Alex J. Mechaber

Competency-Based Education and Training in Internal Medicine

Recent efforts to improve medical education include adopting a new framework based on 6 broad competencies defined by the Accreditation Council for Graduate Medical Education. In this article, the Alliance for Academic Internal Medicine Education Redesign Task Force II examines the advantages and challenges of a competency-based educational framework for medical residents. Efforts to refine specific competencies by developing detailed milestones are described, and examples of training program initiatives using a competency-based approach are presented. Meeting the challenges of a competency-based framework and supporting these educational innovations require a robust faculty development program. Challenges to competency-based education include teaching and evaluating the competencies related to practice-based learning and improvement and systems-based practice, as well as implementing a flexible time frame to achieve competencies. However, the Alliance for Academic Internal Medicine Education Redesign Task Force II does not favor reducing internal medicine training to less than 36 months as part of competency-based education. Rather, the 36-month time frame should allow for remediation to address deficiencies in achieving competencies and for diverse enrichment experiences in such areas as quality of care and practice improvement for residents who have demonstrated skills in all required competencies.

Complementary and Alternative Medicine Use by Primary Care Patients with Chronic Pain

OBJECTIVES To describe the characteristics and attitudes toward complementary and alternative medicine (CAM) use among primary care patients with chronic pain disorders and to determine if CAM use is associated with better pain control. DESIGN Cross-sectional survey. SUBJECTS Four hundred sixty-three patients suffering from chronic, nonmalignant pain receiving primary care at 12 U.S. academic medical centers. OUTCOME MEASURE Self-reported current CAM usage by patients with chronic pain disorders. RESULTS The survey had an 81% response rate. Fifty-two percent reported current use of CAM for relief of chronic pain. Of the patients that used CAM, 54% agreed that nontraditional remedies helped their pain and 14% indicated that their individual alternative remedy entirely relieved their pain. Vitamin and mineral supplements were the most frequently used CAM modalities. There was no association between reported use of CAM and pain severity, functional status, or perceived self-efficacy. Patients who reported having at least a high school education (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.02-1.19, P = 0.016) and high levels of satisfaction with their health care (OR 1.47, 95% CI 1.13-1.91, P = 0.004) were significantly more likely to report using CAM. CONCLUSIONS Complementary and alternative therapies were popular among patients with chronic pain disorders surveyed in academic primary care settings. When asked to choose between traditional therapies or CAM, most patients still preferred traditional therapies for pain relief. We found no association between reported CAM usage and pain severity, functional status, or self-efficacy.

An Online Spaced-Education Game to Teach and Assess Medical Students: A Multi- Institutional Prospective Trial

Purpose To investigate whether a spaced-education (SE) game can be an effective means of teaching core content to medical students and a reliable and valid method of assessing their knowledge. Method This nine-month trial (2008–2009) enrolled students from three U.S. medical schools. The SE game consisted of 100 validated multiple-choice questions–explanations in preclinical/clinical domains. Students were e-mailed two questions daily. Adaptive game mechanics re-sent questions in three or six weeks if answered, respectively, incorrectly or correctly. Questions expired if not answered on time (appointment dynamic). Students retired questions by answering each correctly twice consecutively (progression dynamic). Posting of relative performance fostered competition. Main outcome measures were baseline and completion scores. Results Seven-hundred thirty-one students enrolled. Median baseline score was 53% (interquartile range [IQR] 16) and varied significantly by year (P < .001, dmax = 2.08), school (P < .001, dmax = 0.75), and gender (P < .001, d = 0.38). Median completion score was 93% (IQR 12) and varied significantly by year (P = .001, dmax = 1.12), school (P < .001, dmax = 0.34), and age (P = .019, dmax = 0.43). Scores did not differ significantly between years 3 and 4. Seventy percent of enrollees (513/731) requested to participate in future SE games. Conclusions An SE game is an effective and well-accepted means of teaching core content and a reliable and valid method to assess student knowledge. SE games may be valuable tools to identify and remediate students who could benefit from additional educational support.

Do Attending Physicians, Nurses, Residents, and Medical Students Agree on What Constitutes Medical Student Abuse?

Background Whether attending physicians, residents, nurses, and medical students agree on what constitutes medical student abuse, its severity, or influencing factors is unknown. Method We surveyed 237 internal medicine attending physicians, residents, medical students, and nurses at 13 medical schools after viewing five vignettes depicting potentially abusive behaviors. Results The majority of each group felt the belittlement, ethnic insensitivity, and sexual harassment scenarios represented abuse but that excluding a student from participating in a procedure did not. Only a majority of attending physicians considered the negative feedback scenario as abuse. Medical students rated abuse severity significantly lower than other groups in the belittlement scenario (p < .05). Respondents who felt abused as students were more likely to rate behaviors as abusive (p < .05). Conclusions The groups generally agree on what constitutes abuse, but attending physicians and those abused as students may perceive more behaviors as abusive.

Changes in clinical skills education resulting from the introduction of the USMLE™ step 2 clinical skills (CS) examination

Background: Step 2 Clinical Skills (CS) was recently introduced into the United States Medical Licensing Examination (USMLE™) to ensure that successful candidates for licensure possess the clinical skills to provide safe and effective patient care. Aims: To explore if medical schools had changed the objectives, content, or emphasis in their pre-clinical curriculum in response to its implementation. Methods: In April 2005, the Clerkship Directors in Internal Medicine (CDIM) sent an electronic survey to a single member from each medical school with a CDIM member. The survey instrument included 26 pre-clinical curricular questions with nine questions specifically addressing changes in response to implementation of the Step 2 CS. Results: Forty-five percent of respondents reported changes to the Introduction to Clinical Medicine (ICM) course objectives while 39% and 40% reported changes in content and emphasis. Seventy-four percent felt their students were adequately prepared for the Step 2 CS and 18% were unsure. Conclusions: Over a third of medical schools are implementing changes to the objectives, content, and/or emphasis of their curriculum, at least partially in response to the institution of Step 2 CS.

Training and assessment of CXR/basic radiology interpretation skills: results from the 2005 CDIM Survey.

Background: Despite published literature demonstrating deficiencies in chest radiograph (CXR)/basic radiology interpretation skills of 4th-year medical students, studies and subsequent curricula regarding the training needed to obtain these skills are lacking. Terms such as clinical exposure and radiology teaching have been used to describe the experience for these basic interpretive skills, but best practice methods of delivery, let alone common methods, have yet to be defined. Purpose: The objective is to describe the current methods of teaching and assessing CXR/basic radiology interpretation skills across institutions on the 3rd-year internal medicine (IM) clerkship. Methods: In 2005, the Clerkship Directors in Internal Medicine (CDIM), an international organization representing U.S. and Canadian medical schools, surveyed its institutional members. Twelve questions on the survey dealt with X-ray interpretation. Results: Eighty-eight of 109 members (81%) responded to the survey. Overall, 81% of respondents felt that CXR interpretation is an important clinical skill for medical students. Seventy-six percent indicated that instruction in these skills occurs on the IM clerkship. The most cited methods of instruction were lectures (56%) and teaching rounds (48%). Most schools spent on average of 2 to 4 hr during the IM clerkship on formal radiology instruction. Only 33% indicated that radiology interpretation skills are assessed during the clerkship. The most common assessment methods were written examination (19%) and OSCE (19%). Conclusion: Substantive data regarding attainment and assessment of CXR/basic radiology interpretation skills in the undergraduate curriculum are lacking. Our study provides preliminary descriptive data regarding CXR instruction and assessment on the 3rd-year IM clerkship.

Training and Assessment of ECG Interpretation Skills: Results From the 2005 CDIM Survey

Background: Despite published consensus-based statements on assessment of ECG interpretation skills, studies and curricula regarding the training needed to obtain basic ECG interpretation skills are lacking. These consensus statements have focused on attaining competency in ECG interpretation during postgraduate training; however, recommendations regarding assessment of competency in the undergraduate curriculum are not discussed. Purpose: The purpose is to describe the current methods of teaching and assessing ECG interpretation skills across institutions on the 3rd-year internal medicine (IM) clerkship. Method: In 2005, the Clerkship Directors in Internal Medicine surveyed its institutional members. Twelve questions on the survey dealt with ECG interpretation. Descriptive statistics, chi-square, and Mann–Whitney U were used for analysis. Results: Eighty-eight of 109 members (81%) responded to the survey. Overall, 89% of institutional respondents feel that ECG interpretation is an important clinical skill for medical students with 92% indicating that instruction occurs on the IM clerkship. Lectures (75%) and teaching rounds (44%) were the most cited methods of instruction. Most schools spend 1 to 6 hr during the IM clerkship on formal ECG instruction. Over 63% indicated that ECG interpretation skills are assessed during the clerkship. The most common assessment methods were written exam (40%) and OSCE (23%). Conclusions: Objective data regarding attainment and assessment of basic ECG interpretation competency in the undergraduate curriculum are lacking; our report provides preliminary descriptive data regarding ECG teaching and assessment on the 3rd-year IM clerkship. Further studies are needed to determine the ideal method of instruction and evaluation of this important clinical skill.

Decreasing the Ceiling Effect in Assessing Meeting Quality at an Academic Professional Meeting

Background: The psychometric properties of evaluations at academic meetings have not been well studied. Purpose: To explore the ceiling effect in the evaluation of quality of a professional meeting and whether a change in the scale labels would decrease the ceiling effect. Methods: Cross-sectional study at two national meetings (2009-2010), attendees completed the evaluation on paper forms or online (5-point Likert scale). Results: Of 1,064 evaluations, the mean session ratings was higher among respondents to the paper version in 2009 (4.2; 95% confidence interval [CI], 4.1 to 4.3) as compared to online responders in 2009 (3.0; 95% CI, 2.9 to 3.1) or online responders in 2010 (3.0; 95% CI, 2.9 to 3.1)(p < 0.001). Conclusion: A ceiling effect was present in the evaluation of an academic meeting. A change in the evaluation scale labels decreased the ceiling effect and increased evaluation variability.

Analysis and Publication Rates of Clerkship Directors in Internal Medicine (CDIM) Annual Meeting Abstracts 1995–2005

Background: Abstracts presented at meetings may be a reflection of the meetings quality. Summary: The goal is to determine purpose, content areas, research design, and subsequent publication rates of abstracts presented at Clerkship Directors in Internal Medicines annual meetings. Abstracts presented in 1995–2005 were analyzed. A total of 201 abstracts were analyzed and coded. The purpose of the majority of the studies was description (155, 77%), 44 (22%) were justification studies, and 2 (1%) were clarification studies. In all, 109 (54%) assessed the relationship between teaching and student performance. Seven (4%) were studies about how students learn, study, solve problems, obtain medical knowledge, and think critically. Nineteen (10%) were studies about students’ noncognitive skills, professionalism, interpersonal skills, and well-being studies. In all, 29 (14%) were measurement studies assessing reliability or validity of assessments. Twenty (10%) focused on career or faculty development pertaining to either faculty or residents. Research design of most studies was descriptive or pre-experimental (175, 87%), some were quasi-experimental (13, 7%), and two thirds (135, 66%) were not published as full articles in peer-reviewed journals. and there was an upward trend in publication rates. Conclusions: These findings may serve as an indicator of the quality of the educational meeting. It may further stimulate efforts to develop programs to help program attendees achieve scholarly publications for work presented and serve as a benchmark against which future meetings may be judged.

Journal Watch From ACE (Alliance For Clinical Education): annual review of medical education articles in internal medicine journals 2006-2007.

This journal watch is sponsored by the Alliance for Clinical Education (ACE). The purpose of this article is to summarize medical education manuscripts from specialty journals that are important and relevant to educators across specialties. Specialties included in our review were cardiology, gastroenterology, general internal medicine, pulmonology, nephrology, hematology and oncology, endocrinology, rheumatology, infectious disease, and neurology. We are grateful to Teaching and Learning in Medicine and ACE for giving us the opportunity to publish this review. The Clerkship Directors in Internal Medicine Research Committee conducted this review. Included are English articles published from September 2006 through September 2007. PubMed was searched for peer-reviewed research publications reporting primary data on medical education. Medical subject heading terms included combinations of medical education, medical student, residency training, practice, undergraduate medical education, graduate medical education, internship and residency, and continuing medical education. We also reviewed the bibliographies of all articles found though our PubMed search to identify additional articles that may not have been included in PubMeds search engine. Furthermore, we discussed identified articles with content experts in each specialty to ensure that appropriate journals and articles were included from each subspecialty. The journals that we selected for review are not often read by the typical medical educator. We included articles from general and subspecialty journals of internal medicine excluding the following, which have a focus on medical education or cross-specialties: Academic Medicine, Advances in Health Science Education, Medical Education, Medical Teacher, Teaching and Learning in Medicine, Journal of the American Medical Association, and New England Journal of Medicine. Specialties included in our review were cardiology, gastroenterology, general internal medicine, pulmonology, nephrology, hematology and oncology, endocrinology, rheumatology, infectious disease, and neurology. We also reviewed the bibliographies of all articles found though our PubMed search to identify additional articles. Furthermore, we discussed identified articles with content experts in each specialty to ensure that appropriate journals and articles were included from each subspecialty. Authors rated each article based on relevance, rigor, importance, and generalizibility of findings. We also sought to include articles from each phase in the continuum of medical education: undergraduate, graduate, and continuing medical education as well as qualitative and quantitative studies. Articles were ranked by each author. We then held conference calls and had e-mail discussions to establish consensus on the articles included in this review. The following is a summary of each selected article grouped by theme.