William A. Anderson

Resident Research in Internal Medicine Training Programs

Resident research is strongly supported by many training programs and is solidly endorsed by the Accreditation Council of Graduate Medical Education (ACGME) in their general requirements (1, p. 17). Recently, the Residency Review Committee for Internal Medicine mandated evidence of scholarly activity for each resident before graduation (1, p. 52); scholarly activity was defined as original research, comprehensive case reports, or review of assigned clinical and research topics. We used this broad definition to define resident research in our study. Proponents of resident research see it as a way to improve resident education, promote quality patient care, and provide essential skills for lifelong learning [2-5]. Others have suggested that resident research enhances analytic reading skills and critical thinking and that it can prepare graduates for various research roles in academia and the community [6-11]. Many residents value research training, and the absence of this training has been criticized by graduates of respected medicine training programs [12, 13]. In one university program, no other learning activity was rated as more important than the required research project, and 86% of the graduates and 66% of the senior residents agreed that all physicians should have research experience [14]. Despite the widespread appeal of resident research, there are many perceived barriers to it, including lack of mentors, lack of training opportunities, and lack of infrastructure [2, 15-19]. Other reported barriers include lack of resident interest, lack of curricular time, lack of background instruction, lack of financial support, and the pressures of clinical duties [20-22]. Most of the literature on resident research [2, 8, 10, 16, 17, 23-30] comes from disciplines without a strong research base, such as family medicine, psychiatry, and rehabilitation medicine. In these disciplines, resident research has important links to the viability of the disciplines themselves and to the promotion of academic careers, and it is a justification for reimbursement for services. Similar arguments have been echoed by leaders in subspecialty and general internal medicine [31, 32], and it has been proposed that internal medicine programs become more flexible to allow interested residents to obtain research experience [33]. To this end, the American Board of Internal Medicine established the Clinical Investigator Pathway, which permits board eligibility after 2 years of clinical training and 2 years of research training (34, pp. 8-10). Some programs, most notably that at Brigham and Womens Hospital and the Subspecialty Training and Research program at the University of California, Los Angeles, have developed parallel clinical and research tracks to launch young physicians on research careers [35, 36]. Research training initiatives have been proposed for junior faculty and general internal medicine fellowships [26, 37, 38], and yet the question of research experience for most residents has been largely ignored. In the past decade, two studies pertinent to internal medicine have attempted to quantify research activity during residency. A 1991 survey of all graduate medical education programs [39] reported that more than 75% of these programs had research rotations and that 66% required these rotations. Almost half of the reporting programs required a research project, but subspecialty programs were more likely than programs accepting postgraduate year (PGY)-1 residents to require a project. A survey of internal medicine program directors in 1983 [40] found that 53% of programs offered a research elective, but no information was given about how many residents took advantage of this, what was offered, or what was accomplished. Resident research is considered to be an important pedagogical skill vital to the growth and development of subspecialty and general internal medicine. Yet, basic questions remain unanswered, such as what constitutes resident research; what the requisite knowledge, skills, and attitudes are; and what resources are needed. In an attempt to answer these questions and to determine current readiness to meet the mandated research requirements, we describe 1) the current level of resident research activity; 2) the research environment and available resources; 3) educational outcomes and skills considered important; and 4) important barriers to resident research. Methods A 33-question survey was mailed to all ACGME-accredited internal medicine training programs in September 1993. The surveys were addressed to the program directors listed in the 1993 ACGME Directory of Graduate Medical Education Programs. Subsequent mailings were sent to nonresponders in November 1993 and February 1994. The questions were organized into four sections: research activities of categorical internal medicine residents; opinions about resident research activities; research activities of faculty; and residency demographic information. The following definitions were provided in the survey: 1. Hypothesis-driven research mandates an a priori establishment of a hypothesis, collection of data, and analysis of data with inferential or descriptive statistics. 2. Descriptive studies are observations not driven by a specific hypothesis and may consist of a single case report, a case series, or a description of a population. 3. Literature reviews do not involve the collection of original data or observations. Literature reviews may be analytical reviews that provide a comprehensive, critical assessment of the available published data on a medical subject, and may be subject to meta-analytical techniques. Nonanalytical reviews meet few or none of these criteria, but simply report on findings published in past and current literature without a critical, predesigned framework of appraisal or statistical analysis. In section one of the questionnaire, 21 questions addressed aspects of resident research activities, including mandatory and minimal research expectations for residents; the presence, nature, and efforts of a research director; the presence, components, resources, and format of an organized research program; the presence and nature of protected time for resident research; the current level of resident research activity; and the educational and skill outcomes desired from resident research. Three questions in section two elicited opinions about resident research, asking directors to state the three most important barriers to that research; the three most important reasons that residents engage in research; their level of agreement with the idea of mandatory research activities; and the ability of their programs to implement such activities. Four questions in section three addressed the expectations for and activity of faculty members with regard to research and the availability and suitability of faculty members as resident research mentors. Five questions in section four collected demographic information on the training program, including total faculty number, faculty number by type (full-time or volunteer), and university affiliation. The survey instrument was piloted in six different residency programs, and the results of the pilot were included in the final results. The surveys were completed anonymously. Survey responses were divided into two mutually exclusive groups: those from university-based programs and those from non-university-based programs. University-based programs were defined as programs administered by a department of medicine at a medical school or as community programs integrated with university programs. Non-university-based programs were all other programs, including those at Veterans hospitals, community hospitals [university-affiliated or independent], military hospitals, health maintenance organizations, and large, multispecialty clinics. We chose to divide programs this way because 1) we believed that university-based programs were more likely to have resources pertinent to research and 2) we wanted our data to be comparable with that in previously published studies. Because we surveyed all ACGME-accredited internal medicine training programs, we made a finite population correction before calculating Student t-test results. Percentages and chi-square analyses were used to compare categorical data, and means SDs and Student t-tests were used to compare continuous data. Ranked categorical variables were weighted. First ranking was awarded 3 points, second ranking was awarded 2 points, and third ranking was awarded 1 point. Weighted mean scores were calculated by dividing the total score for an item by the number of responders. For each item, the differences in weighted means for university-based and non-university-based programs were compared using the Student t-test. For all analyses, the level was set at 0.05. Results are given as means SD. Results Of the 415 surveys mailed, 271 were completed and returned, yielding a response rate of 65%. A telephone survey of 10% of randomly selected non-responders was completed, and significant differences between nonresponders and responders were noted. The data were similar for university-based and non-university-based training programs, but those statistically significant differences that did exist are noted. Otherwise, the data reflect the overall trends of all training programs combined. Between 253 and 271 responders answered any given item, and the data are presented as percentages of responders answering a question rather than as percentages of all responders. For most questions, responders were allowed to choose more than one answer; therefore, the cumulative response rate may exceed 100%. The distribution of training programs in the survey was as follows: 55% were at university-affiliated community hospitals; 35% were at university hospitals; 21% were at Veterans hospitals; 18% were at community hospitals integrated with a university; 6% were at community hospitals and were not

Faculty Development for Ambulatory Care Education.

Faculty play an important role in the delivery of quality instruction in the ambulatory setting. As medical schools and residency programs move more clinical training to ambulatory care settings, more faculty must be recruited and trained. Medical educators have attempted to prepare faculty to teach in ambulatory care settings by conducting faculty development programs. This study documents the current practices of a sample of 14 peer-nominated medical educators who conduct this type of faculty development program. The authors conducted telephone interviews to learn what these educators taught, how they conducted and evaluated their programs, and the theoretical framework guiding their selection of program content and format. Results show that these faculty development programs were delivered almost exclusively in the workshop format, and that there was remarkable similarity in the topics and strategies used. Evaluation was generally limited to satisfaction ratings. Based on the results of this study, the authors recommend that faculty development programs that now emphasize the teaching encounter itself should give equal emphasis to (1) the importance of pre-instructional planning; (2) teaching faculty how to employ post-instructional techniques such as reflection; and (3) training learners and clinic staff to collaborate with faculty in the learning process.

Faculty development fellowship programs in family medicine

A new format for training medical school faculty members was begun in 1978 when the federal government and the Robert Wood Johnson Foundation simultaneously began funding separate faculty development programs for family medicine faculty members. The goals of these two programs were to recruit and prepare new physician faculty members for family medicine educational programs. In the present study, the authors assessed the impact of these programs by a review of grant proposals and a survey of alumni for each program. They found that very different fellowship programs developed under these two funding sources. Consequently, the two programs produced participants who went to different academic settings and became involved in quite different activities, especially in the area of scholarly work. However, regardless of the program the participants chose, common factors were found to characterize those who were active in scholarly areas and those who were less active. Based on these findings, recommendations are offered to future planners and funders of faculty development programs for preparing new physician faculty members.

A Suggested Outline for Writing Curriculum Development Journal Articles: The IDCRD Format

Background: During the past decade, medical school and residency faculty have been active in developing and revising curricula for medical education programs. Many of these curriculum development efforts ultimately are published in peer-reviewed professional journals as articles or abstracts. Unlike research publications, no uniform format currently exists for reporting curriculum development efforts in the peer-reviewed literature. Summary: A suggested format for organizing curriculum development manuscripts consists of the introduction, development, curriculum, results, and discussion (IDCRD). Detailed descriptions of each section are discussed herein. Conclusions: The IDCRD manuscript outline is intended to provide useful guidance to medical educators in publishing their curriculum development efforts. Journal editors are encouraged to recognize the importance of providing uniform descriptions of curricula so that readers can benefit from the experience of others and replicate successful curriculum efforts.

Teaching research skills: Development and evaluation of a new research program for residents

Since 1981, the internal medicine training program at Michigan State University has offered an elective research program for residents. Based on the literature and 10 years of experience in primary care faculty development, a research program was developed. It included (a) establishment of educational goals and resident expectations, (b) selection of a research director, (c) a structured research curriculum, (d) research meetings, (e) a research committee to review work, (f) protected time, and (g) a research presentation forum. The research program addressed the topics of critical reading skills, MEDLINE searching skills, basic research methodology, and scientific communication skills. Over the past 10 years, the residents’ scholarly activity has increased greatly as measured by the number of their presentations to state or national scientific meetings, their state and national awards, and their publications.

The Reporting of Curriculum Development Activities in the Health Professions

This study examined how curriculum development efforts are reported in the health professions literature. From the classic curriculum development literature, we abstracted a common set of curriculum development components and steps that we subsequently used to evaluate 85 articles on curriculum development efforts in medicine, nursing, allied health, and dentistry. Only 29% of the articles mentioned all four components of a curriculum, and only 12% of the articles reported all steps in the curriculum development process. Twenty‐seven percent of the articles reported using educational consultants or units in describing curriculum development efforts. More than half the articles’ citations were to references from the content of the profession of the curriculum being developed. Authors of the identified curriculum development articles generally did not follow established curriculum development principles, involve others with curriculum development training, or include curriculum development literature among ...

Twelve tips for increasing transfer of training from faculty development programs

Abstract Physicians serving as faculty in medical schools are taught medical skill and knowledge, but are usually not taught how to be competent teachers, researchers and leaders. Medical schools can provide the appropriate training for academic faculty by providing faculty development. However, to accomplish the purpose of producing competent teachers, researchers and leaders, faculty development programs must be designed to foster transfer of training, the use on the job of what is learned in instruction. Based on experience and empirical research, we provide tips as to how to design and conduct faculty development programs that will enable and motivate medical school faculty to use the skills and knowledge they learn as academic physicians.

On whose shoulders we stand: lessons from Exemplar medical educators.

The hiring of educators in medical schools (faculty who study the educational process and prepare others to become educators) has been one of the most successful educational innovations ever. Starting in 1954, through a collaboration between the Schools of Medicine and Education at the University of Buffalo, the innovation has spread to over half of the medical schools in the United States and to medical schools in several other countries. Practically every medical school and specialty now hires educators to conduct faculty development, evaluate learners, and develop or revise curricula. This article focuses on lessons learned by six-first-generation educators hired in medical education. These individuals made unique contributions that improved the process of educating and evaluating future physicians. Among their most important contributions have been the use of standardized patients, faculty development to improve instruction, and the use of clinical decision making theory. In addition, these professional educators created a home and career path for other professionals and nurtured protégés to continue the work they started. Ten lessons are reported from structured interviews using a standardized protocol. These lessons will hopefully inform current and future medical educators to help them sustain the effective collaboration between medical schools and educators.

Arthur S. Elstein, Ph.D.: Skeptic, Scholar, Teacher and Mentor

Arthur S. Elstein, Ph.D. has said that he has been motivated to address two research questions throughout this career: How do physicians make decisions? and How can we help them make better ones? He has addressed these questions using the tools of a psychologist but the results of his research in medical cognition, medical reasoning, and judgment have had a lasting impact on medical education and how future physicians are prepared. Further, through teaching and mentoring, he has produced a second generation of medical education researchers and leaders; and perhaps most importantly, through his role modeling of skepticism and scholarship, he has taught what a professional educator must do to succeed in medical education. His distinguished thirty-eight year career was primarily at the Office of Medical Education Research and Development at Michigan State Universitys College of Human Medicine (1968–1994) and, after his retirement there, in the Department of Medical Education and the School of Public Health at the University of Illinois at Chicago. During his career he authored or edited four books, wrote 22 book chapters, published 99 articles, and made more than 900 presentations. He received many prestigious awards. This article gives an overview of Elsteins career and accomplishments and his perspectives on significant innovations in medical education, the role of professional medical educators, the major lessons he has learned during his career.

Training in basic computer skills for academic physicians: The certificate of added qualification approach

Background: In the course of an academic fellowship program, many of the physicians participating expressed the need for computer skills training. Purpose: The purpose of the tutorial program was to promote the effective and efficient learning of academic computer skills within the context of a busy fellowship program. Methods: A series of self‐instructional tutorials was developed, including competency tests and practice tasks. Physician fellows participated in the voluntary computer skills tutorial program. Topics included system software, word processing, and graphics. Competency testing led to a “Certificate of Added Qualification,”; (CAQ) in computer skills. Results: Eleven of 20 (55%) physician fellows completed all CAQ requirements during their fellowship program. The results of a follow‐up questionnaire indicated that 95% of the CAQ participants reported using computers at least several times per week. Conclusion: By focusing on the tasks computer novices immediately need to perform, and keeping t...