Klara K. Papp

The effects of sleep loss and fatigue on resident-physicians: a multi-institutional, mixed-method study.

Purpose. To identify and model the effects of sleep loss and fatigue on resident–physicians’ professional lives and personal well-being. Method. In 2001–02, 149 residents at five U.S. academic health centers and from six specialties (obstetrics–gynecology, emergency medicine, family medicine, internal medicine, pediatrics, surgery) were recruited for the study. Residents were all in good standing in their programs. In a mixed-methods design, focus groups consisted of an average of seven (range, three to 14) individuals in the same year of training and residency program, for a total of 60 interns and 89 senior residents. Trained moderators conducted focus groups using a standardized, semistructured discussion guide. Participants also completed a 30-item quantitative questionnaire assessing sleepiness and workplace sleep attitudes that included the Epworth Sleepiness Scale (ESS). Results. Residents described multiple adverse effects of sleep loss and fatigue on learning and cognition; job performance, including professionalism and task performance; and personal life, including personal well-being and relationships with spouse or significant other and family. Only 16% of the sample scored within the “normal” range on the ESS; 84% scored in the range for which clinical intervention is indicated. Sleepiness was consistent across institution, specialty, years of training, age, gender, marital status, and having children. Conclusions. More residents perceived that sleep loss and fatigue had major impact on their personal lives during residency, leaving many personal and social activities and meaningful personal pleasures deferred or postponed. Sleep loss and fatigue also had major impact on residents’ abilities to perform their work. This finding further substantiates the growing concern about the potential impact on professional development. These observations should be taken into account in developing new training guidelines and educational interventions for housestaff.

SNAPPS: a learner-centered model for outpatient education.

The unique character of medical education in the outpatient setting has created challenges in teaching and learning that cannot be solved by the adaptation of traditional inpatient approaches. Previous work and the authors’ own observational study describe a relatively passive learner focused on reporting history and physical examination data to the preceptor. Based on the work of Bordage in cognitive learning, and that of Osterman and Kottkamp on reflective practice for educators, the authors have developed a collaborative model for case presentations in the outpatient setting that links learner initiation and preceptor facilitation in an active learning conversation. This learner-centered model for case presentations to the preceptor follows a mnemonic called SNAPPS consisting of six steps: (1) Summarize briefly the history and findings; (2) Narrow the differential to two or three relevant possibilities; (3) Analyze the differential by comparing and contrasting the possibilities; (4) Probe the preceptor by asking questions about uncertainties, difficulties, or alternative approaches; (5) Plan management for the patient’s medical issues; and (6) Select a case-related issue for self-directed learning. The authors conducted a pilot study of SNAPPS, introducing the model to both third-year medical students and their preceptors. Feedback was enthusiastic and underscored the importance of the paired approach. SNAPPS represents a paradigm shift in ambulatory education that engages the learner and creates a collaborative learning conversation in the context of patient care.

Antibody Responses to Bordetella pertussis Antigens and Clinical Correlations in Elderly Community Residents

A serological study to determine the frequency of Bordetella pertussis infection in 100 adults aged >/=65 years was carried out over a 3-year period. Ten serum samples (collected every 4 months) from each subject were examined for IgA and IgG antibodies to the following B. pertussis antigens: pertussis toxin (PT), filamentous hemagglutinin (FHA), pertactin, and fimbriae-2. A >/=2-fold titer increase in ELISA units from one time period to the next was considered serological evidence of infection. The rate of serologically defined infection (i.e., in which there was an increase in titer against any antigen) was 19.7 per 100 person-years. With the use of more specific criteria that indicate definite B. pertussis infection (>/=2-fold increase in titer to PT) and probable B. pertussis infection (>/=2-fold increase in titer to PT or >/=2-fold increase to fimbriae-2), the rates were 3.3 and 8.0 per 100 person-years, respectively. Fifty percent of individuals with definite B. pertussis infections had time-associated symptomatology. Antibody patterns over time suggest that antibody to FHA and perhaps to pertactin is stimulated by infections with other organisms, as well as B. pertussis infections. Our data suggest that symptomatic pertussis occurs in elderly individuals. Consideration should be given to immunization of the elderly with acellular pertussis vaccines.

Developing a mentorship program for clinical researchers.

Introduction: In academic health centers, the number of physician investigators and the number of research studies headed by clinicians has been declining. The U.S. Institute of Medicine and the National Institutes of Health suggest improved mentoring is important to reversing these trends. Methods: This is a case study review of the role of mentors in developing and sustaining clinical investigators at the Cleveland Clinic. Results: Issues influencing mentoring relationships at the Cleveland Clinic include whether mentoring contracts are formally or informally related and are agreed on; whether there are scheduled meetings for mentors and protégés; whether there are clearly articulated benchmarks and manageable steps; and whether there is a code of mentorship. Conclusions: Interactive group formats can lead to development of a code of mentorship and increased awareness of faculty regarding clinical investigation.

Grade Inflation in the Internal Medicine Clerkship: A National Survey

Background: Grade inflation is a growing concern, but the degree to which it continues to exist in 3rd-year internal medicine (IM) clerkships is unknown. Purpose: The authors sought to determine the degree to which grade inflation is perceived to exist in IM clerkships in North American medical schools. Methods: A national survey of all Clerkship Directors in Internal Medicine members was administered in 2009. The authors assessed key aspects of grading. Results: Response rate was 64%. Fifty-five percent of respondents agreed that grade inflation exists in the Internal Medicine clerkship at their school. Seventy-eight percent reported it as a serious/somewhat serious problem, and 38% noted students have passed the IM clerkship at their school who should have failed. Conclusions: A majority of clerkship directors report that grade inflation still exists. In addition, many note students who passed despite the clerkship director believing they should have failed. Interventions should be developed to address both of these problems.

Educating for the 21st-Century Health Care System: An Interdependent Framework of Basic, Clinical, and Systems Sciences

In the face of a fragmented and poorly performing health care delivery system, medical education in the United States is poised for disruption. Despite broad-based recommendations to better align physician training with societal needs, adaptive change has been slow. Traditionally, medical education has focused on the basic and clinical sciences, largely removed from the newer systems sciences such as population health, policy, financing, health care delivery, and teamwork. In this article, authors examine the current state of medical education with respect to systems sciences and propose a new framework for educating physicians in adapting to and practicing in systems-based environments. Specifically, the authors propose an educational shift from a two-pillar framework to a three-pillar framework where basic, clinical, and systems sciences are interdependent. In this new three-pillar framework, students not only learn the interconnectivity in the basic, clinical, and systems sciences but also uncover relevance and meaning in their education through authentic, value-added, and patient-centered roles as navigators within the health care system. Authors describe the Systems Navigation Curriculum, currently implemented for all students at the Penn State College of Medicine, as an example of this three-pillar educational model. Simple adjustments, such as including occasional systems topics in medical curriculum, will not foster graduates prepared to practice in the 21st-century health care system. Adequate preparation requires an explicit focus on the systems sciences as a vital and equal component of physician education.

Milestones of critical thinking: a developmental model for medicine and nursing.

Critical thinking is essential to a health professional’s competence to assess, diagnose, and care for patients. Defined as the ability to apply higher-order cognitive skills (conceptualization, analysis, evaluation) and the disposition to be deliberate about thinking (being open-minded or intellectually honest) that lead to action that is logical and appropriate, critical thinking represents a “meta-competency” that transcends other knowledge, skills, abilities, and behaviors required in health care professions. Despite its importance, the developmental stages of critical thinking have not been delineated for nurses and physicians. As part of a task force of educators who considered different developmental stage theories, the authors have iteratively refined and proposed milestones in critical thinking. The attributes associated with unreflective, beginning, practicing, advanced, accomplished, and challenged critical thinkers are conceived as independent of an individual’s level of training. Depending on circumstances and environmental factors, even the most experienced clinician may demonstrate attributes associated with a challenged thinker. The authors use the illustrative case of a patient with abdominal pain to demonstrate how critical thinking may manifest in learners at different stages of development, analyzing how the learner at each stage applies information obtained in the patient interaction to arrive at a differential diagnosis and plan for evaluation. The authors share important considerations and provide this work as a foundation for the development of effective approaches to teaching and promoting critical thinking and to establishing expectations for learners in this essential meta-competency.

Clinician educators' experiences with institutional review boards: Results of a national survey

Purpose To explore clinician educators’ perceptions and experiences in obtaining institutional review board (IRB) approval to conduct medical education research (MER). Method Institutional members of the Clerkship Directors in Internal Medicine (CDIM; n = 110) were surveyed in 2006. The survey included questions about familiarity with and clarity of IRB policies, satisfaction with review of education research protocols, and how MER might be facilitated. Results Of 83 respondents (response rate 76%), 50 had submitted a MER protocol to an IRB. Nearly all were deemed exempt (74/154) or minimal risk (71/154). No protocols were rejected or not approved. Nearly a fourth of respondents were unfamiliar with specific IRB policies directly applicable to MER. Among those respondents who had some familiarity with the IRB policies specified, 47% to 52% considered the IRB policies clear. Eighteen of 30 (60%) respondents with recent experience in multiinstitutional MER agreed there were notable differences in the expectations of various institutional IRBs; only two reported that multiple IRB reviews resulted in improvements to the protocol. Half (37/73) indicated they would be more likely to conduct MER if they had a better understanding of the IRB’s role and requirements in MER. Sixty-six of 73 (90%) agreed they would benefit from a national consensus statement regarding the IRB’s role in MER. Conclusions A high percentage of clinician educators in CDIM are conducting IRB-approved MER. They report several challenges with working with IRBs, and they agree that IRBs and clinician educators would benefit from a national consensus on the IRB’s role in MER.

The need for a knowledge system in sleep and chronobiology.

Sleep problems and the disorders that cause them influence health-related quality of life as much as other chronic medical conditions. Of the total U.S. population, 20–35% regularly suffer from insomnia. Only 40% of the time is insomnia associated with psychological distress or psychiatric disease; more commonly it is associated with medical illness or with behavioral traits or habits. Sleepiness severe enough to hamper the activities of daily living is estimated to be present in 30% of the population and is most commonly caused by voluntary restriction of sleep time. Sleep apnea and restless-legs syndrome, common medical causes of sleepiness, are present in some 2–4% of the population and in higher prevalence (10–40%) in those with neuromuscular diseases, renal failure, hypertension, and heart disease. Diagnostic strategies and/or effective interventions are available for insomnia and sleepiness, and for sleep and circadian rhythm disorders. Moreover, epidemiologic studies show that for a condition such as sleep apnea, 80% of men and 90% of women with clinically significant illness remain undetected and/or undiagnosed. The underdiagnosis and undertreatment of sleep disorders is understandable, if not excusable, considering the lack of representation of the topics of sleep and chronobiology in current medical school curricula. A 1990 survey of 126 United States medical schools could document only an average of 1.16 hours per school of instruction in sleep and sleep disorders throughout a four-year program; however, the variance was wide, with 37% of schools reporting no instruction at any level. Given the prevalence of sleep disorders and the relationship of these disorders to significant underlying medical conditions, a strong case can be made for the formal implementation of a curriculum in sleep and chronobiology in medical education, residency, and beyond.

Student Uncertainties Drive Teaching During Case Presentations: More So With Snapps

Purpose To compare the nature of uncertainties expressed by medical students using the six-step SNAPPS technique for case presentations (Summarize history and findings; N>arrow the differential; Analyze the differential; Probe preceptors about uncertainties; Plan management; Select case-related issues for self-study) versus those expressed by students doing customary presentations and to elucidate how preceptors respond. Method The authors performed a secondary analysis in 2009 of data from a 2004–2005 randomized study, comparing SNAPPS users’ case presentations with other students’ presentations. Authors coded transcriptions of audiotaped presentations to family medicine preceptors for type of student uncertainties, nature of preceptor responses, alignment of preceptor responses with uncertainty types, and expansion of preceptors’ responses beyond addressing uncertainties. Results The analysis included 19 SNAPPS and 41 comparison presentations. SNAPPS students expressed uncertainties in all case presentations, nearly twice as many as the comparison group (&khgr;21df = 12.89, P = .0001). Most SNAPPS users’ uncertainties (24/44 [55%]) focused on diagnostic reasoning compared with 9/38 (24%) for comparison students’ (&khgr;21df = 8.08, P = .004). Uncertainties about clinical findings and medications/management did not differ significantly between groups. Preceptors responded with teaching aligned with the uncertainties and expanded 24/66 (36%) of their comments. Conclusion Students can drive the content of the teaching they receive based on uncertainties they express to preceptors during case presentations. Preceptors are ready to teach at “the drop of a question” and align their teaching with the content of students’ questions; these learning moments—in context and just-in-time—can be created by students.