Envisioning Graduate Medical Education in 2030

Impact of Longitudinal Coaching on Pediatric Residents' Professional Identity Formation: A Multi-Institution Qualitative Study

OBJECTIVE

Coaching has emerged in medical education as a strategy for trainees' development and has been endorsed by the Coalition for Physician Accountability and the American Medical Association. However, there is a lack of literature on how coaching impacts residents' professional identity formation (PIF). The purpose of this study was to explore how longitudinal clinical coaching impacted the professional identity of residency graduates.

METHODS

In July to November 2020, we conducted an Institutional Review Board-approved qualitative study with semistructured interviews of residency graduates from 2 pediatric programs who participated in a longitudinal coaching program. We inductively analyzed the transcripts using thematic analysis, guided by the sensitizing principles of PIF. We did a member check to enhance trustworthiness.

RESULTS

We interviewed 34 residency graduates from 2 institutions and identified 4 themes on how coaches influenced residency graduates' PIF by 1) the presence of a trusting relationship; 2) creating trust and sense of belonging through longitudinal encounters, supportive reflection, and formative feedback; 3) integrating clinical skill, career interests, and work-life integration; and 4) reflecting on their own personal and professional identities. Residency graduates highlighted coaching strategies that coaches, coaching programs, and residents themselves can take to promote resident PIF during residency.

CONCLUSIONS

Residency coaches have the potential to influence residents' PIF through their longitudinal relationship grounded in trust. Coaching strategies can be used to enhance resident clinical and professional development during residency training.

Developing a theory of change model for a learning and innovation network: A qualitative study

AIM

The aim of this study is to further develop a preliminary framework into a model that can translate mechanisms into output and impact, based on the views of those working in practice and the relations between the mechanisms: a model that can inform practitioners and organizations on what has to be in place to shape a learning and innovating environment in nursing.

BACKGROUND

A Learning and Innovation Network (LIN) is a network of healthcare professionals, students and education representatives who come together to be part of a nursing community to integrate education, research and practice to contribute to quality of care. In a previous study a preliminary framework was developed through a concept analysis based on publications. The preliminary framework describes input, throughput and output factors in a linear model that does not explain what the components entail in practice and how the components work together.

DESIGN

Focus groups.

METHODS

We designed a Theory of Change (ToC) in four phases. This was based on a focus group interview with lecturer practitioners (Phase 1); a first concept ToC based on thematic analysis of the focus group interview (Phase 2); three paired interviews where the ToC was presented to other lecturer practitioners to complement and verify the ToC model (Phase 3); and adjustment of the model based on the feedback of phase 3 (Phase 4).

RESULTS

The developed ToC model describes important preconditions that have to be in place to start a LIN: a shared vision, a facilitating support system and a diversity of participants who are open to change. It describes the mechanisms by which a wide range of activities can lead to an improvement of the quality of care through collaboration between practice, education and research by working, learning, performing practice based research and implementing new methods together.

CONCLUSION

This study gives a comprehensive overview of the concept of the 'Learning and Innovation Network' (LIN); how the activities in the LIN can lead to impact; and under what conditions. Previously published findings supported elements of the ToC model. The overarching ToC model and the detailed appendix offer a theoretical and practice-based model for practitioners, managers and policy makers.

Reimagining Core Entrustable Professional Activities for Undergraduate Medical Education in the Era of Artificial Intelligence

The proliferation of generative artificial intelligence (AI) and its extensive potential for integration into many aspects of health care signal a transformational shift within the health care environment. In this context, medical education must evolve to ensure that medical trainees are adequately prepared to navigate the rapidly changing health care landscape. Medical education has moved toward a competency-based education paradigm, leading the Association of American Medical Colleges (AAMC) to define a set of Entrustable Professional Activities (EPAs) as its practical operational framework in undergraduate medical education. The AAMC's 13 core EPAs for entering residencies have been implemented with varying levels of success across medical schools. In this paper, we critically assess the existing core EPAs in the context of rapid AI integration in medicine. We identify EPAs that require refinement, redefinition, or comprehensive change to align with the emerging trends in health care. Moreover, this perspective proposes a set of "emerging" EPAs, informed by the changing landscape and capabilities presented by generative AI technologies. We provide a practical evaluation of the EPAs, alongside actionable recommendations on how medical education, viewed through the lens of the AAMC EPAs, can adapt and remain relevant amid rapid technological advancements. By leveraging the transformative potential of AI, we can reshape medical education to align with an AI-integrated future of medicine. This approach will help equip future health care professionals with technological competence and adaptive skills to meet the dynamic and evolving demands in health care.

Uses of Electronic Health Record Data to Measure the Clinical Learning Environment of Graduate Medical Education Trainees: A Systematic Review

PURPOSE

This study systematically reviews the uses of electronic health record (EHR) data to measure graduate medical education (GME) trainee competencies.

METHOD

In January 2022, the authors conducted a systematic review of original research in MEDLINE from database start to December 31, 2021. The authors searched for articles that used the EHR as their data source and in which the individual GME trainee was the unit of observation and/or unit of analysis. The database query was intentionally broad because an initial survey of pertinent articles identified no unifying Medical Subject Heading terms. Articles were coded and clustered by theme and Accreditation Council for Graduate Medical Education (ACGME) core competency.

RESULTS

The database search yielded 3,540 articles, of which 86 met the study inclusion criteria. Articles clustered into 16 themes, the largest of which were trainee condition experience (17 articles), work patterns (16 articles), and continuity of care (12 articles). Five of the ACGME core competencies were represented (patient care and procedural skills, practice-based learning and improvement, systems-based practice, medical knowledge, and professionalism). In addition, 25 articles assessed the clinical learning environment.

CONCLUSIONS

This review identified 86 articles that used EHR data to measure individual GME trainee competencies, spanning 16 themes and 6 competencies and revealing marked between-trainee variation. The authors propose a digital learning cycle framework that arranges sequentially the uses of EHR data within the cycle of clinical experiential learning central to GME. Three technical components necessary to unlock the potential of EHR data to improve GME are described: measures, attribution, and visualization. Partnerships between GME programs and informatics departments will be pivotal in realizing this opportunity.

Are Graduate Medical Trainees Prepared for the Personalized Genomic Medicine Revolution? Trainee Perspectives at One Institution

Although the use of genomics to inform clinical care is increasing, clinicians feel underprepared to integrate personalized medicine (PM) into care decisions. The educational needs of physician residents and fellows, also known as graduate medical trainees (GMTs), have been overlooked. We administered an anonymous, web-based survey to all GMTs participating in training programs affiliated with our institution to evaluate their knowledge, skills, and attitudes toward PM. Of the 1190 GMTs contacted, 319 (26.8%) returned surveys. Most (88.4%) respondents reported receiving PM education in the past. Although the respondents agreed that knowledge of disease genetics (80.9%) or pharmacogenetics (87.1%) would likely lead to improved clinical outcomes, only 33.2% of the respondents felt sufficiently informed about PM. The respondents who had received PM education in residency and/or fellowship had significantly higher self-reported knowledge, ability, awareness, and adoption of PM than those who had not received this education (p < 0.0001, p < 0.0001, p < 0.0001, and p < 0.01, respectively). Targeted training is needed to improve GMTs' confidence in interpreting and explaining genetic test results. The ideal timing for this education appears to be in residency and/or fellowship rather than in medical school.

Using Resident-Sensitive Quality Measures Derived From Electronic Health Record Data to Assess Residents' Performance in Pediatric Emergency Medicine

PURPOSE

Traditional quality metrics do not adequately represent the clinical work done by residents and, thus, cannot be used to link residency training to health care quality. This study aimed to determine whether electronic health record (EHR) data can be used to meaningfully assess residents' clinical performance in pediatric emergency medicine using resident-sensitive quality measures (RSQMs).

METHOD

EHR data for asthma and bronchiolitis RSQMs from Cincinnati Children's Hospital Medical Center, a quaternary children's hospital, between July 1, 2017, and June 30, 2019, were analyzed by ranking residents based on composite scores calculated using raw, unadjusted, and case-mix adjusted latent score models, with lower percentiles indicating a lower quality of care and performance. Reliability and associations between the scores produced by the 3 scoring models were compared. Resident and patient characteristics associated with performance in the highest and lowest tertiles and changes in residents' rank after case-mix adjustments were also identified.

RESULTS

274 residents and 1,891 individual encounters of bronchiolitis patients aged 0-1 as well as 270 residents and 1,752 individual encounters of asthmatic patients aged 2-21 were included in the analysis. The minimum reliability requirement to create a composite score was met for asthma data (α = 0.77), but not bronchiolitis (α = 0.17). The asthma composite scores showed high correlations ( r = 0.90-0.99) between raw, latent, and adjusted composite scores. After case-mix adjustments, residents' absolute percentile rank shifted on average 10 percentiles. Residents who dropped by 10 or more percentiles were likely to be more junior, saw fewer patients, cared for less acute and younger patients, or had patients with a longer emergency department stay.

CONCLUSIONS

For some clinical areas, it is possible to use EHR data, adjusted for patient complexity, to meaningfully assess residents' clinical performance and identify opportunities for quality improvement.

The Effects of Coaching Pediatric Residents on Faculty Coaches' Relationships, Learning, and Professional Identity Formation

PURPOSE

Coaching programs have been implemented in medical education to improve skill development and feedback for trainees. As more faculty take on coaching roles, it is critical to understand how being a coach affects faculty as well as trainees. This study examined the effects of coaching residents on faculty members' relationships, learning, and professional identity formation (PIF), as they move through intersecting communities across landscapes of practice.

METHOD

From July 2020 to January 2021, the authors conducted a mixed-methods study of current and former coaches at 2 institutions with longitudinal pediatric resident coaching programs. They used a concurrent triangulation design in which qualitative and quantitative data were collected simultaneously and integrated during data analysis. A survey explored the impact of coaching on faculty members' learning, relationships, and PIF, and semistructured interviews further examined coaches' experiences. The interview transcripts were analyzed inductively guided by the sensitizing principles of PIF and landscapes of practice.

RESULTS

Of 43 eligible coaches, 32 (74%) completed the survey, and 18 completed interviews. Four themes emerged from the interviews. (1) Coaches' relationships supported belonging in multiple communities. (2) Coaching enabled multidimensional learning. (3) Relationships served as mechanisms of learning for coaches. (4) Coaches' relationships and learning catalyzed PIF. Furthermore, there was a significant difference in the effects of coaching on career growth by faculty rank ( P = .02). Coaches' strengthened PIF increased a sense of purpose, meaning, and professional fulfillment, and inspired new career directions. Survey data further supported these findings.

CONCLUSIONS

Being a coach deepened faculty members' professional identities through their varied relationships, multidimensional learning, and sense of belonging in intersecting communities. This study introduces a framework to understand the factors mediating coaches' PIF and highlights how investing in coaching leads to important benefits for coaches.

Comparison of quantitative internal and external measures of performance for trainees in cytopathology fellowships

INTRODUCTION

Cytopathology fellowships need measures to assess performance of fellows. We sought to compare several internal quantitative assessment metrics in our fellowship with external metrics, such as performance on the American Society of Cytopathology (ASC) Progressive Evaluation of Competency (PEC) examination and United States Medical Licensing Examination (USMLE).

METHODS

Quantitative parameters generated from our laboratory information system (LIS) on cytopathology fellows were evaluated over 6 years, including case volume and diagnostic discrepancies, in addition to ASC PEC and USMLE scores. For discrepancy reports, interpretations made by the fellow were compared with that of the cytopathologist, and classified as none (concordant), minor (<2-levels) or major (≥2-levels).

RESULTS

We evaluated internal and external metrics on 13 fellows over 6 years. The program average diagnostic concordance rate was 89.9%, with an average major discrepancy rate of 1.5%, and an average monthly case volume of 260 cases. More fellows with above-average ASC PEC performance showed above-average concordant diagnoses and lower case volume, while below-average PEC scores were seen more often with higher major discrepancy rates. More fellows with above-average USMLE scores had higher case volumes, while low USMLE scores showed a trend towards higher major discrepancy rates.

CONCLUSION

Our fellowship program has used a variety of internal and external measures of performance for cytopathology fellows. Although the findings show no statistically significant finding correlating performance, these quantitative parameters generated from our LIS were helpful to identify areas of improvement, facilitate comparison to peers, and provide case volume documentation.

Society of Gynecologic Oncology recommendations for fellowship education during the COVID-19 pandemic and beyond: Innovating programs to optimize trainee success

In approximately ten months' time, the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has infected over 34 million people and caused over one million deaths worldwide. The impact of this virus on our health, relationships, and careers is difficult to overstate. As the economic realities for academic medical centers come into focus, we must recommit to our core missions of patient care, education, and research. Fellowship education programs in gynecologic oncology have quickly adapted to the “new normal” of social distancing using video conferencing platforms to continue clinical and didactic teaching. United in a time of crisis, we have embraced systemic change by developing and delivering collaborative educational content, overcoming the limitations imposed by institutional silos. Additional innovations are needed in order to overcome the losses in program surgical volume and research opportunities. With the end of the viral pandemic nowhere in sight, program directors can rethink how education is best delivered and potentially overhaul aspects of fellowship curriculum and content. Similarly, restrictions on travel and the need for social distancing has transformed the 2020 fellowship interview season from an in-person to a virtual experience. During this time of unprecedented and rapid change, program directors should be particularly mindful of the needs and health of their trainees and consider tailoring their educational experiences accordingly.

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The novel coronavirus pandemic has disrupted medical education at all levels.

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Fellowship programs must adapt to the realities of social distancing, workforce redeployments, and laboratory closures.

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The integration of teleconferencing into clinical practice and learning provides both challenges and growth opportunities.

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Program directors should be aware of new stressors our fellows, particularly underrepresented minorities, are facing.

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Programs should take advantage of the opportunity to rethink fellowship education and the needs of our recent graduates.