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Featured researches published by Bonnie M. Miller.


Academic Medicine | 2010

Medical Students' Experiences of Moral Distress: Development of a Web-Based Survey

Catherine Wiggleton; Emil R. Petrusa; Kim Loomis; John L. Tarpley; Margaret J. Tarpley; Mary Lou OʼGorman; Bonnie M. Miller

Purpose To develop an instrument for measuring moral distress in medical students, measuring the prevalence of moral distress in a cohort of students, and identifying the situations most likely to cause it. Moral distress, defined as the negative feelings that arise when one knows the morally correct thing to do but cannot act because of constraints or hierarchies, has been documented in nurses but has not been measured in medical students. Method The authors constructed a survey consisting of 55 items describing potentially distressing situations. Responders rated the frequency of these situations and the intensity of distress that they caused. The survey was administered to 106 fourth-year medical students during a three-week period in 2007; the response rate was 60%. Results Each of the situations was experienced by at least some of the 64 respondents, and each created some degree of moral distress. On average, students witnessed almost one-half of the situations at least once, and more than one-third of the situations caused mild-to-moderate distress. The survey measured individual distress (Cronbach alpha = 0.95), which varied among the students. Whereas women witnessed potentially distressing situations significantly more frequently than did men (P = .04), men tended to become more distressed by each event witnessed (P = .057). Conclusions Medical students frequently experience moral distress. Our survey can be used to measure aspects of the learning environment as well as individual responses to the environment. The variation found among student responses warrants further investigation to determine whether students at either extreme of moral distress are at risk of burnout or erosion of professionalism.


Journal of Surgical Research | 1983

Interorgan relationships of alanine and glutamine during fasting in the conscious dog

Bonnie M. Miller; Eugenio Cersosimo; John McRae; Phillip E. Williams; William W. Lacy; Naji N. Abumrad

This study was designed to assess the interorgan relationships of glutamine and alanine in the conscious, overnight fasted dog, and to determine changes which occur with progressive fasting. Dogs were fasted for 18 hr (n = 6), 48 hr (n = 6), and 96 hr (n = 6) prior to the study. Catheters had been previously implanted in the femoral artery, renal vein, portal vein, and hepatic vein, and were used for blood sampling at 30-min intervals during the 3-hr experimental period. Hepatic and renal blood flows were determined by indocyanine green and para-aminohippuric acid (PAH) extraction methods, respectively. Balance data (micromoles/kilogram/minute) were estimated by multiplying the appropriate arteriovenous concentration differences by blood flows. Hepatic uptake of glutamine decreased 50% after a 48-hr fast, and by 96 hr, the liver became a net producer of glutamine. Gut utilization remained constant throughout fasting. The kidneys utilization gradually increased with fasting. The hepatic extraction of alanine fell with fasting, declining to 40% of its original uptake at 96 hr. The guts production of alanine fell during the first 48 hr of fasting, but remained stable thereafter. The kidneys production of alanine increased throughout the period of starvation. The arterial concentration of glutamine rose with fasting, while that of alanine fell even with a 48 hr fast. The liver, by becoming a net producer of glutamine, and the kidney, by increasing its production of alanine, decrease demands for peripheral release of these two amino acids, and thus may have protein-sparing actions during fasting.


Academic Medicine | 2010

Beyond Flexner: a new model for continuous learning in the health professions.

Bonnie M. Miller; Donald E. Moore; William W. Stead; Jeffrey R. Balser

One hundred years after Flexner wrote his report for the Carnegie Foundation, calls are heard for another “Flexnerian revolution,” a reform movement that would overhaul an approach to medical education that is criticized for its expense and inefficiency, its failure to respond to the health needs of our communities, and the high cost and inefficiency of the health care system it supports. To address these concerns, a group of Vanderbilt educators, national experts, administrators, residents, and students attended a retreat in November 2008. The goal of this meeting was to craft a new vision of physician learning based on the continuous development and assessment of competencies needed for effective and compassionate care under challenging circumstances. The vision that emerged from this gathering was that of a health care workforce comprised of physicians and other professionals, all capable of assessing practice outcomes, identifying learning needs, and engaging in continuous learning to achieve the best care for their patients. Several principles form the foundation for this vision. Learning should be competency based and embedded in the workplace. It should be linked to patient needs and undertaken by individual providers, by teams, and by institutions. Health professionals should be trained in this new model from the start of the educational experience, leading to true interprofessional education, with shared facilities and the same basic coursework. Multiple entry and exit points would provide flexibility and would allow health professionals to redirect their careers as their goals evolved. This article provides a detailed account of the model developed at the retreat and the obstacles that might be encountered in attempting to implement it.


American Journal of Surgery | 2009

Moral distress in the third year of medical school; a descriptive review of student case reflections

Kimberly D. Lomis; Robert O. Carpenter; Bonnie M. Miller

BACKGROUND Medical students may find certain clinical experiences particularly difficult. Moral distress occurs when a trainee sees a situation or behavior as undesirable, but, because of a position in the hierarchy, declines to address the problem. To prompt our students to reflect on such experiences, students are required to submit a brief case description and are assigned to mentor groups to discuss cases. METHODS After exemption from our Institutional Review Board, a database of student submissions was de-identified. A total of 192 case descriptions were analyzed by a single reviewer to identify recurrent themes. Submissions were categorized in a binary fashion as higher or lower levels of distress. Frequency and correlation with levels of distress were assessed for each theme. RESULTS Sixty-seven percent of the submissions were classified as higher distress. Seven major themes were identified, the most common being problems of communication (n = 179). Those students taking action correlated to lower distress. CONCLUSIONS Our review shows that specific situations can be expected to generate moral distress in trainees. Addressing such distress may support the ongoing professional growth of trainees.


Academic Medicine | 2014

Medical Students as Health Educators at a Student-Run Free Clinic: Improving the Clinical Outcomes of Diabetic Patients

Phillip Gorrindo; Alon Peltz; Travis R. Ladner; India Reddy; Bonnie M. Miller; Robert Miller; Michael J. Fowler

Purpose Student-run free clinics (SRFCs) provide service–learning opportunities for medical students and care to underserved patients. Few published studies, however, support that they provide high-quality care. In this study, the authors examined the clinical impact of a medical student health educator program for diabetic patients at an SRFC. Method In 2012, the authors retrospectively reviewed the electronic medical records of diabetic patients who established care at Shade Tree Clinic in Nashville, Tennessee, between 2008 and 2011. They compared clinical outcomes at initial presentation to the clinic and 12 months later. They analyzed the relationship between the number of patient–student interactions (touchpoints) and change in hemoglobin A1c values between these two time points and compared the quality of care provided to best-practice benchmarks (process and outcomes measures). Results The authors studied data from 45 patients. Mean hemoglobin A1c values improved significantly from 9.6 to 7.9, after a mean of 12.5 ± 1.5 months (P < .0001). A trend emerged between increased number of touchpoints and improvement in A1c values (r2 = 0.06, P = .10). A high percentage of patients were screened during clinic visits, whereas a low to moderate percentage met benchmarks for A1c, LDL, and blood pressure levels. Conclusions These findings demonstrate that a medical student health educator program at an SRFC can provide high-quality diabetes care and facilitate clinical improvement one year after enrollment, despite inherent difficulties in caring for underserved patients. Future studies should examine the educational and clinical value of care provided at SRFCs.


Academic Medicine | 2011

Tracking development of clinical reasoning ability across five medical schools using a progress test.

Reed G. Williams; Debra L. Klamen; Christopher B. White; Emil R. Petrusa; Ruth Marie E Fincher; Carol F. Whitfield; John H. Shatzer; Teresita McCarty; Bonnie M. Miller

Purpose Little is known about the acquisition of clinical reasoning skills in medical school, the development of clinical reasoning over the medical curriculum as a whole, and the impact of various curricular methodologies on these skills. This study investigated (1) whether there are differences in clinical reasoning skills between learners at different years of medical school, and (2) whether there are differences in performance between students at schools with various curricular methodologies. Method Students (n = 2,394) who had completed zero to three years of medical school at five U.S. medical schools participated in a cross-sectional study in 2008. Students took the same diagnostic pattern recognition (DPR) and clinical data interpretation (CDI) tests. Percent correct scores were used to determine performance differences. Data from all schools and students at all levels were aggregated for further analysis. Results Student performance increased substantially as a result of each year of training. Gains in DPR and CDI performance during the third year of medical school were not as great as in previous years across the five schools. CDI performance and performance gains were lower than DPR performance and gains. Performance gains attributable to training at each of the participating medical schools were more similar than different. Conclusions Years of training accounted for most of the variation in DPR and CDI performance. As a rule, students at higher training levels performed better on both tests, though the expected larger gains during the third year of medical school did not materialize.


Academic Medicine | 2014

Role-modeling and medical error disclosure: a national survey of trainees.

William Martinez; Gerald B. Hickson; Bonnie M. Miller; David J. Doukas; John D. Buckley; John Song; Niraj L. Sehgal; Jennifer Deitz; Clarence H. Braddock; Lisa Soleymani Lehmann

Purpose To measure trainees’ exposure to negative and positive role-modeling for responding to medical errors and to examine the association between that exposure and trainees’ attitudes and behaviors regarding error disclosure. Method Between May 2011 and June 2012, 435 residents at two large academic medical centers and 1,187 medical students from seven U.S. medical schools received anonymous, electronic questionnaires. The questionnaire asked respondents about (1) experiences with errors, (2) training for responding to errors, (3) behaviors related to error disclosure, (4) exposure to role-modeling for responding to errors, and (5) attitudes regarding disclosure. Using multivariate regression, the authors analyzed whether frequency of exposure to negative and positive role-modeling independently predicted two primary outcomes: (1) attitudes regarding disclosure and (2) nontransparent behavior in response to a harmful error. Results The response rate was 55% (884/1,622). Training on how to respond to errors had the largest independent, positive effect on attitudes (standardized effect estimate, 0.32, P < .001); negative role-modeling had the largest independent, negative effect (standardized effect estimate, −0.26, P < .001). Positive role-modeling had a positive effect on attitudes (standardized effect estimate, 0.26, P < .001). Exposure to negative role-modeling was independently associated with an increased likelihood of trainees’ nontransparent behavior in response to an error (OR 1.37, 95% CI 1.15–1.64; P < .001). Conclusions Exposure to role-modeling predicts trainees’ attitudes and behavior regarding the disclosure of harmful errors. Negative role models may be a significant impediment to disclosure among trainees.


Academic Medicine | 2017

Fostering the Development of Master Adaptive Learners: A Conceptual Model to Guide Skill Acquisition in Medical Education.

William B. Cutrer; Bonnie M. Miller; Martin Pusic; George Mejicano; Rajesh S. Mangrulkar; Larry D. Gruppen; Richard E. Hawkins; Susan E. Skochelak; Donald E. Moore

Change is ubiquitous in health care, making continuous adaptation necessary for clinicians to provide the best possible care to their patients. The authors propose that developing the capabilities of a Master Adaptive Learner will provide future physicians with strategies for learning in the health care environment and for managing change more effectively. The concept of a Master Adaptive Learner describes a metacognitive approach to learning based on self-regulation that can foster the development and use of adaptive expertise in practice. The authors describe a conceptual literature-based model for a Master Adaptive Learner that provides a shared language to facilitate exploration and conversation about both successes and struggles during the learning process.


Academic Medicine | 2010

The Emphasis Program: A Scholarly Concentrations Program at Vanderbilt University School of Medicine

Gerald S. Gotterer; Denis O'day; Bonnie M. Miller

In 1999, a faculty committee at Vanderbilt University School of Medicine reviewed the mission and goals of the school and determined that graduates should receive initial preparation to develop scholarly careers in medicine. The authors describe the design of a scholarly projects course, the Emphasis Program, which is required of all students in the first two years of medical school. Each student undertakes a mentored project in one of nine areas of scholarship related to medicine. Curricular time is devoted to the program during the first two academic years, and students also spend eight weeks working on their projects in the intervening summer. The program includes a core didactic curriculum on topics common to all areas of scholarly work, such as biostatistics and study design. Implemented with the entering class of 2004, 467 students had completed the program as of May 2010, and only two students have been unable to complete projects in the allotted time. The majority of graduating seniors reported that they felt this was a valuable aspect of their medical education. Whereas the program offers a broad spectrum of scholarship opportunities, most students have selected projects in more traditional areas, such as laboratory-based research and patient-oriented research. The authors describe early successes in meeting program goals as well as some of the ongoing challenges of administering a required but individualized program of this nature.


Academic Medicine | 2011

Continuing medical education: the link between physician learning and health care outcomes.

Todd Dorman; Bonnie M. Miller

The past century has seen spectacular gains in the breadth and depth of biomedical knowledge, but the potential of these gains has been limited by inadequate, inequitable, and inefficient translation of knowledge and skills to the health care workplace. We propose that a radically transformed continuing medical education (CME) system is essential to realize biomedicine’s everexpanding potential to improve the health of patients and populations.

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Naji N. Abumrad

Vanderbilt University Medical Center

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