions with the Health Care Team (5-point Likert scale, not at all important to very important), and selected the "top 2" characteristics critical to professional behavior in each domain.

RESULTS

A total of 296 of 312 (95%) responded, including 228 students, 24 residents, 19 fellows, and 25 faculty. Respondents ranked the following components to be important/very important contributors to the expression of professional behavior: Personal Characteristics (98%, mean rating 4.6 ± 0.3), Interactions with Patients (97%, 4.6 ± 0.4), and Interactions with the Health Care Team (96%, 4.6 ± 0.5). Although mean ratings were high for Social Responsibility (4.3 ± 0.6), only 82% indicated that this was important/very important in the expression of professionalism, with a gradual decline from students (4.4 ± 0.6) to residents (3.99 ± 0.8, p = 0.02). The "top 2" contributors to each domain were similar across responders.

CONCLUSIONS

Professionalism was perceived as critically important across the academic training spectrum in neurology, and the view regarding the top contributors to the expression of professionalism remained consistent among the respondents.

Improved participants' understanding in a healthy volunteer study using the SIDCER informed consent form: a randomized-controlled study

Purpose

This study aimed to evaluate the applicability of the principles and informed consent form (ICF) template proposed by the Strategic Initiative for Developing Capacity in Ethical Review (SIDCER) in a clinical pharmacokinetic study by comparing the volunteers’ understanding of the enhanced ICF (developed based on the SIDCER methodology) and the conventional ICF (which was previously approved by local Ethics Committee and used in the clinical study).

Methods

A total of 550 volunteers were randomly assigned to read either the enhanced ICF or the conventional ICF (1:1) in a mock informed consent approach and subsequently performed the post-test questionnaire. The primary endpoint was the proportion of the participants who had the post-test score of ≥80 %; the secondary endpoints were the total score of the post-test, the score of the categorized ICF elements, and time spent for participation.

Results

The proportion of the participants in the enhanced ICF group who achieved the primary endpoint was significantly higher than the conventional ICF group (82.2 % vs. 60.4 %, p < 0.001). The participants in the enhanced ICF group obtained higher scores and spent less time in reading the given ICF and answering the post-test than those in the conventional ICF group (total score 19/21 vs. 18/21, p < 0.001; time spent 20 min vs. 25 min, p < 0.001).

Conclusion

The enhanced ICF improved the understanding of the participants in this study. This demonstrates the applicability of the SIDCER ICF principles and its template in the development of an enhanced ICF for improving the quality of ICFs and subjects’ understanding in clinical research.

Trial registration: TCTR20140727001

A Comparative Analysis of Diagnostic Accuracy of Focused Assessment With Sonography for Trauma Performed by Emergency Medicine and Radiology Residents

BACKGROUND

Focused assessment with sonography in trauma (FAST) is a method for prompt detection of the abdominal free fluid in patients with abdominal trauma.

OBJECTIVES

This study was conducted to compare the diagnostic accuracy of FAST performed by emergency medicine residents (EMR) and radiology residents (RRs) in detecting peritoneal free fluids.

PATIENTS AND METHODS

Patients triaged in the emergency department with blunt abdominal trauma, high energy trauma, and multiple traumas underwent a FAST examination by EMRs and RRs with the same techniques to obtain the standard views. Ultrasound findings for free fluid in peritoneal cavity for each patient (positive/negative) were compared with the results of computed tomography, operative exploration, or observation as the final outcome.

RESULTS

A total of 138 patients were included in the final analysis. Good diagnostic agreement was noted between the results of FAST scans performed by EMRs and RRs (κ = 0.701, P < 0.001), also between the results of EMRs-performed FAST and the final outcome (κ = 0.830, P < 0.0010), and finally between the results of RRs-performed FAST and final outcome (κ = 0.795, P < 0.001). No significant differences were noted between EMRs- and RRs-performed FASTs regarding sensitivity (84.6% vs 84.6%), specificity (98.4% vs 97.6%), positive predictive value (84.6% vs 84.6%), and negative predictive value (98.4% vs 98.4%).

CONCLUSIONS

Trained EMRs like their fellow RRs have the ability to perform FAST scan with high diagnostic value in patients with blunt abdominal trauma.

The Use of Simulation to Teach Suicide Risk Assessment to Health Profession Trainees-Rationale, Methodology, and a Proof of Concept Demonstration with a Virtual Patient

OBJECTIVE

There is increasing use of educational technologies in medical and surgical specialties. Described herein is the development and application of an interactive virtual patient (VP) to teach suicide risk assessment to health profession trainees. We studied the effect of the following: (1) an interaction with a bipolar VP who attempts suicide or (2) completion of a video-teaching module on interviewing a bipolar patient, on medical students' proficiency in assessing suicide risk in standardized patients. We hypothesized that students who interact with a bipolar VP will be at least as likely to assess suicide risk, as their peers who completed a video module.

METHODS

In a randomized, controlled study, we compared the frequency with which second-year students at the Medical College of Georgia asked suicide risk and bipolar symptoms questions by VP/video group.

RESULTS

We recruited 67 students. The VP group inquired more frequently than the video group in 4 of 5 suicide risk areas and 11 of 14 other bipolar symptomatology areas. There were minimal to small effect sizes in favor of the VP technology. The students preferred the video over the VP as an educational tool (p = 0.007).

CONCLUSIONS

Our study provides proof of concept that both VP and video module approaches are feasible for teaching students to assess suicide risk, and we present evidence about the role of active learning to improve communication skills. Depending on the learning context, interviewing a VP or observation of a videotaped interview can enhance the students' suicide risk assessment proficiency in an interview with a standardized patient. An interactive VP is a plausible modality to deliver basic concepts of suicide risk assessment to medical students, can facilitate individual preferences by providing easy access and portability, and has potential generalizability to other aspects of psychiatric training.

Innovative strategies in critical care education

The cadre of information pertinent to critical care medicine continues to expand at a tremendous pace, and we must adapt our strategies of medical education to keep up with the expansion. Differences in learners' characteristics can contribute to a mismatch with historical teaching strategies. Simulation is increasingly popular, but still far from universal. Emerging technology has the potential to improve our knowledge translation, but there is currently sparse literature describing these resources or their benefits and limitations. Directed strategies of assessment and feedback are often suboptimal. Even strategies of accreditation are evolving. This review attempts to summarize salient concepts, suggest resources, and highlight novel strategies to enhance practice and education in the challenging critical care environment.

Gamification as a tool for enhancing graduate medical education

Introduction

The last decade has seen many changes in graduate medical education training in the USA, most notably the implementation of duty hour standards for residents by the Accreditation Council of Graduate Medical Education. As educators are left to balance more limited time available between patient care and resident education, new methods to augment traditional graduate medical education are needed.

Objectives

To assess acceptance and use of a novel gamification-based medical knowledge software among internal medicine residents and to determine retention of information presented to participants by this medical knowledge software.

Methods

We designed and developed software using principles of gamification to deliver a web-based medical knowledge competition among internal medicine residents at the University of Alabama (UA) at Birmingham and UA at Huntsville in 2012–2013. Residents participated individually and in teams. Participants accessed daily questions and tracked their online leaderboard competition scores through any internet-enabled device. We completed focus groups to assess participant acceptance and analysed software use, retention of knowledge and factors associated with loss of participants (attrition).

Results

Acceptance: In focus groups, residents (n=17) reported leaderboards were the most important motivator of participation. Use: 16 427 questions were completed: 28.8% on Saturdays/Sundays, 53.1% between 17:00 and 08:00. Retention of knowledge: 1046 paired responses (for repeated questions) were collected. Correct responses increased by 11.9% (p<0.0001) on retest. Differences per time since question introduction, trainee level and style of play were observed. Attrition: In ordinal regression analyses, completing more questions (0.80 per 10% increase; 0.70 to 0.93) decreased, while postgraduate year 3 class (4.25; 1.44 to 12.55) and non-daily play (4.51; 1.50 to 13.58) increased odds of attrition.

Conclusions

Our software-enabled, gamification-based educational intervention was well accepted among our millennial learners. Coupling software with gamification and analysis of trainee use and engagement data can be used to develop strategies to augment learning in time-constrained educational settings.

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

Changes in the clinical learning environment under resident duty hours restrictions have introduced a number of challenges on today's wards. Additionally, the current group of medical trainees is largely represented by the Millennial Generation, a generation characterized by an affinity for technology, interaction, and group-based learning. Special attention must be paid to take into account the learning needs of a generation that has only ever known life with duty hours. A mnemonic for strategies to augment teaching rounds for hospitalists was created using an approach that considers time limitations due to duty hours as well as the preferences of Millennial learners. These strategies to enhance learning during teaching rounds are Flipping the Wards, Using Documentation to Teach, Technology-Enabled Teaching, Using Guerilla Teaching Tactics, Rainy Day Teaching, and Embedding Teaching Moments into Rounds (FUTURE). Hospitalists serving as teaching attendings should consider these possible strategies as ways to enhance teaching in the post-duty hours era. These techniques appeal to the preferences of today's learners in an environment often limited by time constraints. Hospitalists are well positioned to champion innovative approaches to teaching in a dynamic and evolving clinical learning environment.