Mark J. Graham

Evaluating translational research: a process marker model.

Objective: We examine the concept of translational research from the perspective of evaluators charged with assessing translational efforts. One of the major tasks for evaluators involved in translational research is to help assess efforts that aim to reduce the time it takes to move research to practice and health impacts. Another is to assess efforts that are intended to increase the rate and volume of translation. Methods: We offer an alternative to the dominant contemporary tendency to define translational research in terms of a series of discrete “phases.”Results: We contend that this phased approach has been confusing and that it is insufficient as a basis for evaluation. Instead, we argue for the identification of key operational and measurable markers along a generalized process pathway from research to practice. Conclusions: This model provides a foundation for the evaluation of interventions designed to improve translational research and the integration of these findings into a field of translational studies. Clin Trans Sci 2011; Volume 4: 153–162

Discrediting the notion "working with 'crazies' will make you 'crazy'": addressing stigma and enhancing empathy in medical student education.

People with mental illness around the world continue to suffer from stigmatization and limited care. Previous studies utilizing self-report questionnaires indicate that many medical students regard clinical work with psychiatric patients as unappealing, while the professionalism literature has documented a general decline in students’ capacity for empathy over the course of medical school. Through in-depth interviews, this study attempts to better understand the formation of medical students’ perceptions of psychiatry and the implications of that process for a more general understanding of the impact of emotionally-laden experiences on medical students’ capacity for empathy. Forty-seven fourth-year medical students who had expressed interest or performed well in psychiatry were asked a series of questions to elicit their perceptions of the field of psychiatry. Interview transcripts were systematically coded using content analysis and principles of grounded theory. Stigma, stereotypes, and stressfully intense emotional reactions seemed to adversely affect the students’ expected satisfaction from and willingness to care for the mentally ill, despite enjoying psychiatry’s intellectual content and the opportunity to develop in-depth relationships with patients. Teaching faculty need to directly address the stigma and stereotypes that surround mental illness and actively help medical students cope with the stress that they report experiencing during their psychiatry clerkship in order to improve the recognition and treatment of psychiatric illness by newly graduating physicians. More generally, the relationships that we identify among stress, stigmatization, and stereotyping along an empathic spectrum suggest that increased attention should be paid to the stress that empathy can entail. This perspective may allow for the creation of similarly targeted interventions throughout the medical school curriculum to counteract the decline in empathy, the so-called “hardening of the heart,” associated with physician-training worldwide.

Reliable Assessment of Laparoscopic Performance in the Operating Room Using Videotape Analysis

The Global Operative Assessment of Laparoscopic Skills (GOALS) is a valid assessment tool for objectively evaluating the technical performance of laparoscopic skills in surgery residents. We hypothesized that GOALS would reliably differentiate between an experienced (expert) and an inexperienced (novice) laparoscopic surgeon (construct validity) based on a blinded videotape review of a laparoscopic cholecystectomy procedure. Ten board-certified surgeons actively engaged in the practice and teaching of laparoscopy reviewed and evaluated the videotaped operative performance of one novice and one expert laparoscopic surgeon using GOALS. Each reviewer recorded a score for both the expert and the novice videotape reviews in each of the 5 domains in GOALS (depth perception, bimanual dexterity, efficiency, tissue handling, and overall competence). The scores for the expert and the novice were compared and statistically analyzed using single-factor analysis of variance (ANOVA). The expert scored significantly higher than the novice did in the domains of depth perception (p = .005), bimanual dexterity (p = .001), efficiency (p = .001), and overall competence ( p = .001). Interrater reliability for the reviewers of the novice tape was Cronbach alpha = .93 and the expert tape was Cronbach alpha = .87. There was no difference between the two for tissue handling. The Global Operative Assessment of Laparoscopic Skills is a valid, objective assessment tool for evaluating technical surgical performance when used to blindly evaluate an intraoperative videotape recording of a laparoscopic procedure.

Role-modelling in the operating room: medical student observations of exemplary behaviour

Medical Education 2011: 45: 946–957

Critical Events in the Lives of Interns

BACKGROUNDEarly residency is a crucial time in the professional development of physicians. As interns assume primary care for their patients, they take on new responsibilities. The events they find memorable during this time could provide us with insight into their developing professional identities.OBJECTIVETo evaluate the most critical events in the lives of interns.PARTICIPANTSForty-one internal medicine residents at one program participated in a two-day retreat in the fall of their first year. Each resident provided a written description of a recent high point, low point, and patient conflict.MEASUREMENTSWe used a variant of grounded theory to analyze these critical incidents and determine the underlying themes of early internship. Independent inter-rater agreement of >90% was achieved for the coding of excerpts.MAIN RESULTSThe 123 critical incidents were clustered into 23 categories. The categories were further organized into six themes: confidence, life balance, connections, emotional responses, managing expectations, and facilitating teamwork. High points were primarily in the themes of confidence and connections. Low points were dispersed more generally throughout the conceptual framework. Conflicts with patients were about negotiating the expectations inherent in the physician–patient relationship.CONCLUSIONThe high points, low points, and conflicts reported by early residents provide us with a glimpse into the lives of interns. The themes we have identified reflect critical challenges interns face the development of their professional identity. Program directors could use this process and conceptual framework to guide the development and promotion of residents’ emerging professional identities.

Medical students as teachers: How preclinical teaching opportunities can create an early awareness of the role of physician as teacher

Background: As future physicians, questions about when medical students realize they will have to teach remain under-explored. Aim: To understand when students serving in pre-clinical teaching roles make the connection between teaching and being a physician. Methods: Medical students involved in a peer instruction program included: (1) archived first-year student interview candidate data (n = 60/150); (2) focus groups of first-year students selected as instructors (n = 16/60); and (3) focus groups of second-year students (n = 16/24) who taught for the program. A modified extended-term mixed-method research design involved data from the pre-hire interviews and post-hire focus group. Results: Prior to teaching, none of the first year interviewees made an explicit connection between teaching and being a physician. The new instructors selected to teach minimally made a connection and only after prompting. The majority of the experienced instructors did make the connection; however, and did so spontaneously. Conclusion: It was only after they taught medicine-related material that students saw the benefits of teaching as a way of preparing for becoming a physician and not merely as a way to review or help their peers.

Assessing Resident Knowledge of Acute Pain Management in Hospitalized Children: A Pilot Study

This pilot study was undertaken to evaluate the hypotheses that there are differences in pediatric pain management (PPM) knowledge across resident specialties, that questions in the form of multiple-choice items could detect such differences, and that resident knowledge of analgesic-related adverse drug events (ADEs) would be greater than knowledge of PPM. Questions were based on two general categories of knowledge within acute pain management in hospitalized children: pediatric pain assessment and treatment, and identification of analgesic-related ADEs. As part of the pilot nature of this study, a convenience sample of 60 residents completed a 10-item PPM knowledge assessment prior to a PPM lecture. Twenty-six were pediatric residents (43%), 19 were orthopedic residents (32%), and 15 were anesthesiology residents (25%). All items had content validity. When controlling for resident year, performance by resident specialty was significantly different between anesthesia and orthopedics (P=0.006) and between anesthesia and pediatrics (P<0.001). Resident knowledge of analgesic-related ADEs was not greater than knowledge of PPM. The most difficult topics were opioid equianalgesia, assessment of the cognitively impaired child, and maximal acetaminophen doses. Repeated administration of the PPM knowledge assessment at multiple institutions will allow further evaluation of our initial findings, and with directed educational interventions, provide opportunity for measurement of improvement.

Do workshops in evidence-based practice equip participants to identify and answer questions requiring consideration of clinical research? A diagnostic skill assessment.

Evidence-based practice (EBP) requires practitioners to identify and formulate questions in response to patient encounters, and to seek, select, and appraise applicable clinical research. A standardized workshop format serves as the model for training of medical educators in these skills. We developed an evaluation exercise to assess the ability to identify and solve a problem requiring the use of targeted skills and administered it to 47 North American junior faculty and residents in various specialties at the close of two short workshops in EBP. Prior to the workshop, subjects reported prior training in EBP and completed a previously validated knowledge test. Our post-workshop exercise differed from the baseline measures and required participants to spontaneously identify a suitable question in response to a simulated clinical encounter, followed by a description of a stepwise approach to answering it. They then responded to successively more explicitly prompted queries relevant to their question. We analyzed responses to identify areas of skill deficiency and potential reasons for these deficiencies. Twelve respondents (26%) initially failed to identify a suitable question in response to the clinical scenario. Ability to choose a suitable question correlated with the ability to connect an original question to an appropriate study design. Prior EBP training correlated with the pretest score but not with performance on our exercise. Overall performance correlated with ability to correctly classify their questions as pertaining to therapy, diagnosis, prognosis, or harm. We conclude that faculty and residents completing standard workshops in EBP may still lack the ability to initiate and investigate original clinical inquiries using EBP skills.

Addressing OB/GYN family planning educational objectives at a faith-based institution using the TEACH program ☆ ☆☆ ★

BACKGROUND Traditionally family planning education is limited for obstetrics and gynecology residents training at faith-based institutions. We describe the first formalized educational program to teach contraception, sterilization, and abortion at a Catholic institution. STUDY DESIGN We used a six-step curricular development process to design this formal educational intervention. We created a multiple-choice test that participants completed before and after the workshop. We compared average test scores using one-way analyses of variance and assessed psychometric properties of the test. RESULTS All 16 obstetrics and gynecology residents at this institution participated in the one-day educational program entitled Teaching Everything About Contraceptive Health (TEACH). Residents improved their pre-test scores, on average, from 57% prior to the workshop to 89% immediately after completion of TEACH (p < .001). Improvement persisted 10 months after completion of the program (p < .001). Psychometric assessment supported the use of the instrument with adequate question difficulty and high discrimination. CONCLUSIONS A one day curriculum designed to introduce family planning learning objectives at a Catholic obstetrics and gynecology residency program is feasible and results in improved resident knowledge.

No Time to Think: Making Room for Reflection in Obstetrics and Gynecology Residency

BACKGROUND Reflective practice may help physicians identify and connect with what they value and find meaningful in their work. There are many practical obstacles in teaching narrative skills and reflection to residents in surgical subspecialties. We aimed to assess the feasibility of designing and implementing a writing workshop series within an obstetrics and gynecology curriculum. MATERIALS AND METHODS Between 2008 and 2009, a reflective writing workshop series was introduced into the didactic curriculum of an obstetrics and gynecology residency program. The course included reading fiction and creative writing. Workshops focused on topics residents identified. Residents answered a subjective questionnaire and also completed the Maslach Burnout Inventory and Interpersonal Reactivity Index to assess burnout and empathy. RESULTS Six 1-hour reflective writing workshops took place within the dedicated didactic time for residents. Of the 20 residents in the program, 10 junior residents and 8 senior residents evaluated the workshops. Ten residents participated in more than one workshop, an average of 3.6 workshops. Residents felt that the workshops were enjoyable, and some felt that they influenced their experience of residency, but few felt that it affected their work with patients. Trends in Maslach Burnout Inventory and Interpersonal Reactivity Index scores did not show statistical significance. CONCLUSION A practical curriculum for introducing reflective practice to obstetrics and gynecology residents is described. This model may be useful to educators looking to incorporate reflective practice into residency curricula and lead to collaborative work that may assess the impact of this work on the experience of residents and their patients.