The Enhanced Brief Structured Observation Model: Efficiently Assess Trainee Competence and Provide Feedback.

Introduction: The regular observation of trainees is essential to ascertain trainee proficiency in competency-based assessments. Unfortunately, observation of residents is not frequent enough to facilitate entrustment decisions, and the busy clinician-educator may not have the tools or time to conduct effective and efficient observations. Methods: We created a hands-on faculty development workshop utilizing an enhanced variation of the brief structured observation (BSO) technique to train both primary care and subspecialty pediatric faculty on how to effectively and efficiently observe trainees. The workshop has provided faculty a practical approach to observing trainees in a focused fashion and providing effective feedback on clinical skills based on their observation. In the workshop, faculty had an opportunity to observe residents taking an unrehearsed history from a medical student simulating an acutely ill patient, culminating in feedback on the residents\u27 performance using the subjective, objective, assessment, and plan (SOAP) format. Results: This faculty development workshop has been presented to more than 100 faculty both locally and nationally, and feedback has been uniformly positive, with three institutions incorporating this model into their programs to date. Discussion: This enhanced BSO workshop promotes a model that streamlines the observations of trainees and provides faculty with the tools to encourage more observations

ACCEPT Medical Student Handoff Workshop: The Patient Safety Curriculum Starts in Undergraduate Medical Education

This workshop is an educational intervention designed to improve student skills in patient handoffs. It consists of a one-hour, interactive, small-group session facilitated by a faculty member. The workshop focuses on the importance of specific handoff skills to patient safety and is centered around the principles embodied in the ACCEPT mnemonic: Accurate, Complete (but concise), Clear, Efficient, Presented in writing, and Told in person. Students are provided with a standardized format for both an oral and written handoff along with a pocket card highlighting the required elements. A standardized patient case allows for participants to practice these skills, receive feedback, and undergo formal evaluation. The primary goal of the workshop is to provide a brief but effective handoff-skills training session that can be targeted to participants as early as the third year of medical school. The purpose of this resource is to provide a framework for those considering incorporating handoff teaching in the undergraduate medical curriculum. At George Washington University, we conducted a quasi-randomized study of third-year internal medicine clerks receiving a standardized handoff skills training. Students were followed into their fourth year to assess the durability of the training and the transfer of skills from the simulated setting into the clinical environment. At the core of the training was a one-hour workshop developed by a group of medical educators and hospitalists aimed at teaching third-year medical students a standardized approach to handoffs in the inpatient setting. The workshop was designed to be time efficient, limit faculty resource utilization, and have a lasting impact. Using a handoff evaluation tool, we found that students who participated in the workshop demonstrated an improvement in their oral handoff skills. After an average follow-up of nine months, trained students performed statistically significantly better than untrained controls. Lastly, trained students transferred the skills they were taught to the clinical setting and performed statistically significantly better than untrained controls when assessed doing real-time handoffs during their acting-internship. A retrospective pre-post self-assessment found that 72% of students felt at least somewhat unprepared to perform an effective handoff prior to participating in the educational workshop, while 75% of students felt well prepared or very well prepared after the educational intervention. Eighty-six percent of the students felt the educational intervention to be effective. No student reported that the workshop was ineffective. AAMC MedEdPORTAL publication ID 10302. Link to original

Resource to Develop Medical Students into Peer Mentors

The primary goal of the Peer Mentoring Guide is to develop fourth year medical students (MS-4s) into mentors for first year medical students (MS-1s). The purpose of this resource is to provide others who want to develop a peer mentoring program as part of an advanced students-as-teachers curriculum. The George Washington University was one of the first schools to have a program to prepare medical students for their teaching role as residents and practicing physicians, which was called TALKS (Teaching and Learning Knowledge and Skills). We recently recognized that some participants were interested in going beyond the boundaries of the program to learn advanced teaching skills. Thus, we created an Advanced TALKS program to meet this demand. Peer mentoring was the primary focus for the Advanced TALKS program. For this program we developed the Peer Mentoring Guide presented here for others to use as a resource. There has been increasing recognition of the need to prepare medical students for their teaching role as residents and practicing physicians.1 In one review of the literature, 39 programs were identified where students were trained to be teachers. The roles taken on by the student teacher included portraying standardized patients, tutoring students in academic trouble, teaching clinical skills, simulating a learner, administering an elective course, and teaching peers. Though a recent survey of US medical schools documented 43 formal programs in the 99 schools that responded to the survey, almost all of the other schools had informal programs.2 In addition, there is a growing literature on the value of near peer teaching programs.1,2,3 The course was piloted at our institution with a small group of MS4s (N=5). Although MS4s are a select group and this limits the numbers, the intention was to provide an educational experience that went beyond the general education elective at GWU (the TALKS course) to individuals who wanted more. We created the mentoring program for those students with further interest as an addition to their current curriculum. Over the course of an academic year, the students all completed 2 workshops and then a longitudinal mentoring experience with first year medical students. The primary goal of the Peer Mentoring Guide is to develop fourth year medical students (MS-4s) into mentors for first year medical students (MS-1s). The purpose of this resource is to provide others who want to develop a peer mentoring program as part of an advanced students-as-teachers curriculum. The George Washington University was one of the first schools to have a program to prepare medical students for their teaching role as residents and practicing physicians, which was called TALKS (Teaching and Learning Knowledge and Skills). We recently recognized that some participants were interested in going beyond the boundaries of the program to learn advanced teaching skills. Thus, we created an Advanced TALKS program to meet this demand. Peer mentoring was the primary focus for the Advanced TALKS program. For this program we developed the Peer Mentoring Guide presented here for others to use as a resource. There has been increasing recognition of the need to prepare medical students for their teaching role as residents and practicing physicians.1 In one review of the literature, 39 programs were identified where students were trained to be teachers. The roles taken on by the student teacher included portraying standardized patients, tutoring students in academic trouble, teaching clinical skills, simulating a learner, administering an elective course, and teaching peers. Though a recent survey of US medical schools documented 43 formal programs in the 99 schools that responded to the survey, almost all of the other schools had informal programs.2 In addition, there is a growing literature on the value of near peer teaching programs.1,2,3 The course was piloted at our institution with a small group of MS4s (N=5). Although MS4s are a select group and this limits the numbers, the intention was to provide an educational experience that went beyond the general education elective at GWU (the TALKS course) to individuals who wanted more. We created the mentoring program for those students with further interest as an addition to their current curriculum. Over the course of an academic year, the students all completed 2 workshops and then a longitudinal mentoring experience with first year medical students

Observing Pediatric Residents\u27 Communication Skills During Sick Visits: Do They Determine Concern and Their Reasons for Concern and Are Caregivers Satisfied?

Fifty years ago, Dr. Barbara Korsch published her seminal work on pediatric resident communication skills, demonstrating that residents did not always ascertain the caregivers’ main concern for the visit was and specifically, why those caregivers were concerned. Repeating her study using a direct observation methodology, the authors evaluated 103 pediatric sick visits at a large children’s hospital primary care clinic to determine 1) if residents elicited the caregiver’s main concern about their child’s acute illness, 2) why they were concerned, and 3) whether asking these questions was statistically associated with caregiver satisfaction, which was determined by an exit survey. Results of the study revealed that residents determined the caregivers’ main concern in 84.5% of visits. However, residents established why the caregiver was concerned in only 38.6% of visits. Caregiver satisfaction with the visits was high, with 90.3% rating it “one of the best” or “very “very good.” Higher satisfaction was associated with the resident asking why the caregiver was concerned (z = 2.76, p = .006). We conclude that pediatric residents often ask caregivers about their main concern, but less frequently elicit why caregivers are concerned. Not understanding caregivers’ reasons for concerns about their children, biologically based or not, may be related to unnecessary ongoing anxiety about the illness as noted in Korsch’s studies. Probing the root of caregiver concern may be important for their satisfaction and should highlight this important aspect of communication to those responsible for medical student and pediatric resident communication skills training

Interdisciplinary Workshop to Increase Collaboration Between Medical Students and Standardized Patient Instructors in Teaching Physical Diagnosis to Novices

Traditionally, full-time faculty members have assumed major responsibility for teaching physical examination skills to first- and second-year medical students. Problems with faculty recruitment and adhering to a standardized way of teaching have challenged educators to seek alternatives to teaching the physical examination to novices. To address these problems, we created and implemented a novel curriculum that has standardized the teaching of physical examination skills to novice students by using standardized patient instructors and fourth-year medical students working as an interdisciplinary team (known as a dyad). Feedback after the first iteration of this course revealed confusion about roles, goals, and responsibilities for feedback and evaluation amongst the dyads. To address these issues, an interdisciplinary workshop was created using the theoretical constructs of the GRPI (goals, roles and responsibilities, process, and interpersonal skills) model and Mezirow’s transformative learning theory, both of which address gaps in the dyad relationship. Initial feedback from fourth-year students and standardized patient instructors was enthusiastically positive. Evidence showed the dyad could be strengthened by (1) providing time to learn the theoretical scaffolding underlying working together, (2) meeting and planning approaches to teaching efforts, and (3) enabling medical students and standardized patient instructors to apply the theoretical constructs as the foundation to reflect on their teaching roles in effectively instructing novices in physical exam skills

A Model for a Structured Clinical Development Program for First-Year Residents: Utilizing the Entrance OSCE, Individualized Learning Plans (ILPs), and Peer Clinical Coaching

Identification of incoming residents’ unique strengths and weaknesses in a clinical setting is important for developing an individualized educational curriculum and ultimately addressing specific needs. This resource presents and describes materials for a clinical development program for first year residents. The program is structured around three educational elements: an entrance Objective Structured Clinical Examination (OSCE), Individualized Learning Plan (ILP), and peer clinical coaching. The included files, which describe these three elements, are intended to serve as a resource for residency directors and/or graduate medical education faculty interested in constructing a similar program. In the described clinical development program, first-year Obstetrics and Gynecology residents participated in an entrance OSCE as a component of their orientation to residency. Their performance was evaluated through Faculty and Self-assessment tools and scored on a nine-point scale in accordance with the ACGME core competency scoring evaluation system. These evaluations were utilized in the creation of ILPs. Stated goals were translated into discrete learning objectives and then developed further through a learning strategy and timeline using the SMART model. As a component of a research study, first-year residents were randomized into one of two groups: clinical coaching group or individual implementation group. Senior resident volunteers served as peer clinical coaches after participating in a two-hour interactive workshop. The peer clinical coaches met with first-year residents on a monthly basis for four months to develop the resident’s ILP. Exit questionnaires were completed at the conclusion of the year-long program. The OSCE is a well-utilized tool to ensure direct observation, evaluate clinical performance in a simulated environment, and provide timely feedback. Another potential application of the OSCE is to provide a baseline evaluation of clinical performance that may be utilized in determining a starting point for clinical competencies. Utilizing the feedback from the OSCE to create an ILP may translate valuable feedback into measurable objectives and competencies, while also providing a model for reassessment and follow up. While the OSCE and the faculty mentored ILP have been well characterized in the literature, the concept of clinical coaching is relatively novel to medicine. Teaching and coaching differ in that teachers disseminate knowledge whereas coaches ensure performance. Seeking to elaborate on this relatively novel paradigm, we sought to characterize how resident’s global clinical experience was affected within this working model. Despite time constraints, both first-year residents and peer clinical coaches reported that clinical coaching improved their clinical experience. A structured clinical program incorporating an entrance OSCE, ILP, and peer clinical coaching holds promise in documentation of milestones and promoting life-long learning. AAMC MedEdPORTAL publication ID 10084. Link to original

Interdisciplinary Workshop Using Applied Models to Increase Collaboration and Satisfaction between Medical Students and Standardized Patient Instructors

In an article published in 1993 by Shulman about higher education it was stated that, Teaching takes practice. It takes feedback. It takes instruction. More and more we are becoming aware of that. There has been increasing recognition of the need to prepare medical students for their future teaching roles as intern/residents and physicians. There have been numerous publications addressing peer teaching in undergraduate education, but sparse literature addressing how medical students co-teach physical diagnosis to pre-clinical students in lieu of faculty. Traditionally in North America, full-time faculty members have assumed the major responsibility for teaching first- and second-year medical students physical examination skills. This historic model has its barriers, as recruiting busy faculty without compensation is a problem as is the lack of standardization of teaching content from one faculty member to another. To address these issues, we introduced the concept of Standardized Patient Instructors (SPIs) joining with fourth year medical students (MS-4s) to teach physical examination skills to the first-year medical students (MS-1s) in 2010. The SPIs were trained to teach physical examination maneuvers in a standardized fashion while the MS-4s were in charge of overseeing the MS-1s practice these skills and providing relevant clinical context to the maneuvers. The George Washington University is the first reported school to have such an interdisciplinary program. It has been shown in the literature that with appropriately motivated and mentored senior students, successful courses could be created to meet educational requirements at educational institutions with available resources. Recognizing that some individuals were interested in learning advanced teaching skills and could be used as a valuable asset to teaching alongside appropriate faculty, our goal was to create a program utilizing motivated students and provide a framework that could be implemented in other institutions. The multidisciplinary program was successfully implemented into the curriculum, but not without some unforeseen problems. SPI and MS-4 feedback after the first iteration of this course in the 2010-2011 cycle was fraught with confusion about what were the roles of each group, how the sessions were supposed to run, who assumed a leadership role in the group interaction, and how evaluation was to take place. It was from this feedback that theoretical constructs were examined to help improve the program; namely, the GRPI model and Mezirow\u27s Transformative learning theory. AAMC MedEdPORTAL publication ID 4152. Link to original

A Learner-Centered Diabetes Management Curriculum

OBJECTIVE Diabetes errors, particularly insulin administration errors, can lead to complications and death in the pediatric inpatient setting. Despite a lecture-format curriculum on diabetes management at our children’s hospital, resident diabetes-related errors persisted. We hypothesized that a multifaceted, learner-centered diabetes curriculum would help reduce pathway errors. RESEARCH DESIGN AND METHODS The 8-week curricular intervention consisted of 1) an online tutorial addressing residents’ baseline diabetes management knowledge, 2) an interactive diabetes pathway discussion, 3) a learner-initiated diabetes question and answer session, and 4) a case presentation featuring embedded pathway errors for residents to recognize, resolve, and prevent. Errors in the 9 months before the intervention, as identified through an incident reporting system, were compared with those in the 10 months afterward, with errors classified as relating to insulin, communication, intravenous fluids, nutrition, and discharge delay. RESULTS Before the curricular intervention, resident errors occurred in 28 patients (19.4% of 144 diabetes admissions) over 9 months. After the intervention, resident errors occurred in 11 patients (6.6% of 166 diabetes admissions) over 10 months, representing a statistically significant (P = 0.0007) decrease in patients with errors from before intervention to after intervention. Throughout the study, the errors were distributed into the categories as follows: insulin, 43.8%; communication, 39.6%; intravenous fluids, 14.6%; nutrition, 0%; and discharge delay, 2.1%. CONCLUSIONS An interactive learner-centered diabetes curriculum for pediatric residents can be effective in reducing inpatient diabetes errors in a tertiary children’s hospital. This educational model promoting proactive learning has implications for decreasing errors across other medical disciplines