Formal Versus Informal Judgments: Faculty Experiences With Entrustment in Graduate Medical Education

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.

Longitudinal Assessment of Resident Performance Using Entrustable Professional Activities

IMPORTANCE

Entrustable professional activities (EPAs) are an emerging workplace-based, patient-oriented assessment approach with limited empirical evidence.

OBJECTIVE

To measure the development of pediatric trainees' clinical skills over time using EPA-based assessment data.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of categorical pediatric residents over 3 academic years (2015-2016, 2016-2017, and 2017-2018) assessed on 17 American Board of Pediatrics EPAs. Residents in training at 23 pediatric residency programs in the Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network were included. Assessment was conducted by clinical competency committee members, who made summative assessment decisions regarding levels of supervision required for each resident and each EPA. Data were collected from May 2016 to November 2018 and analyzed from November to December 2018.

INTERVENTIONS

Longitudinal, prospective assessment using EPAs.

MAIN OUTCOMES AND MEASURES

Trajectories of supervision levels by EPA during residency training and how often graduating residents were deemed ready for unsupervised practice in each EPA.

RESULTS

Across the 5 data collection cycles, 1987 residents from all 3 postgraduate years in 23 residency programs were assigned 25 503 supervision level reports for the 17 general pediatrics EPAs. The 4 EPAs that required the most supervision across training were EPA 14 (quality improvement) on the 5-level scale (estimated mean level at graduation, 3.7; 95% CI, 3.6-3.7) and EPAs 8 (transition to adult care; mean, 7.0; 95% CI, 7.0-7.1), 9 (behavioral and mental health; mean, 6.6; 95% CI, 6.5-6.6), and 10 (resuscitate and stabilize; mean, 6.9; 95% CI, 6.8-7.0) on the expanded 5-level scale. At the time of graduation (36 months), the percentage of trainees who were rated at a supervision level corresponding to "unsupervised practice" varied by EPA from 53% to 98%. If performance standards were set to align with 90% of trainees achieving the level of unsupervised practice, this standard would be met for only 8 of the 17 EPAs (although 89% met this standard for EPA 17, performing the common procedures of the general pediatrician).

CONCLUSIONS AND RELEVANCE

This study presents initial evidence for empirically derived practice readiness and sets the stage for identifying curricular gaps that contribute to discrepancy between observed practice readiness and standards needed to produce physicians able to meet the health needs of the patient populations they serve. Future work should compare these findings with postgraduation outcomes data as a means of seeking validity evidence.

Learning and professional acculturation through work: Examining the clinical learning environment through the sociocultural lens

Purpose: We examined studies of the clinical learning environment from the fields of sociology and organizational culture to (i) offer insight into how workplace culture has informed research on postgraduate trainee learning and professional development; (ii) highlight limitations of the literature; and (iii) suggest practical ways to apply sociocultural concepts to challenges in the learning environment. Materials and methods: Concepts were explored by participants at a consensus conference in October 2018. Results: We identified three enduring foci for research using a sociocultural lens: the hidden curriculum, exploration of medical errors, and the impact of time pressures on the relational nature of clinical education. Limitations included the lower value attributed to informal learning and a pejorative valuation of the hidden curriculum; and disconnect between practices in clinical settings and the priorities of the larger organization. Conclusions: Research on the learning environment using a sociocultural lens suggest workplace goals, norms and practices determined which learners engage in learning-relevant activities, to what extent, and the degree of guidance provided, with these factors creating "tacit" curricula that may support or compete with formal learning goals. We close with guidance on how sociocultural constructs could inform research to improve the learning environment.