Rajesh S. Mangrulkar

The promise of competency-based education in the health professions for improving global health

Competency-based education (CBE) provides a useful alternative to time-based models for preparing health professionals and constructing educational programs. We describe the concept of ‘competence’ and ‘competencies’ as well as the critical curricular implications that derive from a focus on ‘competence’ rather than ‘time’. These implications include: defining educational outcomes, developing individualized learning pathways, setting standards, and the centrality of valid assessment so as to reflect stakeholder priorities. We also highlight four challenges to implementing CBE: identifying the health needs of the community, defining competencies, developing self-regulated and flexible learning options, and assessing learners for competence. While CBE has been a prominent focus of educational reform in resource-rich countries, we believe it has even more potential to align educational programs with health system priorities in more resource-limited settings. Because CBE begins with a careful consideration of the competencies desired in the health professional workforce to address health care priorities, it provides a vehicle for integrating the health needs of the country with the values of the profession.

Balancing continuity of care with residents' limited work hours: defining the implications.

The impact of the new resident work-hours rules on all aspects of patient care and education must be considered. While physician fatigue has taken center stage as the primary motivation behind this movement, the effect of these rules on the continuity of care for hospitalized patients needs to be critically analyzed from the perspectives of patients, physicians, and the health care system. The authors describe a conceptual framework that places continuity at the center and then considers the benefits and drawbacks of preserving continuity from the perspectives of the major stakeholders. They describe the categories of outcomes related to residents’ fatigue and sleep deprivation that have been studied. Only a few studies have addressed patient outcomes, while most address resident outcomes. The authors discuss some of the possible solutions, including night float and the British system of shift work, and suggest that these solutions have different effects on each group of stakeholders, including both intended and unintended benefits and harms. Finally, the research agenda that arises from this framework is described. It includes taking into account multiple perspectives, identifying important outcomes, and considering unintended consequences. Using this framework, medical educators may better evaluate previous studies and consider remaining questions.

Teaching Internal Medicine Residents Quality Improvement and Patient Safety: A Lean Thinking Approach

Patient safety (PS) and quality improvement (QI) are among the highest priorities for all health systems. Resident physicians are often at the front lines of providing care for patients. In many instances, however, QI and PS initiatives exclude trainees. By aligning the goals of the health system with those of the residency program to engage residents in QI and PS projects, there is a unique opportunity to fulfill both a corporate and educational mission to improve patient care. Here, the authors briefly describe one residency program’s educational curriculum to provide foundational knowledge in QI and PS to all its trainees and highlight a resident team—based project that applied principles of lean thinking to evaluate the process of responding to an in-hospital cardiopulmonary arrest. This approach provided residents with a practical experience but also presented an opportunity for trainees to align with the health system’s approach to improving quality and safety.

Using a Multimedia Tool to Improve Cardiac Auscultation Knowledge and Skills

AbstractOBJECTIVE: Today’s medical school graduates have significant deficits in physical examination skills. Medical educators have been searching for methods to effectively teach and maintain these skills in students. The objective of this study was to determine if an auscultation curriculum centered on a portable multimedia CD-ROM was effective in producing and maintaining significant gains in cardiac auscultatory skills. DESIGN: Controlled cohort study PARTICIPANTS: All 168 third-year medical students at 1 medical school in an academic medical center. INTERVENTIONS: Students were tested before and after exposure to 1 or more elements of the auscultation curriculum: teaching on ward/clinic rotations, CD-ROM comprehensive cases with follow-up seminars, and a CD-ROM 20-case miniseries. The primary outcome measures were student performance on a 10-item test of auscultation skill (listening and identifying heart sound characteristics) and a 30-item test of auscultation knowledge (factual questions about auscultation). A subset of students was tested for attenuation effects 9 or 12 months after the intervention. RESULTS: Compared with the control group (1 month clinical rotation alone), students who were also exposed to the CD-ROM 20-case miniseries had significant improvements in auscultation skills scores (P<.05), but not knowledge. Additional months of clerkship, comprehensive CD-ROM cases, and follow-up seminars increased auscultation knowledge beyond the miniseries alone (P<.05), but did not further improve auscultation skills. Students’ auscultation knowledge diminished one year after the intervention, but auscultation skills did not. CONCLUSION: In addition to the standard curriculum of ward and conference teaching, portable multimedia tools may help improve quality of physical examination skills.

Fostering the Development of Master Adaptive Learners: A Conceptual Model to Guide Skill Acquisition in Medical Education.

Change is ubiquitous in health care, making continuous adaptation necessary for clinicians to provide the best possible care to their patients. The authors propose that developing the capabilities of a Master Adaptive Learner will provide future physicians with strategies for learning in the health care environment and for managing change more effectively. The concept of a Master Adaptive Learner describes a metacognitive approach to learning based on self-regulation that can foster the development and use of adaptive expertise in practice. The authors describe a conceptual literature-based model for a Master Adaptive Learner that provides a shared language to facilitate exploration and conversation about both successes and struggles during the learning process.

Feeling pressure to stay late: socialisation and professional identity formation in graduate medical education.

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Using a computer simulation for teaching communication skills: A blinded multisite mixed methods randomized controlled trial.

OBJECTIVES To assess advanced communication skills among second-year medical students exposed either to a computer simulation (MPathic-VR) featuring virtual humans, or to a multimedia computer-based learning module, and to understand each groups experiences and learning preferences. METHODS A single-blinded, mixed methods, randomized, multisite trial compared MPathic-VR (N=210) to computer-based learning (N=211). Primary outcomes: communication scores during repeat interactions with MPathic-VRs intercultural and interprofessional communication scenarios and scores on a subsequent advanced communication skills objective structured clinical examination (OSCE). Multivariate analysis of variance was used to compare outcomes. SECONDARY OUTCOMES student attitude surveys and qualitative assessments of their experiences with MPathic-VR or computer-based learning. RESULTS MPathic-VR-trained students improved their intercultural and interprofessional communication performance between their first and second interactions with each scenario. They also achieved significantly higher composite scores on the OSCE than computer-based learning-trained students. Attitudes and experiences were more positive among students trained with MPathic-VR, who valued its providing immediate feedback, teaching nonverbal communication skills, and preparing them for emotion-charged patient encounters. CONCLUSIONS MPathic-VR was effective in training advanced communication skills and in enabling knowledge transfer into a more realistic clinical situation. PRACTICE IMPLICATIONS MPathic-VRs virtual human simulation offers an effective and engaging means of advanced communication training.

When students struggle with gross anatomy and histology: A strategy for monitoring, reviewing, and promoting student academic success in an integrated preclinical medical curriculum

Gross anatomy and histology are now often taught as parts of an integrated medical or dental curriculum. Although this puts these foundational basic sciences into a wider educational context, students may not fully appreciate their importance as essential components of their medical education and may not develop a sufficient level of competency, as they are not stand‐alone courses. The early identification of medical or dental students who struggle with anatomy or histology and the facilitation of adequate didactic support constitute a significant problem in an integrated curriculum. The timely intervention by an academic review board in combination with an individualized faculty‐mediated counseling and remediation process may provide an effective solution to this problem. Anat Sci Educ 8: 478–483.

Developing a professional pathway in health equity to facilitate curricular transformation at the University of Michigan Medical School.

Problem Medical schools are challenged to realign curricula to address society’s needs in a rapidly changing environment, and to support new instruction and assessment methods that require substantial faculty time. Approach In 2010, the University of Michigan Medical school began planning the Global Health and Disparities Path of Excellence (GHD Path), an optional co-curriculum for students interested in health disparities, with explicit goals to (1) draw attention to the school’s social mission; (2) test new, faculty-intensive methods of learning and assessment for all students; and (3) serve as a template for additional co-curricular paths. Outcomes Intended outcomes of the program include enhancing students’ competency in leadership related to ameliorating health disparities and the study institution’s ability to plan feasible and effective schoolwide reforms in self-directed learning, faculty advising systems, narrative-based feedback for goal setting, Web-based student portfolios, and additional Paths of Excellence. Next Steps During academic year 2013–2014, the GHD Path is adding more community-based experiences. The faculty development and support model will be streamlined to decrease resources required for program development while retaining key features of the advising system. Lessons from the GHD Path are central to planning schoolwide reform of instructional methods, faculty advising, and student portfolios. The use of a small-scale program to pilot new ideas to inform longer-term, larger-scale changes at our institution might prove useful to other schools striving to meet societal needs while implementing innovative methods of instruction and assessment.

Variability in student perceptions of mistreatment

As medical schools strive to improve the learning environment, it is important to understand medical students’ perceptions of mistreatment. The purpose of this study was to explore student interpretations of previously reported mistreatment incidents to better understand how they conceptualise the interactions.