Search

Melissa K Myers,1 Claire L Jansson-Knodell,1 Darrell R Schroeder,2 John G O’Meara,3 Sara L Bonnes,4 John T Ratelle5 1Department of Medicine, Mayo Clinic, Rochester, MN, USA; 2Department of Health Sceinces Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA; 3Department of Pharmacy Services, Mayo Clinic, Rochester, MN, USA; 4Department of Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA; 5Department of Medicine, Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA Background: Low-molecular-weight heparin (LMWH) is an effective means of preventing venous thromboembolism (VTE) among medical inpatients. Compared with unfractionated heparin, LMWH is equivalent or superior in efficacy and risk of bleeding. Despite its advantages, LMWH is underused in VTE prophylaxis for general-medicine patients hospitalized at our institution. Thus, a quality improvement (QI) initiative was undertaken to increase LMWH use for VTE prophylaxis among medical patients hospitalized on resident teaching services. Methods: A QI team was formed, consisting of resident and attending physicians with pharmacy leaders. A systems analysis was performed, which showed gaps in resident knowledge as the greatest barrier to LMWH use. A knowledge translation framework was used to improve prescribing practices. Several Plan–Do–Study–Act cycles were executed, including resident-of-resident and pharmacist-of-resident education with performance audit and feedback. Results: Pharmacist-of-resident education elicited the largest improvement and was sustained through a recurring pharmacist-led, interprofessional educational session as part of the monthly hospital orientation for incoming residents. Data analysis showed a statistically significant increase in LMWH use among treatment-eligible hospitalized medical patients, from 12.1% to 69.2%, following intervention (P

Stanislav Henkin,1 Tony Y Chon,2 Marie L Christopherson,3 Andrew J Halvorsen,1,4 Lindsey M Worden,3 John T Ratelle51Department of Medicine, Mayo Clinic, 2Division of General Internal Medicine, Mayo Clinic, 3Department of Nursing, Mayo Clinic, 4Department of Medicine, Internal Medicine Residency Office of Educational Innovations, Mayo Clinic, 5Division of Hospital Medicine, Mayo Clinic, Rochester, MN, USA Background: Teamwork between physicians and nurses has a positive association with patient satisfaction and outcomes, but perceptions of physician–nurse teamwork are often suboptimal.Objective: To improve nurse–physician teamwork in a general medicine inpatient teaching unit by increasing face-to-face communication through interprofessional bedside rounds.Intervention: From July 2013 through October 2013, physicians (attendings and residents) and nurses from four general medicine teams in a single nursing unit participated in bedside rounding, which involved the inclusion of nurses in morning rounds with the medicine teams at the patients’ bedside. Based on stakeholder analysis and feedback, a checklist for key patient care issues was created and utilized during bedside rounds.Assessment: To assess the effect of bedside rounding on nurse–physician teamwork, a survey of selected items from the Safety Attitudes Questionnaire (SAQ) was administered to participants before and after the implementation of bedside rounds. The number of pages to the general medicine teams was also measured as a marker of physician–nurse communication.Results: Participation rate in bedside rounds across the four medicine teams was 58%. SAQ response rates for attendings, residents, and nurses were 36/36 (100%), 73/73 (100%), and 32/73 (44%) prior to implementation of bedside rounding and 36 attendings (100%), 72 residents (100%), and 14 (19%) nurses after the implementation of bedside rounding, respectively. Prior to bedside rounding, nurses provided lower teamwork ratings (percent agree) than residents and attendings on all SAQ items; but after the intervention, the difference remained significant only on SAQ item 2 (“In this clinical area, it is not difficult to speak up if I perceive a problem with patient care”, 64% for nurses vs 79% for residents vs 94% for attendings, P=0.02). Also, resident responses improved on SAQ item 1 (“Nurse input is well received in this area”, 62% vs 82%, P=0.01).Conclusion: Increasing face-to-face communication through interprofessional bedside rounding can improve the perceptions of nurse–physician teamwork, particularly among residents and nurses. Keywords: interprofessional care, teamwork, graduate medical education, hospital medicine

Physician virtues, including humility, are crucial for shaping a physician's identity and practice. The health care literature offers varied views on humility, and the rising call for discussing virtues as a framing for professional identity formation underscores the need for a clearer understanding of physician humility. This review aimed to develop a cohesive conceptualization of physician humility and to define how it functions in medical practice. To achieve this, a comprehensive search was done across PubMed, Ovid MEDLINE, Web of Science, Embase, ERIC, and PsycInfo, covering all records up to 30 October 2023. Articles were included if they discussed physician humility and excluded if they were unrelated to physician humility, focused on nonphysician health professionals, lacked conceptual depth, or focused solely on cultural humility. An applied thematic analysis was conducted. The results provide a synthesized conceptualization of physician humility across stances toward self, others, and the profession. The included articles identified the pivotal role of physician humility within the following 5 domains of medical practice: learning and professional growth, navigating error, uncertainty tolerance, trust and entrustment, and teamwork and communication. The authors highlight some of the intrapersonal, interpersonal, and sociocontextual challenges to cultivating and practicing physician humility. These findings highlight the importance of promoting humility in shaping physicians' actions, thoughts, and relationships with patients, colleagues, and their profession. Integrating such virtues as humility into medical education is essential for upholding the ideals of the medical profession and cultivating moral agents who engage in self-reflection and embody the principles of exemplary physicians., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M24-0842.

Teamwork in graduate medical education (GME) is often hindered in clinical learning environments where discontinuity among residents, supervisors, and other health care professionals is typical. Teaming is a conceptual approach to teamwork in dynamic environments with constantly changing team members and goals. Teaming is built on principles of project management and team leadership, which together provide an attractive strategy for addressing teamwork challenges in GME. Indeed, teaming is now a requirement of the Accreditation Council for Graduate Medical Education Clinical Learning Environment Review program. However, many clinician-educators and leaders may be unfamiliar with teaming and how to integrate it into their GME programs. In this article, the teaming framework is described with a specific example of how it can be applied to improve hospital ward rounds, a common setting of teamwork breakdown. The goal of this article is to educate and encourage GME leaders as they learn new ways to implement teaming to improve patient care and education in their programs., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Continuing medical education (CME) is a requirement for medical professionals to stay current in their ever-changing fields. The recent significant changes that have occurred due to the COVID-19 pandemic have significantly impacted the process of providing and obtaining CME. In this paper, an updated approach to successfully creating and administering CME is offered. Recommendations regarding various aspects of CME development are covered, including competitive assessment, marketing, budgeting, property sourcing, program development, and speaker and topic selection. Strategies for traditional and hybrid CME formats are also explored. Readers and institutions interested in developing CME, especially in the setting of the ongoing pandemic, will be able to use these strategies as a solid framework for producing CME. The recommendations and strategies presented within this paper are based on the authors' opinions, expert opinions, and experiences over 13 years of creating CME events and challenges brought about due to the COVID-19 pandemic., (©Debra Blomberg, Christopher Stephenson, Teresa Atkinson, Anissa Blanshan, Daniel Cabrera, John T Ratelle, Arya B Mohabbat. Originally published in JMIR Medical Education (https://mededu.jmir.org), 15.11.2023.)

Background: Many hospitalized patients do not understand or agree with their clinicians about their discharge plan. However, the effect of disagreement on discharge outcomes is unknown., Objective: To measure the correlation between patient-clinician care agreement and discharge outcomes., Design: A prospective cohort study was performed from September 2019 to March 2020 (Rochester, MN, USA)., Setting and Participants: Internal medicine patients and their primary clinician (resident, advanced practice clinician or attending) hospitalized from September 2019-March 2020 at Mayo Clinic Hospital. Participants were independently surveyed following hospital day #3 ward rounds regarding the goals of the hospitalization and discharge planning., Main Outcome and Measures: Patient-clinician agreement for main diagnosis, patient's main concern, and four domains of discharge planning was assessed. Readiness for hospital discharge, delayed discharge, and 30-day readmission was measured. Then, associations between patient-clinician agreement, delayed discharge, and 30-day readmissions were analyzed using multivariable logistic regression., Results: Of the 436 patients and clinicians, 17.7% completely agreed about what needs to be accomplished before dismissal, 40.8% agreed regarding discharge date, and 71.1% agreed regarding discharge location. In the multivariable model, patient-clinician agreement scores were not significantly correlated with discharge outcomes. Patient-clinician agreement on discharge location was higher for those discharged to home (81.5%) versus skilled nursing facility (48.5%) or assisted living (42.9%) (p < .0001). The agreement on the expected length of stay was highest for home-goers (45.9%) compared to skilled nursing (32.0%) or assisted living (21.4%) (p = .004)., Conclusions: Patients and their clinicians frequently disagree about when and where a patient will go after hospitalization, particularly for those discharged to a skilled nursing facility. While disagreement did not predict discharge outcomes, our findings suggest opportunities to improve effective communication and promote shared mental models regarding discharge earlier in the hospital stay., (© 2022 Society of Hospital Medicine.)

Purpose: To determine if bedside rounds, compared with other forms of hospital ward rounds, improve learning outcomes in medical education., Method: For this systematic review, the authors searched Ovid MEDLINE, Embase, and Scopus from inception through February 20, 2020. Experimental studies were included if they (1) compared bedside rounds to any other form of rounds in a hospital-based setting, and (2) reported a quantitative comparison of a learning outcome (e.g., learner reaction, knowledge, skills, behavior, health care delivery) among physicians-in-training (medical students, residents, fellows). Extraction elements were summarized using descriptive statistics and a narrative synthesis of design, implementation, and outcomes., Results: Twenty studies met inclusion criteria, including 7 randomized trials. All studies involved resident physicians, and 11 also involved medical students. The design and implementation of bedside rounds varied widely, with most studies (n = 13) involving cointerventions (e.g., staff education, real-time order entry).Of the 15 studies that reported learner satisfaction, 7 favored bedside rounds, 4 favored the control, and 4 were equivocal. Of the 4 studies reporting an outcome of learners' knowledge and skills, 2 favored bedside rounds and 2 were equivocal. Of the 8 studies that reported on learner behavior (e.g., bedside communication with patients), 5 favored bedside rounds, 1 favored the control, and 2 were equivocal. Finally, of the 14 studies that reported a health care delivery outcome (e.g., teamwork, rounding time), 8 favored bedside rounds and 6 were equivocal. Due to the high risk of bias and unexplained heterogeneity across studies, the overall strength of evidence was low., Conclusions: In hospital-based settings, learners' satisfaction with bedside rounds is mixed. However, bedside rounds appear to have a positive effect on learner behavior and health care delivery. Given their potential value, additional research is needed to identify barriers to and facilitators of educationally successful bedside rounds., (Copyright © 2022 by the Association of American Medical Colleges.)

Introduction: Professional identity formation (PIF) is the internalization of characteristics, values, and norms of the medical profession. An individual's identity formation has both psychological and sociological influences. Social psychology may be useful to explore the interactions between the psychological and sociological aspects of PIF. In this study, we explored how resident physicians navigated tensions between professional ideals and the reality of medical practice to characterize PIF during residency training., Methods: Using constructivist grounded theory, the authors conducted 23 semi-structured interviews with internal medicine residents. Interview transcripts were processed through open coding and analytic memo writing. During data gathering and analysis, the authors utilized Social Cognitive Theory, specifically the bidirectional influence between person, behavior, and context, to analyze relationships among themes. Theoretical insights were refined through group discussion and constant comparison with newly collected data., Results: Residents described tensions experienced during residency between pre-existing ideals of "a good doctor" and the realities of medical practice, often challenging residents to reframe their ideals. The authors provide evidence for the presence of dynamic, bidirectional influences between identity (person), behavior, and environment (context), and demonstrate how PIF is informed by a complex interplay between these elements. The authors present two examples to demonstrate how residents reframed their ideals during residency training., Discussion: The complex bidirectional influences between person, behavior, and context, informed by SCT, helps illuminate the process of PIF in residency training. This study highlights the effects of the context of residency training on the development of residents' professional identities., (© 2022. The Author(s).)

Background: Initiatives employing medical students' volunteerism and idealism, such as the Student-Run Free Clinics (SRFC) program, are prevalent in US medical schools. Many studies evaluated various aspects of volunteering, sometimes resulting in conflicting evidence. This study simultaneously sought to identify the characteristics of volunteers vs. non-volunteers, and to characterize the volunteers' perception of the SRFC., Methods: We administered a survey to the Long School of Medicine (LSOM) Class of 2018 before their third year of medical school. The authors compared and contrasted the findings of the SRFC volunteers with their non-volunteering counterparts by analyzing their demographics, volunteering history, academic performance, and clinical skills. The volunteers were also asked about their SRFC experiences., Results: While most volunteers were female (62 %) and non-traditional students (67 %), the difference was not statistically significant (p = 0.15 and p = 0.38, respectively). Additionally, there were no statistically significant differences between the two groups in measures of academic performance (p = 0.25). Most of the volunteers learned about the SRFC program prior to starting medical school. Further, while SRFC volunteers were more likely to engage in additional local volunteering initiatives, the difference was not statistically significant (p = 0.03, prespecified  α= 0.006). Importantly, volunteers agreed/strongly agreed that SRFC volunteering emphasized aspects that were missing or underemphasized in the formal medical school curriculum., Conclusions: Medical students' age, gender, undergraduate major, and non-traditional status were not statistically different between volunteers vs. non-volunteers. However, there may be tendencies for volunteers to be female, non-traditional, and locally engaged. Further, the timing of knowledge of the SRFC program may not affect student involvement in the SRFC, either. Most importantly, however, while volunteering does not affect the students' academic performance, it may provide improvements in clinical competencies.

Hospital medicine ward rounds are often conducted away from patients' bedsides, but it is unknown if more time-at-bedside is associated with improved patient outcomes. Our objective is to measure the association between "time-at-bedside," patient experience, and patient-clinician care agreement during ward rounds. Research assistants directly observed medicine services to quantify the amount of time spent discussing each patient's care inside versus outside the patient's room. "Time-at-bedside" was defined as the proportion of time spent discussing a patient's care in his or her room. Patient experience and patient-clinician care agreement both were measured immediately after ward rounds. Results demonstrated that the majority of patient and physicians completely agreement on planned tests (66.3%), planned procedures (79.7%), medication changes (50.6%), and discharge location (66.9%), but had no agreement on the patient's main concern (74.4%) and discharge date (50.6%). Time-at-bedside was not correlated with care agreement or patient experience ( P > .05 for all comparisons). This study demonstrates that spending more time at the bedside during ward rounds, alone, is insufficient to improve patient experience., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Background : Residents are expected to develop the skills to set learning goals. Setting learning goals is part of self-regulated learning, setting the foundation for creating a learning plan, deploying learning strategies, and assessing their progress to those goals. While effective goal setting is essential to resident self-regulated learning, residents struggle with setting learning goals and desire faculty assistance with goal setting. Objective : We aimed to characterize the topics and quality of residents' rotation-specific learning goals. Design : We conducted a prospective study of 153 internal medicine residents, assessing 455 learning goals for general medicine inpatient rotations. We coded learning goal themes, competencies, and learning domains, and assessed quality using the validated Learning Goal Scoring Rubric. We compared topic categories, competencies, learning domains, and quality between the first and second months of postgraduate (PGY)-1 residents and between PGY-1 and PGY-3 residents. We assessed factors associated with learning goal completion. Results : The overall response rate was 80%. The top three learning goal categories were patient management, specific diseases related to general medicine, and teaching skills. There were no changes in learning goal characteristics between PGY-1 months (p ≥ 0.04). There were differences between PGY-1 and PGY-3 residents' learning goals in patient management (28% vs 6%; p < .001), specific disease conditions (19% vs 3%; p < .001), and teaching skills (2% vs 56%; p < .001). There was no difference in learning goal quality between PGY-1 months (1.63 vs. 1.67; p = 0.82). The PGY-3 learning goals were of higher quality than PGY-1 learning goals for the 'specific goal' item (1.38 vs. 0.98, p = 0.005), but not for other items or overall (all p ≥ 0.02). Residents reported 85% (297/347) learning goal completion. Conclusions : Resident rotation-specific learning goals reflect a broad array of topics. Residents' learning goal quality was low and residents may benefit from guidance to support residents' learning goals.

Background: Faculty supervision of invasive bedside procedures (IBPs) in the ICU may enhance procedural education and ensure patient safety. However, there is limited research on teaching effectiveness in the ICU, and there are no best teaching practices regarding the supervision of IBPs., Research Question: We conducted a multi-institutional qualitative study of pulmonary and critical care medicine faculty and fellows to better understand characteristics of effective IBP teachers., Study Design and Methods: Separate focus groups (FGs) were conducted with fellows and faculty at four large academic institutions that were geographically distributed across the United States. FGs were facilitated by a trained investigator, audio-recorded, and transcribed verbatim for analysis. Themes were identified inductively and compared with constructs from social and situated learning theories. Data were analyzed between and across professional groups. Qualitative research software (NVivo; QSR International) was used to facilitate data organization and create an audit trail of the analysis. A multidisciplinary research team was engaged to minimize interpretive bias., Results: Thirty-three faculty and 30 fellows participated. Inductive analysis revealed three categories of themes among successful IBP teachers: traits, behaviors, and context. Traits included calm demeanor, trust, procedural competence, and effective communication. Behaviors included leading preprocedure huddles to assess learners' experiences and define expectations; debriefing to provide feedback; and allowing appropriate autonomy. Context included learning climate, levels of distraction, patient acuity, and institutional culture., Interpretation: We identified specific traits and behaviors of effective IBP teachers that intersect with the practice environment, which highlights the challenge of teaching IBPs. Notably, FG participants emphasized interpersonal, more than technical, aspects of successful IBP teachers. These findings should inform future curricula on teaching IBPs in the ICU, standardize IBP teaching for pulmonary and critical care medicine fellows, and reduce patient injury from procedural complications., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Problem: Conferences are the most common form of continuing medical education (CME), but their effect on clinician practice is inconsistent. Reflection is a critical step in the process of practice change among clinicians and may lead to improved outcomes following conference-based CME. However, reflection requires time to process newly-learned material. Adequate time for reflection may be noticeably absent during many conference presentations. Intervention: The pause procedure is a 90-second 'pause' during a 30-minute presentation so learners can review and discuss content. The goal of the pause procedure is to stimulate learners' active engagement with newly learned material which will, in turn, promote learner reflection. Context: Fifty-six presentations at two hospital medicine CME conferences were assigned to the pause procedure or control. Study outcomes provided by conference participants were validated reflection scores and commitment-to-change (CTC) statements for each presentation. A post-hoc survey of the intervention group was conducted to assess presenters' experiences with the pause procedure. Impact: A total of 527 conference participants completed presentation evaluations (response rate 72.7%). Presentations incorporating the pause procedure failed to lead higher participant reflection scores (percentage 'top box' score; intervention: 39.2% vs. control: 41.7%, p = 0.40) or participant CTC rates (median [IQR]; intervention: 4.64 [3.04, 10.57] vs. control: 8.16 [5.28, 17.12], p = 0.13) than control presentations. However, the majority of presenters (16 out of 17 survey respondents) had never before used the intervention and little active engagement among learners was noted during the pause procedure. Lessons Learned: Adding the pause procedure to CME presentations did not lead to greater reflection or CTC among clinician learners. However, presenters had limited experience with the intervention, which may have reduced their fidelity to the educational principles of the pause procedure. Faculty development may be necessary when planning a new educational intervention that is to be implemented by conference presenters.

Context: Professional identity formation (PIF) involves the development of professional values, actions and aspirations and is central to medical education. Current understanding of PIF is informed by psychological and sociological theories. One ideal of medicine is responsibility to the patient; the development of this ideal is related to learner autonomy. The purpose of this study was to further theorise the relationships between the individual and contextual aspects of PIF through exploring the associations amongst autonomy, making decisions and responsibility for patients during residency training., Methods: Using constructivist grounded theory, we conducted 23 semi-structured interviews with internal medicine residents at an academic medical centre. Interview transcripts were de-identified and processed through open coding and analytic memo writing. During data collection and analysis, we identified social cognitive theory (SCT), specifically reciprocal determinism, or the triadic and reciprocal relationship between context, person and behaviour, as a useful theoretical lens through which to illuminate the relationship between autonomy and PIF. Using SCT to guide analysis, we organised themes, identified relationships amongst themes, and refined them through group discussion and constant comparison with new data., Results: Residents discussed three main themes: autonomy; making decisions, and responsibility for patient care. Autonomy allowed residents to feel personally responsible for patient care, and build confidence and trust. Autonomy allowed residents to feel engaged in making 'real decisions' for patient care. By displaying confidence in their decision making, residents were granted more autonomy. Lack of autonomy led to disengagement and lack of ownership over patient care., Conclusions: This study highlighted the role of autonomy in the PIF of learners. Exploring the tension between autonomy and supervision through the lens of SCT highlighted the interconnectedness of context, behaviour and identity in PIF. To ensure optimal learning environments for PIF, educators should weigh the need for autonomy against the demands for supervision and patient safety., (© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Purpose: Successful training of internal medicine (IM) residents requires accurate assessments. Patients could assess IM residents in a hospital setting, but medical educators must understand how contextual factors may affect assessments. The objective was to investigate relationships between patient, resident, and hospital-encounter characteristics and the results of patient assessments of IM resident professionalism., Method: The authors performed a prospective cohort study of postgraduate year 1 (PGY-1) IM residents and their patients at 4 general medicine inpatient teaching services at Mayo Clinic Hospital-Rochester, Saint Marys Campus in Rochester, Minnesota, from July 1, 2015, through June 30, 2016. Patient assessments of resident professionalism were adapted from validated instruments. Multivariable modeling with generalized estimating equations was used to determine associations between patient assessment scores and characteristics of residents, residents' clinical performance and evaluations (including professionalism assessments in other settings), patients, and hospital encounters and to account for repeated assessments of residents., Results: A total of 409 patients assessed 72 PGY-1 residents (mean [SD], 5.7 [3.0] patient assessments per resident). In the multivariable model, only the highest rating out of 5 levels for overall satisfaction with hospital stay was significantly associated with patient assessment scores of resident professionalism (β [SE], 0.80 [0.08]; P < .001). Hospitalized patients' assessment scores of resident professionalism were not significantly correlated with assessment scores of resident professionalism in other clinical settings., Conclusions: Hospitalized patients' assessment scores of in-hospital resident professionalism were strongly correlated with overall patient satisfaction with hospital stay but were not correlated with resident professionalism in other settings. The limitations of patient evaluations should be considered before incorporating these evaluations into programs of assessment.

Purpose: The purpose of this study was to describe participant characteristics and effective teaching methods at a national continuing medical education (CME) conference on hospital medicine for physician assistants (PAs) and nurse practitioners (NPs)., Methods: In this cross-sectional study, participants provided demographic information and teaching effectiveness scores for each presentation. Associations between teaching effectiveness score and presentation characteristics were determined., Results: In total, 163 of 253 participants (64.4%) completed evaluations of 28 presentations. Many of the participants were younger than 50 years (69.0%), had practiced for fewer than 5 years (41.5%), and worked in nonacademic settings (76.7%). Teaching effectiveness scores were significantly associated with the use of clinical cases (perfect scores for 68.8% of presentations with clinical cases vs. 59.8% without; P = .04)., Conclusion: Many PAs and NPs at an HM CME conference were early-career clinicians working in nonacademic settings. Presenters at CME conferences in hospital medicine should consider using clinical cases to improve their teaching effectiveness among PA and NP learners.

Qualitative research was originally developed within the social sciences. Medical education is a field that comprises multiple disciplines, including the social sciences, and utilizes qualitative research to gain a broader understanding of key phenomena within the field. Many clinician educators are unfamiliar with qualitative research. This article provides a primer for clinician educators who want to appraise or conduct qualitative research in medical education. This article discusses a definition and the philosophical underpinnings for qualitative research. Using the Standards for Reporting Qualitative Research as a guide, this article provides a step-wise approach for conducting and evaluating qualitative research in medical education. This review will enable the reader to understand when to utilize qualitative research in medical education and how to interpret reports using qualitative approaches.

There has been a dramatic growth of scholarly articles in medical education in recent years. Evaluating medical education research requires specific orientation to issues related to format and content. Our goal is to review the quantitative aspects of research in medical education so that clinicians may understand these articles with respect to framing the study, recognizing methodologic issues, and utilizing instruments for evaluating the quality of medical education research. This review can be used both as a tool when appraising medical education research articles and as a primer for clinicians interested in pursuing scholarship in medical education.

Background: Bedside rounds (BR) have been proposed as an ideal method to promote patient-centred hospital care, but there is substantial variation in their implementation and effects. Our objectives were to describe the implementation of BR in hospital settings and determine their effect on patient-centred outcomes., Methods: Data sources included Ovid MEDLINE, Ovid Embase, Scopus and Ovid Cochrane Central Registry of Clinical Trials from database inception through 28 July 2017. We included experimental studies comparing BR to another form of rounds in a hospital-based setting (ie, medical/surgical unit, intensive care unit (ICU)) and reporting a quantitative patient-reported or objectively measured clinical outcome. We used random effects models to calculate pooled Cohen's d effect size estimates for the patient knowledge and patient experience outcome domains., Results: Twenty-nine studies met inclusion criteria, including 20 from adult care (17 non-ICU, 3 ICU), and nine from paediatrics (5 non-ICU, 4 ICU), the majority of which (n=23) were conducted in the USA. Thirteen studies implemented BR with cointerventions as part of a 'bundle'. Studies most commonly reported outcomes in the domains of patient experience (n=24) and patient knowledge (n=10). We found a small, statistically significant improvement in patient experience with BR (summary Cohen's d=0.09, 95% CI 0.04 to 0.14, p<0.001, I 2 =56%), but no significant association between BR and patient knowledge (Cohen's d=0.21, 95% CI -0.004 to -0.43, p=0.054, I 2 =92%). Risk of bias was moderate to high, with methodological limitations most often relating to selective reporting, low adherence rates and missing data., Conclusions: BR have been implemented in a variety of hospital settings, often 'bundled' with cointerventions. However, BR have demonstrated limited effect on patient-centred outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Self-directed learning (SDL) is part of residency training, which residents desire guidance in implementing. To characterize SDL within the clinical context, this study explored residents' perceptions of faculty members' role in promoting and supporting resident SDL., Method: Using a constructivist grounded theory approach, the authors conducted seven focus groups with 46 internal medicine residents at the Mayo Clinic Internal Medicine Residency Program from October 2014 to January 2015. Focus group transcripts were deidentified and processed through open coding and analytic memo writing. Guided by a previously developed SDL model, data were analyzed regarding faculty member involvement in resident SDL. Themes were organized and patterns were discussed at team meetings, with constant comparison with new data. Trustworthiness was established using two member-check sessions., Results: The authors identified themes within the categories of faculty guidance for SDL, SDL versus other-directed learning (ODL), and faculty archetypes for supporting SDL. Clinical teachers play a key role in facilitating resident SDL and can provide guidance at each step in the SDL process. Residents discussed the distinction between SDL and ODL, highlighting the integrated nature of learning and interplay between the two approaches to learning. Residents identified themes relating to three archetypal approaches faculty implement to support resident SDL in the clinical environment (directed, collaborative, and role model SDL), with benefits and challenges of each approach., Conclusions: This study underscores the importance of external guidance for resident SDL and expands on approaches faculty members can use to support SDL in the clinical context.

Effective medical educators can engage learners through self-reflection. However, little is known about the relationships between teaching effectiveness and self-reflection in continuing medical education (CME). We aimed to determine associations between presenter teaching effectiveness and participant self-reflection in conference-based CME. This cross-sectional study evaluated presenters and participants at a national CME course. Participants provided CME teaching effectiveness (CMETE) ratings and self-reflection scores for each presentation. Overall CMETE and CME self-reflection scores (five-point Likert scale with one as strongly disagree and five as strongly agree) were averaged for each presentation. Correlations were measured among self-reflection, CMETE, and presentation characteristics. In total, 624 participants returned 430 evaluations (response, 68.9%) for the 38 presentations. Correlation between CMETE and self-reflection was medium (Pearson correlation, 0.3-0.5) or large (0.5-1.0) for most presentations (n = 33, 86.9%). Higher mean (SD) CME reflection scores were associated with clinical cases (3.66 [0.12] vs. 3.48 [0.14]; p = 0.003) and audience response (3.66 [0.12] vs. 3.51 [0.14]; p = 0.005). To our knowledge, this is the first study to show a relationship between teaching effectiveness and participant self-reflection in conference-based CME. Presenters should consider using clinical cases and audience response systems to increase teaching effectiveness and promote self-reflection among CME learners.

Introduction: Reflection exposes performance gaps and is a step in the process of behavior change among adult learners. However, little is known about the relationships between reflection and behavior change in CME. Our objectives were to measure associations between validated reflection scores and behavior change among CME participants and to identify associations between reflection and characteristics of CME presentations., Methods: This was a cohort study of attendees at a national hospital medicine CME course. Participants provided reflection scores for each presentation and planned commitment-to-change (CTC) statements at the conclusion of the course. Reflection scores from 1 (strongly disagree) to 5 (strongly agree) were averaged for each presentation. CTC statements were linked to their accompanying presentations. A 3-month postcourse survey was conducted to assess if planned CTCs were successfully implemented., Results: In all, 223 of 281 participants (79.4%) returned evaluations. Of the 195 planned CTC statements available for postcourse analysis, 128 (65.6%) were implemented. Reflection scores correlated with the number of planned CTC statements across all presentations (Pearson correlation, 0.65; P < .001). In addition, higher reflection scores (mean [SD]) were associated with the presence of audience response opportunities (Yes: 4.13 [0.18] versus No: 3.96 [0.16]; P = .01) and the use of clinical cases (Yes: 4.09 [0.18] versus No: 3.86 [0.12]; P < .01)., Discussion: To our knowledge, this is the first study to show a relationship between participant reflection and CTC in conference-based CME. Presentations that incorporate clinical cases and audience response systems seem to stimulate participant reflection and behavior change.

Background: Existing theories of self-directed learning (SDL) have emphasized the importance of process, personal, and contextual factors. Previous medical education research has largely focused on the process of SDL. We explored the experience with and perception of SDL among internal medicine residents to gain understanding of the personal and contextual factors of SDL in graduate medical education., Methods: Using a constructivist grounded theory approach, we conducted 7 focus group interviews with 46 internal medicine residents at an academic medical center. We processed the data by using open coding and writing analytic memos. Team members organized open codes to create axial codes, which were applied to all transcripts. Guided by a previous model of SDL, we developed a theoretical model that was revised through constant comparison with new data as they were collected, and we refined the theory until it had adequate explanatory power and was appropriately grounded in the experiences of residents., Results: We developed a theoretical model of SDL to explain the process, personal, and contextual factors affecting SDL during residency training. The process of SDL began with a trigger that uncovered a knowledge gap. Residents progressed to formulating learning objectives, using resources, applying knowledge, and evaluating learning. Personal factors included motivations, individual characteristics, and the change in approach to SDL over time. Contextual factors included the need for external guidance, the influence of residency program structure and culture, and the presence of contextual barriers., Conclusions: We developed a theoretical model of SDL in medical education that can be used to promote and assess resident SDL through understanding the process, person, and context of SDL.

While many hospitalized patients have orders to fast in preparation for interventions, the extent to which these orders are necessary or adhere to evidence-based durations is unknown. In this study, we analyzed the length, indication, and associated outcomes of nil per os (NPO) orders for general medicine patients at an academic institution in the United States, and compared them to the best available evidence for recommended length of NPO. Of 924 NPO orders assessed, the indicated intervention was not performed for 183 (19.8%) orders, largely due to a change in plan (75/183, 41.0%) or scheduling barriers (43/183, 23.5%). When analyzed by indication, the median duration of NPO orders ranged from 8.3 hours for kidney ultrasound to 13.9 hours for upper endoscopy. For some indications, the literature suggested NPO orders may be unnecessary. Furthermore, in indications for which NPO was deemed necessary in the literature, the duration of most NPO orders was much longer than minimally required. These results suggest the need for establishing more robust practice guidelines or institutional protocols for NPO orders. Journal of Hospital Medicine 2017;12:36-39., (© 2017 Society of Hospital Medicine.)

Purpose: The flipped classroom (FC), in which instructional content is delivered before class with class time devoted to knowledge application, has the potential to engage residents. A Mayo Clinic Internal Medicine Residency Program study was conducted to validate an FC perception instrument (FCPI); determine whether participation improved FC perceptions; and determine associations between resident characteristics, change in quality improvement (QI) knowledge, and FC perception scores., Method: All 143 internal medicine residents at Mayo Clinic, Rochester participated from 2014 to 2015; some experienced a flipped QI curriculum and others completed the traditional nonflipped course. The FCPI was developed, and factor analysis revealed an intuitive two-factor structure: preclass activity and in-class application. Residents were surveyed before and after the monthlong curriculum to measure changes in perception, and the QI Knowledge Assessment Tool was employed to measure knowledge improvement., Results: Postcourse FCPI scores significantly increased for three of the eight items. QI knowledge increased significantly among residents who experienced the FC compared with residents who completed the non-FC curriculum. Those without prior FC exposure demonstrated a significant increase in QI knowledge compared with those with previous FC experience. The FCPI had compelling validity evidence with improved scores after curriculum exposure and associations with greater engagement in online modules., Conclusions: Residents who participated in the FC demonstrated improved QI knowledge compared with the control group. Residents valued the in-class application sessions more than the online component. These findings have important implications for graduate medical education as residency training programs increasingly use FC models.

Introduction: Mobile device applications (apps) may enhance live CME courses. We aimed to (1) validate a measure of participant attitudes toward using a conference app and (2) determine associations between participant characteristics and attitudes toward CME apps with conference app usage., Methods: We conducted a cross-sectional validation study of participants at the Mayo Clinic Selected Topics in Internal Medicine Course. A conference app was developed that included presentation slides, note-taking features, search functions, social networking with other attendees, and access to presenter information. The CME app attitudes survey instrument (CMEAPP-10) was designed to determine participant attitudes toward conference apps., Results: Of the 602 participants, 498 (82.7%) returned surveys. Factor analysis revealed a two-dimensional model for CMEAPP-10 scores (Cronbach α, 0.97). Mean (SD) CMEAPP-10 scores (maximum possible score of five) were higher for women than for men (4.06 [0.91] versus 3.85 [0.92]; P = .04). CMEAPP-10 scores (mean [SD]) were significantly associated (P = .02) with previous app usage as follows: less than once per month, 3.73 (1.05); monthly, 3.41 (1.16); weekly, 4.03 (0.69); and daily or more, 4.06 (0.89). Scores were unrelated to participant age, specialty, practice characteristics, or previous app use., Discussion: This is the first validated measure of attitudes toward CME apps among course participants. App usage was higher among younger participants who had previously used educational or professional apps. Additionally, attitudes were more favorable among women and those who had previously used apps. These findings have important implications regarding efforts to engage participants with portable and accessible technology.

Introduction: New teaching approaches for CME are needed. In flipped classrooms, coursework is completed beforehand and applied during class time. Studies of flipped classrooms and their potential benefits in CME have not been published. We sought to develop and validate an instrument measuring flipped classroom perceptions, identify whether participation changed perceptions, and determine which flipped classroom components were perceived as most effective., Methods: In this cross-sectional validation study, 167 participants in the Mayo Clinic's 2015 Internal Medicine Board Review course received surveys. Online modules were developed to deliver content before flipped classroom courses on acid-base disorders and electrolyte disorders. A flipped classroom perception instrument (FCPI) was developed and validated. The FCPI, with eight items structured on 5-point Likert scales, was given to participants before and after their flipped classroom experiences., Results: Of the 167 participants, 111 returned surveys. Flipped classroom perceptions improved, with mean (SD) FCPI scores increasing from 3.74 (0.75) to 3.94 (0.76) (P < .001). The percentage of participants who preferred flipped classrooms increased from 38% before the course to 53% after (P = .002). Positive changes in FCPI scores were unrelated to module completion. Most participants thought knowledge was enhanced by in-class sessions and online modules equally., Discussion: The FCPI, the first validated measure of participants' perceptions of a CME flipped classroom, has strong validity evidence. Participants' perceptions of and preference for the flipped classroom improved after experiencing the flipped CME classroom. These findings support the need to further explore flipped classroom models in CME.

A 59-year-old man was admitted with a 3-month history of daily fevers as well as bilateral knee pain and swelling. Medical history was significant for bilateral knee arthroplasties 4 years prior to admission. Two sets of peripheral blood cultures as well as bilateral knee synovial fluid grew Enterococcus faecalis within 10 hours. Transoesophageal echocardiography revealed aortic and mitral valve vegetations suggestive of infectious endocarditis, with severe regurgitation secondary to large size. The patient's hospitalisation was complicated by acute heart failure, necessitating emergent mitral valve repair and aortic valve replacement, followed shortly thereafter by bilateral total knee arthroplasty resection with placement of antibiotic spacers. He was treated with intravenous penicillin and gentamicin for 4 months and recovered fully. He underwent repeat bilateral knee arthroplasties and was placed on amoxicillin for 6 months postoperatively, with no further evidence of infection., (2016 BMJ Publishing Group Ltd.)

Objective: To evaluate the frequency and appropriateness of nil per os (nothing by mouth) (NPO) orders and determine the number of meals missed because of these orders among hospitalized patients., Patients and Methods: We retrospectively analyzed inpatient NPO orders at an academic institution in the United States. The frequency and duration of NPO orders and the number of meals missed because of these orders were assessed for adult patients admitted to the hospital medicine services from January 1, 2013, through December 31, 2013, with a hospital stay of 2 or more and 30 or fewer days. Two blinded reviewers assessed if the order could be avoided or the period shortened for a random sample of NPO orders of 120 or more minutes' duration that were written for patients on the general medicine ward., Results: A total of 3641 NPO orders were identified. At least one NPO order was placed in 46.6% of the admissions (2211 of 4743). The median duration of NPO orders was 12.8 hours (interquartile range, 9.2-17.3 hours), resulting in 2 (interquartile range, 1-4) missed meals. Of 1130 NPO orders reviewed, 263 (23.3%; 95% CI, 20.9%-25.8%) were deemed avoidable (κ statistic, 0.68), and 482 (42.7%) were unavoidable but led to more missed meals than needed. Taken together, patients could have had 44.8% of the meals (1085 of 2424; 95% CI, 42.8%-46.7%) missed due to NPO orders., Conclusion: Approximately half of the patients admitted to the hospital medicine services experienced a period of fasting. One in 4 NPO orders and nearly half of missed meals could have been avoided. Further study is warranted to assess the generalizability of our findings., (Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: There is little research regarding characteristics of effective continuing medical education (CME) presentations in hospital medicine (HM). Therefore, we sought to identify associations between validated CME teaching effectiveness scores and characteristics of CME presentations in the field of HM., Design/setting: This was a cross-sectional study of participants and didactic presentations from a national HM CME course in 2014., Measurements: Participants provided CME teaching effectiveness (CMETE) ratings using an instrument with known validity evidence. Overall CMETE scores (5-point scale: 1 = strongly disagree; 5 = strongly agree) were averaged for each presentation, and associations between scores and presentation characteristics were determined using the Kruskal-Wallis test. The threshold for statistical significance was set at P < 0.05., Results: A total of 277 out of 368 participants (75.3%) completed evaluations for the 32 presentations. CMETE scores (mean [standard deviation]) were significantly associated with the use of audience response (4.64 [0.16]) versus no audience response (4.49 [0.16]; P = 0.01), longer presentations (≥30 minutes: 4.67 [0.13] vs <30 minutes: 4.51 [0.18]; P = 0.02), and larger number of slides (≥50: 4.66 [0.17] vs <50: 4.55 [0.17]; P = 0.04). There were no significant associations between CMETE scores and use of clinical cases, defined goals, or summary slides., Conclusions: To our knowledge, this is the first study regarding associations between validated teaching effectiveness scores and characteristics of effective CME presentations in HM. Our findings, which support previous research in other fields, indicate that CME presentations may be improved by increasing interactivity through the use of audience response systems and allowing longer presentations., (© 2015 Society of Hospital Medicine.)

Background: Point-of-care ultrasound is a rapidly evolving component of internal medicine (IM) residency training. The optimal approach for teaching this skill remains unclear., Objective: We sought to determine whether the addition of a longitudinal ultrasound curriculum to a stand-alone workshop for ultrasound training improved knowledge retention in IM residents., Methods: We conducted an observational cohort study from July to December 2013. All postgraduate year (PGY)-1 IM residents attended an ultrasound workshop during orientation. Ability to identify static images of ascites, kidney, thyroid, pleural fluid, inferior vena cava, and internal jugular vein was assessed immediately after the workshop. An ultrasound curriculum, including morning report and ultrasound rounds, was initiated during the inpatient medicine rotation. PGY-1 residents were randomly assigned to participate in the longitudinal curriculum. Six months later, we conducted a follow-up survey with all PGY-1 residents., Results: Forty-eight PGY-1 residents (67%) completed the postworkshop test and the 6-month follow-up test. Of these, 50% (24 of 48) had participated in the ultrasound curriculum. Residents not exposed to the curriculum showed a decline in the identification of ascites, pleural effusion, and internal jugular vein at 6 months (P < .05), whereas those who participated in the curriculum maintained their performance (P < .05)., Conclusions: Six months after exposure to a longitudinal ultrasound curriculum, residents were more likely to correctly identify ultrasound images of ascites, kidney, and pleural effusion. The addition of a longitudinal ultrasound curriculum may result in improved knowledge retention in IM residents.

Background: Despite its importance, little is known about internal medicine (IM) residents' ability to assess and communicate a patient's overnight risk during the resident-to-resident handoff., Objective: To evaluate IM residents' ability to identify patients at risk for clinical deterioration using the Patient Acuity Rating (PAR) tool (scored on a 1-7 symmetric scale; 1="Extremely unlikely", 7="Extremely likely"), and to measure how well IM residents conveyed a patient's potential for clinical deterioration during day-to-night handoff., Design and Participants: Observational cohort study of 46 postgraduate year 1 (PGY-1) and 32 postgraduate year 3 (PGY-3) internal medicine residents rotating on one of four general medicine services from October 2013 through January 2014., Main Measures: Primary outcomes were (1) level of agreement between resident handoff giver and receiver regarding patients' clinical risk and (2) accuracy of resident-assigned PAR score in predicting a patient's risk of clinical deterioration over the subsequent 24 hours., Key Results: Analysis of PGY-1 giver-receiver handoff agreement revealed an intraclass correlation coefficient (ICC) (95 % CI) of 0.51 (0.45-0.56), while PGY-3 giver-receiver agreement yielded an ICC (95 % CI) of 0.42 (0.36-0.47). Based on 865 ratings of 378 patients, PGY-1 handoff giver PAR scores of 5 and 6+ were significantly associated with increased odds of clinical deterioration within 24 hours (aOR = 6.5 and 12.4; P = 0.03 and 0.005, respectively). For the 1,170 PAR ratings of 438 patients assigned by PGY-3 handoff givers, PAR scores of 4, 5, and 6+ were significantly associated with increased odds of an event within 24 hours (aORs = 6.0, 9.6, and 18.1; P = 0.03, 0.01, and 0.0008, respectively)., Conclusions: The PAR is a useful tool to quantify IM residents' judgment of patient stability, and may be particularly valuable during resident handoff, given that the level of agreement between giver and receiver regarding patient risk is only fair.

Background: Hospital medicine is a rapidly growing field of internal medicine. However, little is known about internal medicine residents' decisions to pursue careers in hospital medicine (HM)., Objective: To identify which internal medicine residents choose a career in HM, and describe changes in this career choice over the course of their residency education., Design: Observational cohort using data collected from the annual Internal Medicine In-Training Examination (IM-ITE) survey., Participants: 16,781 postgraduate year 3 (PGY-3) North American internal medicine residents who completed the annual IM-ITE survey in 2009-2011, 9,501 of whom completed the survey in all 3 years of residency., Main Measures: Self-reported career plans for individual residents during their postgraduate year 1 (PGY-1), postgraduate year 2 (PGY-2) and PGY-3., Key Results: Of the 16,781 graduating PGY-3 residents, 1,552 (9.3 %) reported HM as their ultimate career choice. Of the 951 PGY-3 residents planning a HM career among the 9,501 residents responding in all 3 years, 128 (13.5 %) originally made this decision in PGY-1, 192 (20.2 %) in PGY-2, and 631 (66.4 %) in PGY-3. Only 87 (9.1 %) of these 951 residents maintained a career decision of HM during all three years of residency education., Conclusions: Hospital medicine is a reported career choice for an important proportion of graduating internal medicine residents. However, the majority of residents do not finalize this decision until their final year.

Anti-glomerular basement membrane disease has been reported to coexist with anti-neutrophil cytoplasmic antibody (ANCA) positive vasculitis. Seronegative anti-GBM disease has been previously described and mostly blamed for the relative insensitivity of earlier serologic assays. A 58-year-old male was transferred to our facility for acute kidney injury. Prior to his hospital admission, the patient had a 2 week history of progressive fatigue, fevers, anorexia, vomiting, decreased urine output, sinus congestion, and non-productive cough. His creatinine reached 13 mg/dL. P-ANCA was positive, anti GBM antibody was negative twice, and urinalysis showed hematuria. Chest x-ray demonstrated diffuse opacities, concerning for pulmonary hemorrhage. Renal biopsy showed a severe necrotizing and crescentic glomerulonephritis with circumferential crescents. There was bright linear glomerular basement membrane staining with IgG consistent with anti-GBM disease. Given these findings, the patient was started on oral cyclophosphamide (160 mg daily), in addition to pulse dose methylprednisolone. He was also initiated on therapeutic plasma exchange. Due to worsening renal function, hemodialysis was started. The patient was discharged from the hospital and completed a course of treatment with cyclophosphamide and prednisone but remains oligo-anuric and hemodialysis dependent at 150 days since presentation. This case highlights the importance of tissue diagnosis in situations similar to this.