This article was downloaded by: [McMaster University] On: 13 February 2015, At: 09:22 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Journal Watch From ACE (Alliance for Clinical Education): Annual Review of Medical Education Articles in Internal Medicine Journals, 2012–2013 a
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Irene Alexandraki , Amber T. Pincavage , Susan Glod , Beth Liston , Carlos Palacio , Deborah f
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DeWaay , Shobhina G. Chheda , Nicholas J. Van Wagoner , Jeffrey S. LaRochelle , Alfred j
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P. Burger , Amy Shaheen , Leigh Simmons , Mark J. Fagan , Debra S. Leizman , Joseph T. o
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Wayne , Diane L. Levine , Karen Szauter & Katherine C. Chretien a
Click for updates
Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida, USA b
Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA c
Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
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Department of Internal Medicine, Ohio State University, Columbus, Ohio, USA
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Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA f
Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA g
Department of Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA h
Department of Internal Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA i
Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA j
Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA k
Department of Internal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA l
Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA m
Department of Medicine, Brown Medical School, Providence, Rhode Island, USA
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Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA
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Department of Internal Medicine, Albany Medical College, Albany, New York, New York, USA p
Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA q
Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, USA r
Department of Medicine, George Washington University School of Medicine, Washington, DC, USA Published online: 15 Oct 2014.
To cite this article: Irene Alexandraki, Amber T. Pincavage, Susan Glod, Beth Liston, Carlos Palacio, Deborah DeWaay, Shobhina G. Chheda, Nicholas J. Van Wagoner, Jeffrey S. LaRochelle, Alfred P. Burger, Amy Shaheen, Leigh Simmons, Mark J. Fagan, Debra S. Leizman, Joseph T. Wayne, Diane L. Levine, Karen Szauter & Katherine C. Chretien (2014) Journal Watch From ACE (Alliance for Clinical Education): Annual Review of Medical Education Articles in Internal Medicine Journals, 2012–2013, Teaching and Learning in Medicine: An International Journal, 26:4, 438-443, DOI: 10.1080/10401334.2014.911095 To link to this article: http://dx.doi.org/10.1080/10401334.2014.911095
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PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Teaching and Learning in Medicine, 26(4), 438–443 C 2014, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2014.911095
Journal Watch From ACE (Alliance for Clinical Education): Annual Review of Medical Education Articles in Internal Medicine Journals, 2012–2013 Irene Alexandraki Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida, USA
Amber T. Pincavage Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
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Susan Glod Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
Beth Liston Department of Internal Medicine, Ohio State University, Columbus, Ohio, USA
Carlos Palacio Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
Deborah DeWaay Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
Shobhina G. Chheda Department of Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
Nicholas J. Van Wagoner Department of Internal Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
Jeffrey S. LaRochelle Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
Alfred P. Burger Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA
Amy Shaheen Department of Internal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
Correspondence may be sent to Irene Alexandraki, University of Central Florida College of Medicine, 6850 Lake Nona Boulevard, Orlando, FL 32827, USA. E-mail: [email protected]
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Leigh Simmons Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
Mark J. Fagan Department of Medicine, Brown Medical School, Providence, Rhode Island, USA
Debra S. Leizman Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA
Joseph T. Wayne Department of Internal Medicine, Albany Medical College, Albany, New York, New York, USA
Diane L. Levine Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
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Karen Szauter Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
Katherine C. Chretien Department of Medicine, George Washington University School of Medicine, Washington, DC, USA
This annual review, sponsored by the Alliance for Clinical Education, presents brief summaries of selected medical education articles published in internal medicine journals typically not read by clinician-educators from other specialties. The purpose of this review is to highlight the most interesting, relevant, and high-quality internal medicine education research published in the past year, to facilitate dissemination of new knowledge, and to cultivate interdisciplinary communication and collaboration among medical educators from various disciplines. A literature search was conducted using PubMed and the Medical Subject Headings (MESH) “Education, Medical,” with subheadings “Education, Medical, Undergraduate,” “Education, Medical, Graduate,” and “Education, Medical, Continuing.” The search was limited to peer-reviewed, full-length, English language original research published in General Internal Medicine and Internal Medicine subspecialty journals, and in ethics, palliative care, and patient safety and quality journals between October 1, 2012, and September 30, 2013. Medical journals typically read across specialties, including Academic Medicine, Medical Education, Medical Teacher, Teaching and Learning in Medicine, Journal of the American Medical Association, New England Journal of Medicine, and Lancet, were excluded. Each retrieved article was critiqued and scored by 18 reviewers on relevance, rigor, importance, generalizability, and potential interest to other disciplines. Through an iterative process including multiple layers of review, the 10 highest rated articles that span the spectrum of medical education were selected.
PATIENT SAFETY AND QUALITY IMPROVEMENT 1. Shaw TJ, Pernar LI, Peyre SE, Helfrick JF, Vogelgesang KR, Graydon-Baker E, et al. Impact of online education on intern behavior around joint commission national patient safety goals: A randomized trial. BMJ Quality & Safety 2012;21(10):819–25. The need to educate medical trainees in patient safety is well recognized, but which educational strategies can effectively change physician behavior related to patient safety are not well known. The authors compared the effectiveness of two online learning methodologies for improving patient-safety behaviors mandated by the Joint Commission National Patient Safety Goals (NPSG). Incoming medicine and surgery/ob-gyn interns were randomized to receive either an online Spaced Education (SE) program consisting of 16 cases and questions that reinforced knowledge over time or an online slideshow with the same content followed by a quiz (SQ). The SE group received feedback after answering each question. Any question answered correctly twice in a row was “retired,” and when 80% of the questions had been retired, the course was considered complete. All participants completed an online exit survey about their confidence around NPSGs and acceptability of the interventions. A randomly selected subgroup of SE and SQ interns completed a central line simulation. Two reviewers scored the interns’ performance on 13 key procedural tasks tested in the simulation station. Both programs improved knowledge retention. Satisfaction and self-reported confidence in safety and quality were significantly higher for SE interns compared with SQ interns.
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SE was more engaging and contextually relevant than SQ. Overall, SE interns demonstrated a mean of 4.79 NPSG-compliant behaviors in the central line simulation scenario, whereas SQ interns demonstrated a mean of 4.17 (p = .09); the difference in the mean of NPSG-compliant behaviors between surgical SE and SQ interns was significant (5.67 and 2.33, respectively, p = .015). A limitation of the study was the lack of a control group in the simulation scenario. This well-designed study found that SE can be engaging and may positively impact intern behavior. Further research is needed to explore whether the behavior change detected in the simulation station translates into a change in clinical practice, and whether this impact is sustained overtime. 2. Taylor CG, Morris C, Rayman G. An interactive 1-h educational programme for junior doctors, increases their confidence and improves inpatient diabetes care. Diabetic Medicine: A Journal of the British Diabetic Association 2012;29(12):1574–8. Inpatient diabetes management has become increasingly complex, but many newly trained doctors may not be adequately prepared to safely manage patients admitted with diabetes. The investigators’ goal was to develop a brief educational intervention in inpatient diabetes care for junior physicians (within 4 years of training following graduation) with contextualized learning objectives readily applicable to clinical practice. A member of the diabetes team delivered a 1-hour case-based educational program to a total of 242 junior medical and surgical doctors across four centers in the United Kingdom, either during the training program’s orientation period or within another scheduled educational session of the training program. The case followed the hospital course of a hypothetical patient with complications of type II diabetes. Approximately 60% of the session was dedicated to understanding types of insulin, their titration, and avoiding prescription errors. The outcomes of the study included changes in self-reported confidence and objective measures of quality in the delivery of inpatient diabetes care during a 24-hour period before and 3 to 5 months after the intervention. A survey was used to assess physician confidence, and through chart audit, physician behavior data were obtained, including insulin infusion use, treatment of hypoglycemia, and prescription errors. Participants’ confidence improved significantly after the intervention in five content areas, including insulin dose adjustment and avoidance of insulin errors. Following the intervention, insulin prescription errors, including failure to prescribe insulin, prescription of the wrong preparation, illegible prescriptions, the use of “u” for units, and failure to sign the prescription decreased significantly (from 15.4% to 7.8%; p < .05). There were no other significant changes. A major limitation of the study was the lack of a control group; increased physician experience could have resulted in some or all of the improvements in quality of care. Nevertheless, the study demonstrated that a short case-based training intervention
can improve physician confidence and may increase the quality of inpatient diabetes care.
DUTY HOURS AND HANDOFFS 3. Sen S, Kranzler HR, Didwania AK, Schwartz AC, Amarnath S, Kolars JC, et al. Effects of the 2011 duty hour reforms on interns and their patients: A prospective longitudinal cohort study. JAMA Internal Medicine 2013;173(8):657–62. Although the most recent Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms were implemented in July 2011, the effects on intern wellness or medical errors have not been fully evaluated. The objective of this study was to assess the impact of the 2011 ACGME duty hour reforms on intern duty hours, sleep, depressive symptoms, and medical errors. Over 3 years (2009–2011), 2323 interns from multiple specialties were surveyed quarterly from 51 residency programs at 10 university-based and four community-based institutions regarding their duty hours, hours of sleep per day, depressive symptoms, and concern about making serious medical errors in the past 3 months. After the 2011 duty hour implementation, interns reported working fewer hours per week (67.0 vs. 64.3; p < .001). However, there was no significant change in the mean number of hours slept daily (6.8 vs. 7.0, p = .17), or symptoms of depression (mean Patient Health Questionnaire-9 scores 5.8 vs. 5.7, p = .55). In addition, more interns were concerned about making serious medical errors after the duty hour reforms (from 19.9% to 23.3%, p = .007). Limitations of this study included the cohort design, self-reported outcomes, low response rate (58%), lack of direct assessment of medical errors, and limited follow-up period (only 1 year after the duty hours were implemented). Overall, this was a large prospective longitudinal study demonstrating that the reduction of intern duty hours after the 2011 ACGME duty hour reforms was associated not with increased sleep or improved depressive symptoms but rather with increased concern about making medical errors. Further studies on the impact of the 2011 duty hour restrictions in subsequent years will be imperative to better understand their impact on trainee well-being and clinical performance. 4. Emlet LL, Al-Khafaji A, Kim YH, Venkataraman R, Rogers PL, Angus DC. Trial of shift scheduling with standardized sign-out to improve continuity of care in intensive care units. Critical Care Medicine 2012;40(12):3129–34. In attaining the goal of restricting work to 80 hours/week, residency and fellowship programs have been faced with the challenge of maintaining a traditional night float model or adopting a shift-based schedule. Emlet and colleagues compared a 12-hour shift-work schedule with a structured sign-out curriculum (with 1-hour overlap for sign-out) for intensive care unit (ICU) fellows (intervention) with traditional day coverage with every fourth night call (control). Both groups worked an average
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of 65 hours/week in a mixed 28-bed medical-surgical ICU. The sign-out curriculum included a 2-hour interactive workshop, after which the intervention group had access to a sign-out feature in the electronic health record. A continuity of care survey, developed using constructs of continuity of care, patient care, educational experience and work environment, and a schedule preference survey were administered to ICU attendings, nurses, and fellows. The validated Critical Care Family Needs Index was administered to families to gauge family satisfaction. Clinical outcomes including mortality, length of stay, and ICU readmission rate were measured. The intervention resulted in a significant decrease in length of stay (5.7 vs. 8.4 days, p = .04) without differences in ICU readmission within 48 hours or mortality. Fellows were split regarding their preference for intervention versus control schedules (37.5% vs. 43.8%; p = .78), whereas both nurses (73% vs. 7%, p = .00) and attendings (54% vs. 18.2%, p = .15) preferred the intervention schedule. There were no statistically significant differences in perceptions of continuity of care, lecture attendance, or family satisfaction. Limitations of this study included the single-center observational design, the low response rate from nurses (42% from control and 26% from intervention groups) and lack of formal validation of the surveys. Also, crossover effects might have played a role as approximately half of the fellows participated in both arms. Nevertheless, this study is one of the first using multiple measures in a 360◦ assessment to compare a shift schedule with sign-out curriculum with a traditional schedule, and it supports the use of a shift schedule as a viable strategy to address work-hour restrictions. 5. Garment AR, Lee WW, Harris C, Phillips-Caesar E. Development of a structured year-end sign-out program in an outpatient continuity practice. Journal of General Internal Medicine 2013;28(1):114–20. Transitions of care in the resident clinic are important but less studied than inpatient handoffs. The authors hypothesized that implementing a structured year-end sign-out program in the resident continuity clinic would increase patient care task completion by interns. Thirty-two resident-intern pairs were randomized to either the structured transfer (intervention) group or the standard transfer (control) group. The intervention group was asked to create a “Ten Tasks List” of outstanding patient care tasks and a “Sign-Out” of their high-priority patients and was encouraged to verbally sign out to the interns inheriting their panels. The interns in the control group reviewed the last office visit note in the electronic medical record at the time of the first patient visit. Each resident in the control group was also asked to create a “Ten Tasks List,” but it was not provided to their intern until after the end of the study. The rates of patient office visits during the academic year were similar for the two groups. Among patients seen during the first 3 months, clinical care tasks were more likely to be completed by interns in the intervention group. The odds of completing the clinical care task was increased if the intern was the assigned primary care
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physician. Only 36% of the high-priority patients were seen by any provider within the first 3 months. Sixty percent of intervention group residents verbally signed out to their intern with 50% of the sign-outs taking less than 1 hour. More than half of the participants agreed that sign-outs are important and standardized sign-outs are useful. Study limitations included the small sample size and unblinded design, and the use of clinical task completion as a surrogate for patient safety outcomes. The study showed that a structured outpatient sign-out process may improve follow-up of clinical care tasks after the year-end resident clinic transition. CLINICAL SKILLS TRAINING 6. Tolsgaard MG, Bjørck S, Rasmussen MB, Gustafsson A, Ringsted C. Improving efficiency of clinical skills training: A randomized trial. Journal of General Internal Medicine 2013;28(8):1072–7. Increasing medical school capacity and decreasing availability of educational resources call for more efficient clinical skills training. Tolsgaard and colleagues evaluated the effect of dyad training, which is training in pairs, on students’ clinical skills and their confidence in managing patient encounters. Forty-nine preclerkship medical students (259 invited) were randomized to either dyad practice (n = 24) or single practice (n = 25). None of the participants had any prior clinical experience. All students received a standard 4-hour course on history taking and practicing physical examination skills in a skills lab. The following day, the students practiced on four different standardized patients either alone or in pairs: taking a history, performing a physical exam, and writing an encounter note. The dyad groups alternated between managing the encounter and observing their partner, then discussed the case together but wrote independent postencounter notes. After 2 weeks and with no clinical experiences between sessions, all students were assessed individually on a performance test that mimicked their previous practice sessions. Encounters were videotaped and rated by two blinded physicians using a previously validated scoring form. The dyad groups scored significantly higher on the performance test compared to the single groups (40.7 vs. 36.9, p = .04). Students in the dyad groups rated their confidence with managing the patient encounter higher than the control groups (p < .001). Study limitations included the small number of participants (19% of the class) and that the impact of dyad training was assessed only 2 weeks after the intervention. The authors concluded that dyad training was more effective than single practice at preparing preclerkship students to manage patient encounters. Dyad training may be a valuable and efficient tool in teaching clinical skills to medical students. Further research is needed to explore its effects over time, as well as during the clinical years. ATTENDING ROUNDS 7. Stickrath C, Noble M, Prochazka A, Anderson M, Griffiths M, Manheim J, et al. Attending rounds in the current
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era: What is and is not happening. JAMA Internal Medicine 2013;173(12):1084–9. Attending rounds may set the foundation for patient care and education in teaching hospitals, but the characteristics of rounds in the current era are not well known. This cross-sectional observational study sought to describe the characteristics of general medicine attending rounds pertinent to patient care, communication, and education. The study was conducted at four teaching hospitals affiliated with one medical school from July 2010 through March 2012. The admitting cycle and patient population varied among the four hospitals. Trained 4thyear medical students observed and recorded activities during rounds of 90 medicine ward teams. The observations included 56 attending physicians, 279 trainees (20.5% residents, 47.4% interns, and 31.5% medical students), and 807 patients. The activities most often observed included discussion of the patient care plan (96.7%) and medication list (68.8%), review of diagnostic studies (90.7%), and communication with the patient (73.4%). In contrast, communication with nursing staff (12%), teaching physical exam skills (14.6%), and learner-identified topics (3.2%) occurred infrequently during rounds. Most activities were more often performed away from the bedside such as the discussion of the patient care plan (59.5%), diagnostic studies (58.9%), and patient medication list (58.7%). Only 66% of all team members were present at the beginning of every patient presentation. The “typical” day consisted of rounds on a mean of nine patients for 2 hours. Discussion about deep venous thrombosis prophylaxis, interprofessional communication, and feedback occurred more often when the attending had participated in a faculty development program. Although this was a study associated with a single medical school, the inclusion of four teaching hospitals makes the findings more generalizable. The study showed that many activities important for patient care and education occur infrequently during rounds. Further research is needed to assess the implications of these observations. 8. Gonzalo JD, Heist BS, Duffy BL, Dyrbye L, Fagan MJ, Ferenchick G, et al. The art of bedside rounds: A multi-center qualitative study of strategies used by experienced bedside teachers. Journal of General Internal Medicine 2013;28(3): 412–20. Bedside rounds have been a cornerstone of clinical education and considered essential for trainees to achieve clinical competence. Concerns have been raised about the diminishing quantity and quality of bedside teaching given the duty hour mandates and current pressures of inpatient medicine. This study sought to identify and understand the strategies used by experienced clinician-educators for preparation, patient selection and role allocation during bedside rounds. The authors conducted a qualitative inductive thematic analysis using transcripts from audio-recorded, semistructured telephone interviews with clinician-educators. Thirty-four internal medicine physicians
from 10 academic institutions were identified through purposive sampling and interviewed. Each participant had served as an inpatient attending for a minimum of 2 weeks in the prior 2 years and performed bedside rounds at least 3 days a week. Most respondents were associate or full professors (51%) with an average of 14 years of academic experience (range: 1–42); the majority had not received any formal training in bedside teaching (74%). On average, the participants conducted bedside rounds with their ward team on 62% of patients. Patients were selected if they were new to the service, required immediate care, or had high educational value. To prepare trainees for bedside rounds, attending physicians sought trainee “buy-in,” defined roles and expectations, established a climate that fosters patient comfort and communication, and tailored bedside activities to learner level. The role of each team member varied; trainees with increased experience were given more autonomy. The fact that each participant had a different bedside rounding style did not allow the authors to identify a “unified model” for bedside rounds. Limitations of the study were the lack of independent verification of the participants’ expertise, and the inclusion of mostly experienced attending physicians from large academic centers. Overall, this study provided an outline of strategies used by experienced clinician-educators that can be used for faculty development and that can guide clinician-educators on how to teach at the bedside.
PROFESSIONALISM 9. Stratton TD, Conigliaro RL. Does gender moderate medical students’ assessments of unprofessional behavior? Journal of General Internal Medicine 2012;27(12):1643–8. Medical professionalism is a widely accepted core clinical competency central to the practice of medicine. However, the role of contextual factors, such as gender, in assessing unprofessional behaviors is poorly understood. In this study, the authors examined whether the assessment of potentially unprofessional behaviors during undergraduate medical training differs between male and female medical students, and whether it varies depending on the gender of the individual whose behavior is assessed. The authors created 18 written scenarios to portray a range of unprofessional behaviors (e.g., from being unprepared on rounds to cheating on exams). Each scenario had two parallel versions to include male and female trainees. Thirdyear medical students were asked to rate depicted behaviors in the randomly ordered 18 scenarios (7 featuring male trainees, 7 female, 4 gender-neutral) using a 4-point Likert-type scale. The responses provided by 91 students (39 female, 52 male) were included in the analysis. There was no difference in the mean ratings of the vignettes based on gender of the medical student assessor or the gender of the “actor” in the scenario. On average, women rated the behaviors as more severe than men in the majority of the gender-specific scenarios, but these differences were not significant (F(1, 87) = 0.33, p = .57, η2 = 0.01). The study
REVIEW OF MEDICAL EDUCATION ARTICLES IN INTERNAL MEDICINE
was limited by the fact that it only measured behaviors, whereas professionalism is multidimensional, encompassing more than a list of characteristics or behaviors. Moreover, it is unclear how closely these written vignettes emulated real, observed behaviors. This study suggests that gender may not moderate medical students’ assessments of unprofessional behaviors. Future studies should explore further the contextual nature of defining and assessing professionalism.
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PHYSICIAN BURNOUT 10. West CP, Dyrbye LN, Satele DV, Sloan JA, Shanafelt TD. Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment. Journal of General Internal Medicine 2012;27(11):1445–52. Burnout is an increasingly common problem in medical students, residents, and physicians. The Maslach Burnout Inventory (MBI) represents the gold standard for measuring burnout; however, it contains 22 items and is therefore challenging to administer. This study extends previous evidence in support of a brief burnout assessment tool. Using adapted representative questions “I feel burned out from my work” for emotional exhaustion, and “I have become more callous toward people since
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I took this job” for depersonalization, the authors retrospectively analyzed data from five previously published studies conducted between 2003 and 2009, correlating MBI scores with physician well-being and patient care outcomes. Three of these studies were multi-institutional including a total of 5,646 medical students, one was a single institution study including 321 internal medicine residents, and one consisted of data from 7905 members of the American College of Surgeons. The authors systematically reanalyzed the data to determine the concurrent validity of these single-item questions relative to the full MBI for evaluating associations between domains of burnout (emotional exhaustion and/or depersonalization) and outcomes such as suicidality, medical student drop-out, unprofessional behaviors, and perceived medical errors. All domains demonstrated concurrent validity between the single-item scores and the MBI scores and exhibited strong predictive associations with the measured outcomes. Although this work is limited by the quality of the original studies and included a relatively smaller sample of residents, this study uniquely evaluated the association of these two questions relative to the MBI and looked at key outcomes rather than the domains of emotional exhaustion and depersonalization. The authors concluded that although the MBI remains the gold standard, these single-item measures appear to be useful substitutes in burnout assessment.
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Journal Watch From ACE (Alliance for Clinical Education): Annual Review of Medical Education Articles in Internal Medicine Journals, 2012–2013 a
b
c
d
e
Irene Alexandraki , Amber T. Pincavage , Susan Glod , Beth Liston , Carlos Palacio , Deborah f
g
h
i
DeWaay , Shobhina G. Chheda , Nicholas J. Van Wagoner , Jeffrey S. LaRochelle , Alfred j
k
l
p
q
m
n
P. Burger , Amy Shaheen , Leigh Simmons , Mark J. Fagan , Debra S. Leizman , Joseph T. o
r
Wayne , Diane L. Levine , Karen Szauter & Katherine C. Chretien a
Click for updates
Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida, USA b
Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA c
Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
d
Department of Internal Medicine, Ohio State University, Columbus, Ohio, USA
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Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA f
Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA g
Department of Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA h
Department of Internal Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA i
Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA j
Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA k
Department of Internal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA l
Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA m
Department of Medicine, Brown Medical School, Providence, Rhode Island, USA
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Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA
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Department of Internal Medicine, Albany Medical College, Albany, New York, New York, USA p
Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA q
Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, USA r
Department of Medicine, George Washington University School of Medicine, Washington, DC, USA Published online: 15 Oct 2014.
To cite this article: Irene Alexandraki, Amber T. Pincavage, Susan Glod, Beth Liston, Carlos Palacio, Deborah DeWaay, Shobhina G. Chheda, Nicholas J. Van Wagoner, Jeffrey S. LaRochelle, Alfred P. Burger, Amy Shaheen, Leigh Simmons, Mark J. Fagan, Debra S. Leizman, Joseph T. Wayne, Diane L. Levine, Karen Szauter & Katherine C. Chretien (2014) Journal Watch From ACE (Alliance for Clinical Education): Annual Review of Medical Education Articles in Internal Medicine Journals, 2012–2013, Teaching and Learning in Medicine: An International Journal, 26:4, 438-443, DOI: 10.1080/10401334.2014.911095 To link to this article: http://dx.doi.org/10.1080/10401334.2014.911095
Downloaded by [McMaster University] at 09:22 13 February 2015
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Teaching and Learning in Medicine, 26(4), 438–443 C 2014, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2014.911095
Journal Watch From ACE (Alliance for Clinical Education): Annual Review of Medical Education Articles in Internal Medicine Journals, 2012–2013 Irene Alexandraki Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida, USA
Amber T. Pincavage Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
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Susan Glod Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
Beth Liston Department of Internal Medicine, Ohio State University, Columbus, Ohio, USA
Carlos Palacio Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
Deborah DeWaay Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
Shobhina G. Chheda Department of Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
Nicholas J. Van Wagoner Department of Internal Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
Jeffrey S. LaRochelle Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
Alfred P. Burger Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA
Amy Shaheen Department of Internal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
Correspondence may be sent to Irene Alexandraki, University of Central Florida College of Medicine, 6850 Lake Nona Boulevard, Orlando, FL 32827, USA. E-mail: [email protected]
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Leigh Simmons Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
Mark J. Fagan Department of Medicine, Brown Medical School, Providence, Rhode Island, USA
Debra S. Leizman Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA
Joseph T. Wayne Department of Internal Medicine, Albany Medical College, Albany, New York, New York, USA
Diane L. Levine Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
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Karen Szauter Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
Katherine C. Chretien Department of Medicine, George Washington University School of Medicine, Washington, DC, USA
This annual review, sponsored by the Alliance for Clinical Education, presents brief summaries of selected medical education articles published in internal medicine journals typically not read by clinician-educators from other specialties. The purpose of this review is to highlight the most interesting, relevant, and high-quality internal medicine education research published in the past year, to facilitate dissemination of new knowledge, and to cultivate interdisciplinary communication and collaboration among medical educators from various disciplines. A literature search was conducted using PubMed and the Medical Subject Headings (MESH) “Education, Medical,” with subheadings “Education, Medical, Undergraduate,” “Education, Medical, Graduate,” and “Education, Medical, Continuing.” The search was limited to peer-reviewed, full-length, English language original research published in General Internal Medicine and Internal Medicine subspecialty journals, and in ethics, palliative care, and patient safety and quality journals between October 1, 2012, and September 30, 2013. Medical journals typically read across specialties, including Academic Medicine, Medical Education, Medical Teacher, Teaching and Learning in Medicine, Journal of the American Medical Association, New England Journal of Medicine, and Lancet, were excluded. Each retrieved article was critiqued and scored by 18 reviewers on relevance, rigor, importance, generalizability, and potential interest to other disciplines. Through an iterative process including multiple layers of review, the 10 highest rated articles that span the spectrum of medical education were selected.
PATIENT SAFETY AND QUALITY IMPROVEMENT 1. Shaw TJ, Pernar LI, Peyre SE, Helfrick JF, Vogelgesang KR, Graydon-Baker E, et al. Impact of online education on intern behavior around joint commission national patient safety goals: A randomized trial. BMJ Quality & Safety 2012;21(10):819–25. The need to educate medical trainees in patient safety is well recognized, but which educational strategies can effectively change physician behavior related to patient safety are not well known. The authors compared the effectiveness of two online learning methodologies for improving patient-safety behaviors mandated by the Joint Commission National Patient Safety Goals (NPSG). Incoming medicine and surgery/ob-gyn interns were randomized to receive either an online Spaced Education (SE) program consisting of 16 cases and questions that reinforced knowledge over time or an online slideshow with the same content followed by a quiz (SQ). The SE group received feedback after answering each question. Any question answered correctly twice in a row was “retired,” and when 80% of the questions had been retired, the course was considered complete. All participants completed an online exit survey about their confidence around NPSGs and acceptability of the interventions. A randomly selected subgroup of SE and SQ interns completed a central line simulation. Two reviewers scored the interns’ performance on 13 key procedural tasks tested in the simulation station. Both programs improved knowledge retention. Satisfaction and self-reported confidence in safety and quality were significantly higher for SE interns compared with SQ interns.
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SE was more engaging and contextually relevant than SQ. Overall, SE interns demonstrated a mean of 4.79 NPSG-compliant behaviors in the central line simulation scenario, whereas SQ interns demonstrated a mean of 4.17 (p = .09); the difference in the mean of NPSG-compliant behaviors between surgical SE and SQ interns was significant (5.67 and 2.33, respectively, p = .015). A limitation of the study was the lack of a control group in the simulation scenario. This well-designed study found that SE can be engaging and may positively impact intern behavior. Further research is needed to explore whether the behavior change detected in the simulation station translates into a change in clinical practice, and whether this impact is sustained overtime. 2. Taylor CG, Morris C, Rayman G. An interactive 1-h educational programme for junior doctors, increases their confidence and improves inpatient diabetes care. Diabetic Medicine: A Journal of the British Diabetic Association 2012;29(12):1574–8. Inpatient diabetes management has become increasingly complex, but many newly trained doctors may not be adequately prepared to safely manage patients admitted with diabetes. The investigators’ goal was to develop a brief educational intervention in inpatient diabetes care for junior physicians (within 4 years of training following graduation) with contextualized learning objectives readily applicable to clinical practice. A member of the diabetes team delivered a 1-hour case-based educational program to a total of 242 junior medical and surgical doctors across four centers in the United Kingdom, either during the training program’s orientation period or within another scheduled educational session of the training program. The case followed the hospital course of a hypothetical patient with complications of type II diabetes. Approximately 60% of the session was dedicated to understanding types of insulin, their titration, and avoiding prescription errors. The outcomes of the study included changes in self-reported confidence and objective measures of quality in the delivery of inpatient diabetes care during a 24-hour period before and 3 to 5 months after the intervention. A survey was used to assess physician confidence, and through chart audit, physician behavior data were obtained, including insulin infusion use, treatment of hypoglycemia, and prescription errors. Participants’ confidence improved significantly after the intervention in five content areas, including insulin dose adjustment and avoidance of insulin errors. Following the intervention, insulin prescription errors, including failure to prescribe insulin, prescription of the wrong preparation, illegible prescriptions, the use of “u” for units, and failure to sign the prescription decreased significantly (from 15.4% to 7.8%; p < .05). There were no other significant changes. A major limitation of the study was the lack of a control group; increased physician experience could have resulted in some or all of the improvements in quality of care. Nevertheless, the study demonstrated that a short case-based training intervention
can improve physician confidence and may increase the quality of inpatient diabetes care.
DUTY HOURS AND HANDOFFS 3. Sen S, Kranzler HR, Didwania AK, Schwartz AC, Amarnath S, Kolars JC, et al. Effects of the 2011 duty hour reforms on interns and their patients: A prospective longitudinal cohort study. JAMA Internal Medicine 2013;173(8):657–62. Although the most recent Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms were implemented in July 2011, the effects on intern wellness or medical errors have not been fully evaluated. The objective of this study was to assess the impact of the 2011 ACGME duty hour reforms on intern duty hours, sleep, depressive symptoms, and medical errors. Over 3 years (2009–2011), 2323 interns from multiple specialties were surveyed quarterly from 51 residency programs at 10 university-based and four community-based institutions regarding their duty hours, hours of sleep per day, depressive symptoms, and concern about making serious medical errors in the past 3 months. After the 2011 duty hour implementation, interns reported working fewer hours per week (67.0 vs. 64.3; p < .001). However, there was no significant change in the mean number of hours slept daily (6.8 vs. 7.0, p = .17), or symptoms of depression (mean Patient Health Questionnaire-9 scores 5.8 vs. 5.7, p = .55). In addition, more interns were concerned about making serious medical errors after the duty hour reforms (from 19.9% to 23.3%, p = .007). Limitations of this study included the cohort design, self-reported outcomes, low response rate (58%), lack of direct assessment of medical errors, and limited follow-up period (only 1 year after the duty hours were implemented). Overall, this was a large prospective longitudinal study demonstrating that the reduction of intern duty hours after the 2011 ACGME duty hour reforms was associated not with increased sleep or improved depressive symptoms but rather with increased concern about making medical errors. Further studies on the impact of the 2011 duty hour restrictions in subsequent years will be imperative to better understand their impact on trainee well-being and clinical performance. 4. Emlet LL, Al-Khafaji A, Kim YH, Venkataraman R, Rogers PL, Angus DC. Trial of shift scheduling with standardized sign-out to improve continuity of care in intensive care units. Critical Care Medicine 2012;40(12):3129–34. In attaining the goal of restricting work to 80 hours/week, residency and fellowship programs have been faced with the challenge of maintaining a traditional night float model or adopting a shift-based schedule. Emlet and colleagues compared a 12-hour shift-work schedule with a structured sign-out curriculum (with 1-hour overlap for sign-out) for intensive care unit (ICU) fellows (intervention) with traditional day coverage with every fourth night call (control). Both groups worked an average
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of 65 hours/week in a mixed 28-bed medical-surgical ICU. The sign-out curriculum included a 2-hour interactive workshop, after which the intervention group had access to a sign-out feature in the electronic health record. A continuity of care survey, developed using constructs of continuity of care, patient care, educational experience and work environment, and a schedule preference survey were administered to ICU attendings, nurses, and fellows. The validated Critical Care Family Needs Index was administered to families to gauge family satisfaction. Clinical outcomes including mortality, length of stay, and ICU readmission rate were measured. The intervention resulted in a significant decrease in length of stay (5.7 vs. 8.4 days, p = .04) without differences in ICU readmission within 48 hours or mortality. Fellows were split regarding their preference for intervention versus control schedules (37.5% vs. 43.8%; p = .78), whereas both nurses (73% vs. 7%, p = .00) and attendings (54% vs. 18.2%, p = .15) preferred the intervention schedule. There were no statistically significant differences in perceptions of continuity of care, lecture attendance, or family satisfaction. Limitations of this study included the single-center observational design, the low response rate from nurses (42% from control and 26% from intervention groups) and lack of formal validation of the surveys. Also, crossover effects might have played a role as approximately half of the fellows participated in both arms. Nevertheless, this study is one of the first using multiple measures in a 360◦ assessment to compare a shift schedule with sign-out curriculum with a traditional schedule, and it supports the use of a shift schedule as a viable strategy to address work-hour restrictions. 5. Garment AR, Lee WW, Harris C, Phillips-Caesar E. Development of a structured year-end sign-out program in an outpatient continuity practice. Journal of General Internal Medicine 2013;28(1):114–20. Transitions of care in the resident clinic are important but less studied than inpatient handoffs. The authors hypothesized that implementing a structured year-end sign-out program in the resident continuity clinic would increase patient care task completion by interns. Thirty-two resident-intern pairs were randomized to either the structured transfer (intervention) group or the standard transfer (control) group. The intervention group was asked to create a “Ten Tasks List” of outstanding patient care tasks and a “Sign-Out” of their high-priority patients and was encouraged to verbally sign out to the interns inheriting their panels. The interns in the control group reviewed the last office visit note in the electronic medical record at the time of the first patient visit. Each resident in the control group was also asked to create a “Ten Tasks List,” but it was not provided to their intern until after the end of the study. The rates of patient office visits during the academic year were similar for the two groups. Among patients seen during the first 3 months, clinical care tasks were more likely to be completed by interns in the intervention group. The odds of completing the clinical care task was increased if the intern was the assigned primary care
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physician. Only 36% of the high-priority patients were seen by any provider within the first 3 months. Sixty percent of intervention group residents verbally signed out to their intern with 50% of the sign-outs taking less than 1 hour. More than half of the participants agreed that sign-outs are important and standardized sign-outs are useful. Study limitations included the small sample size and unblinded design, and the use of clinical task completion as a surrogate for patient safety outcomes. The study showed that a structured outpatient sign-out process may improve follow-up of clinical care tasks after the year-end resident clinic transition. CLINICAL SKILLS TRAINING 6. Tolsgaard MG, Bjørck S, Rasmussen MB, Gustafsson A, Ringsted C. Improving efficiency of clinical skills training: A randomized trial. Journal of General Internal Medicine 2013;28(8):1072–7. Increasing medical school capacity and decreasing availability of educational resources call for more efficient clinical skills training. Tolsgaard and colleagues evaluated the effect of dyad training, which is training in pairs, on students’ clinical skills and their confidence in managing patient encounters. Forty-nine preclerkship medical students (259 invited) were randomized to either dyad practice (n = 24) or single practice (n = 25). None of the participants had any prior clinical experience. All students received a standard 4-hour course on history taking and practicing physical examination skills in a skills lab. The following day, the students practiced on four different standardized patients either alone or in pairs: taking a history, performing a physical exam, and writing an encounter note. The dyad groups alternated between managing the encounter and observing their partner, then discussed the case together but wrote independent postencounter notes. After 2 weeks and with no clinical experiences between sessions, all students were assessed individually on a performance test that mimicked their previous practice sessions. Encounters were videotaped and rated by two blinded physicians using a previously validated scoring form. The dyad groups scored significantly higher on the performance test compared to the single groups (40.7 vs. 36.9, p = .04). Students in the dyad groups rated their confidence with managing the patient encounter higher than the control groups (p < .001). Study limitations included the small number of participants (19% of the class) and that the impact of dyad training was assessed only 2 weeks after the intervention. The authors concluded that dyad training was more effective than single practice at preparing preclerkship students to manage patient encounters. Dyad training may be a valuable and efficient tool in teaching clinical skills to medical students. Further research is needed to explore its effects over time, as well as during the clinical years. ATTENDING ROUNDS 7. Stickrath C, Noble M, Prochazka A, Anderson M, Griffiths M, Manheim J, et al. Attending rounds in the current
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era: What is and is not happening. JAMA Internal Medicine 2013;173(12):1084–9. Attending rounds may set the foundation for patient care and education in teaching hospitals, but the characteristics of rounds in the current era are not well known. This cross-sectional observational study sought to describe the characteristics of general medicine attending rounds pertinent to patient care, communication, and education. The study was conducted at four teaching hospitals affiliated with one medical school from July 2010 through March 2012. The admitting cycle and patient population varied among the four hospitals. Trained 4thyear medical students observed and recorded activities during rounds of 90 medicine ward teams. The observations included 56 attending physicians, 279 trainees (20.5% residents, 47.4% interns, and 31.5% medical students), and 807 patients. The activities most often observed included discussion of the patient care plan (96.7%) and medication list (68.8%), review of diagnostic studies (90.7%), and communication with the patient (73.4%). In contrast, communication with nursing staff (12%), teaching physical exam skills (14.6%), and learner-identified topics (3.2%) occurred infrequently during rounds. Most activities were more often performed away from the bedside such as the discussion of the patient care plan (59.5%), diagnostic studies (58.9%), and patient medication list (58.7%). Only 66% of all team members were present at the beginning of every patient presentation. The “typical” day consisted of rounds on a mean of nine patients for 2 hours. Discussion about deep venous thrombosis prophylaxis, interprofessional communication, and feedback occurred more often when the attending had participated in a faculty development program. Although this was a study associated with a single medical school, the inclusion of four teaching hospitals makes the findings more generalizable. The study showed that many activities important for patient care and education occur infrequently during rounds. Further research is needed to assess the implications of these observations. 8. Gonzalo JD, Heist BS, Duffy BL, Dyrbye L, Fagan MJ, Ferenchick G, et al. The art of bedside rounds: A multi-center qualitative study of strategies used by experienced bedside teachers. Journal of General Internal Medicine 2013;28(3): 412–20. Bedside rounds have been a cornerstone of clinical education and considered essential for trainees to achieve clinical competence. Concerns have been raised about the diminishing quantity and quality of bedside teaching given the duty hour mandates and current pressures of inpatient medicine. This study sought to identify and understand the strategies used by experienced clinician-educators for preparation, patient selection and role allocation during bedside rounds. The authors conducted a qualitative inductive thematic analysis using transcripts from audio-recorded, semistructured telephone interviews with clinician-educators. Thirty-four internal medicine physicians
from 10 academic institutions were identified through purposive sampling and interviewed. Each participant had served as an inpatient attending for a minimum of 2 weeks in the prior 2 years and performed bedside rounds at least 3 days a week. Most respondents were associate or full professors (51%) with an average of 14 years of academic experience (range: 1–42); the majority had not received any formal training in bedside teaching (74%). On average, the participants conducted bedside rounds with their ward team on 62% of patients. Patients were selected if they were new to the service, required immediate care, or had high educational value. To prepare trainees for bedside rounds, attending physicians sought trainee “buy-in,” defined roles and expectations, established a climate that fosters patient comfort and communication, and tailored bedside activities to learner level. The role of each team member varied; trainees with increased experience were given more autonomy. The fact that each participant had a different bedside rounding style did not allow the authors to identify a “unified model” for bedside rounds. Limitations of the study were the lack of independent verification of the participants’ expertise, and the inclusion of mostly experienced attending physicians from large academic centers. Overall, this study provided an outline of strategies used by experienced clinician-educators that can be used for faculty development and that can guide clinician-educators on how to teach at the bedside.
PROFESSIONALISM 9. Stratton TD, Conigliaro RL. Does gender moderate medical students’ assessments of unprofessional behavior? Journal of General Internal Medicine 2012;27(12):1643–8. Medical professionalism is a widely accepted core clinical competency central to the practice of medicine. However, the role of contextual factors, such as gender, in assessing unprofessional behaviors is poorly understood. In this study, the authors examined whether the assessment of potentially unprofessional behaviors during undergraduate medical training differs between male and female medical students, and whether it varies depending on the gender of the individual whose behavior is assessed. The authors created 18 written scenarios to portray a range of unprofessional behaviors (e.g., from being unprepared on rounds to cheating on exams). Each scenario had two parallel versions to include male and female trainees. Thirdyear medical students were asked to rate depicted behaviors in the randomly ordered 18 scenarios (7 featuring male trainees, 7 female, 4 gender-neutral) using a 4-point Likert-type scale. The responses provided by 91 students (39 female, 52 male) were included in the analysis. There was no difference in the mean ratings of the vignettes based on gender of the medical student assessor or the gender of the “actor” in the scenario. On average, women rated the behaviors as more severe than men in the majority of the gender-specific scenarios, but these differences were not significant (F(1, 87) = 0.33, p = .57, η2 = 0.01). The study
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was limited by the fact that it only measured behaviors, whereas professionalism is multidimensional, encompassing more than a list of characteristics or behaviors. Moreover, it is unclear how closely these written vignettes emulated real, observed behaviors. This study suggests that gender may not moderate medical students’ assessments of unprofessional behaviors. Future studies should explore further the contextual nature of defining and assessing professionalism.
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PHYSICIAN BURNOUT 10. West CP, Dyrbye LN, Satele DV, Sloan JA, Shanafelt TD. Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment. Journal of General Internal Medicine 2012;27(11):1445–52. Burnout is an increasingly common problem in medical students, residents, and physicians. The Maslach Burnout Inventory (MBI) represents the gold standard for measuring burnout; however, it contains 22 items and is therefore challenging to administer. This study extends previous evidence in support of a brief burnout assessment tool. Using adapted representative questions “I feel burned out from my work” for emotional exhaustion, and “I have become more callous toward people since
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I took this job” for depersonalization, the authors retrospectively analyzed data from five previously published studies conducted between 2003 and 2009, correlating MBI scores with physician well-being and patient care outcomes. Three of these studies were multi-institutional including a total of 5,646 medical students, one was a single institution study including 321 internal medicine residents, and one consisted of data from 7905 members of the American College of Surgeons. The authors systematically reanalyzed the data to determine the concurrent validity of these single-item questions relative to the full MBI for evaluating associations between domains of burnout (emotional exhaustion and/or depersonalization) and outcomes such as suicidality, medical student drop-out, unprofessional behaviors, and perceived medical errors. All domains demonstrated concurrent validity between the single-item scores and the MBI scores and exhibited strong predictive associations with the measured outcomes. Although this work is limited by the quality of the original studies and included a relatively smaller sample of residents, this study uniquely evaluated the association of these two questions relative to the MBI and looked at key outcomes rather than the domains of emotional exhaustion and depersonalization. The authors concluded that although the MBI remains the gold standard, these single-item measures appear to be useful substitutes in burnout assessment.
