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Background Planning for extreme surges in demand for hospital care of patients requiring urgent life-saving treatment for COVID-19, while retaining capacity for other emergency conditions, is one of the most challenging tasks faced by health care providers and policymakers during the pandemic. Health systems must be well-prepared to cope with large and sudden changes in demand by implementing interventions to ensure adequate access to care. We developed the first planning tool for the COVID-19 pandemic to account for how hospital provision interventions (such as cancelling elective surgery, setting up field hospitals, or hiring retired staff) will affect the capacity of hospitals to provide life-saving care. Methods We conducted a review of interventions implemented or considered in 12 European countries in March to April 2020, an evaluation of their impact on capacity, and a review of key parameters in the care of COVID-19 patients. This information was used to develop a planner capable of estimating the impact of specific interventions on doctors, nurses, beds, and respiratory support equipment. We applied this to a scenario-based case study of 1 intervention, the set-up of field hospitals in England, under varying levels of COVID-19 patients. Results The Abdul Latif Jameel Institute for Disease and Emergency Analytics pandemic planner is a hospital planning tool that allows hospital administrators, policymakers, and other decision-makers to calculate the amount of capacity in terms of beds, staff, and crucial medical equipment obtained by implementing the interventions. Flexible assumptions on baseline capacity, the number of hospitalizations, staff-to-beds ratios, and staff absences due to COVID-19 make the planner adaptable to multiple settings. The results of the case study show that while field hospitals alleviate the burden on the number of beds available, this intervention is futile unless the deficit of critical care nurses is addressed first. Discussion The tool supports decision-makers in delivering a fast and effective response to the pandemic. The unique contribution of the planner is that it allows users to compare the impact of interventions that change some or all inputs.

Background: Previous provider-directed electronic messaging interventions have not by themselves improved anticoagulation use in patients with atrial fibrillation. Direct engagement with providers using academic detailing coupled with electronic messaging may overcome the limitations of the prior interventions. Methods and Results: We randomized outpatient providers affiliated with our health system in a 2.5:1 ratio to our electronic profiling/messaging combined with academic detailing intervention. In the intervention, we emailed providers monthly reports of their anticoagulation percentage relative to peers for atrial fibrillation patients with elevated stroke risk (CHA 2 DS 2 -VASc ≥2). We also sent electronic medical record-based messages shortly before an appointment with an anticoagulation-eligible but untreated atrial fibrillation patient. Providers had the option to send responses with explanations for prescribing decisions. We also offered to meet with intervention providers using an academic detailing approach developed based on knowledge gaps discussed in provider focus groups. To assess feasibility, we tracked provider review of our messages. To assess effectiveness, we measured the change in anticoagulation for patients of intervention providers relative to controls. We identified 85 intervention and 34 control providers taking care of 3591 and 1908 patients, respectively; 33 intervention providers participated in academic detailing. More than 80% of intervention providers read our emails, and 98% of the time a provider reviewed our in-basket messages. Replies to messages identified patient refusal as the most common reason for patients not being on anticoagulation (11.2%). For the group of patients not on anticoagulation at baseline assigned to an intervention versus control provider, the adjusted percent increase in the use of anticoagulation over 6 months was 5.2% versus 7.4%, respectively ( P =0.21). Conclusions: Our electronic messaging and academic detailing intervention was feasible but did not increase anticoagulation use. Patient-directed interventions or provider interventions targeting patients declining anticoagulation may be necessary to raise the rate of anticoagulation. Clinical Trial Registration URL: http://www.clinicaltrials.gov . Unique identifier: NCT03583008.

To describe current patient safety curricula at U.S. and Canadian medical schools and identify factors associated with adoption of these programs.A survey was mailed to institutional members of the Clerkship Directors in Internal Medicine at U.S. and Canadian academic medical schools in 2006. Respondents self-reported implementation of patient safety curricula and associated methods of instruction at the institution level.The survey had a 76% response rate (83/110). Only 25% of institutional members reported that their schools had explicit patient safety curricula. All respondents that reported having curricula use lectures and small-group instruction, and these were more likely to occur in preclinical settings. Topics and methods of instruction included reporting adverse incidents and analysis of medical errors; improvement of physician order writing to prevent medication errors; core measures; national patient safety goals; and standardization of medical care through the use of clinical guidelines and order set templates. Although only 25% of respondents reported having explicit curricula, 72% agreed that patient safety instruction should occur during medical school.Despite calls from regulatory, medical, and educational organizations to increase patient safety training of medical students, internal medicine clerkship directors report that few schools in the United States and Canada have implemented specific patient safety curricula. Most existing patient safety curricula use lecture and small-group discussion as preferred methods of instruction.

This study of patients and family members of patients who believed they had experienced a medical error sought to describe their perceptions of what had occurred; the impact of the error on the patient and family; their perceptions of how the providers and institutions involved responded to the error; and how the providers' response or non-response influenced the patient's reaction. In-depth, qualitative telephone interviews were conducted with community members who believed they or a family member had experienced a medical error. During 17 interviews, 23 incidents which were perceived as errors were reported and described. Errors impacted patients and family members in a variety of ways, causing physical and emotional harm, disrupting day-to-day life, and leading to changes in health-related behaviours. Providers' responses varied, and often did not meet the needs of the patient and family members. Based on these findings, the study recommends open communication about errors and adverse events. L...

Recent data do not exist regarding fourth-year medical students' performance of and attitudes toward procedural and interpretive skills, and how these differ from third-year students'.Cross-sectional survey conducted in February 2006 of 122 fourth-year students from seven U.S. medical schools, compared with their responses in summer 2005. Students estimated their cumulative performance of 22 skills and reported self-confidence and perceived importance using a five-point Likert-type scale.The response rate was 79% (96/122). A majority reported never having performed cardioversion, thoracentesis, cardiopulmonary resuscitation, blood culture, purified protein derivative placement, or paracentesis. One fifth of students had never performed peripheral intravenous catheter insertion, phlebotomy, or arterial blood sampling. Students reported increased cumulative performance of 17 skills, increased self-confidence in five skills, and decreased perceived importance in three skills (two-sided P.05).A majority of fourth-year medical students still have never performed important procedures, and a substantial minority have not performed basic procedures.

INTRODUCTION Professionalism is fundamental to the practice of medicine. Objective structured clinical examinations (OSCEs) have been proposed as appropriate for assessing some aspects of professionalism. This study investigated how raters assign professionalism ratings to medical students' performances in OSCE encounters. METHODS Three standardised patients, 3 doctor preceptors, and 3 lay people viewed and rated 20 videotaped encounters between 3rd-year medical students and standardised patients. Raters recorded their thoughts while rating. Qualitative and quantitative analyses were conducted. Comments about observable behaviours were coded, and relative frequencies were computed. Correlations between counts of categorised comments and overall professionalism ratings were also computed. RESULTS Raters varied in which behaviours they attended to, and how behaviours were evaluated. This was true within and between rater type. Raters also differed in the behaviours they consider when providing global evaluations of professionalism. CONCLUSIONS This study highlights the complexity of the processes involved in assigning ratings to doctor-patient encounters. Greater emphasis on behavioural definitions of specific behaviours may not be a sufficient solution, as raters appear to vary in both attention to and evaluation of behaviours. Reliance on global ratings is also problematic, especially if relatively few raters are used, for similar reasons. We propose a model highlighting the multiple points where raters viewing the same encounter may diverge, resulting in different ratings of the same performance. Progress in assessment of professionalism will require further dialogue about what constitutes professional behaviour in the medical encounter, with input from multiple constituencies and multiple representatives within each constituency.

Trainees are exposed to medical errors throughout medical school and residency. Little is known about what facilitates and limits learning from these experiences.To identify major factors and areas of tension in trainees' learning from medical errors.Structured telephone interviews with 59 trainees (medical students and residents) from 1 academic medical center. Five authors reviewed transcripts of audiotaped interviews using content analysis.Trainees were aware that medical errors occur from early in medical school. Many had an intense emotional response to the idea of committing errors in patient care. Students and residents noted variation and conflict in institutional recommendations and individual actions. Many expressed role confusion regarding whether and how to initiate discussion after errors occurred. Some noted the conflict between reporting errors to seniors who were responsible for their evaluation. Learners requested more open discussion of actual errors and faculty disclosure. No students or residents felt that they learned better from near misses than from actual errors, and many believed that they learned the most when harm was caused.Trainees are aware of medical errors, but remaining tensions may limit learning. Institutions can immediately address variability in faculty response and local culture by disseminating clear, accessible algorithms to guide behavior when errors occur. Educators should develop longitudinal curricula that integrate actual cases and faculty disclosure. Future multi-institutional work should focus on identified themes such as teaching and learning in emotionally charged situations, learning from errors and near misses and balance between individual and systems responsibility.

Article-at-a-Glance Background Fifty hospitals collaborated in a patient safety initiative developed and implemented by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association. Methods A consensus group identified safe practices and suggested implementation strategies. Four collaborative learning sessions were offered, and teams monitored their progress and shared successful strategies and lessons learned. Reports from participating teams and an evaluation survey were then used to identify successful techniques for reconciling medications. Results For the 50 participating hospitals, implementation strategies most strongly correlated with success included active physician and nursing engagement, having an effective improvement team, using small tests of change, having an actively engaged senior administrator, and sending a team to multiple collaborative sessions. Discussion Adoption of the reconciling safe practices proved challenging. The process of writing medication orders at patient transfer points is complex. The hospitals' experiences demonstrated that implementing the proposed safe practices requires a team effort with leadership support and vigilant measurement.

"Clerkship sharing" is the coexistence of students from 2 or more medical schools rotating on the same specialty at a single clerkship site.Clerkship sharing was characterized by answering three related questions regarding the prevalence of clerkship sharing on internal medicine inpatient rotations, stakeholders views of the advantages and disadvantages of clerkship sharing, and the ways that clerkship sharing affects medical student outcomes at an institution.In 2001, the Clerkship Directors in Internal Medicine (CDIM) surveyed its members; 1 section addressed clerkship sharing on inpatient rotations. In addition, the authors surveyed a convenience sample of teachers and learners at 41% of schools with clerkship sharing. Finally, using a 10-year database from one institution, we searched for differences in clerkship outcomes among students who rotated at clerkship sites with or without clerkship sharing.The overall clerkship director (CD) survey response rate was 78% (96/123); 22 of 96 (23%) of CDs reported having clerkship sharing on inpatient rotations. Advantages reported included a greater diversity of clinical exposure for students (77%) and a fostering of collegial relationships (73%). We also collected 79 teacher and 77 medical student surveys from 9 (41%) medical schools identified as having clerkship sharing. The majority of these teachers and learners believed that sharing improves teaching and the overall rotation quality. All surveyed groups were concerned that clerkship sharing affected the clarity of clerkship goals, objectives, and grading. However, clerkship outcomes from 1 institution demonstrated no effect of clerkship sharing on faculty ratings of students or student examination performance.Clerkship sharing appears to be an emerging clerkship model, and, although it may have inherent advantages that benefit student education, CDs should address challenges such as common goals and expectations for students and teachers.

To celebrate its 50th anniversary, the Association of Professors of Medicine (APM) has dedicated its pages in The American Journal of Medicine in 2004 to the future of academic internal medicine. In this issue, the APM invited the Clerkship Directors in Internal Medicine to discuss the future of medical student education.

Purpose Students' ratings of preceptors are widely used in medical education for feedback and evaluation purposes. The present study investigated students' ratings of the clinical teaching skills of inpatient attending physicians, inpatient residents, and outpatient attending physicians to assess differences among types of preceptors and relative strengths and weaknesses. Method A total of 268 students from three academic years (1997-2000) at one medical school rated preceptors on an end-of-clerkship evaluation, for a total of 1,680 ratings. When the ratings were aggregated by preceptors' names and types, there were 691 mean ratings of preceptors. Relative strengths and weaknesses were identified. Differences in mean ratings by preceptor type (inpatient attending physician, inpatient resident, and outpatient attending physician) were evaluated, and strengths and weaknesses were identified by rank ordering the items' means. Results Students tended to rate outpatient attending physicians higher than inpatient attending physicians or residents. Areas where ratings suggested relative strengths included showing an interest in teaching, respecting students' opinions, and being available to students. Areas of relative weakness included increasing physical examination and interviewing skills. Conclusions Students' ratings are useful for identifying strengths and weakness for groups of preceptors and, as such, are important sources of information for setting priorities for faculty development efforts.

Although medical malpractice influences the way that physicians learn to practice medicine, information related to malpractice cases is among the most closely guarded data in the hospital and is rarely available to training programs. In this issue, Hochberg and colleagues describe an intervention in which they used data from their hospital's closed malpractice cases as part of a training seminar for surgical residents on malpractice. The authors of this commentary believe that there is very low risk and great potential value to more openly sharing this type of information. They point to potential conflicts between the goals of the risk management discipline (as it has been practiced in some settings in the past) and those of the patient safety discipline as one reason such data are not disseminated widely, and they highlight what they believe to be hopeful trends toward greater transparency. They call on patient safety professionals and educators to use their hospitals' malpractice data to better prepare learners and improve patient care.

Assessment of professionalism in undergraduate medical education is challenging. One approach that has not been well studied in this context is performance-based examinations.This study sought to investigate the reliability of standardized patients' scores of students' professionalism in performance-based examinations.Twenty students were observed on 4 simulated cases involving professional challenges; 9 raters evaluated each encounter on 21 professionalism items. Correlational and multivariate generalizability (G) analyses were conducted.G coefficients were .75, .53, and .68 for physicians, standardized patients (SPs), and lay raters, respectively. Composite G coefficient for all raters reached acceptable level of .86. Results indicated SP raters were more variable than other rater types in severity with which they rated students, although rank ordering of students was consistent among SPs.SPs' ratings were less reliable and consistent than physician or lay ratings, although the SPs rank ordered students more consistently than the other rater types.

BACKGROUND Recent changes in healthcare system and training mandates have altered the clinical learning environment. We incorporated reflective writing into Internal Medicine clerkships (IMcs) in multiple institutions so students could consider the impact of clerkship experiences on their personal and professional development. We analyzed student reflections to inform curricula and support learning.

Medical students and preceptors commonly disagree on methods of clinical instruction in ambulatory care, although the extent of the problem is not documented.The purpose is to identify disagreement and concordance between students and preceptors for teaching behaviors in ambulatory care.We surveyed students and preceptors at 4 U.S. schools. Respondents rated 58 behaviors on two scales. Disagreement was recognized when the percentage of students and preceptors who recommended a behavior and rated it important differed by over 15% (p.01).Disagreement was identified for 8 behaviors (14%). Six were valued less by students, including "watch the student perform critical tasks in history taking and other communication" (59% compared with 82%). Two behaviors were valued more by students, including "delegate responsibility to the student for the wrap up discussion with the patient" (82% compared with 61%).Students and preceptors disagree regarding the value of a minority of teaching behaviors. Because some are potentially important, however, early negotiation regarding their use may enhance teaching effectiveness and mutual satisfaction with learning.

Recent data do not exist on medical students' performance of and attitudes toward procedural and interpretive skills deemed important by medical educators.A total of 171 medical students at seven medical schools were surveyed regarding frequency of performance, self-confidence, and perceived importance of 21 procedural and interpretive skills.Of the 122 responding students (71% response rate), a majority had never performed lumbar puncture, thoracentesis, paracentesis, or blood culture, and students reported lowest self-confidence in these skills. At least one-quarter of students had never performed phlebotomy, peripheral intravenous catheter insertion, or arterial blood sampling. Students perceived all 21 skills as important to learn and perform during medical school.Through the third year of medical school, a majority of students had never performed important procedures, and a substantial minority had not performed basic procedures. Students had low self-confidence in skills they rarely performed, but perceived all skills surveyed as important.

PURPOSE To characterize the involvement of internal medicine department chairs in the core third-year internal medicine clinical clerkship. METHOD In 2003, the Clerkship Directors in Internal Medicine (CDIM) surveyed its membership. Along with demographics, clerkship directors were asked if the department's chair participated in the clerkship, the number of hours per month the clerkship director and chair discussed clerkship issues, and if published job expectations were discussed. RESULTS The response rate was 62% (158/254): 103 responses (89 clerkship directors) represented unique medical schools, which formed the basis of the analysis. Eighty-two percent (84/103) reported the chair taught in the clerkship: 54% as teaching attending, 53% as ward attending, 13% as ambulatory attending, and 20% other (e.g., lectures, student rounds, morning report). Of them, 36% performed two activities; 14% three activities; and 2% four activities. Thirty-six percent of the clerkship directors discussed published expectations with their chair. They spent 1.7 (SD 2.2) hours per month with the chair discussing clerkship issues. However, 17% spent zero hours per month with the chair, and 29% spent zero hours per month with a dean's office representative. Chairs who taught spent more time each month with the clerkship director compared with chairs who did not teach (1.9 versus .82 hours, p = .01, Mann-Whitney). There was no association between the chairs' teaching and clerkship directors' demographics. CONCLUSIONS Internal medicine department chairs are significantly involved in the clinical education of medical students, both administratively and through direct teaching. Chairs who teach spend more time discussing clerkship issues with the clerkship director. Chairs and clerkship directors should discuss expectations, and chairs should continue to visibly demonstrate their commitment to students' education.