Remediation of the Deficiencies of Physicians Across the Continuum From Medical School to Practice...Hauer et. al.

Remediation of the Deficiencies of Physicians Across the Continuum From Medical School to Practice: A Thematic Review of the Literature.

Despite widespread endorsement of competency-based assessment of medical trainees and practicing physicians, methods for identifying those who are not competent and strategies for remediation of their deficits are not standardized. This literature review describes the published studies of deficit remediation at the undergraduate, graduate, and continuing medical education levels. Thirteen studies primarily describe small, single-institution efforts to remediate deficient knowledge or clinical skills of trainees or below-standard-practice performance of practicing physicians. Working from these studies and research from the learning sciences, the authors propose a model that includes multiple assessment tools for identifying deficiencies, individualized instruction, deliberate practice followed by feedback and reflection, and reassessment. The findings of the study reveal a paucity of evidence to guide best practices of remediation in medical education at all levels. There is an urgent need for multiinstitutional, outcomes-based research on strategies for remediation of less than fully competent trainees and physicians with the use of long-term follow-up to determine the impact on future performance. Read online.

Hauer, Karen E. MD; Ciccone, Andrea MS; Henzel, Thomas R. EdD; Katsufrakis, Peter MD, MBA; Miller, Stephen H. MD, MPH; Norcross, William A. MD; Papadakis, Maxine A. MD; Irby, David M. PhD.

Academic Medicine: December 2009 - Volume 84 - Issue 12 - pp 1822-1832

Impact of an In-Person Versus Web-Based Practice Standardized Patient Examination. Hauer et. al.

Background: Optimal methods of preparing students for highstakes standardized patient (SP) examinations are unknown.

Purposes: The purpose is to compare the impact of two formats of a formative SP examination (Web-based vs. in-person) on scores on a subsequent high-stakes SP examination and to compare students’ satisfaction with each formative examination format.

Methods: Clustered randomized trial comparing a Web-based module versus in-person formative SP examination. We compared scores on a subsequent high-stakes SP examination and satisfaction.

Results: Scores on the subsequent high-stakes SP examination did not differ between the two formative formats but were higher after the formative assessment than without ( p < .001). Satisfaction was higher with the in-person than Web-based formative assessment format (4.00 vs. 3.62 on a 5-point scale, p= .01).

Conclusions: Two formats of a formative SP examination led to equivalent improvement
in scores on a subsequent high-stakes examination. Students preferred an in-person formative examination to online but were satisfied with both.

Hauer, KE, Chou, CL, Souza, KH, Henry, D, Loeser, H, Burke, C, Mayfield, C, O’Sullivan, PO. Impact of an In-Person Versus Web-Based Practice Standardized Patient Examination on Student Performance on a Subsequent High-Stakes. Teaching and Learning in Medicine, 21: 4, 284 — 290.

http://dx.doi.org/10.1080/10401330903228307

Innovations in Medical Education: Really Good Stuff

Recently published in "Really Good Stuff" from Medical Education. Volume43, Issue11,2009.

http://www3.interscience.wiley.com/journal/117964731/home

Near-peer videos for physical examination instruction (p 1095-1096). Adam D Schickedanz, Judy E Kim, Calvin L Chou

Continuity in a longitudinal out-patient attachment...Wamsley MA, Dubowitz N, Kohli P, Cooke M, O'Brien BC

Continuity in a longitudinal out-patient attachment for Year 3 medical students.

Med Educ. 2009 Aug 6;

Authors: Wamsley MA, Dubowitz N, Kohli P, Cooke M, O'Brien BC

Medical Education 2009Context Concerns about the quality of medical student learning experiences during traditional clerkships have prompted calls to restructure clinical education around continuity. Many US medical schools have added longitudinal out-patient attachments to enhance student continuity with patients and supervising doctors. However, continuity with patients can be difficult to achieve and little is known about the independent effect of continuity with a supervising doctor and setting. This study describes students' perceptions of the types of continuity experienced in longitudinal attachments and the learning associated with continuity. Methods This is a qualitative study using a grounded theory approach. Interviews were conducted with 12 Year 3 medical students about their continuity experiences with patients, supervisors and settings during their attachment. The resulting data were subjected to thematic analysis. Results Continuity with supervising doctors provided students with career mentorship and personal support. Student autonomy varied and was most dependent on the supervisor and setting. Students with patient continuity were more likely to report learning about chronic illness and communication skills. Students described the longitudinal attachment as helping them to develop their clinical skills and gain self-confidence within their role as future doctors, and as influencing their career choice. Conclusions There is much variation in student experiences of patient continuity during a longitudinal attachment. Continuity with patients, supervisors and settings affects student learning in different ways. Additional dimensions of the experience, such as the nature of the patient-doctor relationship, the pace of work and the patient population, impact learning outcomes and should be considered when continuity experiences are being designed.

PMID: 19674297 Learn More

Remediation techniques for student performance problems...Saxena V, O'Sullivan PS, Teherani A, Irby DM, Hauer KE

Remediation techniques for student performance problems after a comprehensive clinical skills assessment.

Acad Med. 2009 May;84(5):669-76

Authors: Saxena V, O'Sullivan PS, Teherani A, Irby DM, Hauer KE

PURPOSE: Poor performance on a medical school comprehensive clinical skills assessment after core clerkships requires remediation. Little is known about techniques used to remedy students' skills deficits and their effectiveness. The authors identified remediation strategies used at U.S. medical schools and determined instructors' confidence in remediation.

METHOD: In the fall of 2007, the authors surveyed persons responsible for remediation at U.S. medical schools that conduct comprehensive clinical assessments and remediation. Respondents reported their use of four types of remediation strategies: (1) clinical activities, (2) independent study, (3) precepted video review of exam recording, and (4) organized group activities for deficits in history-taking, physical examination, knowledge, clinical reasoning, professionalism, and communication. The authors assessed confidence in remediation for the six skill areas and analyzed these measures using repeated-measures analysis of variance.

RESULTS: Fifty-three of 71 (74.6%) participants responded. Educators most commonly employ the precepted video review remediation activity across the six skill areas, and they use the clinical activities least commonly. Confidence in remediating the six skill areas was below the "agree" level. Confidence was highest for remediating history-taking and physical examination problems and lowest for professionalism.

CONCLUSION: Educators express modest confidence in remediating fourth-year students' clinical skills deficiencies. The finding that schools employ primarily video review for remediation suggests a potential need to augment opportunities for mentored skills practice to address deficits more effectively. The remediation literature similarly stresses the importance of multiple approaches tailored to particular deficits.

PMID: 19704207 Learn More

Consequences within medical schools for students with poor performance...Hauer KE, Teherani A, Kerr KM, Irby DM, O'Sullivan PS

Consequences within medical schools for students with poor performance on a medical school standardized patient comprehensive assessment.

Acad Med. 2009 May;84(5):663-8

Authors: Hauer KE, Teherani A, Kerr KM, Irby DM, O'Sullivan PS

PURPOSE: Medical schools increasingly employ comprehensive standardized patient assessments to ensure medical students' clinical competence. The consequences of poor performance on the assessment and the institutional factors associated with imposing consequences are unknown.


METHOD: In 2006, the investigators surveyed 122 U.S. medical school curriculum deans about comprehensive assessments using standardized patients after core clerkships, with questions about exam characteristics, institutional commitment to the examination (years of experience, exam infrastructure, clerkship director involvement), academic consequences of failing the assessment, and satisfaction with remediation.

RESULTS: Ninety-three of 122 (76%) deans responded. Eighty-two (88%) conducted a comprehensive assessment in years three or four of medical school. Of those, required remediation was the only consequence of failing employed by 61 schools (74%), and only 39 (47%) required retesting for graduation. Participants were somewhat satisfied with (mean 3.45 out of maximum 5, SD 1.08) and confident in (3.37, SD 1.17) their remediation process. Satisfaction and confidence were associated with requiring remediation (P = .003) and retesting (P < .001), but experience with the exam, exam infrastructure, and clerkship director involvement were not. No school demographic characteristics or measures of institutional commitment were related to external reporting of students' comprehensive assessment scores. CONCLUSIONS: Despite the prevalence of comprehensive assessments, schools attach few academic consequences to poor performance. Educators are only moderately satisfied with their efforts to remediate poor performers. However, schools with greater trust in their remediation process than other schools are more likely to enforce consequences of poor performance. PMID: 19704205 Learn more

Becoming an academic doctor: perceptions of scholarly careers. O'Sullivan PS, Niehaus B, Lockspeiser TM, Irby DM ...

Becoming an academic doctor: perceptions of scholarly careers.

Med Educ. 2009 Apr;43(4):335-41

Authors: O'Sullivan PS, Niehaus B, Lockspeiser TM, Irby DM

OBJECTIVES: Despite a recognised need to prepare future faculty members, little research has been conducted on how best to accomplish this task, especially among learners and faculty members within research-intensive medical schools.

METHODS: We interviewed 40 medical students, residents and faculty members from a single institution in the USA and asked questions about which careers the school does and should prepare individuals for, and the strengths of the institution for doing so. Interviews were conducted in person at a location chosen by the participant. All interviews were transcribed and coded using qualitative methods and software. The coding and themes were reviewed and discussed among members of the research team and verified by external reviewers.

RESULTS: We identified five themes related to becoming an academic doctor: early exposure to research; role models and mentoring; career pathways; interplay of personal and social factors, and career support for junior faculty members.

CONCLUSIONS: Results suggest that opportunities should be structured within undergraduate and graduate medical education to stimulate interest in careers as academic doctors and to aid junior faculty members to act as role models who can encourage learners to pursue careers in academic medicine.

PMID: 19335575 Learn More