David E. Kern

Attributes of Excellent Attending-Physician Role Models

Background Although effective role models are important in medical education, little is known about the characteristics of physicians who serve as excellent clinical role models. We therefore conducted a case–control study to identify attributes that distinguish such physicians from their colleagues. Methods We asked members of the internal-medicine house staff at four teaching hospitals to name physicians whom they considered to be excellent role models. A total of 165 physicians named by one or more house-staff members were classified as excellent role models (these served as the case physicians in our study). A questionnaire was sent to them as well as to 246 physicians who had residency-level teaching responsibilities but who were not named (controls). Of these 411 physicians, 341 (83 percent) completed questionnaires while unaware of their case–control status. Results Of the 341 attending physicians who responded, 144 (42 percent) had been identified as excellent role models. Having greater assigned ...

Teaching the Teachers: National Survey of Faculty Development in Departments of Medicine of U.S. Teaching Hospitals

OBJECTIVE: To determine the prevalence, topics, methods, and intensity of ongoing faculty development (FD) in teaching skills.DESIGN: Mailed survey.PARTICIPANTS: Two hundred and seventy-seven of the 386 (72%) U.S. teaching hospitals with internal medicine residency programs.MEASUREMENTS: Prevalence and characteristics of ongoing FD.RESULTS: One hundred and eight teaching hospitals (39%) reported ongoing FD. Hospitals with a primary medical school affiliation (university hospitals) were more likely to have ongoing FD than nonuniversity hospitals. For nonuniversity hospitals, funding from the Health Resources Services Administration and >50 house staff were associated with ongoing FD. For university hospitals, >100 department of medicine faculty was associated. Ongoing programs included a mean of 10.4 topics (standard deviation, 5.4). Most offered half-day workshops (80%), but 22% offered ≥1-month programs. Evaluations were predominantly limited to postcourse evaluations forms. Only 14% of the hospitals with ongoing FD (5% of all hospitals) had “advanced” programs, defined as offering ≥10 topics, lasting >2 days, and using ≥3 experiential teaching methods. These were significantly more likely to be university hospitals and to offer salary support and/or protected time to their FD instructors. Generalists and hospital-based faculty were more likely to receive training than subspecialist and community-based faulty. Factors facilitating participation in FD activities were supervisor attitudes, FD expertise, and institutional culture.CONCLUSIONS: A minority of U.S. teaching hospitals offer ongoing faculty development in teaching skills. Continued progress will likely require increased institutional commitment, improved evaluations, and adequate resources, particularly FD instructors and funding.

The Role of Cultural Diversity Climate in Recruitment, Promotion, and Retention of Faculty in Academic Medicine

BACKGROUND: Ethnic diversity among physicians may be linked to improved access and quality of care for minorities. Academic medical institutions are challenged to increase representation of ethnic minorities among health professionals.OBJECTIVES: To explore the perceptions of physician faculty regarding the following: (1) the institution’s cultural diversity climate and (2) facilitators and barriers to success and professional satisfaction in academic medicine within this context.DESIGN: Qualitative study using focus groups and semi-structured interviews.PARTICIPANTS: Nontenured physicians in the tenure track at the Johns Hopkins University School of Medicine.APPROACH: Focus groups and interviews were audio-taped, transcribed verbatim, and reviewed for thematic content in a 3-stage independent review/adjudication process.RESULTS: Study participants included 29 faculty representing 9 clinical departments, 4 career tracks, and 4 ethnic groups. In defining cultural diversity, faculty noted visible (race/ethnicity, foreign-born status, gender) and invisible (religion, sexual orientation) dimensions. They believe visible dimensions provoke bias and cumulative advantages or disadvantages in the workplace. Minority and foreign-born faculty report ethnicity-based disparities in recruitment and subtle manifestations of bias in the promotion process. Minority and majority faculty agree that ethnic differences in prior educational opportunities lead to disparities in exposure to career options, and qualifications for and subsequent recruitment to training programs and faculty positions. Minority faculty also describe structural barriers (poor retention efforts, lack of mentorship) that hinder their success and professional satisfaction after recruitment. To effectively manage the diversity climate, our faculty recommended 4 strategies for improving the psychological climate and structural diversity of the institution.CONCLUSIONS: Soliciting input from faculty provides tangible ideas regarding interventions to improve an institution’s diversity climate.

Relation of low-severity violence to women’s health

AbstractOBJECTIVE: To determine if women who experience low-severity violence differ in numbers of physical symptoms, psychological distress, or substance abuse from women who have never been abused and from women who experience high-severity violence. DESIGN: Cross-sectional, self-administered, anonymous survey. SETTING: Four community-based, primary care, internal medicine practices. PATIENTS: Survey respondents were 1,931 women aged 18 years or older. SURVEY DESIGN: Survey included questions on violence; a checklist of 22 physical symptoms; the Symptom Checklist-22 (SCL-22) to measure depression, anxiety, somatization, and self-esteem; CAGE questions for alcohol use; and questions about past medical history. Low-severity violence patients had been “pushed or grabbed” or had someone “threaten to hurt them or someone they love” in the year prior to presentation. High-severity violence patients had been hit, slapped, kicked, burned, choked, or threatened or hurt with a weapon. MAIN RESULTS: Of the 1,931 women, 47 met criteria for current low-severity violence without prior abuse, and 79 met criteria for current high-severity violence without prior abuse, and 1,257 had never experienced violence. The remaining patients reported either childhood violence or past adult abuse. When adjusted for socioeconomic characteristics, the number of physical symptoms increased with increasing severity of violence (4.3 for no violence, 5.3 for low-severity violence, 6.4 for high-severity violence, p<.0001). Psychological distress also increased with increasing severity of violence (mean total SCL-22 scores 32.6 for no violence, 35.7 for low-severity violence, 39.5 for high-severity violence, p<.0001). Women with any current violence were more likely to have a history of substance abuse (prevalence ratio [PR] 1.8 for low-severity, 1.9 for high-severity violence) and to have a substance-abusing partner (PR 2.4 for both violence groups). CONCLUSIONS: In this study, even low-severity violence was associated with physical and psychological health problems in women. The data suggest a dose-response relation between the severity of violence and the degree of physical and psychological distress.

Predictive validity evidence for medical education research study quality instrument scores: Quality of submissions to JGIM's medical education special issue

BackgroundDeficiencies in medical education research quality are widely acknowledged. Content, internal structure, and criterion validity evidence support the use of the Medical Education Research Study Quality Instrument (MERSQI) to measure education research quality, but predictive validity evidence has not been explored.ObjectiveTo describe the quality of manuscripts submitted to the 2008 Journal of General Internal Medicine (JGIM) medical education issue and determine whether MERSQI scores predict editorial decisions.Design and ParticipantsCross-sectional study of original, quantitative research studies submitted for publication.MeasurementsStudy quality measured by MERSQI scores (possible range 5–18).ResultsOf 131 submitted manuscripts, 100 met inclusion criteria. The mean (SD) total MERSQI score was 9.6 (2.6), range 5–15.5. Most studies used single-group cross-sectional (54%) or pre-post designs (32%), were conducted at one institution (78%), and reported satisfaction or opinion outcomes (56%). Few (36%) reported validity evidence for evaluation instruments. A one-point increase in MERSQI score was associated with editorial decisions to send manuscripts for peer review versus reject without review (OR 1.31, 95%CI 1.07–1.61, p = 0.009) and to invite revisions after review versus reject after review (OR 1.29, 95%CI 1.05–1.58, p = 0.02). MERSQI scores predicted final acceptance versus rejection (OR 1.32; 95% CI 1.10–1.58, p = 0.003). The mean total MERSQI score of accepted manuscripts was significantly higher than rejected manuscripts (10.7 [2.5] versus 9.0 [2.4], p = 0.003).ConclusionsMERSQI scores predicted editorial decisions and identified areas of methodological strengths and weaknesses in submitted manuscripts. Researchers, reviewers, and editors might use this instrument as a measure of methodological quality.

A Systematic Review of Teamwork Training Interventions in Medical Student and Resident Education

BackgroundTeamwork is important for improving care across transitions between providers and for increasing patient safety.ObjectiveThis review’s objective was to assess the characteristics and efficacy of published curricula designed to teach teamwork to medical students and house staff.DesignThe authors searched MEDLINE, Education Resources Information Center, Excerpta Medica Database, PsychInfo, Cumulative Index of Nursing and Allied Health Literature, and Scopus for original data articles published in English between January 1980 and July 2006 that reported descriptions of teamwork training and evaluation results.MeasurementsTwo reviewers independently abstracted information about curricular content (using Baker’s framework of teamwork competencies), educational methods, evaluation design, outcomes measured, and results.ResultsThirteen studies met inclusion criteria. All curricula employed active learning methods; the majority (77%) included multidisciplinary training. Ten curricula (77%) used an uncontrolled pre/post design and 3 (23%) used controlled pre/post designs. Only 3 curricula (23%) reported outcomes beyond end of program, and only 1 (8%) >6weeks after program completion. One program evaluated a clinical outcome (patient satisfaction), which was unchanged after the intervention. The median effect size was 0.40 (interquartile range (IQR) 0.29, 0.61) for knowledge, 0.38 (IQR 0.32, 0.41) for attitudes, 0.41 (IQR 0.35, 0.49) for skills and behavior. The relationship between the number of teamwork principles taught and effect size achieved a Spearman’s correlation of .74 (p = .01) for overall effect size and .64 (p = .03) for median skills/behaviors effect size.ConclusionsReported curricula employ some sound educational principles and appear to be modestly effective in the short term. Curricula may be more effective when they address more teamwork principles.

Faculty Development in Teaching Skills: An Intensive Longitudinal Model

Although reflection contributes to the personal growth of clinician–educators and is important for effective teaching, few teaching skills programs report its use. The Johns Hopkins Faculty Development Program in Teaching Skills, first implemented in 1987 as a theoretically grounded, longitudinal model for faculty development of clinician–educators, comprises a set of conditions intended to promote reflective learning. This paper describes the program and reports evaluation results for 98 participants and a comparison group of 112 nonparticipants between 1988 and 1996. Participants met with facilitators weekly for nine months for 3.5 hours, in stable groups of four to six individuals. Educational methods used across seven content areas emphasized relationships and collaboration, and included information provision, experiential learning with reflection, and personal awareness sessions. A pre–post evaluation design with comparison group measured changes in self-assessed teaching and professional skills, teaching enjoyment, and learning effectiveness. A post-only evaluation design appraised overall program quality, educational methods, facilitation, learning environment, and perceived impact of participation. Program participants had significantly greater pre–post-change scores than nonparticipants for all 14 outcomes (p < .05). Multiple regression modeling indicated that program participation was associated with pre–post improvement in all outcomes except administration skills, controlling for all participant and nonparticipant baseline characteristics (p < .05). All measured programmatic characteristics were highly rated by participants. Experiential methods with reflection were rated significantly higher than information-provision and personal awareness sessions (p < .001). Evaluation results demonstrate a positive impact of this alternative approach to faculty development on clinician–educator perceptions of their attitudes and behaviors towards learners and colleagues.

Stories From Early-Career Women Physicians Who Have Left Academic Medicine: A Qualitative Study at a Single Institution

Purpose The number of women in academic medicine has steadily increased, although gender parity still does not exist and women leave academics at somewhat higher rates than men. The authors investigated the reasons why women leave careers in academic medicine. Method Semistructured, one-on-one interviews were conducted in 2007–2008 with 20 women physicians who had left a single academic institution to explore their reasons for opting out of academic careers. Data analysis was iterative, and an editing analysis style was used to derive themes. Results A lack of role models for combining career and family responsibilities, frustrations with research (funding difficulties, poor mentorship, competition), work–life balance, and the institutional environment (described as noncollaborative and biased in favor of male faculty) emerged as key factors associated with a decision to leave academic medicine for respondents. Faced with these challenges, respondents reevaluated their priorities and concluded that a discrepancy existed between their own and institutional priorities. Many respondents expressed divergent views with the institutional norms on how to measure success and, as a consequence, felt that they were undervalued at work. Conclusions Participants report a disconnection between their own priorities and those of the dominant culture in academic medicine. Efforts to retain women faculty in academic medicine may include exploring the aspects of an academic career that they value most and providing support and recognition accordingly.

An evaluation of residency training in interviewing skills and the psychosocial domain of medical practice

Competent use of interviewing skills is important for the care of all patients but is especially critical, and frequently deficient, in meeting the needs of patients experiencing emotional distress. This study presents an evaluation of a curriculum in communication and psychosocial skills taught to first-year medical residents. A randomized experimental design compared trained and untrained residents’ (n=48) performances with a simulated patient presenting with atypical cbest pain and psychosocial distress. Evaluation was based on analysis of videotapes, simulated patient report of residents’ behaviors, and cbart notation. Trained compared with untrained residents asked more open-ended questions and fewer leading questions, summarized main points more frequently, did more psychosocial counseling, and were rated as baving better communication skills by the simulated patient. The use of more focused and psychosocially directed questions, and fewer leading and grab-bag questions, was associated with more accurate diagnoses and management recorded in the medical chart. However, no significant difference was found in the charting practices of trained versus untrained residents.

Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements.

BACKGROUND: The Accreditation Council for Graduate Medical Education duty hour requirements may affect residents’ understanding and practice of professionalism.OBJECTIVE: We explored residents’ perceptions about the current teaching and practice of professionalism in residency and the impact of duty hour requirements.DESIGN: Anonymous cross-sectional survey.PARTICIPANTS: Internal medicine, neurology, and family practice residents at 3 teaching hospitals (n=312).MEASUREMENTS: Using Likert scales and open-ended questions, the questionnaire explored the following: residents’ attitudes about the principles of professionalism, the current and their preferred methods for teaching professionalism, barriers or promoters of professionalism, and how implementation of duty hours has affected professionalism.RESULTS: One hundred and sixty-nine residents (54%) responded. Residents rated most principles of professionalism as highly important to daily practice (91.4%, 95% confidence interval [CI] 90.0 to 92.7) and training (84.7%, 95% CI 83.0 to 86.4), but fewer rated them as highly easy to incorporate into daily practice (62.1%, 95% CI 59.9 to 64.3), particularly conflicts of interest (35.3%, 95% CI 28.0 to 42.7) and self-awareness (32.0%, 95% CI 24.9 to 39.1). Role-modeling was the teaching method most residents preferred. Barriers to practicing profession-alism included time constraints, workload, and difficulties interacting with challenging patients. Promoters included role-modeling by faculty and colleagues and a culture of professionalism. Regarding duty hour limits, residents perceived less time to communicate with patients, continuity of care, and accountability toward their colleagues, but felt that limits improved professionalism by promoting resident well-being and teamwork.CONCLUSIONS: Residents perceive challenges to incorporating professionalism into their daily practice. The duty hour implementation offers new challenges and opportunities for negotiating the principles of professionalism.