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Competency-based assessment of learners may benefit from a more holistic, inclusive, approach for determining readiness for unsupervised practice. However, despite movements towards greater patient partnership in health care generally, inclusion of patients in postgraduate medical learners' assessment is largely absent.We conducted a scoping review to map the nature, extent and range of literature examining the inclusion (or exclusion) of patients within the assessment of postgraduate medical learners. Guided by Arskey and O'Malley's framework and informed by Levac et al. and Thomas et al., we searched two databases (MEDLINE® and Embase®) from inception until February 2021 using subheadings related to assessment, patients and postgraduate learners. Data analysis examined characteristics regarding the nature and factor influencing patient involvement in assessment.We identified 41 papers spanning four decades. Some literature suggests patients are willing to be engaged in assessment, however choose not to engage when, for example, language barriers may exist. When stratified by specialty or clinical setting, the influence of factors such as gender, race, ethnicity or medical condition seems to remain consistent. Patients may participate in assessment as a stand-alone group or part of a multi-source feedback process. Patients generally provided high ratings but commented on the observed professional behaviours and communication skills in comparison with physicians who focused on medical expertise.Factors that influence patient involvement in assessment are multifactorial including patients' willingness themselves, language and reading-comprehension challenges and available resources for training programmes to facilitate the integration of patient assessments. These barriers however are not insurmountable. While understudied, research examining patient involvement in assessment is increasing; however, our review suggests that the extent which the unique insights will be taken up in postgraduate medical education may be dependent on assessment systems readiness and, in particular, physician readiness to partner with patients in this way.

There is an increasing need to focus on how best to train respiratory physicians to perform EUS with bronchoscope-guided fine-needle aspiration biopsy (EUS-B-FNA). At current, training is mostly performed in the clinical environment under expert supervision; however, the advent of simulation-based education now provides a low-risk setting for novice trainees to learn and practice basic endosonography skills from identifying and understanding normal anatomy as well as pathology, maneuvering of endoscope, interpretation of images, and mastering of sampling techniques. In this descriptive educational paper, we used a six-step approach as a framework to describe the development of a structured training program combining EUS-B-FNA with the already well-established certification training program in endobronchial ultrasound transbronchial needle aspiration. This comprehensive training curriculum includes a theoretical course to achieve foundational knowledge, followed by simulation-based training until mastery standards are met, and supervised clinical apprenticeship. All steps should end with an objective assessment to achieve certification. This systematic development will hopefully encourage endosonography leaders and educators to collaborate and implement an evidence-based comprehensive endosonography curriculum that aims to provide the trainee with the essential EUS-B competencies to ensure that lung cancer patients are diagnosed and staged correctly.

Introduction Education scholarship requires peer reviewers. For novice scholars, reviewing is an important developmental activity that cultivates deeper participation in the scholarship community. Yet getting started with reviewing is challenging for those not involved with the educational scholarship community. Beyond scientific expertise, reviewers must have a mentoring mindset, skills in providing constructive feedback, and knowledge of common ethical challenges associated with producing and evaluating scholarship. Methods Our workshop introduced novice health professions educators to peer reviewing. It included four stimulus presentations about the peer reviewer's mindset and skills, followed by reinforcement activities. The workshop could be adapted to variously sized groups. An 8:1 ratio of participants to facilitators was ideal for activities. Topics covered included considerations before accepting an invitation, the review process, the good citizen approach to reviewing, and reviewer ethics. The session concluded with suggestions for continued development of peer reviewer competencies. The workshop was evaluated using a custom survey. Results Throughout 2019 and early 2020, 58 health professions educators and trainees participated in the workshop across varied venues. Evaluations were obtained from 33 participants (57%). Nearly all rated the workshop as high quality and valuable to peer reviewer preparation. Most (26 of 33; 75%) gained confidence about their qualifications to serve as reviewers. Eighty percent (28 of 33) believed they could recognize ethical dilemmas. Discussion This workshop provided a springboard for peer reviewing health professions education scholarship. Participants generally praised the experience for introducing them to the world of peer review and preparing them for it.

BackgroundWith increasing physician mobility, there is interest in how medical schools and postgraduate medical education institutions across the world develop and maintain the competence of medical teachers. Published reviews of faculty development (FD) have predominantly included studies from the United States and Canada.ObjectiveWe synthesized the international FD literature (beyond the US and Canada), focusing on FD type, intended audience, study format, effectiveness, differences among countries, and potential unique features.MethodsWe identified English-language publications that addressed FD for medical faculty for teaching and related activities, excluding US and Canadian publications.ResultsA search of 4 databases identified 149 publications, including 83 intervention studies. There was significant growth in international FD publications for the most recent decade, and a sizable number of studies were from developing economies and/or resulted from international collaborations. Focal areas echo those in earlier published reviews, suggesting the international FD literature addresses similar faculty needs and organizational concerns.ConclusionsThe growth in publications in recent years and a higher proportion of reporting on participant reactions, coupled with less frequent reporting of results, transfer to practice, and impact on learners and the organization, suggest this is an evolving field. To enhance international FD, educators and researchers should focus on addressing common needs expressed by faculty, including curriculum design and evaluation, small group teaching, assessing professionalism and providing feedback. Future research should focus on approaches for developing comprehensive institutional FD programs that include communities of learning and practice and evaluating their impact.

This Conversation Starter article uses four selected abstracts, one each from the four regional Association of American Medical Colleges (AAMC) Group on Educational Affairs (CGEA) 2018 spring meetings, as a springboard for unpacking the definition of peer-assisted learning (PAL). The aim of this article is to prompt deeper reflection on this phenomenon and, in so doing, to foster scholarly program evaluation of this widely adopted instructional approach. This analysis calls for a more nuanced definition of PAL, one that emphasizes process over structure, one that stimulates examination of "doing" PAL and how this affects the personal and professional development of all involved.

Context Nonphysician members of the interprofessional palliative care team often participate in teaching physicians and others in the context of workplace learning due to the interprofessional collaborative nature of the specialty. Objectives This pilot study examines the beliefs of the nonphysician members of the interprofessional team about teaching physicians-in-training, the disciplinary training and expertise that informs their teaching, and approaches to teaching in the workplace. Methods Semistructured interviews were conducted. All interviews were audio recorded and transcribed verbatim. Initial open coding by two researchers identified the codes, and then the constant comparative method was used to find patterns by axial coding, categories, and themes within the data. Results Of the 10 health care professionals involved with palliative medical education at one academic medical center, six enrolled in the pilot. Those who participated included chaplains, nurses, a social worker, and a physician assistant. Three major themes were identified from the informal teachers: 1) using professional identity as a foundation for teaching, 2) teaching through experiential learning or debriefing, and 3) teaching to perceived gaps in physician training. Conclusion Nonphysician members of the interprofessional team interacted with physicians-in-training guided by their discipline-based skills and perspectives on patient care. They directed their informal teaching toward perceived educational gaps using reflection and debriefing. Future studies could explore the educational roles of health care professionals across diverse institutions and specialties.

To improve the teaching performance of emergency physicians, it is necessary to understand the attributes of expert teachers and the optimal methods to deliver faculty development. A working group of medical educators was formed to review the literature, summarize what is known on the topic, and provide recommendations for future research. This occurred as a track of the 2012 Academic Emergency Medicine (AEM) consensus conference "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success." The group concluded that the current state of research on these topics is limited. Improvement in understanding will come through research focusing on Kirkpatrick's higher levels of evaluation (behavior and results).

OBJECTIVES This study aimed to test the extent to which the use of medicalese (i.e. formal medical terminology and semantic qualifiers) alters the test performance of medical graduates; to tease apart the extent to which any observed differences are driven by language difficulties versus differences in medical knowledge; and to assess the impact of varying the language used to present clinical features on the ability of the test to consistently discriminate between candidates. METHODS Six clinical cases were manipulated in the context of pilot items on the Canadian national qualifying examination. Features indicative of two diagnoses were presented uniformly in lay terms, medical terminology and semantic qualifiers, respectively, and in mixed combinations (e.g. features of one diagnosis were presented using lay terminology and features of the other using medicalese). The rate at which the indicated diagnoses were named was considered as a function of language used, site of training, birthplace and medical knowledge (as measured by overall performance on the examination). RESULTS In the mixed conditions, Canadian medical graduates were not influenced by the language used to present the cases, whereas international medical graduates (IMGs) were more likely to favour the diagnosis associated with medical terminology relative to that associated with lay terms. This was true regardless of whether the entire sample or only North American-born candidates were considered. Within the IMG cohort, high performers were not influenced by the language manipulation, whereas low performers were. Uniform use of lay terminology resulted in the highest test reliability compared with the other experimental conditions. CONCLUSIONS The results indicate that the influence of medical terminology is driven more by substandard medical knowledge than by the language issues that challenge some candidates. Implications for both the assessment and education of medical professionals are discussed.

Context Diagnostic accuracy is maximised by having clinical signs and diagnostic hypotheses in mind during the physical examination (PE). This diagnostic reasoning approach contrasts with the rote, hypothesis-free screening PE learned by many medical students. A hypothesis-driven PE (HDPE) learning and assessment procedure was developed to provide targeted practice and assessment in anticipating, eliciting and interpreting critical aspects of the PE in the context of diagnostic challenges. Objectives This study was designed to obtain initial content validity evidence, performance and reliability estimates, and impact data for the HDPE procedure. Methods Nineteen clinical scenarios were developed, covering 160 PE manoeuvres. A total of 66 Year 3 medical students prepared for and encountered three clinical scenarios during required formative assessments. For each case, students listed anticipated positive PE findings for two plausible diagnoses before examining the patient; examined a standardised patient (SP) simulating one of the diagnoses; received immediate feedback from the SP, and documented their findings and working diagnosis. The same students later encountered some of the scenarios during their Year 4 clinical skills examination. Results On average, Year 3 students anticipated 65% of the positive findings, correctly performed 88% of the PE manoeuvres and documented 61% of the findings. Year 4 students anticipated and elicited fewer findings overall, but achieved proportionally more discriminating findings, thereby more efficiently achieving a diagnostic accuracy equivalent to that of students in Year 3. Year 4 students performed better on cases on which they had received feedback as Year 3 students. Twelve cases would provide a reliability of 0.80, based on discriminating checklist items only. Conclusions The HDPE provided medical students with a thoughtful, deliberate approach to learning and assessing PE skills in a valid and reliable manner.

Medical education fellowship programs (MEFPs) are a form of faculty development contributing to an organization's educational mission and participants' career development. Building an MEFP requires a systematic design, implementation, and evaluation approach which aligns institutional and individual faculty goals. Implementing an MEFP requires a team of committed individuals who provide expertise, guidance, and mentoring. Qualified MEFP directors should utilize instructional methods that promote individual and institutional short and long term growth. Directors must balance the use of traditional design, implementation, and evaluation methodologies with advancing trends that may support or threaten the acceptability and sustainability of the program. Drawing on the expertise of 28 MEFP directors, we provide twelve tips as a guide to those implementing, sustaining, and/or growing a successful MEFP whose value is demonstrated by its impacts on participants, learners, patients, teaching faculty, institutions, the greater medical education community, and the population's health.

Being a clinician-teacher is exciting and stimulating. Most clinician-teachers simply enjoy teaching and value contributing to the development of young professionals. Clinicians also find that teaching keeps their knowledge and skills up to date. Clinical teachers are asked to fulfill a variety of roles.

This study examines validity evidence for the Patient Note Scoring Rubric, which was developed for a local graduation competency exam (GCE) to assess patient notes written in the new United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills format. The rubric was designed to measure three dimensions: Documentation, justified differential diagnosis (DDX), and Workup.Analyses used GCE data from 170 fourth-year medical students who completed five standardized patient (SP) cases in May 2012. Five physician raters each scored all responses for one case. Internal structure was examined using correlations between dimensions and between cases; a generalizability study was also conducted. Relationship to other variables was examined by correlating patient note scores with SP encounter scores. Consequence was assessed by comparing pass-fail rates between the rubric and the previous global rating. Response process was examined using rater feedback.Correlations between scores from different dimensions ranged between 0.33 and 0.44. Reliability of scores based on the phi coefficient was 0.43; 15 cases were required to reach a phi coefficient of 0.70. Evidence of case specificity was found. Documentation scores were moderately correlated with SP scores for data gathering (r = 0.47, P.001). There was no meaningful change in pass-fail rates. Raters' feedback indicated that they required more training for scoring the DDX and Workup dimensions.There is initial validity evidence for use of this rubric to score local clinical exams that are based on the new USMLE patient note format.

OBJECTIVES This study examined validity evidence of end-of-rotation evaluations used to measure progress toward mastery of core competencies in residents. In addition, this study investigated whether end-of-rotation evaluations can be used to detect problem residents during their training. METHODS Historical data for a 4-year period (2009–2012), containing 4986 observations of 291 internal medicine residents, were examined. Residents were observed and assessed by fellows, faculty members and programme directors on nine domains, including the six Accreditation Council for Graduate Medical Education core competencies, as part of their end-of-rotation evaluations. Descriptive statistics were used to collect evidence of the response process. Correlations between competencies and a generalisability study were used to examine the internal structure of the end-of-rotation evaluations. Hierarchical regression was used to estimate the increase in scores across years of training. Scores on endof-rotation evaluations were compared with trainees identified as problem residents by programme directors. RESULTS Compared with fellows, faculty and programme directors had significantly greater variability in assigning scores across different competencies. Correlations between competencies ranged from 0.69 to 0.92. The reliability of end-of-rotation evaluations was adequate (fellows, phi coefficient [φ] = 0.68; faculty [including programme directors], φ = 0.71). Mean scores increased by 0.21 points (95% confidence interval 0.18–0.24) per postgraduate year. Mean scores were significantly correlated with classification as a problem resident (r = 0.33, p < 0.001); problem residents also had significantly lower ratings across all competencies during PGY-1 compared with all other residents. CONCLUSIONS End-of-rotation evaluations are a useful method of measuring the growth in resident performance associated with core competencies when sufficient numbers of end-of-rotation evaluation scores are used. Furthermore, end-of-rotation evaluation scores provide preliminary evidence with which to detect and predict problem residents in subsequent postgraduate training years.

A common approach to teaching and assessing the physical exam is to have medical students first learn 140 or so maneuvers, from head to toes, and then demonstrate mastery of the maneuvers using a standardized patient checklist. This approach tends to decontextualize the physical exam. While students can learn the individual maneuvers, they may be unable to put the pieces together in a useful structural pattern that they can use to analyze and sort out a differential diagnosis at the bedside. The Hypothesis-Driven Physical Examination (HDPE) was originally developed as an assessment procedure in which students use a differential diagnosis to anticipate discriminating physical findings, execute the maneuvers, appreciate the patient's findings, and interpret the findings by offering the most likely diagnosis. This resource, the HDPE Student Study Guide, contains 160 physical exam maneuvers grouped according to 19 chief complaints, each with three to four relevant prototypical diagnoses, for a total of 60 distinct diagnoses. The maneuvers are presented as a series of charts. Medical students tested with this HDPE procedure, which included immediate feedback from a patient instructor (specialized standardized patient), performed better 1 year later. As few as 12 cases can be used to reliably (Cronbach's α >.80) assess mastery. The main purpose of the HDPE is to promote contextualized and meaningful learning and help provide a more selective approach to physical diagnosis, focusing on key, discriminating clinical findings as well as an array of structural patterns that can facilitate transfer from preclinical to clinical settings and from patient to patient.

This study aimed to test the extent to which the use of medicalese (i.e. formal medical terminology and semantic qualifiers) alters the test performance of medical graduates; to tease apart the extent to which any observed differences are driven by language difficulties versus differences in medical knowledge; and to assess the impact of varying the language used to present clinical features on the ability of the test to consistently discriminate between candidates.Six clinical cases were manipulated in the context of pilot items on the Canadian national qualifying examination. Features indicative of two diagnoses were presented uniformly in lay terms, medical terminology and semantic qualifiers, respectively, and in mixed combinations (e.g. features of one diagnosis were presented using lay terminology and features of the other using medicalese). The rate at which the indicated diagnoses were named was considered as a function of language used, site of training, birthplace and medical knowledge (as measured by overall performance on the examination).In the mixed conditions, Canadian medical graduates were not influenced by the language used to present the cases, whereas international medical graduates (IMGs) were more likely to favour the diagnosis associated with medical terminology relative to that associated with lay terms. This was true regardless of whether the entire sample or only North American-born candidates were considered. Within the IMG cohort, high performers were not influenced by the language manipulation, whereas low performers were. Uniform use of lay terminology resulted in the highest test reliability compared with the other experimental conditions.The results indicate that the influence of medical terminology is driven more by substandard medical knowledge than by the language issues that challenge some candidates. Implications for both the assessment and education of medical professionals are discussed.

OBJECTIVE: To determine if structured teaching of bedside cardiac examination skills improves medical residents’ examination technique and their identification of key clinical findings. DESIGN: Firm-based single-blinded controlled trial. SETTING: Inpatient service at a university-affiliated public teaching hospital. PARTICIPANTS: Eighty Internal Medicine residents. METHODS: The study assessed 2 intervention groups that received 3-hour bedside teaching sessions during their 4-week rotation using either: (1) a traditional teaching method, “demonstration and practice” (DP) (n=26) or (2) an innovative method, “collaborative discovery” (CD) (n=24). The control group received their usual ward teaching sessions (n=25). The main outcome measures were scores on examination technique and correct identification of key clinical findings on an objective structured clinical examination (OSCE). RESULTS: All 3 groups had similar scores for both their examination technique and identification of key findings in the preintervention OSCE. After teaching, both intervention groups significantly improved their technical examination skills compared with the control group. The increase was 10% (95% confidence interval [CI] 4% to 17%) for CD versus control and 12% (95% CI 6% to 19%) for DP versus control (both P

To provide background for future hepatitis A vaccine trials, sera were collected from 0- to 4-year-old Liberian infants and their mothers on two occasions an average of 14.75 months apart and tested for antibody to hepatitis A virus (anti-HAV). The prevalence of anti-HAV rose from 2.5% in infants 0–6 months of age to 70% in children 3–4 years of age and did not differ between male and female infants. The annual incidence of new infections was slightly lower in the first year of life (35%) than in the subsequent 3 years, when it averaged 45%. The presence of HBV infection did not affect the incidence of HAV seroconversion. No clinical hepatitis was recognized in the subjects who seroconverted. Dual hepatitis A and B virus infection were observed; these were all clinically inapparent. The extraordinary incidence of HAV infection documented in the present study offers an opportunity for vaccine efficacy trials requiring minimal numbers of subjects.