Karen E. Hauer

Remediation of the Deficiencies of Physicians Across the Continuum From Medical School to Practice: A Thematic Review of the Literature

Despite widespread endorsement of competency-based assessment of medical trainees and practicing physicians, methods for identifying those who are not competent and strategies for remediation of their deficits are not standardized. This literature review describes the published studies of deficit remediation at the undergraduate, graduate, and continuing medical education levels. Thirteen studies primarily describe small, single-institution efforts to remediate deficient knowledge or clinical skills of trainees or below-standard-practice performance of practicing physicians. Working from these studies and research from the learning sciences, the authors propose a model that includes multiple assessment tools for identifying deficiencies, individualized instruction, deliberate practice followed by feedback and reflection, and reassessment. The findings of the study reveal a paucity of evidence to guide best practices of remediation in medical education at all levels. There is an urgent need for multiinstitutional, outcomes-based research on strategies for remediation of less than fully competent trainees and physicians with the use of long-term follow-up to determine the impact on future performance.

A Cross-sectional Descriptive Study of Mentoring Relationships Formed by Medical Students

To describe medical students’ mentoring relationships and determine characteristics associated with having mentors, 232/302 (77%) of third- and fourth-year medical students at the University of California at San Francisco (UCSF) were surveyed. Twenty-six percent of third-year and 45% of fourth-year students had mentors. Most met their mentors during inpatient clerkships (28%), research (19%), or sought them on the basis of similar interests (23%). On multivariate analysis, students who performed research prior to (odds ratio [OR], 4.8; 95% confidence interval [95% CI], 1.4 to 16.7; P=.01) or during medical school (OR, 2.4; 95% CI, 1.1 to 5.6; P=.03) and students satisfied with advising from all sources at UCSF (OR, 1.8; 95% CI, 1.4 to 2.4; P<.001) were more likely to have mentors.

Third-year medical students' experiences with dying patients during the internal medicine clerkship: a qualitative study of the informal curriculum.

Purpose To explore third-year medical students’ experiences with death and dying patients during the first internal medicine clerkship. Method In August 2002, through purposeful sampling, the authors targeted for open-ended interviews 32 third-year medical students at the University of California, San Francisco in the first core internal medicine clerkship. Interviews averaged 45 minutes in length and were audiotaped, transcribed, and analyzed using a grounded theory approach. Results Twenty-eight (87.5%) students participated in interviews. All students encountered death or dying patients, and most cared directly for at least one dying patient. Students’ relationships with patients were characterized by attachment, empathy, and advocacy. Students valued preparation by preclinical end-of-life (EOL) courses, but assigned greater value to patient care experiences guided by teams that acknowledged deaths, role-modeled EOL care, and respected students’ participation in patient care. Clerkship experiences in EOL care affected students’ developing professional identities by affording opportunities to manage strong emotions, understand the challenges of transitioning to residency, and gain a sense of self-efficacy as future physicians providing EOL care. Conclusions Third-year medical students’ experiences with dying patients affect their skills and attitudes in EOL care, as well as the emergence of their professional identities. The behaviors and attitudes modeled by residents and attendings during the clerkships can strongly influence students’ perceptions of and self-efficacy in EOL care. Further research and interventions into how residents and attendings model responses to death in the clinical clerkship may suggest strategies not only for EOL training, but also for mentoring professional development.

Faculty staff perceptions of feedback to residents after direct observation of clinical skills.

Medical Education 2012: 46 : 201–215

Competency-Based Education and Training in Internal Medicine

Recent efforts to improve medical education include adopting a new framework based on 6 broad competencies defined by the Accreditation Council for Graduate Medical Education. In this article, the Alliance for Academic Internal Medicine Education Redesign Task Force II examines the advantages and challenges of a competency-based educational framework for medical residents. Efforts to refine specific competencies by developing detailed milestones are described, and examples of training program initiatives using a competency-based approach are presented. Meeting the challenges of a competency-based framework and supporting these educational innovations require a robust faculty development program. Challenges to competency-based education include teaching and evaluating the competencies related to practice-based learning and improvement and systems-based practice, as well as implementing a flexible time frame to achieve competencies. However, the Alliance for Academic Internal Medicine Education Redesign Task Force II does not favor reducing internal medicine training to less than 36 months as part of competency-based education. Rather, the 36-month time frame should allow for remediation to address deficiencies in achieving competencies and for diverse enrichment experiences in such areas as quality of care and practice improvement for residents who have demonstrated skills in all required competencies.

The role of role: learning in longitudinal integrated and traditional block clerkships

Medical Education 2012: 46:698–710

Twelve tips for implementing tools for direct observation of medical trainees’ clinical skills during patient encounters

Background: Direct observation of medical trainees by their supervisors with actual patients is essential for trainees to develop clinical skills competence. Despite the many available tools for direct observation of trainees by supervisors, it is unclear how educators should identify an appropriate tool for a particular clinical setting and implement the tool to maximize educational benefits for trainees in a manner that is feasible for faculty. Aims and methods: Based on our previous systematic review of the literature, we provide 12 tips for selecting and incorporating a tool for direct observation into a medical training program. We focus specifically on direct observation that occurs in clinical settings with actual patients. Results: Educators should focus on the existing tools for direct observation that have evidence of validity. Tool implementation must be a component of an educational program that includes faculty development about rating performance, providing meaningful feedback, and developing action plans collaboratively with learners. Conclusions: Educators can enhance clinical skills education with strategic incorporation of tools for direct observation into medical training programs. Identification of a psychometrically sound instrument and attention to faculty development and the feedback process are critical to the success of a program of direct observation.

More is better: students describe successful and unsuccessful experiences with teachers differently in brief and longitudinal relationships.

Purpose Clerkship experiences that structure student–teacher continuity may promote learning differently than brief student–teacher relationships. The authors compared students’ successful and unsuccessful teaching experiences in brief and longitudinal relationships. Method A multicenter, qualitative interview study was conducted in 2009–2010 of students in two clerkship models that provide different durations of student–teacher relationships. Each student described a successful and unsuccessful teaching relationship early and late in the core clerkship year. Questions explored teachers’ strategies and behaviors and students’ efforts to improve unsuccessful relationships. Interview transcripts were coded to identify major themes. Results Fifty-four students completed interviews. Students in brief relationships struggled to be known; students in longitudinal relationships felt respected as learners and partners. Teaching strategies differed in the two relationship durations. Questioning about factual knowledge was common in brief relationships; collaborative knowledge sharing and application to patients occurred in longitudinal relationships. Hierarchy characterized brief relationships. Longitudinal students experienced evolving expectations in response to their growing skills and contributions. Only students in longitudinal relationships described successfully intervening to improve unsuccessful relationships; students in brief relationships felt powerless. Conclusions Clerkship students in brief relationships learn to adapt to teachers’ preferences and questioning to facilitate their participation and knowledge acquisition; longitudinal students experience collaborative interactions focused on their development as care providers. In longitudinal relationships, students gain confidence to influence their own learning and modify circumstances to meet their learning needs. These findings suggest that medical students’ clinical experiences may be enhanced by deliberately structuring longitudinal attachments to supervisors.

Medical students' perceptions of mentoring: a focus-group analysis

Characteristics of medical students’ mentoring relationships and factors that affect mentoring during medical school are poorly understood. The authors conducted four focus groups with fourth-year medical students to explore what students sought from mentors, perceived barriers to mentoring and suggestions for improvement. Data were analyzed using grounded theory. Students with and without mentors described a mentoring relationship as a personal connection with a faculty member invested in helping the student achieve a personal and professional vision. The short duration of courses, abrupt change from classroom learning to clerkships and limited exposure to clinicians were perceived as barriers to mentoring. Students recommended that the school explicitly promote mentoring with early education about finding mentors, placing the responsibility on students while also expanding the pool of potential mentors. It is concluded that medical students characterize mentoring in terms of the interpersonal dynamics of the relationship, emphasizing personal connection and advocacy. Educating and empowering students along with faculty education regarding students’ needs may improve mentoring.

Development of a longitudinal integrated clerkship at an academic medical center

Abstract In 2005, medical educators at the University of California, San Francisco (UCSF), began developing the Parnassus Integrated Student Clinical Experiences (PISCES) program, a year-long longitudinal integrated clerkship at its academic medical center. The principles guiding this new clerkship were continuity with faculty preceptors, patients, and peers; a developmentally progressive curriculum with an emphasis on interdisciplinary teaching; and exposure to undiagnosed illness in acute and chronic care settings. Innovative elements included quarterly student evaluation sessions with all preceptors together, peer-to-peer evaluation, and oversight advising with an assigned faculty member. PISCES launched with eight medical students for the 2007/2008 academic year and expanded to 15 students for 2008/2009. Compared to UCSFs traditional core clerkships, evaluations from PISCES indicated significantly higher student satisfaction with faculty teaching, formal didactics, direct observation of clinical skills, and feedback. Student performance on discipline-specific examinations and United States Medical Licensing Examination step 2 CK was equivalent to and on standardized patient examinations was slightly superior to that of traditional peers. Participants’ career interests ranged from primary care to surgical subspecialties. These results demonstrate that a longitudinal integrated clerkship can be implemented successfully at a tertiary care academic medical center.