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In the 1990's the Accreditation Council for Graduate Medical Education (ACGME) recognized a need to fully integrate learning outcomes assessment into the accreditation process for resident physician training programs. ACGME leaders had concluded that by increasing emphasis on curricular development and by evaluating student performance through measurement of learning outcomes, the accreditation process would become a more reliable predictor of the residency program's success. In 1994 the ACGME created an initiative that would transform the current accreditation model of minimum threshold requirements towards a student performance based model of improved learning outcomes based on curricular development. responsible for the accreditation of over 8037 physician residency training programs in the United States. One hundred fifty of these programs provide training in the specialty of pathology and its anatomic and clinical sub-disciplines (AMA , 2007). Concurrent with the beginning of the ACGME Outcomes Project (1994) , four major pathology education groups in North America entered into a collaboration to improve the quality of pathology resident training. Their focus encompassed improvements in both clinical and managerial skills . The findings of this joint study culminated in the publishing of the Graylyn Conference Report in 1995 (Smith et al., 2006). One of the major recommendations in the report was that resident training in clinical laboratory administration should be improved. National leaders in pathology education felt that these changes were necessary to accommodate the evolving role of the pathologist as a clinical and administrative leader in a rapidly changing health care delivery setting. Prior to this current investigation, no studies appear to exist that provide an in-depth analysis of the perceptions of the residency directors about the need of expanded training in laboratory administration. This quantitative study has evaluated the amount of time and priority given to managerial training, the inclusion of administration topics in the curriculum and the extent of learning outcomes assessment in administration that residency program directors believe are being linked to successful professional performance in recent graduates . / Educational Administration

The Institute of Medicine report "To Err is Human," released in late 1999, raised the issue of human error in medicine to a new level of attention. This study examines the frequency, severity, and type (FST) of errors associated with postoperative surgical complications at a tertiary care, university-based medical center, addressing the intersection of three domains: patient safety, graduate medical education, and simulation-based training. The study develops and validates a classification system for medical error that is specific to surgery, affirming reliability internally and externally. Baseline data on the FST of errors is collected over a 12-month period. A hybrid, simulation based training session is developed, validated, and applied to a cohort of surgical residents, focusing on the three most common types of errors identified from pilot data, namely judgment error, incomplete understanding of the problem, and inattention to detail, all human factor errors. The impact of the training is evaluated by measuring the FST of errors occurring during the 6-month period following the training sessions. The study demonstrates that there is a continuous decrement in the incidence of postoperative complications and a proportional decrease in error, which starts at the beginning of the baseline data collection and continues linearly throughout the 12 baseline months and subsequent 6 post-training months. There is no additional decrement in the rate of change following training, and no change in the rate of the index errors following the training. This study suggests that surgical error is frequent (>2%) and principally due to human factors rather than systems or communication. This study demonstrates that creating an environment where residents are continuously involved in identifying and characterizing errors results in a significant and sustained decrease in postoperative complications and the errors specifically associated with them. Contrary to expectations, a validated, well-designed, active-learning training module does not result in an additional identifiable improvement in patient outcome or in the incidence of index errors. These results are at variance with many recent studies addressing medical error and, if verified by additional studies, challenge several strongly held ideas related to patient safety training.

The purpose of this phenomenological study was to describe how professional educators make sense of their role in helping novice practitioners make meaning from authentic clinical practice. Simultaneously studying a clinical educator from teacher and graduate medical education, and subsequently setting their stories side by side, speaks to the interest both professions have in learning from the other. Both clinical educators were Board certified in their respective area of practice. In-depth phenomenological interviewing was used as the study’s methodology, and the professional formation construct served as the study’s conceptual framework. Data corroborate findings in the literature that there is a lack of consensus about what the clinical educator role entails. Participants showed alignment with the professional formation conceptual framework and demonstrated that the clinical educator role is multifaceted, complex, and made up of more than discrete functions. Their capacity to support professional formation comes from their ownership of a special mix of cognitive and behavioral processes, professional knowledge, and personal attributes. Given both professions’ interest in and ongoing efforts to improve clinical education, the study can help both continue their work toward understanding the clinical educator role and ensuring that people selected for the role are chosen through thoughtful methods and provided with clinical-educator-specific professional development throughout the professional lifespan.

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Background In July 2014, the Institute of Medicine released a review of the governance of Graduate Medical Education (GME), concluding that changes to GME financing were needed to reward desired performance and to reshape the workforce to meet the nation's needs. In light of the rapid emergence of alternative payment systems, we evaluated the financial value of resident participation in operative surgical care. Methods The Department of Surgery provided Current Procedural Terminology (CPT) codes for procedures performed by the general surgical service at our institution for the 2011 academic year. For each code, the charge and total instances were provided. CPTs allowing an assistant fee were identified using the Searchable Medicare Physician Fee Schedule. This approach enabled calculation of the potential resident contribution to GME funding. Results A total of 515 unique CPTs were potentially billable for a total of 6,578 procedures, of which 2,552 (39%) were reimbursable. These CPTs would have generated $1,882,854 in assistant charges. The top 50 most frequent CPTs resulted in 4,247 procedures. Within the top 50, 1362 procedures (32% of the top 50, 21% of the total) were reimbursable. Of the total assistant charges, $963,227 (51%) occurred in the top 50 most frequent CPTs. Conclusions Credit for resident participation in operative care as co-surgeon would average $67,244 per resident, compared to our current funding of $142,635 per resident. This type of alternative funding could provide 47% of current educational support. The skew in distribution of procedures also suggests that such a system could provide guidance to a more balanced operative experience. Such performance-based credentialing could be used to ensure appropriate housestaff for a given case; these reimbursements could also be adjusted based on quality metrics to provide for transformational change in patient outcomes.

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A presente tese tem por objetivos: identificar concepções sobre Medicina Convencional e Acupuntura que contribuem para o entendimento dos motivos que levam médicos a procurarem conhecer ou se especializar em medicina chinesa, identificar expectativas dos médicos investigados com relação ao exercício da Acupuntura e desvelar o significado dos discursos sobre prática médica e sobre mudança de especialidade médica. Com a hipótese de que os médicos que buscam especialização em Medicina Chinesa - Acupuntura objetivam exercer Acupuntura de forma integrada à Medicina Convencional, o que se dá a partir de uma nova visão de mundo, tendo por referência o contexto de uma prática médica mais abrangente e com relação médico-paciente mais humanista. O tema estudado é de relevância, visto que atualmente é crescente a procura de médicos por especialização em práticas médicas não convencionais, mais freqüentemente, Acupuntura. Também porque tem aumentado o afluxo de pacientes para estas especialidades e, finalmente, porque a discussão do humanismo na medicina é bastante presente na atualidade. Neste contexto, interessa-nos estudar o médico que tem formação na medicina convencional e busca se especializar-se em Acupuntura. Dada a natureza do problema, a pesquisa realizada é quanti-qualitativa. Foram pesquisados 175 médicos do 'Curso de Desenvolvimento em Medicina Chinesa-Acupuntura' do Center-AO - Centro de Pesquisa e Estudo da Medicina Chinesa e UNIFESP - EPM, com questionários composto por perguntas abertas e fechadas. Os dados obtidos foram analisados estatisticamente com metodologia que se aplicou no caso específico do presente estudo, bem como, com técnica de coleta de material denominada do tipo temática, baseada nas respostas dos médicos. As respostas foram analisadas com a técnica de análise de conteúdo, buscando desvelar unidades de significado, e a partir daí, estabelecemos categorias gerais e específicas, que passaram a dar significado aos discursos. Dessa forma obtivemos três grupos categoriais: "Aprimoramento profissional", "Ampliar seu próprio horizonte de vida" e "Compreender o paciente em uma dimensão mais abrangente". Nossos dados revelaram que médicos de especialidades médicas cognitivas e intermediárias são mais atraídos para a especialização em Acupuntura. Também revelaram que os médicos de nosso estudo pretendem exercer Acupuntura em diversos espaços de prática como consultório e outros espaços da medicina privada, SUS, hospitais, pesquisa e docência, entre outros, de forma integrada à Medicina Convencional, no bojo da qual a Acupuntura se firma como especialidade médica. / The main goal of the thesis is to identify conceptions relating to Conventional Medicine and Acupuncture that contributes to the understanding of reasons why doctors search for or specialize in Chinese medicine, identify expectations of the doctors researched in connection with the practice of Acupuncture and reveal the meaning of speeches about medical practice and changes of medical specialization. Assuming as a hypothesis that doctors specialize in Chinese medicine aims to practice Acupuncture integrated with Conventional Medicine, which comes from a new view of the world, having as base a more broaden medical practice in view of a more humanistic doctor-patient relationship. The subject is relevant in view of the current growth in number of doctors searching for specialization in unconventional medical practices, most frequently, Acupuncture. In addition to that, the number of patients of such practices is increasing and, finally, since the discussion of humanistic values in medicine is a current matter. In view of the above, it is important to study the doctor who has as a base the conventional medicine and who searches for specialization in Acupuncture. Due to the nature of the problematic a quantitative-qualitative research was carried on. 175 doctors from 'Curso de Desenvolvimento em Medicina Chinesa-Acupuntura' of Center-AO - Centro de Pesquisa e Estudo da Medicina Chinesa e UNIFESP - EPM- São Paulo, was researched and subjected to a questionnaire of open and closed questions. The obtained data was statistically analyzed with the methodology applicable to the concrete case of the present study, in addition to the applicable collection of material denominated thematic, based on the doctor's answers. Such answers were analyzed in face of the "content analysis" method, seeking to reveal significance units, and from than on, establishing general and specific categories, which leads to the meaning of speeches. In face of that, 3 categories were established: "Professional Improvement", "Broaden self life horizon" and "Understand patients in a more broaden dimension". The data collected reveals that doctors who specialize in cognitive and intermediary medical practices are more drawn to Acupuncture specialization. The data also revealed that doctors subject to the present study aim to practice Acupuncture in several environments, such as private offices and clinics, public hospitals (SUS), academic research, among others, in an integrated way with Conventional Medicine, which establishes Acupuncture as a medical specialization.

A presente tese tem por objetivos: identificar concepções sobre Medicina Convencional e Acupuntura que contribuem para o entendimento dos motivos que levam médicos a procurarem conhecer ou se especializar em medicina chinesa, identificar expectativas dos médicos investigados com relação ao exercício da Acupuntura e desvelar o significado dos discursos sobre prática médica e sobre mudança de especialidade médica. Com a hipótese de que os médicos que buscam especialização em Medicina Chinesa - Acupuntura objetivam exercer Acupuntura de forma integrada à Medicina Convencional, o que se dá a partir de uma nova visão de mundo, tendo por referência o contexto de uma prática médica mais abrangente e com relação médico-paciente mais humanista. O tema estudado é de relevância, visto que atualmente é crescente a procura de médicos por especialização em práticas médicas não convencionais, mais freqüentemente, Acupuntura. Também porque tem aumentado o afluxo de pacientes para estas especialidades e, finalmente, porque a discussão do humanismo na medicina é bastante presente na atualidade. Neste contexto, interessa-nos estudar o médico que tem formação na medicina convencional e busca se especializar-se em Acupuntura. Dada a natureza do problema, a pesquisa realizada é quanti-qualitativa. Foram pesquisados 175 médicos do 'Curso de Desenvolvimento em Medicina Chinesa-Acupuntura' do Center-AO - Centro de Pesquisa e Estudo da Medicina Chinesa e UNIFESP - EPM, com questionários composto por perguntas abertas e fechadas. Os dados obtidos foram analisados estatisticamente com metodologia que se aplicou no caso específico do presente estudo, bem como, com técnica de coleta de material denominada do tipo temática, baseada nas respostas dos médicos. As respostas foram analisadas com a técnica de análise de conteúdo, buscando desvelar unidades de significado, e a partir daí, estabelecemos categorias gerais e específicas, que passaram a dar significado aos discursos. Dessa forma obtivemos três grupos categoriais: "Aprimoramento profissional", "Ampliar seu próprio horizonte de vida" e "Compreender o paciente em uma dimensão mais abrangente". Nossos dados revelaram que médicos de especialidades médicas cognitivas e intermediárias são mais atraídos para a especialização em Acupuntura. Também revelaram que os médicos de nosso estudo pretendem exercer Acupuntura em diversos espaços de prática como consultório e outros espaços da medicina privada, SUS, hospitais, pesquisa e docência, entre outros, de forma integrada à Medicina Convencional, no bojo da qual a Acupuntura se firma como especialidade médica. / The main goal of the thesis is to identify conceptions relating to Conventional Medicine and Acupuncture that contributes to the understanding of reasons why doctors search for or specialize in Chinese medicine, identify expectations of the doctors researched in connection with the practice of Acupuncture and reveal the meaning of speeches about medical practice and changes of medical specialization. Assuming as a hypothesis that doctors specialize in Chinese medicine aims to practice Acupuncture integrated with Conventional Medicine, which comes from a new view of the world, having as base a more broaden medical practice in view of a more humanistic doctor-patient relationship. The subject is relevant in view of the current growth in number of doctors searching for specialization in unconventional medical practices, most frequently, Acupuncture. In addition to that, the number of patients of such practices is increasing and, finally, since the discussion of humanistic values in medicine is a current matter. In view of the above, it is important to study the doctor who has as a base the conventional medicine and who searches for specialization in Acupuncture. Due to the nature of the problematic a quantitative-qualitative research was carried on. 175 doctors from 'Curso de Desenvolvimento em Medicina Chinesa-Acupuntura' of Center-AO - Centro de Pesquisa e Estudo da Medicina Chinesa e UNIFESP - EPM- São Paulo, was researched and subjected to a questionnaire of open and closed questions. The obtained data was statistically analyzed with the methodology applicable to the concrete case of the present study, in addition to the applicable collection of material denominated thematic, based on the doctor's answers. Such answers were analyzed in face of the "content analysis" method, seeking to reveal significance units, and from than on, establishing general and specific categories, which leads to the meaning of speeches. In face of that, 3 categories were established: "Professional Improvement", "Broaden self life horizon" and "Understand patients in a more broaden dimension". The data collected reveals that doctors who specialize in cognitive and intermediary medical practices are more drawn to Acupuncture specialization. The data also revealed that doctors subject to the present study aim to practice Acupuncture in several environments, such as private offices and clinics, public hospitals (SUS), academic research, among others, in an integrated way with Conventional Medicine, which establishes Acupuncture as a medical specialization.

Background: There is considerable evidence that physicians lack sufficient training in facilitating transition from pediatric to adult care systems for adolescents and young adults (A/YA). While several primary care residency programs have introduced health care transition (HCT) curricula in recent years, there are few studies that assess the effectiveness of HCT teaching models. Purpose: To assess the impact of a residency education program that uses electronic health records (EHR) and other methods to teach residents how to prepare A/YA for transition to adult care. Methods: In a mixed methods, quasi-experimental research design, quantitative methods were used to measure change in knowledge, confidence and experience among 67 Pediatrics and Med-Peds residents who participated in the program. All residents and a comparison group were invited to complete a 35-item pre/post-survey; a retrospective chart review provided documentation of age-specific HCT preparation tasks completed by residents during well visits for A/YA aged 12-21. Descriptive and correlational analyses were conducted to compare differences between resident and control test scores for 5 outcome variables, and to measure resident utilization of the HCT tool in the EHR. Using the Reach Effectiveness-Adoption Implementation Maintenance (RE-AIM) evaluation model as a guide, semi-structured interviews were conducted concurrently with residents and faculty to assess program acceptability, feasibility, and other important attributes. Interviews were transcribed and analyzed using a constant comparative, iterative process. Results: Survey results showed residents (11 matched pairs) scored significantly higher than controls (13 matched pairs) in 2 of 5 outcomes: exposure to HCT learning activities (p=.0005) and confidence in providing primary care for YSHCN (p=.0377). Overall utilization of the EHR tool among 51 residents was 52.8% (57 of 108 patient visits). In interviews conducted with 16 residents and 6 faculty, both groups said that HCT training is a highly relevant need. Residents said they had little knowledge or experience in HCT prior to the intervention but felt more confident in their abilities afterwards. The HCT tool in the EHR was the only intervention element among multiple modalities that reached all study participants, with more than 80% of residents interviewed reporting they used the HCT tool "usually" or "always." Factors that influenced program adoption included accessibility of educational materials, ease of use, time constraints, patient age and health condition, and attending physicians' enforcement of the protocol. Conclusion: This study contributes to the body of knowledge concerning HCT by increasing our understanding of ways to effectively educate residents about transition preparation. Results show a positive intervention effect on selected dimensions of resident knowledge, confidence, and practice in HCT, highlighting program strengths and weaknesses. The program is distinctive in educating residents to prepare all A/YA for HCT, as recommended by major medical associations for pediatric and adult care physicians, and in its use of the EHR as a primary teaching tool, a consideration for reducing time-intensive didactic instruction. It provides a model that can be adapted by other residency and provider training programs, and suggests a need to integrate acquisition of health care self-management skills more broadly in child and adolescent health preventive care tools and policies.