Janet P. Hafler

Formal art observation training improves medical students' visual diagnostic skills.

BackgroundDespite evidence of inadequate physical examination skills among medical students, teaching these skills has declined. One method of enhancing inspection skills is teaching “visual literacy,” the ability to reason physiology and pathophysiology from careful and unbiased observation.ObjectiveTo improve students’ visual acumen through structured observation of artworks, understanding of fine arts concepts and applying these skills to patient care.DesignProspective, partially randomized pre- vs. post-course evaluation using mixed-methods data analysis.ParticipantsTwenty-four pre-clinical student participants were compared to 34 classmates at a similar stage of training.InterventionTraining the Eye: Improving the Art of Physical Diagnosis consists of eight paired sessions of art observation exercises with didactics that integrate fine arts concepts with physical diagnosis topics and an elective life drawing session.MeasurementsThe frequency of accurate observations on a 1-h visual skills examination was used to evaluate pre- vs. post-course descriptions of patient photographs and art imagery. Content analysis was used to identify thematic categories. All assessments were blinded to study group and pre- vs. post-course evaluation.ResultsFollowing the course, class participants increased their total mean number of observations compared to controls (5.41u2009±u20090.63 vs. 0.36u2009±u20090.53, pu2009<u20090.0001) and had increased sophistication in their descriptions of artistic and clinical imagery. A ‘dose-response’ was found for those who attended eight or more sessions, compared to participants who attended seven or fewer sessions (6.31u2009+u20090.81 and 2.76u2009+u20091.2, respectively, pu2009=u20090.03).ConclusionsThis interdisciplinary course improved participants’ capacity to make accurate observations of art and physical findings.

Advancing educators and education by defining the components and evidence associated with educational scholarship

Objectiveu2002 This study aimed to establish documentation standards for medical education activities, beyond educational research, for academic promotion consistent with principles of excellence and scholarship.

Decoding the learning environment of medical education: a hidden curriculum perspective for faculty development.

Medical student literature has broadly established the importance of differentiating between formal-explicit and hidden-tacit dimensions of the physician education process. The hidden curriculum refers to cultural mores that are transmitted, but not openly acknowledged, through formal and informal educational endeavors. The authors extend the concept of the hidden curriculum from students to faculty, and in so doing, they frame the acquisition by faculty of knowledge, skills, and values as a more global process of identity formation. This process includes a subset of formal, formative activities labeled faculty development programs that target specific faculty skills such as teaching effectiveness or leadership; however, it also includes informal, tacit messages that faculty absorb. As faculty members are socialized into faculty life, they often encounter conflicting messages about their role. In this article, the authors examine how faculty development programs have functioned as a source of conflict, and they ask how these programs might be retooled to assist faculty in understanding the tacit institutional culture shaping effective socialization and in managing the inconsistencies that so often dominate faculty life.

Assessing Procedural Skills Training in Pediatric Residency Programs

OBJECTIVE. The objective of this study was to assess the opinions of pediatric program directors regarding procedural skills training of pediatric residents. METHODS. We developed a survey based on the Residency Review Committees guidelines for procedural training. It included items about the importance of 29 procedures encountered in pediatric training, estimates of residents competence in performing them, and the teaching of procedural skills. The survey was sent to members of the Association of Pediatric Program Directors. The primary outcome was the perceived importance for residents to achieve competence in these procedures, rated on a 10-point Likert scale. Secondary outcomes included perception of resident competence to perform procedures and educational methods used by respondents for teaching procedural skills. Associations between demographic characteristics and perceived importance or competence were also assessed. RESULTS. Surveys were sent to 139 programs, and 112 responded. Thirteen procedures were rated 8 or higher by >75% of program directors. Seven skills that were prioritized by the Residency Review Committee did not achieve this level of consensus. Respondents reported that many residents failed to achieve competence by the end of training in 9 of 13 procedures that they rated as very important, including venipuncture, neonatal intubation, and administering injections. Residents who perform the majority of venipunctures and intravenous catheter placements at their institutions were more likely to be judged competent in performing these skills than residents who do not. CONCLUSIONS. The Residency Review Committees list of procedures does not necessarily reflect the opinions of pediatric program directors on the most essential skills for trainees. Many residents may not develop competence in several important procedures by the end of residency, most notably vascular access and life-saving skills. A more robust and standardized method is needed for teaching procedural skills and for documenting competence.

Documentation Systems for Educators Seeking Academic Promotion in U.S. Medical Schools

Purpose. To explore the state and use of teaching portfolios in promotion and tenure in U.S. medical schools. Method. A two-phase qualitative study using a Web-based search procedure and telephone interviews was conducted. The first phase assessed the penetration of teaching portfolio-like systems in U.S. medical schools using a keyword search of medical school Web sites. The second phase examined the current use of teaching portfolios in 16 U.S. medical schools that reported their use in a survey in 1992. The individual designated as having primary responsibility for faculty appointments/promotions was contacted to participate in a 30–60 minute interview. Results. The Phase 1 search of U.S. medical schools’ Web sites revealed that 76 medical schools have Web-based access to information on documenting educational activities for promotion. A total of 16 of 17 medical schools responded to Phase 2. All 16 continued to use a portfolio-like system in 2003. Two documentation categories, honors/awards and philosophy/personal statement regarding education, were included by six more of these schools than used these categories in 1992. Dissemination of work to colleagues is now a key inclusion at 15 of the Phase 2 schools. The most common type of evidence used to document education was learner and/or peer ratings with infrequent use of outcome measures and internal/external review. Conclusions. The number of medical schools whose promotion packets include portfolio-like documentation associated with a faculty members excellence in education has increased by more than 400% in just over ten years. Among early-responder schools the types of documentation categories have increased, but students’ ratings of teaching remain the primary evidence used to document the quality or outcomes of the educational efforts reported.

Reforming Procedural Skills Training for Pediatric Residents: A Randomized, Interventional Trial

BACKGROUND: Pediatric housestaff are required to learn basic procedural skills and demonstrate competence during training. To our knowledge, an evidenced-based procedural skills curriculum does not exist. OBJECTIVE: To create, implement, and evaluate a modular procedural skills curriculum for pediatric residents. METHODS: A randomized, controlled trial was performed. Thirty-eight interns in the Boston Combined Residency Program who began their training in 2005 were enrolled and randomly assigned. Modules were created to teach residents bag-mask ventilation, venipuncture, peripheral intravenous catheter (PIV) insertion, and lumbar puncture skills. The curriculum was administered to participants in the intervention group during intern orientation. Interns in the control group learned procedural skills by usual methods. Subjects were evaluated by using a structured objective assessment on simulators immediately after the intervention and 7 months later. Success in performing live-patient procedures was self-reported by subjects. The primary outcome was successful performance of the procedure on the initial assessment. Secondary outcomes included checklist and knowledge examination scores, live-patient success, and qualitative assessment of the curriculum. RESULTS: Participants in the intervention group performed PIV placement more successfully than controls (79% vs 35%) and scored significantly higher on the checklist for PIV placement (81% vs 61%) and lumbar puncture (77% vs 68%) at the initial assessment. There were no differences between groups at month 7, and both groups demonstrated declining skills. There were no statistically significant differences in success on live-patient procedures. Those in the intervention group scored significantly higher on knowledge examinations. CONCLUSIONS: Participants in the intervention group were more successful performing certain simulated procedures than controls when tested immediately after receiving the curriculum but demonstrated declining skills thereafter. Future efforts must emphasize retraining, and residents must have sufficient opportunities to practice skills learned in a formal curriculum.

Pediatric residents' perceptions of communication competencies: Implications for teaching.

Background: Medical regulatory organizations worldwide require competency in communication skills. Pediatric communication competencies are unique, and little is known about pediatric residents’ perceptions regarding these skills. Aim: The purpose of this study was to examine pediatric residents’ attitudes about communication skills, their perceptions of the importance of learning 15 specific communication skills relevant to pediatrics, confidence in these skills, and relevant program supports. Methods: We developed a 47-item cross-sectional questionnaire to study pediatric residents’ attitudes and perceptions regarding communication competencies. 104 pediatric housestaff in a university-affiliated program in the US were asked to complete the questionnaire. Scale variables were created and evaluated for reliability. Data were analysed using descriptive and univariate statistics. Results: Response rate was 86% (89/104). Cronbachs alpha reliabilities of the Importance Scale (r = 0.92) and Confidence Scale (r = 0.90) were excellent. Ninety nine percent of the participants agreed that learning to communicate effectively with patients was a priority. All agreed it is important to demonstrate empathy and caring, and to teach medical students to communicate effectively with patients. Pediatric residents agreed that the 15 communication competencies studied were important to learn. Most reported confidence in core communication competencies (interviewing, listening, building rapport, demonstrating caring and empathy), but only half or fewer were confident in 7 more advanced communication skills (ability to discuss end-of-life issues, speaking with children about serious illness, giving bad news, dealing with the ‘difficult’ patient/parent, cultural awareness/sensitivity, understanding psychosocial aspects, and understanding patients’ perspectives). Few reported the availability of relevant program supports for learning these skills. Conclusions: Pediatric residents perceive communication competencies as important and a priority for learning, yet report a lack of confidence in advanced communication skills and insufficient program supports. Our measurement scales can add to the evaluation of residency programs, and may provide suggestions for pediatric curricular content in core and advanced communication skills.

Influence of new educational technology on problem‐based learning at Harvard Medical School

Purposeu2002 Computers with 50‐inch, wall‐mounted plasma screens and broadband Internet access were installed in all small group tutorial rooms at Harvard Medical School. This study examines how the introduction of this educational technology impacted on the problem‐based learning tutorials.

Scholarly activities recorded in the portfolios of teacher-clinician faculty.

Purpose To explore what contributions to scholarship teacher-clinician faculty list in the portfolios that they use as evidence for promotion. Method In 1998, the authors randomly selected 15 Harvard Medical School teacher-clinicians (five from each rank of assistant, associate, and full professor) from among 120 such faculty members who had been successfully promoted between 1990 and 1997. Using a descriptive research study design, the authors counted and categorized the contributions to scholarship, teaching, and committee service that the faculty listed in their portfolios. They did not assess the quality or weighting of the contributions. Results According to the portfolios, the faculty members had contributed to both teaching and scholarships at local, regional, and national levels. They listed not only peer-reviewed original journal articles, but also works that integrated and synthesized knowledge: specifically, chapters, textbooks, editorials, syllabi, newsletters, computer resources, and videotapes. Faculty generally had published in multiple areas of scholarship, which fell in two domains: the faculty members subspecialty and medical education. The number of publications increased at each promotion level. The faculty also participated in broad-based teaching and education at the student, resident, fellow, and continuing medical education levels. Leadership contributions in education had occurred not only locally and regionally but also at a national level. Finally, faculty participated actively in service to the medical school, hospital, and national organizations, with leadership roles at the associate and full professor levels. Conclusion The academic culture at Harvard Medical School has shifted from promotion based solely on original scholarship to promotion based on a broad array of educational contributions. The faculty, as they seek promotion, create portfolios that list written scholarship, teaching, and service at the local, regional, and national levels and at all ranks of promotion.

Guiding principles for the development of global health education curricula in undergraduate medical education

Background: Global health education (GHE) at undergraduate medical institutions has expanded significantly over the last 30 years, but many questions remain regarding the best practices for the development and implementation of global health programs. Aim: To identify key themes essential to the development of GHE programs. Method: We discuss five themes relevant to GHE in the context of existing literature and practice. Results: The following themes are essential to the development of GHE programs: the definition and scope of GHE, student competencies in global health, the challenges and opportunities associated with inter-institutional relationships, principles for GHE student placements, and the evaluation of GHE programs. We place these themes in the context of current literature and practice, and provide practical guidance on how these themes might be successfully implemented by institutions seeking to develop or refine GHE programs. Conclusions: Institutions developing or evaluating GHE programs should focus on these themes as they build their global health curricula.