H. Barrett Fromme

Direct Observation in Medical Education: A Review of the Literature and Evidence for Validity

In 2000, the Accreditation Council for Medical Education introduced a new initiative that substantively changed the method by which residency programs are evaluated. In this new competency-based approach to residency education, assessment of performance became a main area of interest, and direct observation was offered as a tool to assess knowledge and skills. Despite being an inherent part of medical education as faculty and learners work together in clinical experiences, direct observation has traditionally been an informal and underused assessment method across all specialties. Residents and students report rarely being observed during their educational process, even though they value the experience. Reasons for this include a lack of faculty time, a lack of faculty skills, a potential stressful effect on the learner, and a perceived lack of validation of the assessment. This article examines the literature regarding the use of direct observation in medical education with a focus on validity evidence. We performed a PubMed search of articles pertaining to direct observation, using key words such as direct observation, performance observation, clinical observation, students, and residents. A subsequent search was conducted in known articles, focusing on variations of the term observation in the titles of articles and introducing the concept of clinical competence. In conclusion, direct observation is a unique and useful tool in the assessment of medical students and residents. Assessing learners in natural settings offers the opportunity to see beyond what they know and into what they actually do, which is fundamentally essential to training qualified physicians. Although the literature identifies several threats to its validity as an assessment, it also demonstrates methods to minimize those threats. Based on the current recommendations and need for performance assessment in education and with attention paid to the development and design, direct observation can and should be included in medical education curricula.

How medical students learn from residents in the workplace: A qualitative study

Purpose To explore what third-year medical students learn from residents and which teaching strategies are used by excellent resident teachers in their interactions with students in the clinical workplace environment. Method In this multi-institutional qualitative study between January and March 2012, the authors conducted focus groups with medical students who were midway through their third year. Qualitative analysis was used to identify themes. Results Thirty-seven students participated. Students contributed 228 comments related to teaching methods used by residents. The authors categorized these into 20 themes within seven domains: role-modeling, focusing on teaching, creating a safe learning environment, providing experiential learning opportunities, giving feedback, setting expectations, and stimulating learning. Role-modeling, the most frequently classified method of teaching in this study, was not included in three popular “Resident-as-Teacher” (RAT) models. Strategies including offering opportunities for safe practice, involving students in the team, and providing experiential learning opportunities were not emphasized in these models either. Almost 200 comments representing the knowledge and skills students learned from residents were categorized into 33 themes within nine domains: patient care, communication, navigating the system, adaptability, functioning as a student/resident, lifelong learning, general comments, career/professional development, and medical content. Most of these areas are not emphasized in popular RAT models. Conclusions Residents serve as critically important teachers of students in the clinical workplace. Current RAT models are based largely on the teaching behaviors of faculty. The content and teaching strategies identified by students in this study should serve as the foundation for future RAT program development.

The qualities and skills of exemplary pediatric hospitalist educators: a qualitative study.

Purpose To identify the qualities and skills of exemplary and ideal pediatric hospitalist educators. Method The authors conducted a prospective, multi-institutional qualitative study from November 2008 through January 2009 in which they interviewed pediatric hospitalists who were identified as exemplary educators at three academic pediatric residency programs. They then conducted focus groups with residents and medical students who had recently worked with these hospitalists. Qualitative analysis was used to identify themes. Results All six hospitalists identified as exemplary participated. Among invited learners, 14/18 residents (78%) and 16/18 medical students (89%) participated. Together, the participants contributed 266 comments, which the authors categorized into 36 themes within the four domains of teaching skills, personal qualities, patient care skills, and role modeling. New qualities and skills—including self-reflection/insight, encouraging autonomy, time management, knowledge acquisition, and systems knowledge—and differences in perceptions among hospitalists, residents, and students were identified. Differences between the qualities and skills of actual exemplary hospitalist educators and perceptions of those of an ideal hospitalist educator were also identified. Conclusions Pediatric hospitalists in academic residency programs have unique opportunities to significantly affect the education of medical students and residents. This study validates and expands on prior studies of the qualities and skills needed to be a successful hospitalist educator. Researchers and educators designing faculty development programs to train more successful hospitalist educators may wish to target these qualities and skills as well as the differences in medical student and resident needs.

Residents-as-Teachers Publications: What Can Programs Learn From the Literature When Starting a New or Refining an Established Curriculum?

BACKGROUND Teaching residents how to teach is a critical part of resident education because residents are often the major teachers of medical students. The importance of formal residents-as-teachers (RAT) curricula has been emphasized throughout the literature, yet not all residency programs have such a curriculum in place. OBJECTIVE The purpose of our study was to (1) review the medical education literature for established RAT curricula, (2) assess published curriculas reproducibility, (3) evaluate the type of outcomes achieved using the Kirkpatrick model of evaluation, and (4) identify curricula that training programs could feasibly adopt. METHODS We performed a literature review using PubMed, Medline, Scopus, PsycINFO, ERIC, and Embase. Key search words included residents, residents as teachers, teaching, internship and residency, and curriculum. In addition, a search of MedEdPORTAL was performed using the same key terms. Articles were evaluated based on the reproducibility of curricula and the assessment tools. Evaluation of educational outcomes was performed using the Kirkpatrick model. RESULTS Thirty-nine articles were deemed appropriate for review. Interventions and evaluation techniques varied greatly. Only 1 article from the literature was deemed to have both curricula and assessments that would be fully reproducible by other programs. CONCLUSIONS A literature review on RAT curricula found few articles that would be easily reproduced for residency programs that want to start or improve their own RAT curricula. It also demonstrated the difficulty and lack of rigorous outcome measurements for most curricula.

Acute Scrotal Swelling in a Newborn With Bacteremia

clinically stable and afebrile throughout his course. On hospital day 4, the patient was discharged to complete a 10-day course of intramuscular ceftriaxone daily as an outpatient. The following day his primary care physician noted him to be well appearing, afebrile, and active, but there was left scrotal swelling with mild discomfort on palpation. The scrotum was not discolored and did not transilluminate. An emergent scrotal ultrasound demonstrated areas of heterogeneously increased and decreased echogenicity with a complex hydrocele and enlarged epididymis. Doppler showed increased flow around the left testis, which measured 1.0 cm × 0.8 cm × 0.8 cm. The right testis was normal in appearance. A radiologic diagnosis of chronic left testicular torsion was made, and the patient was scheduled for urologic surgery the following day. At surgery, the left spermatic cord showed no evidence of torsion, but both the epididymis and the cord had significant inflammation. The testis was of normal size and pink, with an inflammatory peel around the entire testis. As the testis was high riding on initial exploration, an orchidopexy was performed. The pathology of the inflammatory peel confirmed the presence of necrosis and inflammatory debris, leading to a final diagnosis of left epididymitis. Postoperatively the patient underwent renal ultrasound (RUS) and voiding cystoureterogram (VCUG). The RUS revealed bilateral grade 1 hydronephrosis without evidence of a duplicated system or ectopic ureter. The VCUG was negative. A repeat RUS was obtained 1 month later with resolution of the hydronephrosis. The patient has been doing well since.

A novel workplace-based assessment for competency-based decisions and learner feedback

Abstract Background: Increased recognition of the importance of competency-based education and assessment has led to the need for practical and reliable methods to assess relevant skills in the workplace. Methods: A novel milestone-based workplace assessment system was implemented in 15 pediatrics residency programs. The system provided: (1) web-based multisource feedback (MSF) and structured clinical observation (SCO) instruments that could be completed on any computer or mobile device; and (2) monthly feedback reports that included competency-level scores and recommendations for improvement. Results: For the final instruments, an average of five MSF and 3.7 SCO assessment instruments were completed for each of 292 interns; instruments required an average of 4–8 min to complete. Generalizability coefficients >0.80 were attainable with six MSF observations. Users indicated that the new system added value to their existing assessment program; the need to complete the local assessments in addition to the new assessments was identified as a burden of the overall process. Conclusions: Outcomes – including high participation rates and high reliability compared to what has traditionally been found with workplace-based assessment – provide evidence for the validity of scores resulting from this novel competency-based assessment system. The development of this assessment model is generalizable to other specialties.

Residents' Perspectives on Rewards and Challenges of Caring for Ambulatory Care Patients Living With Chronic Illness: Findings From Three Academic Health Centers.

Purpose To elicit residents’ perspectives on rewards and challenges of caring for ambulatory patients with chronic illness and ways to improve their education in caring for these patients. Method The authors conducted a qualitative study with internal medicine residents during ambulatory medicine block rotations at three academic health centers from October 2011 through February 2012. Focus group questions covered rewards and challenges of caring for patients with chronic illness and strengths and weaknesses of residency education therein, and the Chronic Care Model provided a framework for interpretation. Qualitative analysis was used to identify themes. Results Five focus groups were conducted with 28 residents. Discussions yielded 224 comments, which were categorized into 5 domains and 36 themes. Twelve themes related to perceptions of challenges in providing care, and 3 themes related to perceptions of rewards in providing care. Eight themes focused on strategies to improve the patient experience. Strengths of the residency program were identified in 7 themes. Six themes related to ways for improving learning about caring for patients with chronic disease in the ambulatory setting. Conclusions Residents perceived rewards, challenges, and barriers in caring for patients with chronic illness in the ambulatory setting, from providers’ and patients’ perspectives. They have developed strategies to provide effective patient care. Residents identified best practices in their residency for resident education and patient care and also made suggestions for improvement. Findings have significant implications for residency education and practice redesign in the 21st century for care of patients with chronic illness.

Top Medical Education Studies of 2016: A Narrative Review

Education, like clinical medicine, should be based on the most current evidence in the field. Unfortunately, medical educators can be overwhelmed by the sheer volume and range of resources for this literature. This article provides an overview of 15 articles from 2016 that the authors consider the top articles in the field of pediatric medical education. The 7 authors, all medical educators with combined leadership and expertise across the continuum of pediatric medical education, used an iterative 3-stage process to review more than 6339 abstracts published in 2016. This process was designed to identify a small subset of articles that were most relevant to educational practices and most applicable to pediatric medical education. In the first 2 stages, pairs of authors independently reviewed and scored abstracts in 13 medical education-related journals and reached consensus to identify the articles that best met these criteria. In the final stage, all articles were discussed using a group consensus model to select the final articles included in this review. This article presents summaries of the 15 articles that were selected. The results revealed a cluster of studies related to observed standardized clinical encounters, self-assessment, professionalism, clinical teaching, competencies/milestones, and graduate medical education management strategies. We provide suggestions on how medical educators can apply the findings to their own practice and educational settings. This narrative review offers a useful tool for educators interested in keeping informed about the most relevant and valuable information in the field.

What's the Purpose of Rounds? A Qualitative Study Examining the Perceptions of Faculty and Students

BACKGROUND: Rounds are a critical activity on any inpatient service, but there is little literature describing the purpose of rounds from the perspective of faculty and trainees in teaching hospitals. OBJECTIVE: To evaluate and compare the perceptions of pediatric and internal medicine attendings and medical students regarding the purpose of inpatient attending rounds. METHODS: The authors conducted 10 semistructured focus groups with attendings and medical students in the spring of 2014 at 4 teaching hospitals. The protocol was approved by the institutional review boards at all institutions. The authors employed a grounded theory approach to data collection and analysis, and data were analyzed by using the constant‐comparative method. Two transcripts were read and coded independently by 2 authors to generate themes. RESULTS: Forty‐eight attendings and 31 medical students participated in the focus groups. We categorized 218 comments into 4 themes comprised of 16 codes representing what attendings and medical students believed to be the purpose of rounds. These themes included communication, medical education, patient care, and assessment. CONCLUSIONS: Our results highlight that rounds serve 4 purposes, including communication, medical education, patient care, and assessment. Importantly, both attendings and students agree on what they perceive to be the many purposes of rounds. Despite this, a disconnect appears to exist between what people believe are the purposes of rounds and what is happening during rounds.

An Unusual Cause of a Red and Swollen Eye in an 11-Month-Old Child:

2001 Westminster Publications, Inc., 708 Glen Cove Avenue, Glen Head, NY 11545, U.S.A. to methicillin, ana the foreign material was identified as green paint, similar in appearance to the material found in paintball pellets. A postoperative CT showed resolution of the abscess and no signs of additional foreign material. Further questioning ofthe mother did not elicit any history of trauma, penetrating injuries, exposure to green paint, or paintball games. Follow-up with the ophthalmologist revealed no complications and normal vision in the right eye.