Stephen J. Huot

Construct validity of the miniclinical evaluation exercise (miniCEX).

Purpose To investigate the construct validity of the miniclinical evaluation exercise (miniCEX). Method Forty faculty participants from 16 internal medicine residency programs enrolled in a randomized, controlled trial of faculty development. Using a standard nine-point miniCEX rating form, participants watched and rated performances of standardized residents on nine scripted clinical videotapes depicting three levels of performance (unsatisfactory, marginal/satisfactory, and high satisfactory/superior). The nine-point rating scale was 1–3 = unsatisfactory, 4–6 = marginal/satisfactory, and 7–9 = superior. The performances were rated for three clinical skills, history taking, physical examination, and counseling. Results For each of the three clinical skills, the faculty participants were able to successfully discriminate among the three levels of performance using the miniCEX scale. Differences among ratings of the three performance levels were statistically significant; however, the range in ratings among the participants for each videotape was wide. Conclusion The authors believe this to be the first study to document the construct validity of the miniCEX. Although the miniCEX appears to have reliability and construct validity, further research is needed to improve individual faculty observation skills and reduce interrater variability.

Feedback and the mini clinical evaluation exercise

We studied the nature of feedback given after a miniCEX. We investigated whether the feedback was interactive; specifically, did the faculty allow the trainee to react to the feedback, enable self-assessment, and help trainees to develop an action plan for improvement. Finally, we investigated the number of types of recommendations given by faculty. One hundred and seven miniCEX feedback sessions were audiotaped. The faculty provided at least 1 recommendation for improvement in 80% of the feedback sessions. The majority of the sessions (61%) involved learner reaction, but in only 34% of the sessions did faculty ask for self-assessment from the intern and only 8% involved an action plan from the faculty member. Faculty are using the miniCEX to provide recommendations and often encourage learner reaction, but are underutilizing other interactive feedback methods of self-assessment and action plans. Programs should consider both specific training in feedback and changes to the miniCEX form to facilitate interactive feedback.

Physician leadership: enhancing the career development of academic physician administrators and leaders.

As the health care environment grows more complex, there is greater opportunity for physician administrative and management leadership. Although physicians in general, and academic physicians in particular, view management as outside their purview, the increased importance of physician administrative leadership represents an opportunity for academic physicians interested in working at the interface of clinical medicine, health care, finance, and management. These physicians are called academic physician administrators and leaders (APALs). APALs are clinician–administrators whose academic contributions include both scholarly work related to their administrative duties and administrative leadership of academically important programs. However, existing academic career development infrastructure, such as academic promotions, is oriented toward traditional clinician–educator and clinician–researcher faculty. The APAL career path differs from traditional academic pathways because APALs require unique skills, different mentors, and a more expansive definition of academic productivity. This article describes how academic medical institutions could enhance the career development of academic physicians in administrative and leadership positions.

Effectiveness of a focused educational intervention on resident evaluations from faculty a randomized controlled trial.

OBJECTIVE: To improve the quality and specificity of written evaluations by faculty attendings of internal medicine residents during inpatient rotations.DESIGN: Prospective randomized controlled trial.SETTING: Four hospitals: tertiary care university hospital, Veterans’ Administration hospital, and two community hospitals.PARTICIPANTS: Eighty-eight faculty and 157 residents from categorical and primary-care internal medicine residency training programs rotating on inpatient general medicine teams.INTERVENTION: Focused 20-minute educational session on evaluation and feedback, accompanied by 3 by 5 reminder card and diary, given to faculty at the start of their attending month.MEASUREMENTS AND MAIN RESULTS: Primary outcomes: 1) number of written comments from faculty specific to unique, preselected dimensions of competence; 2) number of written comments from faculty describing a specific resident behavior or providing a recommendation; and 3) resident Likert-scale ratings of the quantity and effect of feedback received from faculty. Faculty in the intervention group provided more written comments specific to defined dimensions of competence, a median of three comments per evaluation form versus two in the control group, but when adjusted for clustering by faculty, the difference was not statistically significant (P=.09). Regarding feedback, residents in the intervention group rated the quantity significantly higher (P=.04) and were significantly more likely to make changes in clinical management of patients than residents in the control group (P=.04).CONCLUSIONS: A brief, focused educational intervention delivered to faculty prior to the start of a ward rotation appears to have a modest effect on faculty behavior for written evaluations and promoted higher quality feedback given to house staff.

Metabolic complications of urinary diversions: An overview

Patients with urinary diversions present unique challenges to internists who have an important role in their long-term management. Advances in surgical techniques over the past 30 years have given rise to a number of urinary diversion procedures that use various intestinal segments. In its normal function, the intestine absorbs water and solutes. When placed in contact with the urinary stream, the intestine can create numerous metabolic abnormalities. These include bone disease, hepatobiliary disease, infection, malignancy, neurologic complications, nutritional deficiencies, and a number of electrolyte and acid-base disorders. An overview of these metabolic abnormalities and their causes is provided, as well as recommendations for screening and management of patients.

Teaching and learning in an 80-hour work week: a novel day-float rotation for medical residents.

The 80-hour workweek limit for residents provides an opportunity for residency directors to creatively innovate their programs. Our novel day-float rotation augmented both the educational structure within the inpatient team setting and the ability for house staff to complete their work within the mandated limits. Descriptive evaluation of the rotation was performed through an end-of-rotation questionnaire. The average length of the ward residents’ work week was quantified before and after the rotation’s implementation. Educational portfolios and mentored peer-teaching opportunities enriched the rotation. As measured by our evaluation, this new rotation enhanced learning and patient care while reducing work hours for inpatient ward residents.

Vascular Na+-K+ Pump Activity in Dahl S and R Rats

Abstract Ouabain-sensitive 86rubidium uptake was used to estimate sodium-potassium pump activity in the tail arteries of Dahl salt-sensitive and Dahl salt-resistant rats on normal and high oral intakes of salt. Uptake was increased in the salt-sensitive strain relative to the resistant strain at a given salt intake. It was also increased in a given strain when the salt intake was increased. In each case the increased ouabain-sensitive uptake was associated with increased ouabain-insensitive uptake which in part reflects the permeability of the cell membrane to rubidium. The results suggest that the increased pump activity is a secondary compensatory response to increased passive penetration of sodium. In this respect, the Dahl salt-sensitive rat is similar to SHR, another genetic model, but different from the other low-renin, presumably, volume-expanded models of hypertension we have studied.

Role of a humoral sodium-potassium pump inhibitor in experimental low renin hypertension

Recent evidence suggests that the vascular sodium-potassium pump suppression previously observed in animals with various models of low renin hypertension results from a circulating heat stable ouabain-like agent. It appears to come from or be influenced by the anteroventral third ventricle area of the brain and its action on blood vessels results in depolarization of the smooth muscle cell. Suppression of the vascular sodium-potassium pump, with ouabain for example, increases contractile activity and the contractile responses to vasoactive agents. Thus the humoral pump inhibitor may be involved in the genesis and maintenance of experimental low renin hypertension.

Internal medicine residents’ clinical and didactic experiences after work hour regulation

AbstractBACKGROUND: Work hour regulations for house staff were intended in part to improve resident clinical and educational performance. OBJECTIVE: To characterize the effect of work hour regulation on internal medicine resident inpatient clinical experience and didactic education. DESIGN: Cross-sectional mail survey. PARTICIPANTS: Chief residents at all accredited U.S. internal medicine residency programs outside New York. MEASUREMENTS AND MAIN RESULTS: The response rate was 62% (202/324). Most programs (72%) reported no change in average patient load per intern after work hour regulation. Many programs (48%) redistributed house staff admissions through the call cycle. The number of admissions per intern on long call (the day interns have the most admitting responsibility) decreased in 31% of programs, and the number of admissions on other days increased in 21% of programs. Residents on outpatient rotations were given new ward responsibilities in 36% of programs. Third-year resident ward and float time increased in 34% of programs, while third-year elective time decreased in 22% of programs. The mean weekly hours allotted to educational activities did not change significantly (12.7 vs 12.4,P=.12), but 56% of programs reported a decrease in intern attendance at educational activities. CONCLUSIONS: In response to work hour regulation, many internal medicine programs redistributed rather than reduced residents’ inpatient clinical experience. Hours allotted to educational activities did not change: however, most programs saw a decrease in intern attendance at conferences, and many reduced third-year elective time.

Developing an internet-based communication system for residency training programs

Administrative communication is increasingly challenging for residency programs as the number of training sites expands. The Internet provides a cost-effective opportunity to address these needs. Using the World Wide Web, we developed a single, reliable, accurate, and accessible source of administrative information for residents, faculty, and staff in a multisite internal medicine residency at reduced costs. Evaluation of the effectiveness of the website was determined by tracking website use, materials and personnel costs, and resident, staff, and faculty satisfaction. Office supply and personnel costs were reduced by 89% and personnel effort by 85%. All users were highly satisfied with the web communication tool and all reported increased knowledge of program information and a greater sense of “connectedness.” We conclude that an internet-based communication system that provides a single, reliable, accurate, and accessible source of information for residents, faculty, and staff can be developed with minimum resources and reduced costs.