Search

Background: Clinical reasoning is essential to medical practice, but because it entails internal mental processes, it is difficult to assess. Functional magnetic resonance imaging (fMRI) and think-aloud protocols may improve understanding of clinical reasoning as these methods can more directly assess these processes. The objective of our study was to use a combination of fMRI and think-aloud procedures to examine fMRI correlates of a leading theoretical model in clinical reasoning based on experimental findings to date: analytic (i.e., actively comparing and contrasting diagnostic entities) and nonanalytic (i.e., pattern recognition) reasoning. We hypothesized that there would be functional neuroimaging differences between analytic and nonanalytic reasoning theory.Methods: 17 board-certified experts in internal medicine answered and reflected on validated U.S. Medical Licensing Exam and American Board of Internal Medicine multiple-choice questions (easy and difficult) during an fMRI scan. This procedure was followed by completion of a formal think-aloud procedure.Results: fMRI findings provide some support for the presence of analytic and nonanalytic reasoning systems. Statistically significant activation of prefrontal cortex distinguished answering incorrectly versus correctly (p < 0.01), whereas activation of precuneus and midtemporal gyrus distinguished not guessing from guessing (p < 0.01).Conclusions: We found limited fMRI evidence to support analytic and nonanalytic reasoning theory, as our results indicate functional differences with correct vs. incorrect answers and guessing vs. not guessing. However, our findings did not suggest one consistent fMRI activation pattern of internal medicine expertise. This model of employing fMRI correlates offers opportunities to enhance our understanding of theory, as well as improve our teaching and assessment of clinical reasoning, a key outcome of medical education. [ABSTRACT FROM AUTHOR]

Unlabelled: The Uniformed Services University of the Health Sciences (USU) houses the nation's only federal medical school, the F. Edward Hébert School of Medicine. A key aspect of the curriculum at USU is leadership education as graduates go on to serve the Department of Defense through a variety of senior positions in the military. We surveyed a specific group of USU graduates who have achieved the rank of General or Admiral ("flag officers") to enhance our understanding of successful leadership for military physicians and to gain an understanding of how USU might shape its curriculum in the future.Methods: We sent an Internet-based survey to 13 flag officer graduates. The first section of the survey contained items from the multifactor leadership questionnaire-6S, a questionnaire with evidence of reliability and validity for evaluating leadership styles. The second section of the survey contained open-ended questions addressing key characteristics of an effective leader in the Military Health System, experiences that prepared them for leadership, USU's role in leadership positions, and advice for USU for better educating future leaders. The second section of the survey was coded using the constant comparative method.Results: Eight flag officers (63%) responded to the survey. They all scored highly on transformational leadership style. Qualitative themes reached saturation for each open-ended question. The flag officers identified characteristics consistent with published literature from other fields regarding effective leadership. They endorsed USU's role in achieving their leadership positions and suggested areas for improvement.Conclusions: Characteristics of effective leadership (transformational leadership style) identified by the flag officers surveyed in this study are consistent with the literature from other fields. These finding have important implications for leadership education at USU and potentially other institutions. The results also provide additional data to support the notion that USU is meeting its societal obligation to educate future leaders in military medicine. [ABSTRACT FROM AUTHOR]

Purpose: Each year military medical students participate in a separate, military match culminating with the Joint Services Graduate Medical Education Selection Board (JSGMESB). Prior studies have explored postinterview communication that occurs during the National Resident Matching Program (NRMP), but not during the JSGMESB. We examined the frequency and nature of communication during the JSGMESB and compared it with the NRMP.Methods: Cross-sectional survey study of senior students conducted at Uniformed Services University of the Health Sciences (USU) and seven civilian U.S. medical schools during March to May 2010. Respondents answered questions regarding communication with residency programs during the match.Results: Significantly fewer USU respondents communicated with programs compared with the civilian cohort (54.1% vs. 86.4%, p < 0.01). Specific inquiries regarding rank order were more commonly experienced by USU respondents compared with civilians (17.5% vs. 4.8%, p = 0.02). USU respondents found postinterview communication both helpful (41.3%) and stressful (41.3%). 11.1% of USU respondents indicated that they moved a program higher on their final rank lists because of further communication with these programs.Conclusions: Postinterview communication during the JSGMESB process is less common and less stressful than that reported in the NRMP. USU respondents are more likely to be asked directly about their rank list and occasionally do change their lists. Uniform guidance mirroring the NRMP's dealing with direct inquiries about rank lists could potentially improve the process. [ABSTRACT FROM AUTHOR]

The Uniformed Services University's (USU) F. Edward Hébert School of Medicine was chartered in 1972, with the goal of providing high-quality physicians for the Uniformed Services. In exchange for their education, USU graduates incur an active duty service obligation, after which they may choose to stay on active duty or transition to civilian practice. The purpose of this study is to describe the practice characteristics of USU graduates after this obligation has been completed in order to determine the societal benefits during this phase of their careers. To accomplish this purpose, we performed a retrospective cohort study of the first 20 years of USU graduates (1980-1999). We used the American Medical Association Physician Masterfile to determine the graduates' current practice location and characteristics, as well as their board certification status. Of these 2,760 graduates, nearly all (91%) were involved in active clinical practice in over 100 self-declared specialties, the vast majority (89%) practiced in locations other than the immediate vicinity of the medical school (i.e., Maryland and the District of Columbia), and most still worked for the federal government (71%). Finally, USU graduates in full-time clinical practice had a board certification rate of 93%, which was better than the average of all other graduates of U.S. Medical Schools (88%) in the same time period. Thus, it seems USU is attaining its goal of producing high-quality physicians who continue to benefit the nation after their service obligation has been completed, with many still in federal service. [ABSTRACT FROM AUTHOR]

Objective: The purpose of the study was to investigate the relationship between authenticity (how close to actual practice) of preclerkship instructional formats and preclerkship and clerkship outcome measures. A secondary purpose was to investigate the effect of student's small-group assignment during preclerkship period on instructional formats and preclerkship and clerkship outcome measurements.Methods: A prospective, randomized, crossover study was carried out with preclerkship students taking a clinical reasoning course. Students were randomized to small groups and exposed to three formats of differing instructional authenticity across three subject areas. Three student cohorts were taught using one instructional format per subject area with each cohort receiving a different instructional format for each of the three areas. Outcome measures at the end of the preclerkship year and the clerkship year were selected to determine the effect of each instructional format. Hierarchical linear modeling was performed to assess impact of format on outcomes and to assess potential group effect on outcomes.Results: Increasingly authentic instructional formats did not significantly improve clinical reasoning performance. Small-group assignment did not significantly contribute to the outcomes providing evidence that teacher training was successful.Conclusions: Increasing authenticity of instructional formats does not appear to significantly improve clinical reasoning performance. Faculty can be successfully trained to teach consistently in a clinical reasoning course. Medical educators should balance increasing authenticity with factors such as cognitive load and learner experience as well as engaging in frame-of-reference training to minimize group effects with designing new instructional formats. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the relationship between self-reported research experience and medical students' performance in medical school and internship.Methods: We collected data from seven year-groups (1993-1999; N = 1,112) and examined 7 performance outcomes: medical school preclinical grade point average (GPA), medical school clinical GPA, cumulative medical school GPA, U.S. Medical Licensing Examination Step 1 and 2 scores, and scores on a previously validated program director's survey of intern professionalism and expertise. We then conducted a series of multiple linear regressions to determine the relations between self-reported research experience and our seven outcomes.Results: When compared to those who reported no prior research experience, students who reported research experience performed significantly better on U.S. Medical Licensing Examination Step 1 and had a higher medical school preclinical GPA. However, these same students scored significantly lower on intern professionalism and expertise ratings. Self-reported research experience did not show statistically significant correlations with the other outcome variables.Conclusions: The results from our large, multiyear, cohort study suggest that prior research experience may account for some variance in outcomes in the early stages of medical school education, but that variance explained diminishes considerably as trainees progress into the more senior phases of education. On the other hand, prior research experience may be negatively related to students' performance in internship. In all cases, however, effect sizes are small. [ABSTRACT FROM AUTHOR]

Context A challenge for medical educators is to better understand the personal factors that lead to individual success in medical school and beyond. Recently, educational researchers in fields outside medicine have acknowledged the importance of motivation and emotion in students' learning and performance. These affective factors have received less emphasis in the medical education literature. Objectives This longitudinal study examined the relations between medical students' motivational beliefs (task value and self-efficacy), achievement emotions (enjoyment, anxiety and boredom) and academic achievement. Methods Second-year medical students (n = 136) completed motivational beliefs and achievement emotions surveys following their first and second trimesters, respectively. Academic achievement was operationalised as students' average course examination grades and national board shelf examination scores. Results The results largely confirmed the hypothesised relations between beliefs, emotions and achievement. Structural equation modelling revealed that task value beliefs were positively associated with course-related enjoyment (standardised regression coefficient [?] = 0.59) and were negatively related to boredom (? = - 0.25), whereas self-efficacy beliefs were negatively associated with course-related anxiety only (? = - 0.47). Furthermore, student enjoyment was positively associated with national board shelf examination score (? = 0.31), whereas anxiety and boredom were both negatively related to course examination grade (? = - 0.36 and - 0.27, respectively). The overall structural model accounted for considerable variance in each of the achievement outcomes: R2 = 0.20 and 0.14 for the course examination grade and national board shelf examination score, respectively. Conclusions This study suggests that medical students' motivational beliefs and achievement emotions are important contributors to their academic achievement. These results have implications for medical educators striving to understand the personal factors that influence learning and performance in medical training. [ABSTRACT FROM AUTHOR]

Background: Medical education programs need outcome measurements to promote curriculum improvement and to help meet accreditation standards.Purpose: Determine the added value of qualitative comments written by program directors (PDs) in response to a survey concerning first postgraduate year (PGY-1) graduates. We hypothesized that these comments would serve as an additional outcome measurement for our graduates, adding information not readily captured in numeric data.Methods: PD evaluation form surveys from 1993-2002. All qualitative comments offered in response to free text questions were coded and compared with numeric ratings.Results: A total of 1,247 surveys were included (80% response rate). Comments about specific graduates were coded as positive, negative, or neutral and were categorized into themes. Inter-rater reliability was high (kappa= 0.82). Compared with 4% of graduates who received one or more numeric ratings of less than satisfactory, 7% had one or more qualitative phrases classified as negative.Conclusions: Qualitative comments can serve as a useful outcome measurement. [ABSTRACT FROM AUTHOR]

Background: Medical educators grapple with predicting performance of graduates identified as struggling during medical school. Students appear before student promotions committees (SPCs) for multiple cognitive and noncognitive reasons and performance outcomes for this cohort have not been well defined in the literature. Purpose: To determine the predictive validity of SPC appearance with respect to performance on a Program Director's (PD's) Evaluation Form completed at the end of internship (PGY-1). Method: Residents were classified as 'below average,' 'average,' or 'above average' based on PD Evaluation Form ratings. This PD instrument has been shown to be feasible, reliable, and valid. Below-average residents were defined as having a below-average rating on any question on the PD Evaluation Form. We compared SPC and non-SPC cohorts with respect to these PD Evaluation Form ratings. The t test was used for statistical analysis. Results: Seven years of graduating classes from our institution were included. Of students who graduated from our institution, 119 of 856 students (14%) were presented at our SPC during medical school during our study period. There were 196 residents (23%) identified as below average. The PD Evaluation Form response rate for this period was 77%. Students who appeared at our SPC were significantly more likely to have below-average scores for almost all PD Evaluation Form questions with small to moderate effect sizes. Conclusions: Students who appear before SPCs are at higher risk of below-average performance as rated by a PD Evaluation Form at the end of PGY-1. However, only a minority of trainees that appeared before our SPC received below-average ratings during internship. These data provide predictive validity evidence that SPC appearance during medical school does identify below average performance during internship. Our data support that SPC appearance during medical school, regardless of cause, is a risk for below average performance during internship. [ABSTRACT FROM AUTHOR]

Background: The Uniformed Services University of the Health Sciences (USUHS) F. Edward Hébert School of Medicine exists to provide physicians who will become leaders in military medicine in both war and peacetime. Studying the career accomplishments of graduates who have reached or are near the end of their military career is one way to assess how well USUHS is meeting this societal charge.Methods: Self-reported survey of all 2,689 USUHS graduates since its inception in 1976. Data were collected with regard to residency completed, additional degrees obtained, leadership positions and rank obtained, deployment experience, and academic affiliations.Results: Our survey resulted in a 59% response rate (712 of 1,199 respondents) for the matriculating classes of 1980-1989 and a 68% (1,822 of 2,689 respondents) total response rate for all graduates. Career outcome data were analyzed for graduates of the 1980-1989 classes in this article. For this cohort, the board certification rate was 99%; 20% obtained additional degrees; 96% have worked as full-time clinicians; 14% received below-the-zone promotions; 51% had deployed for combat and 42% for humanitarian missions; and 57% continue to hold medical school faculty appointments.Discussion: Many accomplishments, to include high sustained board certification rates from a diverse array of specialties, broad deployment experience, achievement of high leadership responsibilities and senior rank, as well as important contributions to academic medicine were achieved by these graduates. Our results support that USUHS is accomplishing its societal charge. [ABSTRACT FROM AUTHOR]

Background: Shortages in primary care careers such as internal medicine are projected in the future. Conducting research is an explicit requirement for graduate medical education and interest in research is growing in undergraduate medical education. Purpose: We hypothesized that a medical student research initiative could increase student research productivity and foster mentoring relationships with internists. Method: We compared the number of medical student presentations, awards, and peer-reviewed publications before and after a brief research initiative at a single institution and recorded comments from student participants; data collected before the initiative were retrospective, and data after the initiative were collected prospectively. Mann-Whitney U was used for statistical analysis. Results: Twenty-seven students participated in our workshop initiative during the study period (2000-2005). Eighteen (67%) subsequently had presentations, research awards, and/or publications during the study period. Mann-Whitney U testing of groups (all pre-initiative Uniformed Services University students and initiative participants) showed a statistically significant increase in regional presentations (p = .003), research awards (p = .01), and publications (p = .02) after the research initiative. Student comments not only revealed research mentoring benefits but also commented on receiving career counseling advice from mentors. Conclusions: Our study findings support the feasibility of this initiative as well as produced significant outcomes in terms of quantified research productivity and student mentoring. [ABSTRACT FROM AUTHOR]

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 Examinations1-3 (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. [ABSTRACT FROM AUTHOR]

Background: Despite published literature demonstrating deficiencies in chest radiograph (CXR)/basic radiology interpretation skills of 4th-year medical students, studies and subsequent curricula regarding the training needed to obtain these skills are lacking. Terms such as clinical exposure and radiology teaching have been used to describe the experience for these basic interpretive skills, but best practice methods of delivery, let alone common methods, have yet to be defined. Purpose: The objective is to describe the current methods of teaching and assessing CXR/basic radiology interpretation skills across institutions on the 3rd-year internal medicine (IM) clerkship. Methods: In 2005, the Clerkship Directors in Internal Medicine (CDIM), an international organization representing U.S. and Canadian medical schools, surveyed its institutional members. Twelve questions on the survey dealt with X-ray interpretation. Results: Eighty-eight of 109 members (81%) responded to the survey. Overall, 81% of respondents felt that CXR interpretation is an important clinical skill for medical students. Seventy-six percent indicated that instruction in these skills occurs on the IM clerkship. The most cited methods of instruction were lectures (56%) and teaching rounds (48%). Most schools spent on average of 2 to 4 hr during the IM clerkship on formal radiology instruction. Only 33% indicated that radiology interpretation skills are assessed during the clerkship. The most common assessment methods were written examination (19%) and OSCE (19%). Conclusion: Substantive data regarding attainment and assessment of CXR/basic radiology interpretation skills in the undergraduate curriculum are lacking. Our study provides preliminary descriptive data regarding CXR instruction and assessment on the 3rd-year IM clerkship. [ABSTRACT FROM AUTHOR]

Background: Evaluation methods within and across clerkships are rapidly evolving, including greater emphasis or frameworks for descriptive evaluation and direct observation of competence. Purpose: The purpose of this study is to describe current evaluation methods, use of the Reporter-Interpreter-Manager/Educator (RIME) framework, and grade assignment by internal medicine clerkship directors. Methods: In 2005, the Clerkship Directors in Internal Medicine surveyed its 109 institutional members. Topics included evaluation methods and grade contribution, use of evaluation sessions and/or RIME, and grade assignment (criterion referenced or normative). Results: Response rate was 81% (88/109). The evaluation methods were as follows: teachers' evaluations, 93% (64% of grade); National Board of Medical Examiners subject examination, 81% (25% of grade); faculty written exam, 34% (14% of grade); objective structured clinical examinations, 32% (12% of grade); direct observation, 22% (7% of grade). RIME is used by 42% of respondents. Many clerkship directors (43%) meet with teachers to discuss student performance. Criterion-referenced grading is used by 59%, and normative grading is used by 27%. Unsatisfactory grades are given for examination failures (72%), unprofessional behavior (49%), poor clinical performance (42%), and failure to meet requirements (18%). Conclusions: Internal medicine clerkship directors emphasize description and observation of students. RIME and discussions with teachers are becoming commonplace. [ABSTRACT FROM AUTHOR]

Background: For more than a decade, primary care residency training programs have struggled to attract graduates of U.S. medical schools. Internal medicine (IM) interest groups (IMIGs) have been widely instituted to foster student interest in careers in IM. Residents can participate in many IMIG activities. Studies have not assessed the benefits gained by resident participants in such groups.Methods: A questionnaire was sent to residents at two IM residency training programs that contribute to IMIG activities at one medical school. Both participating and nonparticipating residents were included.Results: The questionnaire was completed by 44 of 58 IM residents (76% response rate; 25 participants and 19 nonparticipants). Free-text advantages reported were teaching (n=6), mentoring (n=8), and leadership (n=5) opportunities, staying current in IM (n=3), encouraging students to enter IM (n=6), and improving resident morale (n=6). Likert-scale responses were higher for participants than for nonparticipants for all questions; nonparticipants also reported that involvement in IMIG activities is beneficial for residents. Statistically significant results were seen for questions regarding the following: improves resident morale, fosters leadership opportunities, is a valuable experience, and feeling qualified to participate.Conclusions: Residents perceive that participation in an IMIG confers significant benefit, providing additional justification for conducting these interest groups. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to determine the feasibility and construct validity of our graduate and employer survey and its potential use in programmatic evaluation. Methods: An identical survey instrument was sent to fellowship graduates from our institution and their employers. We estimated feasibility through determining our survey response rate. Construct validity was assessed by comparing graduate self-ratings and employer ratings and through comparing survey ratings with passing board-certification examinations and referrals to the National Practitioner Databank. Results: Eleven years of graduates were included (n = 38 graduates). Response rates were 84% and 82% for graduates and their employers, respectively. Mean supervisor ratings were greater than graduate self-ratings on all questions. The lowest rating consistently across survey years was in graduates' self-perception of their ability to direct a PFT lab. One fellow failed his pulmonary boards and 1 failed his critical care boards on the first attempt. No graduates were referred to the National Practitioner Databank during our study period. Conclusions: This fellowship survey appears to be feasible and have construct validity. The consistency in the relatively low self-rating of graduates in directing a PFT lab has led to important areas for curriculum reform. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to determine how well published expectations are being met for internal medicine (IM) clerkship directors (CDs). Method: In 2005, the Clerkship Directors in Internal Medicine (CDIM) surveyed its institutional members. One section addressed expectations, in terms of requirements and resources, of and for CDs. Survey questions were categorical (yes, no, or unsure) addressing the essential responsibilities and resources outlined in the Alliance for Clinical Education (ACE) consensus statement. Descriptive statistics, MannWhitney U, and chi-square testing were used for inferential statistical procedures. Results: Eighty-eight of 109 institutional members responded to the survey (81% response rate). For each responsibility, more than 90% of respondents reported that they were required to meet the expectation; however, for each of the 8 essential resources, the percentage of respondents who were meeting the expectation varied from 41% for additional time and resources for administering other courses to 95% for sufficient material resources to support clerkship requirements. With the exception of larger institutions having greater access to new technology (p = .038, MannWhitney U) and a defined budget (p = .012, MannWhitney U), there were no differences in demographics between respondents who did and did not meet expectations or resources. Conclusion: IM CDs reported that they are expected to achieve essential responsibility benchmarks. Essential resources were being met in a variable fashion. [ABSTRACT FROM AUTHOR]

Chest pain with electrocardiographic changes is usually a life-threatening presentation of cardiac ischemia. There are, however, a variety of noncardiac conditions that have been reported to mimic these clinical and electrocardiographic changes. An Asian woman presented with chest pain and ST segment elevations in the distribution of the left anterior descending artery. She had persisting chest pain and ST segment elevations that were refractory to medical therapy, leading to thrombolytic therapy and rescue angiography, which revealed no evidence of coronary artery disease by coronary catherization. Cholecystitis was subsequently diagnosed with hepatobiliary scintigraphy. The patient's fever and ST segment elevations promptly resolved with antibiotic treatment. Four previous cases of ST segment elevation attributed to cholecystitis have been reported. Although the electrocardiographic changes attributed to cholecystitis have been shown to be correctable, the pathophysiological mechanism underlying these changes remains unclear. Prompt recognition of cholecystitis can ensure appropriate treatment and may prevent the performance of unnecessary diagnostic and therapeutic interventions. [ABSTRACT FROM AUTHOR]

The decision to undergo pericardectomy for symptomatic pericardial constriction is usually dictated by an image of an abnormal pericardium. We report a case of symptomatic pericardial constriction despite radiographic and pathological evidence of a normal pericardium. The patient was successfully treated with a pericardectomy, with resolution of constrictive hemodynamics and symptoms. Our report suggests that a normal pericardium by computed tomography and biopsy should not preclude pericardectomy for patients who have refractory symptoms, physical findings, and intracardiac pressures diagnostic of constrictive pericarditis. [ABSTRACT FROM AUTHOR]

The Food and Drug Administration recently banned the sale of ephedra alkaloids because of their association with arrhythmic sudden death, myocardial infarction, and stroke. This has resulted in the emergence of formulations marketed for weight loss and performance enhancement that are "ephedra free" but contain other sympathomimetic substances, the safety of which has not been established. We report a case of exercise-induced syncope in a healthy 22-year-old woman that occurred 1 hour after she took the second dose of Xenadrine EFX, an ephedra-free weight-loss supplement. Electrocardiography revealed prolongation of the QT interval (corrected QT, 516 milliseconds); this resolved in 24 hours. Results of echocardiography and exercise stress testing were normal. Nine months of monitoring with an implanted loop recorder revealed no arrhythmias in the absence of Xenadrine EFX. Although this product contains a number of compounds whose pharmacologic effect is poorly characterized, notable quantities of phenylephrine are present, and the proarrhythmic potential of this compound in the setting of exercise is discussed. [ABSTRACT FROM AUTHOR]

BACKGROUND: Step 2 Clinical Skills (CS) was recently introduced into the United States Medical Licensing Examination (USMLE) to ensure that successful candidates for licensure possess the clinical skills to provide safe and effective patient care. AIMS: To explore if medical schools had changed the objectives, content, or emphasis in their pre-clinical curriculum in response to its implementation. METHODS: In April 2005, the Clerkship Directors in Internal Medicine (CDIM) sent an electronic survey to a single member from each medical school with a CDIM member. The survey instrument included 26 pre-clinical curricular questions with nine questions specifically addressing changes in response to implementation of the Step 2 CS. RESULTS: Forty-five percent of respondents reported changes to the Introduction to Clinical Medicine (ICM) course objectives while 39% and 40% reported changes in content and emphasis. Seventy-four percent felt their students were adequately prepared for the Step 2 CS and 18% were unsure. CONCLUSIONS: Over a third of medical schools are implementing changes to the objectives, content, and/or emphasis of their curriculum, at least partially in response to the institution of Step 2 CS. [ABSTRACT FROM AUTHOR]

Polyethylene glycols (PEGs) are commonly utilized as a bowel prep prior to colonoscopy. They are generally well-tolerated, and reports of allergic reactions are rare. A recent search of the literature reveals only 4 prior reported cases of allergic reactions and only 1 other case of anaphylaxis. We report a second case of anaphylaxis following the ingestion of PEG solution, making this the fifth reported case of an allergic reaction to PEG bowel prep. [ABSTRACT FROM AUTHOR]

Background: Failure to regain consciousness after general anesthesia has a multitude of life-threatening causes, including neurological injury, metabolic derangements, or drug effects. Failure to promptly recognize the cause of unconsciousness after anesthesia can result in significant patient morbidity or mortality, costly laboratory and radiographic evaluation, and physician anxiety. Rarely, patients fail to awaken after anesthesia due to a psychiatric cause. The early recognition of psychogenic coma can result in reduced iatrogenic complications, hospital cost, and physician anxiety.Case: We present a case of a 28-year-old female who became unresponsive after general anesthesia for an upper endoscopy. Physical, laboratory, and radiographic examination after the procedure revealed no apparent organic cause for her failure to awaken. The patient spontaneously awoke after 16 hours without neurological deficit.Discussion: We reviewed the literature and identified 10 previously reported cases of postanesthesia psychogenic coma. We have compared and contrasted our case with the 10 previous reports and propose bedside clues to assist the physician with diagnosing this unusual condition. [ABSTRACT FROM AUTHOR]

Purpose: The United States is experiencing an accelerating physician shortage, especially within primary care. Medical educators are actively seeking ways to predict student specialty match and workforce requirements. Previous studies investigating specialty match have focused on factors known at the time of matriculation. This study examined whether third-year clerkship performance could be used to predict specialty match later in medical school.Method: The authors evaluated the clerkship performance of 802 students graduating from the Uniformed Services University between 2007 and 2011. They examined the relationship of students' clerkship grades and National Board of Medical Examiners' clinical subject examination scores to specialty match. In addition, the authors combined student performance in family medicine, internal medicine, and pediatrics to create composite variables and assessed their associations with the match.Results: Among 802 students, 339 (42.4%) students matched to primary care specialties. There was a positive association between higher family medicine (Odds ratio [OR] 1.65, 95% confidence interval [CI] 1.05, 2.59), general surgery (OR 1.91, 95% CI 1.22, 2.99), internal medicine (OR 2.17, 95% CI 1.35, 3.49), and pediatrics (OR 2.59, 95% CI 1.52, 4.43) clerkship grades and students matching into family medicine, general surgery, internal medicine, and pediatrics, respectively. Only family medicine showed a weak correlation between higher National Board of Medical Examiners' scores and specialty match.Conclusions: Higher clerkship performance in four of six Uniformed Services University third-year clerkships is associated with matching into the corresponding specialty. Clerkship performance provides a potential tool for educators in counseling students and predicting future specialty match. [ABSTRACT FROM AUTHOR]

Self-efficacy is a personal belief in one's capability to successfully execute the behaviors necessary to attain designated types of performances. Sometimes described as task-specific self-confidence, self-efficacy is a key component in many contemporary theories of motivation and learning. The purpose of this study was to develop a survey for measuring students' medical skills self-efficacy and to collect reliability and validity evidence for the instrument. A secondary purpose was to explore differences in students' self-efficacy from year 1 of medical school to year 4. We created 19 survey items based on the 6 core competencies of the Accreditation Council for Graduate Medical Education, and we collected data from 304 medical students. Results from an exploratory factor analysis suggested three interpretable factors: patient care self-efficacy (eight items, Cronbach's alpha = 0.92), interpersonal skills self-efficacy (three items, Cronbach's alpha = 0.76), and evidence-based medicine self-efficacy (three items, Cronbach's alpha = 0.79). We then compared students' self-efficacy at different stages of training using a one-way multivariate analysis of variance. Consistent with our expectations, we found several statistically significant differences, suggesting students' self-efficacy increased considerably from year 1 of medical school to year 4, F(9, 725) = 30.58, p < 0.001, Wilks' lambda = 0.46. Using this survey, medical educators and researchers have a psychometrically sound tool for measuring students' medical skills self-efficacy during undergraduate medical education. Practical implications and future directions are discussed. [ABSTRACT FROM AUTHOR]

Introduction: Finding ways to improve communication and self-reflection skills is an important element of medical education and continuing professional development. This study examines the relationship between self-reflection and educational outcomes.Methods: We correlate performance in a preclinical course that focuses on self-reflection as it relates to contextual elements of patient care (Human Context of Health Care), with educational measures such as overall grade point average, clinical clerkship scores, and Medical College Admission Test (MCAT) scores.Results: Student performance in Human Context of Health Care correlated with MCAT-Verbal scores, MCAT-writing sample scores, clerkship grades, and overall medical school grade point average (R = 0.3; p < 0.001).Conclusion: Writing and self-reflection skills are often neglected in undergraduate medical curricula. Our findings suggest that these skills are important and correlate with recognized long-term educational outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the association between tertiary reviewer (admissions committee member) comments and medical students' performance during medical school and into internship.Methods: We collected data from seven year-groups (1993-1999) and coded tertiary reviewer comments into 14 themes. We then conducted an exploratory factor analysis to reduce the dimensions of the themes (excluding the Overall impression theme). Subsequently, we performed Pearson correlation analyses and multiple linear regression analysis to examine the relationship between the factors and seven outcome measures: medical school preclinical grade point average (GPA), medical school clinical GPA, cumulative medical school GPA, U.S. Medical Licensing Examination Step 1 and 2 scores, and scores on a program director's evaluation measuring intern professionalism and expertise.Results: We extracted seven factors from the 13 themes and found small-to-moderate, significant correlations between the factors, the Overall impression theme, and the outcome measures. In particular, positive comments on Test and Maturity were associated with higher U.S. Medical Licensing Examination Step 1 and 2 scores. Negative comments on Interview and Recommendations were associated with lower ratings of professionalism during internship. Comments on Overall impression were significantly associated with all the outcome measures.Conclusions: Tertiary reviewer comments were weakly associated with performance in medical school and internship. Compared with positive comments, negative comments had stronger associations with medical school and internship performance measures. [ABSTRACT FROM AUTHOR]

Background: Objective Structured Clinical Examinations (OSCEs) are used at the majority of U.S. medical schools. Given the high resource demands with constructing and administering OSCEs, understanding how OSCEs relate to typical performance measures in medical school could help educators more effectively design curricula and evaluation to optimize student instruction and assessment.Purpose: To investigate the correlation between second-year and third-year OSCE scores, as well as the associations between OSCE scores and several other typical measures of students' medical school performance.Methods: We tracked the performance of a 5-year cohort (classes of 2007-2011). We studied the univariate correlations among OSCE scores, U.S. Medical Licensing Examination (USMLE) scores, and medical school grade point average. We also examined whether OSCE scores explained additional variance in the USMLE Step 2 Clinical Knowledge score beyond that explained by the Step 1 score.Results: The second- and third-year OSCE scores were weakly correlated. Neither second- nor third-year OSCE score was strongly correlated with USMLE scores or medical school grade point average.Conclusion: Our findings suggest that OSCEs capture a viewpoint that is different from typical assessment measures that largely reflect multiple choice questions; these results also support tenets of situated cognition theory. [ABSTRACT FROM AUTHOR]

Purpose: Physician proficiency in clinical encounter documentation is a universal expectation of medical education. However, deficiencies in note writing are frequently identified, which have implications for patient safety, health care quality, and cost. This study aimed to create a compendium of tools for educators' practical implementation or future research., Method: A scoping review was conducted using the Arksey and O'Malley framework. PubMed, Embase, Ovid All EBM Reviews, Web of Science, and MedEdPortal were searched for articles published from database inception to November 16, 2023, using the following search terms: documentation, note-writing, patient note, electronic health record note, entrustable professional activity 5, and other terms. For each note-writing assessment tool, information on setting, section(s) of note that was assessed, tool properties, numbers and roles of note writers and graders, weight given, if used in grading, learner performance, and stakeholder satisfaction and feasibility was extracted and summarized., Results: A total of 5,257 articles were identified; 32 studies were included. Eleven studies (34.4%) were published since 2018. Twenty-two studies (68.8%) outlined creating an original assessment tool, whereas 10 (31.2%) assessed a curriculum intervention using a tool. Tools varied in length and complexity. None provided data on equity or fairness to student or resident note writers or about readability for patients. Note writers often had missing or incomplete documentation (mean [SD] total tool score of 60.3% [19.4%] averaged over 25 studies), often improving after intervention. Selected patient note assessment tool studies have been cited a mean (SD) of 6.3 (9.2) times. Approximately half of the tools (53.1%) or their accompanying articles were open access., Conclusions: Diverse tools have been published to assess patient notes, often identifying deficiencies. This compendium may assist educators and researchers in improving patient care documentation., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Background: The Military Health System is a unique subsector within the nation's Graduate Medical Education (GME), with a different incentive structure for specialty selection for military medical students compared with their civilian counterparts. Changes by the Defense Health Agency (DHA) in 2017 emphasized a shift in military GME to training "operational" medical specialties. This study sought to gain insight into military medical students' reactions to the 2017 DHA transition by examining whether students continued to select "operational" specialties at similar rates as well as whether students remained satisfied with attending medical school., Methods: We performed a retrospective analysis of Uniformed Services University (USU) post-match students from 2015 to 2020 using anonymized data from the Association of American Medical Colleges (AAMC) Graduation Questionnaire, separated into pre-DHA (2015-2017) and post-DHA (2018-2020) transition groups., Results: Regarding both intent to practice an operational specialty and satisfaction with choosing medical school, there was no statistically significant difference between the preand post-DHA transition groups., Conclusions: Whether preor post-DHA transition, USU medical students demonstrated similar preferences for operational specialties as well as similar levels of satisfaction with medical school attendance, suggesting that this transition may not significantly influence medical students' career preferences nor blunt their desire to enter military medicine., Competing Interests: The authors have indicated they have no financial relationships relevant to this article to disclose. The preliminary results were presented at the Uniformed Services University Projects Day in March of 2022. The data that support the findings of this study are available on request from the corresponding author. all data is freely accessible., (2024.)

Introduction: Professional identity formation is central to physicians' identity over their full careers. There is little guidance within military service on how to leave careers as clinician educator faculty in graduate medical education programs. The objective of our study was to explore how leaving this community of practice (COP) affects a clinician educator's professional identity., Methods: We used reflexive thematic analysis with Communities of Practice as a sensitizing construct. Fifteen semi-structured interviews were conducted among active-duty clinician educators at the point of their retirement from the military. Interview questions focused participants' lived experiences as clinician educators and professional identity changes leading to and resulting from the decision to retire., Results: We found the clinician educators' journey through a time of professional transition led to three connected themes: Loss Precedes Growth, Fallow Season-Liminal Space, and New Growth., Discussion: The experiences of military clinician educators retiring from active duty demonstrate how leaving one COP emanates across a range of professional identities. In addition, the decision to leave a professional COP can lead to a sense of disloyalty to that community. Normalizing this transition in a way that honors the community's values offers the opportunity to enable the decision to retire. Understanding retirement as a process that first involves identity loss, followed by the discomfort of a liminal space before achieving new growth creates the opportunity to engage in rituals that celebrate the service of departing community members, releasing them to grow into new identities., Competing Interests: Disclosures: The authors declare no conflict of interest., (Copyright © 2024 The Alliance for Continuing Education in the Health Professions, the Association for Hospital Medical Education, and the Society for Academic Continuing Medical Education.)

Problem: There is a need within graduate health professions education (HPE) programs to align advising practices to support an increasing number of working adult learners, especially those studying part-time and from remote locations. Despite the recognized importance of the advisor-advisee relationship in graduate learner success, many advisors lack formal training and have to manage multiple completing priorities. Furthermore, a lack of established evidence-based practices for graduate HPE advising has left each program navigating advising independently., Approach: The Department of Health Professions Education, Uniformed Services University, established a small cadre of faculty to serve as academic advisors (n = 7) in August 2018. This cadre uses an advising model based on 5 advising practices, called TOTAL Advising- train the advisors, onboard the learners, touch base frequently, annually review learners, and learner review. These advising practices are meant to provide a wrap-around support system to ensure learners feel empowered to fully engage in the program, while managing the demands of their personal and professional lives. TOTAL Advising provides the framework needed to achieve 3 guiding beliefs: each learner is capable of completing the program, fostering community, and providing clear communication., Outcomes: Between May 2020-May 2024, learners who completed a degree (n = 21) were interviewed about their advising experiences by a program evaluator after they graduated. The themes observed from these reflect the program's 3 guiding beliefs. Additionally, from May 2018-May 2024, of the 574 learners who enrolled in the program, 568 (99%) graduated with a certificate or degree, only 6 (1%) were disenrolled., Next Steps: The next steps for TOTAL Advising involve a comprehensive evaluation of the effectiveness of the training program for advisors and collaborating with other graduate HPE programs to share best practices in advising, discuss emerging challenges, and shape advising practices in the broader HPE community., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Introduction: Continuing professional development for health professionals increasingly relies on e-learning. However, there is insufficient research into the instructional strategies health professionals prefer to engage with in e-learning. An empirical study was undertaken to answer the research question: What instructional strategies do learners prefer in e-learning modules to improve their learning experience?, Methods: The Department of Health Professions Education at the Uniformed Services University of Health Sciences developed six, stand-alone, self-paced modules for health professionals focusing on education and leadership. The module evaluation survey consisted of six Likert scale questions and two open-ended questions. Responses from these anonymized module evaluations from 2019 to 2022 were analyzed. Descriptive statistics for the Likert scale questions were calculated. Responses to the two open-ended questions were compiled and analyzed thematically., Results: All survey respondents found the content of the modules helpful and met their stated learning objectives. A majority (94%) agreed or strongly agreed that readings and videos increased their knowledge in the topic area and that quizzes effectively strengthened their understanding of the topics. Four themes emerged from the qualitative data: pedagogical strategies, technology issues, feedback and interaction, and transfer of learning., Conclusions: This study foregrounds the voice of the learner, which emphasizes health professionals' preference for instructional strategies that align with their needs as adult learners. The findings highlight the value of content relevance, expert creation, and authentic examples in enhancing learner satisfaction., Competing Interests: Disclosures: The authors declare no conflict of interest., (Copyright © 2024 The Alliance for Continuing Education in the Health Professions, the Association for Hospital Medical Education, and the Society for Academic Continuing Medical Education.)

Introduction: Past research has examined civilian and military medical schools' preparation of physicians for their first deployment. Most recently, our research team conducted a large-scale survey comparing physicians' perceptions of their readiness for their first deployment. Our results revealed that military medical school graduates felt significantly more prepared for deployment by medical school than civilian medical school graduates. In order to further investigate these results and deepen our understanding of the two pathways' preparation of military physicians, this study analyzed the open-ended responses in the survey using a qualitative research design., Materials and Methods: We used a descriptive phenomenological design to analyze 451 participants' open-ended responses on the survey. After becoming familiar with the data, we coded the participants' responses for meaningful statements. We organized these codes into major categories, which became the themes of our study. Finally, we labeled each of these themes to reflect the participants' perceptions of how medical school prepared them for deployment., Results: Four themes emerged from our data analysis: (1) Civilian medical school equipped graduates with soft skills and medical knowledge for their first deployment; (2) Civilian medical school may not have adequately prepared graduates to practice medicine in an austere environment to include the officership challenges of deployment; (3) Military medical school prepared graduates to navigate the medical practice and operational aspects of their first deployment; and (4) Military medical school may not have adequately prepared graduates for the realism of their first deployment., Conclusions: Our study provided insight into the strengths and areas for growth in each medical school pathway for military medical officers. These results may be used to enhance military medical training regardless of accession pathway and increase the readiness of military physicians for future large-scale conflicts., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Developing the clinical reasoning skills necessary to becoming an astute diagnostician is essential for medical students. While some medical schools offer longitudinal opportunities for students to practice clinical reasoning during the preclinical curriculum, there remains a paucity of literature fully describing what that curriculum looks like. As a result, medical educators struggle to know what an effective clinical reasoning curriculum should look like, how it should be delivered, how it should be assessed, or what faculty development is necessary to be successful. We present our Introduction to Clinical Reasoning course that is offered throughout the preclinical curriculum of the Uniformed Services University of the Health Sciences. The course introduces clinical reasoning through interactive lectures and 28 case-based small group activities over 15 months.The curriculum is grounded in script theory with a focus on diagnostic reasoning. Specific emphasis is placed on building the student's semantic competence, constructing problem lists, comparing and contrasting similar diagnoses, constructing a summary statement, and formulating a prioritized differential diagnosis the student can defend. Several complementary methods of assessment are utilized across the curriculum. These include assessments of participation, knowledge, and application. The course leverages clinical faculty, graduate medical education trainees, and senior medical students as small group facilitators. Feedback from students and faculty consistently identifies the course as a highly effective and engaging way to teach clinical reasoning., Conclusion: Our Introduction to Clinical Reasoning course offers students repeated exposure to well-selected cases to promote their development of clinical reasoning. The course is an example of how clinical reasoning can be taught across the preclinical curriculum without extensive faculty training in medical education or clinical reasoning theory. The course can be adapted into different instructional formats to cover a variety of topics to provide the early learner with sequential exposure and practice in diagnostic reasoning., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Purpose: High-ranking educational leaders in academic medicine oversee multiple clinical programs. This requires them to prioritize dozens of emergent tasks and responsibilities daily, from educational policy and strategy to staff management, financial planning, onboarding of trainees, and facility planning and management. Identifying their key responsibilities and frequently used skills and competencies may clarify the educational needs of senior educational leaders and facilitate targeted professional development to promote effective and efficient performance., Method: In August 2022 researchers interviewed 12 designated education officers (DEOs) from U.S. Department of Veterans Affairs (VA) Veterans Health Administration medical centers about their daily work and most challenging responsibilities. Content analysis of interview transcripts identified key responsibilities and activities identified by participants and prioritization of the perceived skills needed to complete them., Results: Participants emphasized 4 key areas of responsibility: fiscal, administrative, affiliate partnership, and educational duties. They identified 12 skills as baseline requirements for effective performance for which additional professional development would be useful and suggested that both new and more established educational leaders receive targeted professional development and mentoring to foster these capacities., Conclusions: The key skills participants identified by area of perceived responsibility are relevant to VA DEOs, designated institutional officers, and senior academic leaders who develop health professions education programs, oversee clinical training, and manage educational change. Structured orientation programs and ongoing professional development for senior educational leaders could emphasize these areas of responsibility, potentially enriching DEOs' performance and reducing burnout., Competing Interests: Other disclosures: Neither the authors nor their family members have a financial interest in any commercial product, service, or organization providing financial support for this research. The authors report no actual or potential conflicts of interest in regard to this article., (Copyright © 2024 the Association of American Medical Colleges.)

Leadership development is a challenge for all health care systems. Military Medicine has unique challenges with increased frequency of physician turnover and more junior leaders taking on positions of leadership earlier in their careers. Military medical corps officers are also challenged with leading in clinical, academic, and operational settings. Effective leadership within the Military Healthcare System requires an intentional and ongoing leadership development process across the careers of military medical corps officers. This article describes the leadership lifecycle of military medical corps officers, highlighting existing leadership development opportunities and providing an example of a leadership lifecycle from junior staff to senior executive for other organizations. The article concludes with specific recommendations that will allow military medicine to continue to strengthen the leadership skills of its officers to meet ever growing challenges., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Physicians must be leaders more than ever with innumerable challenges. Despite this need, there is a paucity of consistent leadership development (LD) from medical student to staff physician. Military medicine has additional challenges-working within a large health care organization, constant turnover, working in a variety of contexts-that make the need for LD even more pressing. The purpose of this paper is to describe the LD life cycle for military undergraduate and graduate medical education (UME and GME), providing examples for other organizations while identifying steps to meet the future needs in military medicine. The Health Professions Scholarship Program produces over 75% of graduates for military medicine each year. Yet, since learners are dispersed throughout civilian medical schools any LD results in a heterogeneous experience. Uniformed Services University has a 4-year LD program required for all students as well as other opportunities for leadership professional growth. Military GME programs are unique, requiring a military unique curriculum to prepare graduates for their initial assignments. Military unique curriculum vary, but include clinical topics relevant to military medicine as well as leadership. There is no Military Healthcare System-wide leadership curriculum used by everyone at this time. Based on these UME and GME approaches to LD, there have been multiple lessons learned formed on the authors experience and published literature: learners do not typically see themselves as leaders; learners want applicable curriculum with less lecturing and more application and discussion; programs are often siloed from one another and sharing curriculum content does not typically occur; no one-size-fits-all model. On the basis of the lessons learned and the current state of UME and GME leadership education, there are 5 recommendations to enhance UME and GME leadership programs: (1) develop a Health Professions Scholarship Program Leadership Curriculum; (2) develop a MHS GME Leadership Curriculum; (3) integrate UME and GME Leadership Curricula; (4) develop faculty to teach leadership; and (5) conduct research on UME and GME in military and share lessons learned. We suggest a roadmap for strengthening LD within military medicine and civilian institutions., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Impostor phenomenon (IP) is an experience where an individual believes that their success was because of chance or luck and was not associated with the mastery of skills. There is a gap in the literature in understanding what role, if any, onboarding (e.g., orientation weeks) into a military medical school plays into student experiences with IP. For many, onboarding serves as the first exposure to the climate, culture, and learning environment of both medical school and the military. Prevention, or early intervention, of IP may reduce potential effects on a medical trainee's confidence and competence in their profession, which may ultimately enhance health care team performance and impact patient outcomes. This study explores if and why military medical students experience IP during a 2-week-long orientation into a military medical school., Materials and Methods: The study participants were medical students at a military medical school. Researchers conducted semi-structured interviews in August 2022 to explore if and why students experienced IP and deployed the Clance IP Scale as a measure with validity evidence for ascertaining the presence and magnitude of IP. Researchers calculated total scores from the Clance IP Scale and thematically analyzed interview transcripts., Results: Researchers interviewed 29 matriculating military medical students. Twenty-one (75%) students reported frequent or intense IP experiences on the Clance IP Scale indicating that IP was present in our study sample. Thematic analysis identified six themes that drove one's experience with IP: reevaluation of merit, individualized diversity and inclusion experiences, administrative and financial support, preconceived expectations, building relationships, and new community roles., Conclusions: Our identified themes provide us with a better understanding of if and why military medical students experience IP during onboarding. Our findings are also consistent with the situated learning theory, which places emphasis on the sense of belonging and may provide a unique and insightful lens through which IP can be further explored and studied, particularly at a military medical school where various identities, dynamics, and aspirations can converge simultaneously. Additionally, our findings suggest that existing practices may benefit from a number of improvements including, but not limited to, tailoring onboarding activities to entail more reflective discussion using small groups, especially for topics related to diversity and inclusion, revisiting areas where students may feel inadequately prepared to transition and perform well in a medical school, reevaluating administrative and financial support that can be roadblocks to a student's transition into the new environment and removing these barriers, and ensuring cultural coherence (organizational alignment of vision and mission) among faculty, staff, and upperclassmen. Future research directions include better understanding how developing single or multiple, identities can impact a medical students' experience with IP during onboarding, pre-clerkship, clerkship, or post-clerkship period, if at all., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

From dual process to a family of theories known collectively as situativity, both micro and macro theories of cognition inform our current understanding of clinical reasoning (CR) and error. CR is a complex process that occurs in a complex environment, and a nuanced, expansive, integrated model of these theories is necessary to fully understand how CR is performed in the present day and in the future. In this perspective, we present these individual theories along with figures and descriptive cases for purposes of comparison before exploring the implications of a transtheoretical model of these theories for teaching, assessment, and research in CR and error.

Background: Clinical reasoning (CR) is a crucial ability that can prevent errors in patient care. Despite its important role, CR is often not taught explicitly and, even when it is taught, typically not all aspects of this ability are addressed in health professions education. Recent research has shown the need for explicit teaching of CR for both students and teachers. To further develop the teaching and learning of CR we need to improve the understanding of students' and teachers' needs regarding content as well as teaching and assessment methods for a student and trainer CR curriculum., Methods: Parallel mixed-methods design that used web-surveys and semi-structured interviews to gather data from both students (n survey  = 100; n interviews  = 13) and teachers (n survey  = 112; n interviews  = 28). The interviews and surveys contained similar questions to allow for triangulation of the results. This study was conducted as part of the EU-funded project DID-ACT ( https://did-act.eu )., Results: Both the surveys and interview data emphasized the need for content in a clinical reasoning (CR) curriculum such as "gathering, interpreting and synthesizing patient information", "generating differential diagnoses", "developing a diagnostic and a treatment plan" and "collaborative and interprofessional aspects of CR". There was high agreement that case-based learning and simulations are most useful for teaching CR. Clinical and oral examinations were favored for the assessment of CR. The preferred format for a train-the-trainer (TTT)-course was blended learning. There was also some agreement between the survey and interview participants regarding contents of a TTT-course (e.g. teaching and assessment methods for CR). The interviewees placed special importance on interprofessional aspects also for the TTT-course., Conclusions: We found some consensus on needed content, teaching and assessment methods for a student and TTT-course in CR. Future research could investigate the effects of CR curricula on desired outcomes, such as patient care., (© 2024. The Author(s).)

Clinical reasoning has been characterized as being an essential aspect of being a physician. Despite this, clinical reasoning has a variety of definitions and medical error, which is often attributed to clinical reasoning, has been reported to be a leading cause of death in the United States and abroad. Further, instructors struggle with teaching this essential ability which often does not play a significant role in the curriculum. In this article, we begin with defining clinical reasoning and then discuss four principles from the literature as well as a variety of techniques for teaching these principles to help ground an instructors' understanding in clinical reasoning. We also tackle contemporary challenges in teaching clinical reasoning such as the integration of artificial intelligence and strategies to help with transitions in instruction (e.g., from the classroom to the clinic or from medical school to residency/registrar training) and suggest next steps for research and innovation in clinical reasoning.

Issue :  Clinical reasoning is essential to physicians' competence, yet assessment of clinical reasoning remains a significant challenge. Clinical reasoning is a complex, evolving, non-linear, context-driven, and content-specific construct which arguably cannot be assessed at one point in time or with a single method. This has posed challenges for educators for many decades, despite significant development of individual assessment methods. Evidence :  Programmatic assessment is a systematic assessment approach that is gaining momentum across health professions education. Programmatic assessment, and in particular assessment for learning, is well-suited to address the challenges with clinical reasoning assessment. Several key principles of programmatic assessment are particularly well-aligned with developing a system to assess clinical reasoning: longitudinality, triangulation, use of a mix of assessment methods, proportionality, implementation of intermediate evaluations/reviews with faculty coaches, use of assessment for feedback, and increase in learners' agency. Repeated exposure and measurement are critical to develop a clinical reasoning assessment narrative, thus the assessment approach should optimally be longitudinal, providing multiple opportunities for growth and development. Triangulation provides a lens to assess the multidimensionality and contextuality of clinical reasoning and that of its different, yet related components, using a mix of different assessment methods. Proportionality ensures the richness of information on which to draw conclusions is commensurate with the stakes of the decision. Coaching facilitates the development of a feedback culture and allows to assess growth over time, while enhancing learners' agency. Implications:   A programmatic assessment model of clinical reasoning that is developmentally oriented, optimizes learning though feedback and coaching, uses multiple assessment methods, and provides opportunity for meaningful triangulation of data can help address some of the challenges of clinical reasoning assessment.