May 2020

posted in: 2020 Journal Clubs | 0

Keeping Punxsutawney Phil away from our students
Mitigating “Educational Groundhog Day” – The Role of Learner Handoffs Within Clinical Rotations: A Survey of Pediatric Educational Leaders.

Fuchs J, King M, Devon EP, Guffey D, Keeley M, Rocha MEM. Academic Pediatrics. 2020;20(1):113-118.  doi:10.1016/j.acap.2019.08.011
Reviewed by: Chelsea Howie and Joanna Holland, Dalhousie University, Halifax NS



What were the study questions? What are the current procedures for learner handover (LH) within pediatric clerkships and subinternships? Are faculty interested in a LH bundle?
How was the study done? A cross-sectional survey was distributed electronically to 411 physician members of COMSEP representing 152 medical schools, and responses from schools with block clerkships and subinternships were used. The survey consisted of 8 multiple choice and one written question evaluating current protocols and practices for LH, as well as gauging interest in a LH bundle. Categorical and continuous responses were statistically analyzed, and an inductive approach was used to analyze written responses.
What were the results? Responses from 141 individuals were included. Most faculty spent 5 to7 days supervising students on an inpatient service (50% clerkship, 48% subinternship). Less than a quarter provide a LH to incoming faculty, despite 77% (clerkship) and 88% (subinternship) reporting finding the LHs they do receive to be moderately to extremely useful. Most faculty reported needing 1-3 days to assess the baseline competency of students (53% clerkship, 64% subinternship) and at least 5 more days to establish entrustment of professional skills without supervision (71% clerkship, 67% subinternship). Threequarters of faculty were moderately to extremely interested in using a LH bundle. Themes from narrative data included: (1) Instrument features including ease and time to complete, generalizability, format and content; (2) Stakeholder buy-in, including faculty, residents, student affairs and students; (3) Impact, including entrustment and possible negative implications such as biasing incoming faculty; and  (4) Utility, which described both endorsement and opposition of an LH bundle.
What are the implications? Introduction of a structured, practical LH framework may help to better communicate student competence during changes in supervising faculty, and thus accelerate entrustment decisions surrounding medical students. LHs may encourage specific, goal-directed feedback, and mitigate the “educational groundhog day” effect for students: repetitively experiencing the worry-provoking first day of a rotation with each change in supervising faculty.
Editor’s Note: This study highlights faculty perspectives of LH, including the opportunity to allow students to continually progress over the course of a rotation. Concerns regarding the potential negative bias of faculty towards learners is certainly the counterargument, and it would be interesting to study learners’ perspectives on the pros and cons of LH. Furthermore, this was a study based on the COMSEP Annual Survey, so I will put a plug in to please complete Annual Survey and help provide robust data for great projects that our members are doing! (KFo)

Residency application factors related to success in pediatric internship

Application factors associated with clinical performance during pediatric internship.

Gross C, O’Halloran C, Winn A, Lux S, Michelson C, Sectish T, Sox C. Academic Pediatrics 2020.

Reviewed by Julia Donner

What was the study question?  What specific aspects of the residency application are predictive of clinical performance during pediatric internship?

How was the study done?  A retrospective cohort study of pediatric residents at the Boston Combined Residency Program between 2013-2017 was conducted with the primary outcome being the average of overall ACGME Pediatric Milestones scores at the end of intern year. Application factors analyzed included letter of recommendation (LOR) strength, clerkship grades, medical school reputation, master’s or PhD degrees, gender, USMLE Step 1 score, Alpha Omega Alpha membership, private/public medical school, and interview score. These factors were controlled for by match year and milestone grading committee.

What were the results?  The application factors associated with higher overall Milestone scores at the conclusion of intern year were the strength of LOR, number of clerkship honors, medical school ranking, having a master’s degree, and not having a PhD. LOR scores were associated with high average scores in most Milestone domains followed by the number of clerkship honors. Factors not associated with Milestone scores were interview scores, AOA membership, medical school type, gender, USMLE score, and gap time between undergraduate and medical school. Overall, only 18% of the variance in Milestone scores was explained by the factors studied.

What are the implications of these findings?  When considering the admission of future pediatric residents, admission committees should focus on LOR and clerkship performance as metrics for a candidate’s success. Of note, standardized testing scores were not among the key factors predicting clinical success, which supports the recent NBME decision to make Step 1 pass/fail. Overall, more studies are needed to determine what aspects of a residency application best lend themselves to evaluation of competency as well as to discern what currently undefined factors lead to variance in Milestone scores.

Editor’s note: All of us are constantly in search of the Holy Grail when it comes to predicting which senior medical students will be the highest performing residents. We haven’t found it yet but several studies indicate that measures of actual elbow to elbow contact between learners and experienced clinicians, as reflected in clinical performance evaluations and letters of recommendation, come closest while multiple choice tests do not (RR).

Students on Ethics

Alignment of Ethics Curricula in Medical Education: A Student Perspective

Liu Y, Erath A, Salwi S, Sherry A, & Mitchell MB. Teaching and Learning in Medicine. Published online January 31, 2020. DOI: 10.1080/10401334.2020.1717959  Reviewed by Michele Haight

What was the study question? How can student perspectives promote student engagement and improve the alignment of content, teaching and assessment in UME ethics curricula?

How was the study done? The Vanderbilt University School of Medicine (VUSM) Medical Ethics, Law and Policy student group conducted an extensive literature review of international medical ethics education in undergraduate medical education and combined it with their experience as students to propose recommendations.

What were the results? The results indicated that there is consensus by all key stakeholders (faculty, leadership, students, etc.) that medical ethics education is important and “essential to sustainable professionalism in medicine.” The literature also revealed that, although medical students noted the value of the medical ethics curricula, they did not prioritize or engage with medical ethics content the same way they engaged with basic science or clinical content. In addition to identifying the “hidden curriculum” of formalized ethics coursework as a barrier to student engagement, the VUSM student group also posited that misalignment of ethics content, instructional design and assessment methods significantly contributed to the lack of student engagement with ethics curricula.

What are the implications of these findings? Recommendations from the VUSM student group include the following: 1.) Adoption of LCME minimal standards for UME ethics content to provide uniformity and consistency to UME ethics curricula. 2.) Practical applications of ethical principles to real cases rather than rote rules or abstract, philosophical content. 3.) Longitudinal ethics curricula rather than a single, finite session. 4.) Thoughtful consideration as to where the ethics content occurs in the curriculum in order to optimize its relevance, maximize its value, and promote student engagement. 5.) Proposed teaching modalities include: Interactive large group sessions, team-based learning, small group sessions and simulations. 6.) Assessment modalities need to capture the subjective nature of medical ethics. Proposed assessment modalities include: reflective essays, participation in small group discussions, simulation debriefs, and case presentations.

Editor’s Note: Not surprisingly, just about every one of these proposals applies not just to effective teaching of ethics, but effective teaching in general.  Just about every medical school topic would benefit from such a thoughtful and comprehensive review. (JG)