T. Robert Vu

Which experiences in the hidden curriculum teach students about professionalism

Purpose To examine the relationship between learner experience in the “hidden curriculum” and student attribution of such experiences to professionalism categories. Method Using the output of a thematic analysis of 272 consecutive narratives recorded by 135 students on a medical clerkship from June through November 2007, the authors describe the frequency of these experiences within and across student-designated Association of American Medical Colleges–National Board of Medical Examiners professionalism categories and employ logistic regression to link varieties of experience to specific professionalism categories. Results Thematic analysis uncovered two main domains of student experience: medical–clinical interaction and teaching-and-learning experiences. From a student perspective the critical incident stories evoked all professionalism categories. Most frequently checked off categories were caring/compassion/communication (77%) and respect (69%). Logistic regression suggested that student experiences within the teaching-and-learning environment were associated with professionalism categories of excellence, leadership, and knowledge and skills, whereas those involving medical–clinical interactions were associated with respect, responsibility and accountability, altruism, and honor and integrity. Experiences of communicating and working within teams had the broadest association with learning about professionalism. Conclusions Student narratives touched on all major professionalism categories as well as illuminating the contexts in which critical experiences emerged. Linked qualitative and quantitative analysis identified those experiences that were associated with learning about particular aspects of professionalism. Experiences of teamwork were especially relevant to student learning about professionalism in action.

Exploring the Meaning of Respect in Medical Student Education: an Analysis of Student Narratives

ABSTRACTBACKGROUNDRespect for others is recognized in the medical literature and society as an essential attribute of the good medical professional. However, the specific meaning of respect varies widely and is underexplored as a lived experience of physicians-in-training.OBJECTIVETo describe third-year medical students’ narratives of respect and disrespect [(dis)respect] during their internal medicine clerkship.DESIGNQualitative thematic analysis of 152 third-year student narratives that ‘taught them something about professionalism,’ focusing on (dis)respect.APPROACHImmersion/crystallization narrative analysis.RESULTSWe reviewed 595 professionalism narratives and found that one in four narratives involved (dis)respect. We then found that 2/3 of these narratives were negative (describing instances of disrespect rather than respect). In the other coded categories, the proportion of negative narratives was significantly lower. In order to better understand these results, we analyzed the content of the (dis)respect narratives and identified six primary themes: (1) content and manner of communication (including, appreciating or belittling, being sensitive or blunt and respecting privacy); (2) conduct: behaviors expressing (dis)respect; (3) patient centeredness: honoring others’ preferences, decisions and needs; (4) treating others as equals; (5) valuing the other and their experience and/or problem; and (6) nurturing students’ learning.CONCLUSIONSFocusing on the lived experience of (dis)respect on wards broadens the concept of respect beyond any one type of act, behavior or attitude. Students perceive respect as a way of being that applies in all settings (private and public), with all participants (patients, family members, nurses, colleagues and students) and under all circumstances (valuing others’ time, needs, preferences, choices, opinions and privacy). Respect seems to entail responding to a need, while disrespect involves ignoring the need or bluntly violating it.

The Subinternship Curriculum in Internal Medicine: A National Survey of Clerkship Directors

Background: The 4th-year internal medicine subinternship (subI), with its strong emphasis on experience-based learning and increased patient responsibilities, is an important component of undergraduate medical education. Discussions have begun amongst educational leaders on the importance of standardizing curriculum and evaluation tools utilized during the subinternship. Purpose: The objective of this survey was to describe the current state of educational practices regarding the subI curriculum, use of Clerkship Directors in Internal Medicine (CDIM) curricular guidelines, evaluation methodologies, and subintern call frequency and duty hours. Methods: The survey was a part of the CDIM annual survey sent to 109 institutional members in 2005. The subinternship survey included 17 questions that addressed the prevalence of formal curricula in the subinternship, use of CDIM curricular guidelines and resources, and the evaluation tools utilized for assessment of the subinternship. Two questions examined the call frequency and duty hours of the subinterns. Results: Eighty-eight members responded (81%). Of the respondents, 37% have a formal curriculum and 35% used CDIM curricular guidelines for the subinternship. More than half of the respondents agreed that the curricular guide helped organize their subI rotations (53%), and 48% agreed that it enhanced the quality of subI education. A global rating summative evaluation form (56%) was the most commonly used evaluation tool in the subinternship. Objective Structured Clinical Examinations 1−3 (1%) and Mini-Clinical Evaluation Exercise (mini-CEX) 4 (2%) were much less utilized during the subinternship. The respondents expressed an interest in the development of a standardized exam (47%) and clinical assessment tools such as the mini-CEX (59%). The vast majority of IM subinterns participate in 3 to 9 calls per rotation and spend less than 80 hr in the hospital per week. Conclusions: A formal curriculum is offered in slightly more than one third of subIs. Clerkship directors expressed interest in developing standardized evaluation tools to assess subintern competencies. The majority of IM subinterns spend less than 80 hr in the hospital per week. Further studies are needed to assess barriers to incorporating a formal curriculum and develop standardized tools to assess subintern competencies.

Is Reflective Ability Associated With Professionalism Lapses During Medical School

Purpose Recently, many have argued that learning to reflect on one’s experiences is a critical component of professional identity formation and of professionalism. However, little empirical evidence exists to support this claim. This study explored the association between reflective ability and professionalism lapses among medical students. Method The authors conducted a retrospective case–control study of all students who matriculated at Indiana University School of Medicine from 2001 to 2009. The case group (n = 70) included those students who had been cited for a professionalism lapse during medical school; the students in the control group (n = 230) were randomly selected from the students who had not been cited for a professionalism lapse. Students’ professionalism journal entries were scored using a validated rubric to assess reflective ability. Mean reflection scores were compared across groups using t tests, and logistic regression analysis was used to assess the relationship between reflective ability and professionalism lapses. Results Reflection scores for students in the case group (2.46 ± 1.05) were significantly lower than those for students in the control group (2.82 ± 0.83) (P = .01). A lower reflection score was associated with an increased likelihood that the student had been cited for a professionalism lapse (odds ratio = 1.56; P < .01). Conclusions This study revealed a significant relationship between reflective ability and professionalism, although further study is needed to draw any conclusions regarding causation. These findings provide quantitative evidence to support current anecdotal claims about the relationship between reflection and professionalism.

Internal Medicine Residency Program Directors' Views of the Core Entrustable Professional Activities for Entering Residency: An Opportunity to Enhance Communication of Competency Along the Continuum.

Purpose To examine internal medicine (IM) residency program directors’ (PDs’) perspectives on the Core Entrustable Professional Activities for Entering Residency (Core EPAs)—introduced into undergraduate medical education to further competency-based assessment—and on communicating competency-based information during transitions. Method A spring 2015 Association of Program Directors in Internal Medicine survey asked PDs of U.S. IM residency programs for their perspectives on which Core EPAs new interns must or should possess on day 1, which are most essential, and which have the largest gap between expected and observed performance. Their views and preferences were also requested regarding communicating competency-based information at transitions from medical school to residency and residency to fellowship/employment. Results The response rate was 57% (204/361 programs). The majority of PDs felt new interns must/should possess 12 of the 13 Core EPAs. PDs’ rankings of Core EPAs by relative importance were more varied than their rankings by the largest gaps in performance. Although preferred timing varied, most PDs (82%) considered it important for medical schools to communicate Core EPA-based information to PDs; nearly three-quarters (71%) would prefer a checklist format. Many (60%) would be willing to provide competency-based evaluations to fellowship directors/employers. Most (> 80%) agreed that there should be a bidirectional communication mechanism for programs/employers to provide feedback on competency assessments. Conclusions The gaps identified in Core EPA performance may help guide medical schools’ curricular and assessment tool design. Sharing competency-based information at transitions along the medical education continuum could help ensure production of competent, practice-ready physicians.

An Entrustable Professional Activity (EPA)-Based Framework to Prepare Fourth-Year Medical Students for Internal Medicine Careers

The purpose of the fourth year of medical school remains controversial. Competing demands during this transitional phase cause confusion for students and educators. In 2014, the Association of American Medical Colleges (AAMC) released 13 Core Entrustable Professional Activities for Entering Residency (CEPAERs). A committee comprising members of the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine applied these principles to preparing students for internal medicine residencies. The authors propose a curricular framework based on five CEPAERs that were felt to be most relevant to residency preparation, informed by prior stakeholder surveys. The critical areas outlined include entering orders, forming and answering clinical questions, conducting patient care handovers, collaborating interprofessionally, and recognizing patients requiring urgent care and initiating that care. For each CEPAER, the authors offer suggestions about instruction and assessment of competency. The fourth year of medical school can be rewarding for students, while adequately preparing them to begin residency, by addressing important elements defined in the core entrustable activities. Thus prepared, new residents can function safely and competently in supervised postgraduate settings.

The Association Between Peer and Self-Assessments and Professionalism Lapses Among Medical Students

Peer and self-assessments are widely used to assess professionalism during medical school as part of a multisource feedback model. The purpose of this study was to examine the associations between peer and self-assessments and professionalism lapses at a large medical school. A retrospective case–control study design was used to compare peer and self-assessment scores from Years 1 to 3 of medical school for students who had been cited for professionalism lapses during medical school (case group; n = 78) with those of a randomly selected control group (n = 230). Students in the case group had significantly lower peer assessment scores than students in the control group during all 3 years. Year 3 peer assessment scores showed the greatest difference (cases = 7.81 ± 0.65, controls = 8.22 ± 0.34, p < .01). Students with lower peer assessment scores were also significantly more likely to have been cited for a professionalism lapse (odds ratio = 6.25, 95% CI [3.13, 11.11], p < .01). This study reinforces the value of peer assessments of professionalism, which may be useful to help identify students who may be at risk for professionalism lapses during medical school.

Drivers of Application Inflation: A National Survey of Internal Medicine Residents

AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.

Experiences of Female and Male Medical Students With Death, Dying, and Palliative Care: One Size Does Not Fit All

Background: Medical students learn about death, dying, and palliative care (DDPC) through formal curricular offerings and informal clinical experiences; however, the lessons learned in the clinic may be at odds with the formal curriculum. Reflective writing is a means for students to “bracket” their DDPC experiences and reconcile conflicts between the formal and informal curriculum. Objectives: The aim of this study is to compare the level of reflection demonstrated in medical students’ narratives on DDPC with other experiences and to examine the domains of professionalism that students perceive to be prevalent in their DDPC experiences. Methods: Third-year medical students submitted professionalism narratives during their internal medicine clerkship. We identified a subset of narratives related to DDPC (n = 388) and randomly selected control narratives (n = 153). We assessed the level of reflection demonstrated in the narratives using a validated rubric and analyzed the professionalism domains that students identified as relevant to their experience. Results: There was no difference in reflective level between DDPC and control narratives. Within the DDPC group, female students demonstrated higher reflection (2.24 ± 0.71) than male students (2.01 ± 0.77; P < .001). Caring, compassion and communication, and honor and integrity were prominent among DDPC narratives. More females identified caring, compassion, and communication as relevant to their DDPC experiences, whereas more males identified altruism. Conclusion: Males and females have different perceptions of DDPC experiences, and female students appear to be more deeply impacted. These findings can help clinical faculty engage students more effectively with this challenging topic.