Gail M. Sullivan

Effects of an inpatient geriatrics rotation on internal medicine residents’ knowledge and attitudes

AbstractOBJECTIVE: The purpose of this study is to assess the effect of a geriatrics-focused acute medicine inpatient rotation and the presence or absence of a geriatrician as attending physician on knowledge about and attitudes toward older patients and the field of geriatrics. DESIGN: Randomized trial. INTERVENTION: A 4-week acute care inpatient internal medicine rotation at a university-affiliated Veterans Affairs Medical Center; experiences included caring for acutely ill, older medical patients, interdisciplinary team meetings, geriatrics-based noon conferences, interaction with geriatrics-trained nurse practitioners, and a syllabus of readings on geriatric medicine. PARTICIPANTS: Postgraduate year 1, 2, and 3 internal medicine residents were randomly assigned to one of three groups: (1) the intervention with a geriatrics-trained internist attending (n=44); (2) the intervention with a non-geriatricstrained internist attending (n=25); or (3) no exposure to the intervention (n=24). INSTRUMENTS: Knowledge was assessed using a 35-item test. Attitudes were evaluated using a 24-item questionnaire. RESULTS: There were no differences among the three groups of residents in pretest knowledge (p=.971, analysis of variance). There was a significant difference in the changes in scores from the pretest baseline among the three groups (group 1=.030, group 2=.051, group 3=−.009;p=.039). Both groups assigned to the intervention showed significant improvement in knowledge (p=.011); the presence or absence of a geriatrics-trained attending physician did not alter the results. Resident attitude scores were generally positive and did not change after the intervention. CONCLUSIONS: An intensive integrated acute medicine rotation in geriatrics improved residents’ knowledge of geriatric medicine. The presence of a geriatrics-trained attending physician was not necessary for this improvement. Residents’ attitudes toward geriatric medicine and their geriatrics education were generally positive and were not influenced by this experience.

A Milestone in the Milestones Movement: the JGME Milestones Supplement

The definition of the current competencies as well as their optimal assessment has remained controversial.,14,15 The purpose of competency assessment will need to be clarified, beyond formative vs. summative. Multiple agendas derived from different stakeholders may need to give way to the few that directly impact the goal of producing high caliber, independent practitioners.16 Streamlining the various purposes for assessment will be an important issue for the embryonic milestones as well. The reality for most training programs is that the supply of time and money is decreasing. No matter how laudable the goals of valid, reliable, and national educational outcomes, their implementation must be feasible within this reality. Therefore cost-effectiveness will need to be considered in future assessment studies. We must ensure the competent performance of graduate physicians, in the right balance of specialties, at a reduced cost to the nation; the milestones project may well be measured by how well it contributes to these aims. Will milestones advance the field of assessment and mark a turning point in GME? We urge readers to continue to the national conversation that seeks answers to these questions.

Resident training in nursing home care: survey of successful educational strategies.

OBJECTIVE: To identify educational strategies for resident training in nursing home care deemed successful by a large number of programs.

Knowledge Translation for Education Journals in the Digital Age

Studies have revealed critical delays in translating clinical research findings into practice; they have also highlighted overly rapid adoption of new interventions with limited supporting evidence.1 This too slow or too fast adoption of innovation occurs in medical education as well. Examples include the slow adoption of problem-based learning in the 1980s, the standardization of patients for assessment in the 1990s, and the current rapid move to online teaching modules for a wide array of objectives.2–6

So you want to write? Practices that work.

“I love deadlines. I love the whooshing noise they make as they go by.” -Douglas Adams The Salmon of Doubt: Hitchhiking the Galaxy One Last Time1 Many of us envy and even view with awe the ease with which others write. Program directors and faculty educators often find writing to be uncomfortable, slow, and readily postponed. Yet with a dearth of useful information regarding successful, feasible, and affordable strategies to teach the next generation of physicians, educators must contribute to the national and international discussion. In addition, “publish or perish” is an often-heard term for persons involved in training residents and fellows, particularly at university-based institutions. Whether used to describe research interventions, policy matters, or reviews, writing skills share common elements and fortunately (for those who believe they lack them) are not genetic traits but learned abilities. This editorial will present some current evidence and expert recommendations regarding strategies to move your ideas outward—onto paper or computer screen. One caveat: the goal is not to publish material that is inaccurate or of little use to other educators. According to British pharmacologist David Colquhoun, “Any paper, however bad, can now get published in a journal that claims to be peer-reviewed.”2 The explosion of journals with varying peer-review processes has resulted in exponential publication of marginally worthwhile papers: an estimated 1.6 million papers in 23 000 journals were published in 2006.2 For the purposes of this editorial, we will assume that your work or ideas are important, and the primary deficiency lies instead in generating your words.

Resources for Clinicians Becoming Clinician-Educators.

Early in my career I was lucky to work with terrific mentors and mentees. I am not always sure they were fortunate to work with me. With no formal training in education—other than as a learn-as-you-go piano and ballet teacher and teaching assistant in my youth—I might have benefited greatly from a crash course in educational theory and basic teaching skills. Forty years ago, medical teachers did not receive additional training in education. Back then, the PhDs listed on medical school and residency rosters represented basic scientists, not educators or social scientists. Now there are increasing numbers of medical school and residency program faculty with formal training in education and the social sciences. I see this transition as a groundbreaking change in medical education, in contrast to the “flipped” classroom, which was the norm when I was in training, or simulation, which we called role play, or outcomes-based assessment, formerly labeled clinical skills examination. In my mind, a revolution has begun with the hiring and promoting of faculty with new educational skills and tools, acquired through formal and informal means. This departure from the past may result in more rational, evidence-based training programs. After all, whether used to acquire a new language, new science, or new craft, it is the same human brain that is engaged in the learning process. Medical teachers cannot afford to ignore the science and art of how humans learn. Yet many current program directors, medical school teachers, and other clinician educators did not major in education in college, nor will they have the finances and time to obtain an additional degree. Fortunately, it is not the initials after ones name that are essential but the skill set. Although experiential learning is among the most powerful ways to learn, there are many terrific articles that can enhance ones knowledge, and, if translated into practice, ones skills as a teacher, program director, or educational researcher. I have assembled a list of favorite articles to which I frequently refer faculty, fellows, and authors (table). If you have submitted a paper to the Journal of Graduate Medical Education, it is likely that you have been referred to 1 or more of these articles. This list is not intended to be comprehensive, or to replace a systematic review of influential articles in medical education. Instead, these articles represent idiosyncratic choices that may provide a gentle nudge to start reading outside your clinical field to enhance your educator tool kit. TABLE Reading List for Clinician Educators TABLE Reading List for Clinician Educators (continued) Since reading in a vacuum is not likely to be as helpful as focused reading, I suggest that articles be read when they pertain to an immediate need such that the information can be implemented quickly after reading. As with every other medical skill, teaching and research skills must be practiced and refined to be most effective. Please send us your recommendations as well. Let us know what methods you have employed to enhance your performance as an educator. Happy reading!

How to Create a Bad Survey Instrument

A s educators and education researchers, we often survey trainees, faculty, and patients as a rapid and accurate method to obtain data on outcomes of interest. The Accreditation Council for Graduate Medical Education surveys residents and faculty every year; institutions survey graduating residents and staff regarding learning environments; program directors survey residents about rotation experiences and faculty skills; and researchers use surveys to measure a range of outcomes, from empathy to well-being to patient satisfaction. As editors, we see survey instruments in submitted manuscripts daily. These include questionnaires previously used in other studies, and others that are ‘‘homegrown.’’ In a 2012 review of papers submitted to this journal, 77% used a survey instrument to assess at least 1 outcome, and a more recent study of 3 high-impact medical education journals found that 52% of research studies used at least 1 survey. Despite advice from many sources, including this journal, we continue to see manuscript submissions with surveys unlikely to yield reliable or valid data. We suggest that if you want to create a dubious, lowquality survey, follow the tips in bold below (and see the TABLE). If not, read further about each item. Remember that creating a credible survey may take more time and effort, but it is well worth the investment.

The Burnout Conundrum: Nature Versus Nurture?

F rom my training in epidemiology, I know that incidence and prevalence rates vary enormously according to both the disease detection methods and definitions used and the selection bias for differing populations. These problems are present when we attempt to study the prevalence and effects of interventions on well-being, resilience, and burnout in medical trainees and practicing physicians. Take the example of primary biliary cirrhosis (PBC), a progressive inflammatory liver disease diagnosed through clinical criteria. It was my impression that this was a frequently occurring disease when I trained at Yale University, home of world-renowned hepatologist, Dr. Gerald Klatskin. I saw patients with this disease nearly every week, and it was always high on my list of differential diagnoses. Only after leaving Yale did I realize that this condition is not common. PBC prevalence rose from 1 to 10 cases per million before 1986 to 400 cases per million after 1986; this change is not attributed to an actual increase in incidence, but rather to greater awareness and detection. PBC disease is attributed to environmental triggers interacting with a genetically vulnerable person; thus, host and environmental factors are both important. This is also likely the case for resilience and burnout in physicians.

Update in Geriatric Medicine

INTRODUCTIONWith an aging population, internists will provide care to a growing number of older adults, a population at risk of developing multiple chronic medical conditions and geriatric syndromes. For this update in geriatric medicine, we highlight recent key articles focused on preventive strategies and lifestyle changes that reduce the burden of disease and functional decline in older adults.METHODSWe identified English-language articles published between March 1, 2010 and March 31, 2011 by review of the contents of major geriatrics/general medicine journals and journal watch services including: New England Journal of Medicine, Annals of Internal Medicine, Journal of the American Medical Association, Lancet, Archives of Internal Medicine, British Medical Journal, Journal of the American Geriatrics Society, and the Journals of Gerontology. We also reviewed updates to the Cochrane database of systematic reviews and articles highlighted by the ACP Journal Club and Journal Watch. Inclusion criteria included (1) randomized controlled trials, (2) conditions exclusive or common to older adults, and (3) commonly seen in generalist practices. After abstract review, each author selected five articles, and these were reviewed again by all authors. Through multiple discussions, consensus was reached on the final articles selected for inclusion based on their quality and potential to improve the health of older patients cared for by generalists.

A health professions education editors’ open letter to our community

As editors of journals concerned with health professions education, we take very seriously the influence of our published articles on curriculum development, learner assessment and, ultimately, the quality of health care provided to our communities. As members of the International Editors Group of Health Professions Education Journals, we routinely gather at international meetings to share new ideas, voice concerns and provide support to each other as we grapple with financial, logistical, technical and political challenges faced by our journals. It is therefore appropriate that we clearly communicate our concerns about increasing risks related to current regulations and attitudes affecting international travel, global meetings and global health. As a community of scholars we must reach out to each other, challenge ideas, and identify the most effective and creative approaches regarding how healthcare education can facilitate better health. Doing so benefits all of us, rich or poor, regardless of race, ethnicity, and language, country of residence or cultural values. Disease knows no borders. While health systems, medical knowledge, skills, and medications evolve in response to our unique local conditions, we never know when something in one of our countries will become important (maybe even life-saving) in another.