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BACKGROUND: Gender inequity is pervasive in academic medicine. Factors contributing to these gender disparities must be examined. A significant body of literature indicates men and women are assessed differently in teaching evaluations. However, limited data exist on how faculty gender affects resident evaluation of faculty performance based on the skill being assessed or the clinical practice settings in which the trainee-faculty interaction occurs. OBJECTIVE: Evaluate for gender-based differences in the assessment of general internal medicine (GIM) faculty physicians by trainees in inpatient and outpatient settings. DESIGN: Retrospective cohort study SUBJECTS: Inpatient and outpatient GIM faculty physicians in an Internal Medicine residency training program from July 1, 2015, to December 31, 2018. MAIN MEASURES: Faculty scores on trainee teaching evaluations including overall teaching ability and Accreditation Council for Graduate Medical Education (ACGME) competencies (medical knowledge [MK], patient care [PC], professionalism [PROF], interpersonal and communication skills [ICS], practice-based learning and improvement [PBLI], and systems-based practice [SBP]) based on the institutional faculty assessment form. KEY RESULTS: In total, 3581 evaluations by 445 trainees (55.1% men, 44.9% women) assessing 161 GIM faculty physicians (50.3% men, 49.7% women) were included. Male faculty were rated higher in overall teaching ability (male=4.69 vs. female=4.63, p=0.003) and in four of the six ACGME competencies (MK, PROF, PBLI, and SBP) based on our institutional evaluation form. In the inpatient setting, male faculty were rated more favorably for overall teaching (male = 4.70, female = 4.53, p=

Background: High-quality transitions of care are crucial for patient safety in hospitals, yet few undergraduate curricula include transition-of-care training. In 2012, the Wayne State University Office of Graduate Medical Education (WSUGME) required its residency programs to use the SAIF-IR mnemonic (summary, active issues, if-then contingency planning, follow-up activities, interactive questioning, readback) to ensure accurate and uniform handoffs. Subsequent program evaluations indicated that resident awareness and adoption of the mnemonic at our primary clinical site, Ascension Providence Rochester Hospital (APRH), could be improved. According to our institution's 2016 Clinical Learning Environment Review (CLER), 88% of residents reported following a standardized transition of care handoff, and 53% reported that faculty rarely supervised their handoffs. A 2016 WSUGME internal survey also revealed low rates of awareness (7% to 10%) of the mandated mnemonic. WSUGME then created a direct observation tool, the Transitions of Care-Clinical Evaluation Exercise (TOC-CEX), for faculty to monitor resident skill in using the mnemonic and thus standardize transitions of care as a practice habit at APRH. Methods: Since 2014, WSUGME had relied on 2 methods for training residents in the required handoff mnemonic: (1) introduction to the SAIF-IR mnemonic during the WSUGME orientation for all interns and (2) simulations during an objective simulated handoff evaluation activity for all postgraduate year (PGY) 1s and PGY 2s. In 2017, WSUGME innovated a direct observation tool, the TOC-CEX, for adoption by faculty at APRH to assess resident knowledge of and monitor their skill in using the SAIF-IR mnemonic in 3 primary care programs. The total number of possible participants was 138, and the actual number of individuals in the sample was 95. A majority (86%) of the observations during the study period were of PGY 1 residents, and thus the analysis reflects the ratings of 99% of all interns but only 69% of all possible residents. Results: WSUGME found that faculty use of a direct observation instrument in the clinical learning environment during 2017-2019 increased awareness and adoption of the SAIF-IR mnemonic among residents. Using a z-test of equal proportions on resident responses on an internal WSUGME survey, we found a significant rise in the percentage reporting yes to the question “Does your program have a mechanism for monitoring handoffs?” (χ2[3]=23.6, P

The Wayne State University Office of Graduate Medical Education (WSUGME) uses an objective structured clinical examination (OSCE) to assess its programs’ contribution to enhancing residents’ communication skills. In response to revisions in Michigan’s opioid-prescribing mandates in 2017, WSUGME developed a pain management case in collaboration with faculty and the Wayne State University School of Medicine to educate residents about these mandates while gauging their skills in Systems-Based Practice (SBP), an Accreditation Council for Graduate Medical Education Core Competency. This study examined whether resident OSCE performance predicted year-end milestones scores in SBP1 (coordinates patient care within various health care delivery settings), SBP2 (works in interdisciplinary teams to enhance patient safety and improve patient care quality), and SBP3 (practices and advocates for cost-effective, responsible care). Participants included two cohorts of first- (PRG-1) and second-year (PRG-2) residents in 6 programs: one cohort from academic year 2018-2019 (n = 33), the other from 2019-2020 (n = 37). Before the OSCE, WSUGME emailed residents the new state prescription requirements. During the simulated encounter, standardized patients rated residents on a validated communication instrument, and WSUGME conducted a linear regression of patient ratings on resident SBP milestone scores. The ratings of communication skills of PRG-1 residents did not predict any of the year-end SBP milestones. However, ratings of communication skills of PRG-2 residents predicted SBP1 and SBP2, though not SBP3, milestones. The OSCE opioid case proved to be a valid measure of PRG-2 residents’ competence gained across the first year but was less meaningful when applied to PRG-1 residents.

Background The Accreditation Council for Graduate Medical Education's Next Accreditation System requires continuous program improvement as part of program evaluation for residency training institutions and programs. Objective To improve the institutional- and program-level evaluation processes, to operationalize a culture of continuous quality improvement (CQI), and to increase the quality and achievement of action items, the Wayne State University Office of Graduate Medical Education (WSU GME) incorporated CQI elements into its program evaluation process. Methods Across 4 academic years, WSU GME phased the following 4 CQI elements into the evaluation process at the program and institutional levels, including the annual program evaluation (APE) and the annual institutional review: (1) An APE template; (2) SMART (specific, measurable, accountable, realistic, timely) format for program and institutional goals; (3) Dashboard program and institutional metrics; and (4) Plan-do-study-act cycles for each action item. Results Action item goals improved in adherence to the SMART format. In 2014, 38% (18 of 48) omitted at least 1 field, compared with 0% omitting any fields in 2018. More complete action items took less time to resolve: 1.7 years compared with 2.4 years (t(43.3) = 2.87, P = .003). The implementation of CQI in the APE was well received by program leadership. Conclusions After leveraging CQI methods, both descriptions of institutional- and program-level goals and the time required for their achievement improved, with overall program director and program coordinator satisfaction.

Purpose Graduate medical education programs have a responsibility to monitor resident wellness. Residents are at risk of burnout, depression, and suicide. Burnout and depression are associated with poor patient care. Many existing tools measure burnout, depression, and general human well-being, but resident wellness is a distinct construct. We aimed to develop an instrument to measure resident wellness directly. Methods An expert panel from two purposefully different graduate medical education institutions generated a behavior- and experience-based model of resident wellness. The panel and resident leaders from both institutions generated 92 items, which were tested alongside anchor scales measuring burnout, depression, personality, optimism, life satisfaction, and social desirability in a convenience sample of 62 residents. Ten items were selected using a combination of factor analysis, a genetic algorithm, and purposeful selection. The 10-item scale was distributed to 5 institutions at which 376 residents completed it anonymously. Exploratory factor analysis was used to examine the factor structure of the scale. Results The model of resident wellness aligned with an accepted framework of well-being in the literature. The 10-item Resident Wellness Scale broadly covered the model and correlated meaningfully with anchor scales. The factor structure of the scale suggested sensitivity to meaningful work, life security, institutional support, and social support. Conclusions This novel Resident Wellness Scale is designed to track residents' wellness longitudinally. It is sensitive to aspects of resident wellness that have been shown to reduce burnout and depression and appears to be a psychometrically strong measure of resident wellness.

Background: Monitoring and improving resident physicians' well-being are crucial because clinical care burdens can cause burnout, depression, and suicide. Burnout negatively affects patient care. Promoting well-being requires cultural change best achieved through a merging of institutional top-down efforts with resident and faculty bottom-up efforts. Methods: The Wayne State University Office of Graduate Medical Education targeted three residency programs (52 residents) at one hospital site for wellness interventions as part of the Alliance of Independent Academic Medical Centers (AIAMC) National Initiative VI. Institution-led efforts included promotion of employee wellness resources, prioritization of wellness at administrative meetings, and program evaluation and assessment. Resident- and faculty-led efforts included the formation of wellness committees that organized events and activities and communicated with program evaluation committees to address wellness concerns. Impact was assessed using mixed methods: the quantitative Resident Wellness Scale, a modified form of the Medical School Learning Environment Survey, and a qualitative Resident Wellness Semi-Structured Interview. Results: Institutional efforts were successfully applied through multiple administrative channels. Resident-led efforts were less successful initially, but wellness committees led by faculty champions were formed within programs and strengthened the resident-led efforts. Quantitative measures indicated that well-being increased and then declined, perhaps attributable to cohort effects. Qualitative analysis revealed multiple dimensions of well-being. We discuss limitations of the work and future directions. Conclusion: Resident well-being requires cooperation and a combination of top-down institutional and bottom-up trainee efforts. Because resident well-being is a complex phenomenon, efforts to improve and sustain it must also be multidimensional and broadly applied.

Author(s): Aghera, Amish; Emery, Matt; Bounds, Richard; Bush, Colleen; Stansfield, R. Brent; Gillett, Brian; Santen, Sally A. | Abstract: Introduction: Goal setting is used in education to promote learning and performance. Debriefing after clinical scenario-based simulation is a well-established practice that provides learners a defined structure to review and improve performance. Our objective was to integrate formal learning goal generation, using the SMART framework (Specific, Measurable, Attainable, Realistic, and Time-bound), into standard debriefing processes (i.e., “SMART Goal Enhanced Debriefing”) and subsequently measure the impact on the development of learning goals and execution of educational actions.Methods: This was a prospective multicenter randomized controlled study of 80 emergency medicine residents at three academic hospitals comparing the effectiveness of SMART Goal Enhanced Debriefing to a standard debriefing. Residents were block randomized on a rolling basis following a simulation case. SMART Goal Enhanced Debriefing included five minutes of formal instruction on the development of SMART learning goals during the summary/application phase of the debrief. Outcome measures included the number of recalled learning goals, self-reported executed educational actions, and quality of each learning goal and educational action after a two-week follow-up period. Results: The mean number of reported learning goals was similar in the standard debriefing group (mean 2.05 goals, SD 1.13, n=37 residents), and in the SMART Goal Enhanced Debriefing group (mean 1.93, SD 0.96, n=43), with no difference in learning goal quality. Residents receiving SMART Goal Enhanced Debriefing completed more educational actions on average (Control group actions completed 0.97 (SD 0.87), SMART debrief group 1.44 (SD 1.03) p=0.03). Conclusion: The number and quality of learning goals reported by residents was not improved as a result of SMART Goal Enhanced Debriefing. Residents did, however, execute more educational actions, which is consistent with the overarching intent of any educational intervention.

This large, multi-institutional study examines the relative contribution of residency specialty and institution to resident satisfaction with their learning environment and workload.Survey responses from 798 residents were linked to institution (N = 20) and specialty (N = 10) and to characteristics of individual residency programs (N = 126) derived from the FREIDA Online database. Hierar chical linear modeling was used to estimate relative contributions of these factors to resident satisfaction with workload and learning environment.Institution had greater influence than specialty on resident ratings of satisfaction with their workload and learning environment. Institution and specialty accounted for more variance in satisfaction with workload than with the learning environment. There is evidence that characteristics of a given residency program in a given institution have additional impact beyond these main effects. However, characteristics of institutions or programs, such as program selectivity, off-duty periods, or number of faculty, did not explain statistically significant amounts of variance in resident satisfaction ratings.This study is the first to quantify the degree to which institution and specialty contribute to differences in resident perceptions of their learning environment and workload. Although organizational and institutional cultures are presumed to influence the learning environment, estimating the size of these influences requires a multi-institutional and multispecialty dataset, such as this one. These results suggest that there is empirical justification for institutional interventions to improve the learning environment.

Background: The Wayne State University Graduate Medical Education (GME) Office and Ascension Crittenton Hospital developed an educational initiative to increase resident awareness of health disparities and local community health priorities. The Plan-Do-Study-Act (PDSA) rapid-cycle performance improvement framework was used for implementation and evaluation. Methods: During the first PDSA cycle, residents attended 5 didactic sessions. During the second PDSA cycle, residents participated in a problem-based learning (PBL) case. The following data were collected: evaluations of the didactic sessions and case, the number of appointments for diabetes self-management and education (DSME) referred by faculty and residents, and responses to questions on the annual GME surveys related to resident understanding of health disparities and the hospital’s community health needs assessment (CHNA). Results: Eighty-eight percent of residents defined health disparities at least partially correctly in both project years. The percentage of residents who knew how to access their hospital’s CHNA increased from 25% to 29% year over year. Residents rated PBL more effective in achieving learning objectives than didactics, but the difference was not statistically significant. Six appointments for DSME were referred by program faculty and residents in the 2-month period immediately before the didactic sessions, and 6 referrals were made in a 2-month period between the didactic sessions and the PBL case. In the 2-month period immediately following the PBL case, 9 appointments for DSME were referred by residents and program faculty. Conclusion: Residents have a good understanding of health disparities, although many may not recognize disparities that exist in their local community. PBL was more effective than didactics for resident education about local health disparities, CHNA, and DSME. Aligning GME and hospital leadership in a common vision for disparities education, as well as community engagement, is critical to successful outcomes.

Empathy is crucial for effective clinical care but appears to decline during undergraduate medical training. Understanding the nature of this decline is necessary for addressing it. The Jefferson Scale of Empathy (JSE) is used to measure medical students' clinical empathy attitudes. One recent study described a 3-factor model of the JSE. This model was found in responses from matriculating medical students, but little is known about how the factor structure of the scale changes during clinical training. The Learning Environment Study is a longitudinal prospective study of two cohorts from 28 medical schools. At matriculation and at the end of each subsequent year, students self-reported clinical empathy attitudes using the JSE. Data from 4,797 students were randomly partitioned for exploratory (EFA) and confirmatory factor analyses using responses from preclinical and clinical years of medical school. Five models were compared for confirmatory factor analysis: two null models for control, the recent 3-factor model, and the two models resulting from the EFAs of preclinical and clinical year responses. Preclinical year responses yielded a 3-factor model similar to the recent 3-factor model. Clinical year responses yielded a 4-factor model ("feelings," "importance," "ease," and "metacognitive effort") suggesting changes in the structure of clinical empathy attitudes over time. Metacognitive effort showed the largest decline over time. The model is a better fit for both preclinical and clinical responses and may provide more insight into medical students' clinical empathy attitudes than other models. The emergence of metacognitive effort in the clinical years suggests empathy may become more nuanced for students after clinical exposure and may account for much of the observed decline in clinical empathy attitudes.

Phenomenon: Medical students' coping abilities are important for academic success and emotional health. The authors explored differences in students' use of active, problem-solving strategies and emotional, inwardly directed approaches; the change in coping strategies used during medical school; and coping strategy impact on performance. Approach: One hundred eighty-three students completed the Ways of Coping Scale at matriculation and end of the 2nd and 3rd years. Frequency of each of 8 ways of coping, changes in coping strategy use over time, and relationship of coping method with preclinical and clinical scores were calculated. Findings: Students varied widely in use of coping mechanisms. Over time, students shifted to using emotional strategies more frequently while decreasing their use of active strategies. Coping strategies were unrelated to preclinical academic performance (R2 = .09, adjusted R2 = .04, ns) but were related to clinical performance (R2 = .23, adjusted R2 = .18, p < .0001), wi...

Background Although there is some consensus about the competencies needed to enter residency, the actual skills of graduating medical students may not meet expectations. In addition, little is known about the association between undergraduate medical education and clinical performance at entry into and during residency. Objective We explored the association between medical school of origin and clinical performance using a multi-station objective structured clinical examination for incoming residents at the University of Michigan Health System. Methods Prior to assuming clinical duties, all first-year residents at the University of Michigan Health System participate in the Postgraduate Orientation Assessment (POA). This assesses competencies needed during the first months of residency. Performance data for 1795 residents were collected between 2002 and 2012. We estimated POA variance by medical school using linear mixed models. Results Medical school predicted the following amounts of variance in performance—data gathering scores: 1.67% (95% confidence interval [CI] 0.36–2.93); assessment scores: 4.93% (95% CI 1.84–6.00); teamwork scores: 0.80% (95% CI 0.00–1.82); communication scores: 2.37% (95% CI 0.66–3.83); and overall POA scores: 4.19% (95% CI 1.59–5.35). Conclusions The results show that residents' medical school of origin is weakly associated with clinical competency, highlighting a potential source of variability in undergraduate medical education. The practical significance of these findings needs further evaluation.

Determine postgraduate first-year (PGY-1) trainees ability to perform patient care handoffs and associated medical school training.About 173 incoming PGY-1 trainees completed an OSCE handoff station and a survey eliciting their training and confidence in conducting handoffs. Independent t-tests compared OSCE performance of trainees who reported receiving handoff training to those who had not. Analysis of variance examined differences in performance based on prior handoff instruction and across levels of self-assessed abilities, with significance set at p0.05.About 35% of trainees reported receiving instruction and 51% reported receiving feedback about their handoff performance in medical school. Mean handoff performance score was 69.5%. Trainees who received instruction or feedback during medical school had higher total and component handoff performance scores (p0.05); they were also more confident in their handoff abilities (p0.001). Trainees with higher self-assessed skills and preparedness performed better on the OSCE (p0.05).This study provides evidence that incoming trainees are not well prepared to perform handoffs. However, those who received instruction during medical school perform better and are more confident on standardized performance assessments. Given communication failures lead to uncertainty in patient care and increases in medical errors, medical schools should incorporate handoff training as required instruction.

The management of hemorrhage shock requires support of central aortic pressure including perfusion to the brain and heart as well as measures to control bleeding. Emerging endovascular techniques including resuscitative endovascular balloon occlusion of the aorta serve as potential lifesaving adjuncts in this setting. The Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) course was developed to provide fundamental endovascular training for trauma surgeons.ESTARS 2-day course incorporated pretest/posttest examinations, precourse materials, lectures, endovascular and open vascular instruments, Vascular Intervention System Trainer endovascular simulator, and live animal laboratories for training and testing. Curriculum included endovascular techniques for trauma; review of wires, sheaths, and catheters; as well as regional vascular injury management. Animal laboratories integrated arterial access, angiography, coil embolization, resuscitative endovascular balloon occlusion of the aorta, control of iliac artery injury, and vascular shunt placement. Students completed a knowledge test (precourse/postcourse) and a summative skills assessment. The test measured knowledge and judgment in vascular injury management as defined in the course objectives. Vascular Intervention System Trainer and animal laboratory were used for final examinations. Subjective performance was graded by expert observers using a global assessment scale and performance metrics.Four pilot ESTARS courses were completed, with four participants each. Knowledge and performance significantly improved after ESTARS. Mean test examination scores increased by 77% to 85%, with a mean change of 9 percentage points [paired t (15) = 7.82, p0.0001]. The test was unidimensional (Cronbach's α = 0.67). Technical skill significantly improved for both endovascular simulation and live animal laboratory examinations. All participants passed the live animal laboratory practical examination.The ESTARS curriculum is effective at teaching a basic set of endovascular skills for resuscitation and hemorrhage control to trauma surgeons. ESTARS was confirmed as a stepwise and hierarchical curriculum demonstrating measurable improvements in performance metrics and should serve as a model for future competency-based structured training in endovascular trauma skills.

Psychological theories of human altruism suggest that helping results from an evolved tendency in caregiving mammals to respond to distress or need with empathy and sympathy. However, theories from biology, economics, and social psychology demonstrate that social animals also evolved to affiliate with and help desirable social partners. These models make different predictions about the affect of those we should prefer to help. Empathic models predict a preference to help sad, distressed targets in need, while social affiliative models predict a preference for happy, positive, successful targets. We compared these predictions in 3 field studies that measured the tendency to help sad, happy, and neutral confederates in a real-world, daily context: holding the door for a stranger in public. People consistently held the door more for happy over sad or neutral targets. To allow empathic motivations to compete more strongly against social affiliative ones, a 4th study examined a more consequential form of aid for hypothetical hospital patients in clear need. These conditions enhanced the preference to help a sad over a happy patient, because sadness made the patient appear sicker and in greater need. However, people still preferred the happy patient when the aid required a direct social interaction, attesting to the strength of social affiliation motives, even for sick patients. Theories of prosocial behavior should place greater emphasis on the role of social affiliation in motivating aid, particularly in everyday interpersonal contexts. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

To examine, using a systems framework, the relative influence of individual-level and institution-level factors on student perceptions of the medical school educational environment.A series of hierarchical linear models were fit to a large, 18-school longitudinal dataset of student perceptions of the educational environment, various demographics, and student empathy, tolerance of ambiguity, coping, and patient-provider orientation. Separate models were evaluated for individual-level factors alone, institution-level factors alone, and the combination of individual- and institution-level factors.The individual-level model accounted for 56.7% of the variance in student perceptions of the educational environment. However, few specific variables at the individual level had noteworthy direct effects on these perceptions. Similarly, the institution-level model accounted for 10.3% of the variance in student perceptions, but the specific characteristics of the institution explained little of this impact. The combined individual- and institution-level model attributed 45.5% of the variance in student perceptions to individual-level factors and 10.8% to institution-level factors. Again, specific variables explained little of this impact.These findings indicate that the impact of individual-level factors on perceptions of the educational environment is about four times greater than institution-level factors. This contrast reflects the fact that the educational environment is defined through a learner, not institutional lens. Nonetheless, institutions vary in learner perceptions of their environments, and these differences may provide some support for institutional initiatives to improve the educational environment. More broadly, these results evidence the complexity of the educational environment, both in defining it and in understanding its dynamics.

Background Medical students have difficulty performing and interpreting musculoskeletal physical examinations and interpreting the findings. Research has focused on students' knowledge deficits, but there are few direct assessments of students' ability to perform a hypothesis-driven physical examination (HDPE). We developed a novel musculoskeletal Objective Structured Clinical Exam (OSCE) focusing on HDPE skills for disorders of the shoulder, back and knee, and used it to explore medical student diagnostic reasoning. Methods A multidisciplinary group of musculoskeletal specialists developed and gathered validity evidence for a three station OSCE focusing on the HDPE of the shoulder, back and knee, emphasizing the ability to anticipate (identify pre-encounter) expected physical exam findings, and subsequently perform discriminatory physical examination maneuvers. The OSCE was administered to 45 final year medical students. Trained faculty observed and scored students’ ability to anticipate exam findings and perform diagnostic examination maneuvers on simulated patients. Encounters were digitally recorded and scored again by another trained faculty member. Inter-rater reliability for each maneuver was estimated using type-2 intra-class correlations (ICC). Percentages of perfect scores for anticipation and performance were calculated. Pearson’s correlation between anticipation and performance scores was computed for each maneuver and their relationship to diagnostic accuracy was tested with logistic regression. Results Inter-rater reliability was good (ICC between .69 and .87) for six exam maneuvers. Maneuver performance was overall poor, with no discriminatory maneuver performed correctly by more than two thirds of students, and one maneuver only performed correctly by 4 % of students. For the shoulder and knee stations, students were able to anticipate necessary discriminatory exam findings better than they could actually perform relevant exam maneuvers. The ability to anticipate a discriminatory finding correlated with the ability to perform the associated maneuver correctly, with the exception of the ability to perform maneuvers needed to diagnose a torn anterior cruciate ligament of the knee. Neither the ability to anticipate or perform was predictive of identifying correct diagnoses for the different cases. Conclusions A novel musculoskeletal OSCE, based on principles of the hypothesis-driven physical examination, was able to identify significant deficiencies in examination skills needed to diagnose common disorders of the shoulder, back and knee amongst graduating medical students. In addition, the OSCE demonstrated that accurate anticipation of discriminatory examination findings correlates with ability to perform the associated maneuver; however, the ability to anticipate exceeds the ability to perform. Students do not appear to be using the physical exam to inform their diagnostic reasoning. The findings of this study have implications for both assessment and teaching of the musculoskeletal exam. Electronic supplementary material The online version of this article (doi:10.1186/s12909-016-0780-4) contains supplementary material, which is available to authorized users.

Accreditation and professional organizations have recognized the importance of measuring medical students' perceptions of the learning environment, which influences well-being and professional competency development, to optimize professional development. This study was conducted to explore interactions between students' perceptions of the medical school learning environment, student demographic variables, and students' professional attributes of empathy, coping, tolerance of ambiguity, and patient-centeredness to provide ideas for improving the learning environment.Twenty-eight medical schools at 38 campuses recruited 4,664 entering medical students to participate in the two-cohort longitudinal study (2010-2014 or 2011-2015). The authors employed chi-square tests and analysis of variance to examine the relationship between Medical School Learning Environment Survey (MSLES) scores and student characteristics. The authors used mixed-effects models with random school and campus effects to test the overall variances accounted for in MSLES scores at the end of the first year of medical school.Student attributes and demographic characteristics differed significantly across schools but accounted for only 2.2% of the total variance in MSLES scores. Medical school campus explained 15.6% of the variance in MSLES scores.At year's end, students' perceptions toward the learning environment, as reported on the MSLES, differed significantly according to the medical school campus where they trained. Further studies are needed to identify specific factors, such as grading policies, administrative support, and existence of learning communities, which may influence perceptions of the learning environment at various schools. Identifying such variables would assist schools in developing a positive learning environment.

Purpose The purpose of this study is to examine the reliability and validity of the revised Diabetes Knowledge Test (DKT2). The original test was updated to reflect current diabetes care and education guidelines. The test has 2 components: a 14-item general test and a 9-item insulin use subscale. Methods Two samples were used to evaluate the DKT2. The first came from an online survey company (Qualtrics, LCC) (n = 101) and the second from University of Michigan’s (UofM) Diabetes Registry (n = 89). Cronbach’s coefficient alpha was used to calculate reliability. To examine validity, comparisons by type of diabetes, insulin use and oral medication use, and educational level were completed. Correlations between diabetes duration and both the general test and insulin subscale were calculated for the UofM sample. Results The two samples differed demographically. While the reliabilities between the samples were disparate, when combined, the coefficient alphas demonstrated reliability for both the general test (.77) and the insulin use subscale (.84). The validation comparisons proved to be similar; different results occurred between samples but when combined demonstrated validity. Conclusions The reliability and validity tests were inconsistent by sample. The different results can, in part, be attributed to the demographic differences between the 2 samples. With the exception of age, the samples differed in every other measured variable. However, when the samples were combined, the analyses supported the reliability and validity of the Diabetes Knowledge Test 2. The DKT2 is a quick and low-cost method of assessing general knowledge of diabetes and diabetes self-care.

Objective This study measures diabetes care perceptions of patients and their providers, and examines perceptions differences of patient–provider pairs. Methods Patient and provider perceptions were assessed using the Diabetes Semantic Differential Scales (DSDS) which ask respondents to rate diabetes care concepts using contrasting adjective pairs. The DSDS was scored by two methods: using means and using factor analysis. Persons with diabetes 40-years-old or older were recruited. Using a “snowball” sampling strategy, potential provider participants were identified by their patients; 71 providers agreed. These providers represented 51% of the patient participants and created 138 patient–provider pairs. Results For the mean scores, there were significant differences between patients and providers for 5 of the 18 semantic differentials (28%). Similarly, the factor scores indicated significant differences for 14 of 54 factors (26%). The effect sizes indicated practical differences. Conclusion Significant differences exist between patient and provider perceptions. Generally, patients have the more positive diabetes perceptions. Practice implications During patient and provider discussions, participants can perceive diabetes concepts differently. The DSDS can determine perception differences. While it is best to use factor analyses to score the DSDS, mean scores are more easily calculated and indicate the broad conceptual areas where patient and provider differ.

Neuroscientific research has consistently found that the perception of an affective state in another activates the observer's own neural substrates for the corresponding state, which is likely the neural mechanism for "true empathy." However, to date there has not been a brain-imaging investigation of so-called "cognitive empathy", whereby one "actively projects oneself into the shoes of another person," imagining someone's personal, emotional experience as if it were one's own. In order to investigate this process, we conducted a combined psychophysiology and PET and study in which participants imagined: (1) a personal experience of fear or anger from their own past; (2) an equivalent experience from another person as if it were happening to them; and (3) a nonemotional experience from their own past. When participants could relate to the scenario of the other, they produced patterns of psychophysiological and neuroimaging activation equivalent to those of personal emotional imagery, but when they could not relate to the other's story, differences emerged on all measures, e.g., decreased psychophysiological responses and recruitment of a region between the inferior temporal and fusiform gyri. The substrates of cognitive empathy overlap with those of personal feeling states to the extent that one can relate to the state and situation of the other.

Context Admissions interviews are unreliable and have poor predictive validity, yet are the sole measures of non-cognitive skills used by most medical school admissions departments. The low reliability may be due in part to variation in conditional reliability across the rating scale. Objectives To describe an empirically derived estimate of conditional reliability and use it to improve the predictive validity of interview ratings. Methods A set of medical school interview ratings was compared to a Monte Carlo simulated set to estimate conditional reliability controlling for range restriction, response scale bias and other artefacts. This estimate was used as a weighting function to improve the predictive validity of a second set of interview ratings for predicting non-cognitive measures (USMLE Step II residuals from Step I scores). Results Compared with the simulated set, both observed sets showed more reliability at low and high rating levels than at moderate levels. Raw interview scores did not predict USMLE Step II scores after controlling for Step I performance (additional r2 = 0.001, not significant). Weighting interview ratings by estimated conditional reliability improved predictive validity (additional r2 = 0.121, P

A majority of medical students feel uncomfortable with dying patients.We designed a pilot program to train medical students to be hospice volunteers to determine (1) the value of contact with dying patients in changing medical students' comfort level and (2) the mechanics of starting such a course in cooperation with a nonacademic agency.Students were required to undergo hospice training provided by the local hospice. Students were eligible for Hospice volunteer placement after the training was completed. This provided students with an opportunity to interact with dying patients in a nonclinical capacity. Quantitative data and qualitative data were collected about the students' experiences with patients as well as about the effectiveness of the rotation.First- through fourth-year medical students were recruited to participate in this semester long project via a medical school-wide e-mail.(1) A self-rating questionnaire on emotions and attitudes about death and dying at three points in time: before training, after training, and after placement; (2) A Likert-type questionnaire on barriers to participation and the usefulness of the components of an end-of-life course; (3) The "Attitudes About End-of-Life Scale"; (4) An in-depth structured interview with students after completion of the course.Fourteen students participated in the evaluation phase of the program and reported increased comfort in interacting with dying patients after participating in the program. Students had less anxiety and fear of being around a dying person after placement as compared to before training. In-depth student interviews provided valuable qualitative data on the impact of the pilot, and insight into the strengths and areas for improvement in this type of elective.A Hospice based elective can be an effective model for facilitating learning about how to approach the patient with a terminal illness.

Alexithymia is a multifaceted personality construct related to deficits in the recognition and verbalization of emotions. It is uncertain what causes alexithymia or which stage of emotion processing is first affected. The current study was designed to determine if trait alexithymia was associated with impaired early semantic decoding of facial emotion. Participants performed the Emostroop task, which varied the presentation time of faces depicting neutral, angry, or sad expressions before the classification of angry or sad adjectives. The Emostroop effect was replicated, represented by slowed responses when the classified word was incongruent with the background facial emotion. Individuals with high alexithymia were slower overall across all trials, particularly when classifying sad adjectives; however, they did not differ on the basic Emostroop effect. Our results suggest that alexithymia does not stem from lower-level problems detecting and categorizing others’ facial emotions. Moreover, their impairment does not appear to extend uniformly across negative emotions and is not specific to angry or threatening stimuli as previously reported, at least during early processing. Almost in contrast to the expected impairment, individuals with high alexithymia and lower verbal IQ scores had even more pronounced Emostroop effects, especially when the face was displayed longer.To better understand the nature of alexithymia, future research needs to further disentangle the precise phase of emotion processing and forms of affect most affected in this relatively common condition

Objectives Emergency medicine (EM) faculty often aim to improve resident performance by enhancing the quality and delivery of feedback. The acceptance and integration of external feedback is influenced by multiple factors. However, it is interpreted through the “lens” of the learner's own self-assessment. Ideally, following an educational activity with feedback, a learner should be able to generate and act upon specific learning goals to improve performance. Examining the source of generated learning goals, whether from one's self-assessment or from external feedback, might shed light on the factors that lead to improvement and guide educational initiatives. Using a standard oral board scenario, the objective of this study was to determine the effects that residents’ self-assessment and specific feedback from faculty have on not only the generation of learning goals but also the execution of these goals for performance improvement. Methods In this cross-sectional educational study at four academic programs, 72 senior EM residents participated in a standardized oral board scenario. Following the scenario, residents completed a self-assessment form. Next, examiners used a standardized checklist to provide both positive and negative feedback. Subsequently, residents were asked to generate “SMART” learning goals (specific, measurable, attainable, realistic, and time-bound). The investigators categorized the learning goals as stemming from the residents’ self-assessments, feedback, or both. Within 4 weeks, the residents were asked to recall their learning goals and describe any actions taken to achieve those goals. These were grouped into similar categories. Descriptive statistics were used to summarize the data. Results A total of 226 learning goals were initially generated (mean ± SD = 3.1 ± 1.3 per resident). Forty-seven percent of the learning goals were generated by the residents’ self-assessments only, while 27% were generated by the feedback given alone. Residents who performed poorly on the case incorporated feedback more often than high performers when generating learning goals. Follow-up data collection showed that 62 residents recalled 89 learning goals, of which 52 were acted upon. On follow-up, the numbers of learning goals from self-assessment and feedback were equal (25% each, 13 of 52), while the greatest number of reportedly executed learning goals came from self-assessments and feedback in agreement (40%). Conclusions Following feedback on an oral board scenario, residents generated the majority of their learning goals from their own self-assessments. Conversely, at the follow-up period, they recalled an increased number of learning goals stemming from feedback, while the largest proportion of learning goals acted upon stemmed from both feedback and self-assessments in agreement. This suggests that educators need to incorporate residents’ self-assessments into any delivered feedback to have the greatest influence on future learning goals and actions taken to improve performance. Resumen Objetivos El profesorado de Medicina de Urgencias y Emergencias (MUE) a menudo tiene el objetivo de mejorar el rendimiento del residente y mejorar la calidad y el aporte de retroalimentacion al residente. La aceptacion e integracion de la retroalimentacion externa estan influidas por multiples factores. Sin embargo, se interpreta a traves de “los ojos” de la propia autoevaluacion del alumno. Lo ideal seria que, tras una actividad formativa con retroalimentacion, un alumno fuera capaz de generar y actuar por objetivos de aprendizaje especificos (OAE) para mejorar el rendimiento. La observacion de la fuente de OAE generados, bien desde la autoevaluacion de uno mismo o la retroalimentacion externa, podria dar luz a los factores que permiten una via de mejora y guiar las iniciativas formativas. A traves del escenario de un examen oral clasico, el objetivo de este estudio fue determinar los efectos que la autoevaluacion de los residentes y la retroalimentacion especifica del profesorado tienen, no solo en la generacion de OAE, sino tambien en la ejecucion de estos objetivos en la mejora del rendimiento. Metodologia En este estudio docente transversal de cuatro programas universitarios participaron 72 residentes avanzados de MUE en el escenario de un examen oral clasico. Tras el examen, los residentes completaron un formulario de autoevaluacion. Despues, los examinadores utilizaron una lista de comprobacion estandarizada para proporcionar retroalimentacion positiva y negativa. Posteriormente, se pidio a los residentes generar OAE “SMART” [Specific (especifico), Measurable (cuantificable), Attainable (asequible), Realistic (realista), Time-bound (tiempo determinado)]. Los investigadores clasificaron los OAE como derivados de las autoevaluaciones de los residentes y/o la retroalimentacion. En las primeras cuatro semanas, se pidio a los residentes recordar sus OAE y describir cualquier accion llevada a cabo para conseguir aquellos objetivos. Estos se agruparon en categorias similares. Se utilizo la estadistica descriptiva para resumir los datos. Resultados Se genero un total de 226 OAE (media por residente 3,1; DE ±1,3). Un 47% de los OA se generaron solo por las autoevaluaciones de los residentes y un 27% solo por la retroalimentacion. Los residentes que rindieron pobremente en el caso, incorporaron la retroalimentacion mas a menudo que los que tuvieron un rendimiento alto cuando se generaron los OAE. Los datos del seguimiento mostraron que 62 residentes recordaron 89 OAE, de los cuales 52 se llevaron a cabo. En el seguimiento, el numero de OAE de la autoevaluacion y de la retroalimentacion fue el mismo (25% cada uno, 13 de 52), mientras que el mayor numero de OAE supuestamente llevados a cabo vino por igual de las autoevaluaciones y de la retroalimentacion (40%). Conclusiones Tras la retroalimentacion en un examen oral, los residentes generaron la mayoria de sus OAE desde sus propias autoevaluaciones. Al contrario, tras un periodo de seguimiento, recordaron un numero mayor de OAE derivados de la retroalimentacion, mientras que la mayor proporcion de OAE llevados a cabo derivan por igual tanto de la retroalimentacion como de la autoevaluacion. Esto sugiere que los docentes necesitan incorporar la autoevaluacion de los residentes en cualquier retroalimentacion proporcionada con el fin de tener la mayor influencia en los futuros OAE y las acciones llevadas a cabo para mejorar su rendimiento.

The Multiple Mini-Interview (MMI) uses multiple, short-structured contacts to evaluate communication and professionalism. It predicts medical school success better than the traditional interview and application. Its acceptability and utility in emergency medicine (EM) residency selection are unknown.We theorized that participants would judge the MMI equal to a traditional unstructured interview and it would provide new information for candidate assessment.Seventy-one interns from 3 programs in the first month of training completed an eight-station MMI focused on EM topics. Pre- and post-surveys assessed reactions. MMI scores were compared with application data.EM grades correlated with MMI performance (F[1, 66] = 4.18; p0.05) with honors students having higher scores. Higher third-year clerkship grades were associated with higher MMI performance, although this was not statistically significant. MMI performance did not correlate with match desirability and did not predict most other components of an application. There was a correlation between lower MMI scores and lower global ranking on the Standardized Letter of Recommendation. Participants preferred a traditional interview (mean difference = 1.36; p0.01). A mixed format (traditional interview and MMI) was preferred over a MMI alone (mean difference = 1.1; p0.01). MMI performance did not significantly correlate with preference for the MMI.Although the MMI alone was viewed less favorably than a traditional interview, participants were receptive to a mixed-methods interview. The MMI does correlate with performance on the EM clerkship and therefore can measure important abilities for EM success. Future work will determine whether MMI performance predicts residency performance.

Physiological resonance between individuals is considered fundamental to the biological capacity for empathy. Observers of pain and distress commonly exhibit increases in reported distress, autonomic arousal, facial mimicry, and overlapping neural activity. An important, unstudied question is whether physiological stress can also resonate. Physiological stress is operationalized as activation of the hypothalamic pituitary adrenocortical (HPA) and sympatho-adrenomedullary (SAM) axes. People often report an aversive state resulting from the stress of another, but this could be conveyed through resonating arousal or distress, without activating the physiological stress response. Physiological stress is particularly important to examine since it commonly occurs chronically, with known negative effects on health. Salivary cortisol and salivary alpha-amylase (sAA) were measured in both speakers and observers during a modified Trier Social Stress Test (TSST) to assess activation of the HPA and SAM axes (respectively). Cortisol (but not sAA) responses resonated between speakers and observers. The cortisol response of observers increased with trait empathy and was not related to the speaker's subjective fear or distress. This study provides a novel method for examining physiological resonance, and indicates that we can indeed catch another's physiological stress, suggesting a specific health risk for those in the social network of stressed individuals.

Background Physicians communicate with patients using electronic mail (e-mail) with increasing frequency. Communication skills specific to e-mail do not appear to be taught explicitly in medical school. Therefore, the effect of an instructive session on effective e-mail communication was examined. Method Four simulated e-mails from a parent were developed. Students responded to an initial e-mail and then participated in a session on effective e-mail communication. Responses to a final e-mail were assessed using a rubric with subscores for medical knowledge, communication, and professionalism. Results Performance improved from the first to final e-mail response in the overall score and in each subscore. Improvement was sustained over the course of the academic year. Interrater reliability revealed good agreement. Conclusions Communicating effectively with patients via e-mail is not intuitive but can be taught. It is feasible to introduce responses to a simulated e-mail case in a clinical clerkship as an assessment tool.

Previous studies have demonstrated that emotions are automatically processed. Even with subliminal presentations, subjects involuntarily mimic specific facial expressions, are influenced by the valence of a preceding emotion during judgments, and exhibit slowed responses to personally meaningful emotions; these effects are due to reflexive mimicry, unconscious carryover of valence, and attentional capture, respectively. However, perception-action effects indicate that rapid processing should involve deep, semantic-level representations of emotion (e.g., “fear”), even in the absence of a clinical emotion disorder. To test this hypothesis, we developed an emotional Stroop task (Emostroop) in which subjects responded nonverbally to emotion words superimposed over task-irrelevant images of faces displaying congruent or incongruent emotional expressions. Subjects reliably responded more slowly to incongruent than to congruent stimuli, and this interference was related to trait measures of emotionality. Rapid processing of facial emotions spontaneously activates semantic, content-rich representations at the level of the specific emotion.

Background Professionalism assessment has become necessary for all postgraduate training programs because it is now required for accreditation. To validate the novel items we generated to assess professionalism, we tested whether residents’ ratings of faculty they judged as outstanding in professionalism would be distinguishable from those they judged as not outstanding. Methods Educators from core clinical disciplines generated 20 items assessing professionalism behaviors on a 7-point frequency scale anchored by “always” and “never.” Thirty-five surgical and pediatric residents completed the form twice, anonymously rating 1 faculty member they judged as outstanding and another they judged as not outstanding. Results The residents produced 69 faculty ratings with means that differed significantly on all items between the outstanding and not-outstanding faculty. The form was highly unidimensional, with the primary factor’s eigenvalue being 11.5 and Cronbach’s alpha being 0.97. Groups differed most on items, ie, “listens well,” “inspires trust,” “answers questions directly,” and “demonstrates respect for all.” Conclusion The behaviors that best distinguished clinical faculty judged by residents as outstanding professionals were listening, trustworthiness, answering directly, and respect.

Objective The purpose of this study was to establish data for normative distributions for pudendal and perineal nerve compound muscle action potential data in healthy women across a wide age range and varied history of vaginal deliveries. Study design We studied 42 continent women, aged 20 to 67 years, including 29% nulliparous women with a disposable St. Mark's electrode to stimulate the pudendal nerve at the ischial spine by a transvaginal approach. The pudendal terminal motor latency and amplitude were detected with the use of surface patch electrodes overlying the external anal sphincter; the perineal responses were measured with the use of a surface ring electrode at the proximal urethra. Results None of the data were distributed normally and required the use of negative inverse and cube root transformations to create a normal distribution. Clinical correlations were found with advancing age and vaginal delivery. Conclusion The collection of these data allows for the definition of normal limits and begins the study of clinically important variables on test results and clinical outcomes.

Subspecialty fellowship program directors (PDs) are keenly interested in monitoring and enhancing their trainees’ academic progress throughout their fellowship experience. In addition to assessing trainee clinical acumen and knowledge base, PDs are required to demonstrate growth in clinical performance to validate advancement to subsequent training years, for which training programs have been confronted with increasing requirements by the Accreditation Council for Graduate Medical Education (ACGME). The ACGME has established core competency domains under which trainee progress can be objectively evaluated (medical knowledge, patient care, practice-based learning and improvement, systems-based practice, interpersonal and communication skills, and professionalism). These assessments potentially identify strengths and weaknesses at the individual level, prompting additional study and clinical exposures in these domains. Further, these evaluations facilitate the PDs’ identification of potential strengths and deficiencies in fellowship training at the institution, such that one can optimize the focus of future didactic lectures, faculty and program development, and potentially even strategic faculty recruitment. The standardized training examination addresses both educational development of the individual trainee, and resources in imparting training and education on the part of the training program. Therefore, the goal of such an examination needs to be formative, that is, to perform an assessment that will provide feedback to the trainee and PD which can be used to inform future teaching and learning opportunities. This is in contrast to American Board of Internal Medicine (ABIM) certification, which functions as a summative examination and is intended to evaluate clinical proficiency and competence for licensing purposes. Given the objective of the GTE, gastroenterology fellows are encouraged to not dedicate formal “study” in anticipation of taking the GTE.