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Since academic literature indicates that emotional intelligence (EI) is tied to work performance, there is increasing interest in understanding physician EI. We studied the EI of resident physicians in surgery, pediatric, and pathology residency programs at three academic centers to describe the EI profiles of residents in different specialties and determine whether gender differences in resident physician EI profiles mirror those in the general population. 325 residents were electronically invited to complete the validated Trait Emotional Intelligence Questionnaire (TEIQue), a tool comprised of 153 items that cluster to 15 independent facets, 4 composite factors, and 1 global EI score. The overall response rate was 42.8% (n=139, 84 women). Global EI of all residents (mean=101.0, SD=8.0) was comparable to the general population sample and was not statistically different between specialties or genders. EI profiling demonstrated distinct strengths and opportunities for development between specialty groups with an effect of specialty on sociability factor (p=0.005) and five TEIQue facets including optimism, stress management, emotion management, assertiveness, and social awareness (p=0.008-0.043). Women scored higher than men in emotionality factor (p=0.044) and the TEIQue facets impulse control, empathy, relationships, and self-motivation (p=0.004-0.049). Men scored higher than women in sociability factor (p=0.034) and 2 facets including stress management and emotion management (p=0.008-0.023). Linear regression demonstrated that age had a statistically significant predictive relationship with Global EI, though the effect was small (B=0.033, p=0.014). These findings suggest that similar to the general population, male and female residents may benefit from specific training of different EI domains to enhance well-rounded development. EI profiling may also inform future educational programming decisions for each specialty. Future research should focus on the functional relationship between educational interventions that promote targeted EI development and enhanced clinical performance.

Professionalism represents a fundamental characteristic of physicians. Professional organizations have developed professionalism competencies for physicians and medical students. The aim of teaching medical professionalism is to ensure the development of a professional identity in medical students. Professional identity formation is a process developed through teaching principles and appropriate behavioral responses to the stresses of being a physician. Addressing lapses and critical reflection is an important part of the educational process. The “hidden curriculum” within an institution plays an important role in professional identity formation. Assessment of professionalism involves multiple mechanisms. Steps in remediating professionalism lapses include (1) initial assessment, (2) diagnosis of problems and development of an individualized learning plan, (3) instruction encompassing practice, feedback and reflection and (4) reassessment and certification of competence. No reliable outcomes data exist regarding the effectiveness of different remediation strategies.

Graduate medical education (GME) is a critical link in the educational chain for physicians. Graduating from a strict apprenticeship model, GME has become a highly structured educational system whose peer-review organization provides an intentional and direct approach to ensuring that GME not only addresses the public's expectations of the profession but also positions itself to be a foundational structure in the outcomes-focused healthcare environment of the nation. GME is currently in a state of accelerated change—grounded in both educational and patient outcomes. This article provides an update on the significant changes that have occurred in GME over the past 10 years, a review of current initiatives and the perspectives related to educating physicians-in-training. Additionally, an analysis is provided on the future of GME, including areas of continued focus and uncertainty.

Indiana University-Purdue University Indianapolis (IUPUI) / In relationship-centered care, the relationship formed between physician and patient is critical to the creation of positive patient outcomes and patient satisfaction (Inui, 1996; Laine & Davidoff, 1996; Tresolini, 1994). Medical educators have increasingly utilized Objective Structured Clinical Examinations (OSCEs) to assess medical students’ abilities to utilize a relationship-centered approach in clinical interviewing. OSCEs, however, have recently come under scrutiny as critics contend that the overly scripted and standardized nature of the OSCE may not accurately reflect how medical students build and maintain relationships with patients. Although some studies have looked at how standardized patients help teach medical students interviewing skills, few studies have looked specifically at how the structured nature of the OSCE may influence relationship-building between standardized patients and medical students. Therefore, this study asks the question “How is relationship-centered care negotiated between standardized patients and medical students during a summative diagnostic OSCE?” Using an ethnographic methodology (Bochner & Ellis, 1996), data consists of an ethnographic field journal, transcripts of semi-structured interviews with SPs and medical students, and transcripts of headache and chronic cough videotaped scenarios. Using grounded theory (Strauss & Corbin, 1990, 1998), a back-and-forth thematic analysis was conducted in discovering the saturation of conceptual categories, linking relationships, and in critically comparing interpretive categorical concepts with relevant literature (Josselson & Leeblich, 1999). Findings suggest that standardized patients and medical students hold differing expectations for 1) diagnostic information gathering and 2) making personal connections upon entering a diagnostic summative OSCE. SPs “open up” both verbally and nonverbally when medical students “go beyond the checklist” by asking discrete diagnostic questions and when overtly trying to connect emotionally. Fourth year medical students, however, expect SPs to “open-up” during what they experience as a rushed, time-constrained, and overly structured “gaming” exercise which contradicts their own clinical experiences in being more improvisational during empathetic rapport building. Differences between SPs and medical students’ expectations and communication practices influence how they perform during summative diagnostic OSCEs. Findings may suggest the re-introduction of more relationship-focused OSCEs which positions SPs as proactive patients who reflexively co-teach students about the importance of making personal connections.

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This thesis investigates problems with current assessment and feedback practices in surgical training, and proposes ways to mediate some of these issues. In the first study, we report a number of barriers that might prevent supervisors from providing constructive feedback to medical trainees, including a fear of being labeled as intimidating or harassing. We also identify some barriers which make it challenging for supervisors to accurately report the progress of underperforming trainees including insufficient documentation, a perceived lack of support from program leadership, insufficient opportunities to observe performance, competing demands on time, fear of appeals or legal action, and fear of reciprocated poor staff evaluations. The second study examines the effectiveness of two new tools for assessing trainees’ performance and determines that these tools might be helpful in overcoming some of the barriers identified in the first study to help supervisors provide more meaningful feedback to trainees. Participants reported that the new tools were helpful for improving learning in six ways: by sparking a dialogue regarding performance; by promoting a structured, procedure-specific framework which could be used as a mechanism for providing high quality feedback; by providing a framework for directing future learning; by facilitating a systematic tracking of progress over time; by promoting an increased motivation to learn; and by introducing a learning focus to the intraoperative environment. Together, the data from this thesis provide us with a better understanding of how we might improve the use of assessments and feedback in surgical training. The hope is that our findings will improve the education of new physicians and ultimately improve patient care. / Thesis / Master of Science (MSc) / This thesis investigates problems with current assessment and feedback practices in surgical training, and proposes ways to mediate some of these issues. We present two studies. In the first, we explore barriers that might prevent supervisors from providing constructive feedback to medical trainees. We also identify some barriers which make it challenging for supervisors to accurately report the progress of underperforming trainees. The second study examines the effectiveness of two new tools for assessing trainees’ performance and demonstrates that these tools might be helpful in overcoming some of the barriers identified in the first study to help supervisors provide more meaningful feedback to trainees. Together, the data from this thesis provide us with a better understanding of how we might improve the use of assessment and feedback in surgical training. The hope is that our findings will improve the education of new physicians and ultimately improve patient care.

<p>This thesis explores the Cognitive Load Theory (CLT) framework with health professions education research, and applies the principles of CLT to one specific area of health professions education: the acquisition of cardiac and respiratory auscultation and physical assessment skill in undergraduate nursing students. The first study evaluates context-based learning environments on the acquisition of auscultation skill and physical assessment performance. Results suggest that for novice level students, high-context-based learning environments may contribute to extraneous cognitive load and may not be beneficial for learning. The next cluster of studies evaluates auscultation test performance following manipulation of cognitive load variables. The interleaving approach instruction was found to be most helpful for auscultation test performance. The series of studies conducted in this thesis demonstrate a useful direction for health professions research and promotes the use of cognitive load theory as a framework for instructional design and evaluation.</p> / Doctor of Philosophy (PhD)

Background: Physicians do not always provide appropriate patient care, due in part to inadequacy in their education and training. Performance outcomes, such as individuals' examination scores have been linked to future performance as physicians, accentuating the need for high-quality educational institutions. While the medical school accreditation process in the United States assures a uniform standard of quality, approximately one quarter of physicians in training and in practice in the United States graduated from medical schools located outside of the United States or Canada. These graduates of international medical schools (IMGs) have been more likely than domestically educated doctors to practice primary care and treat underserved and minority populations. An increasing proportion of IMGs who seek to enter post-graduate training programs and subsequent licensure in the United States graduated from medical schools located in the Caribbean. The quality of medical education at some of these schools has been questioned. Accreditation systems are frequently viewed as a way to ensure the quality of medical education, although currently there is limited data linking an educational oversight mechanism to better performance of the graduates. In addition, accreditation systems vary in the methodology, standards, and procedures used to evaluate educational programs. The purpose of the first phase of the present research was to examine medical education accreditation practices around the world, with special focus on the Caribbean region, to determine the association of accreditation of medical schools with student/graduate performance on examinations. The aim of the second phase of this research was to evaluate the quality of a select group of accrediting agencies and the association of quality with student/graduate outcomes. Methods All IMGs seeking to enter graduate training positions in the United States must first be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). In addition to other requirements, ECFMG certification includes passing scores on the United States Medical Licensing Examination (USMLE) Step 1 (basic science), Step 2 Clinical Knowledge (CK), and Step 2 Clinical Skills (CS). In the first phase, all IMGs taking one or more examinations leading to ECFMG certification during the five-year study period (January 1, 2006 through December 31, 2010), and who graduated from, or attended at the time of testing, a school located in a country that met the accreditation inclusion criteria, were included in the study population. First-attempt pass rates for each examination were calculated based on personal variables (gender, years elapsed since graduation at the time the individual took an examination [<3 years versus ≥ years], native language [English versus all others]), and on accreditation status of an individual's medical school. Next, separately for each examination, a generalized estimating equations model was used to investigate the effect of accreditation after controlling for the personal variables. Following the assessment of accreditation on test performance at the global level, the same analyses were conducted separately on the data from students/graduates who attended medical schools located in the Caribbean, and on the data from students/graduates who attended medical school not located in the Caribbean. In the second phase, the quality of a select group of accrediting agencies was evaluated according to the criteria determined by a panel of experts to be the most salient features of an accreditation system. Accreditation systems that used 80% or more of the criteria were given a quality grade of A, and systems using less than 80% of the criteria were given a grade of B. The association between the quality of an accreditation system and student performance, as measured by first-attempt pass rates on USMLE, was investigated in this second phase. The Temple University Office for Human Subject Protections Institutional Review Board determined by expedited review that this study qualified for exemption status. Results As of January 2011, there were 173 countries with medical schools listed in the International Medical Education Directory (IMED), of which 118 met the inclusion criteria. During the study period approximately 67,000 students/graduates took Step 1 for the first time, 55,600 took Step 2 CK, and 58,200 took Step 2 CS. Over one quarter of the test takers graduated from, or were students at, schools located in the Caribbean. For the global population, better performance on Step 1 was associated with the male gender, testing within three years of graduation, non-native English-speaking status, and attending a school located in a country with a system of accreditation. For the Caribbean population on Step 1, results were similar, except native English speakers outperformed non-native English speakers. After controlling for covariates, the odds of passing Step 1 for those from accredited schools were 1.8 times greater for the global group and 4.9 times greater for the Caribbean group as compared to the odds of passing the examination on the first attempt for individuals from nonaccredited schools. In contrast, in the non-Caribbean group accreditation was not associated with examination performance. Increased performance on Step 2 CK for the global group was associated with the female gender, testing within three years of graduation, non-native English-speaking status, and attending a school located in a country with a system of accreditation. For the Caribbean population on Step 2 CK, females, those testing closer to graduation, and native English speakers outperformed their counterparts. After controlling for covariates, the odds of passing Step 2 CK for those from accredited schools were 1.3 times greater for the global group and 2.3 times greater for the Caribbean group as compared to individuals from nonaccredited schools. Accreditation was not associated with examination performance for the non-Caribbean group. For all three groups (global, Caribbean, and non-Caribbean), better performance on Step 2 CS was associated with the female gender, testing within three years of graduation, native English- speaking status, and attending a school located in a country with a system of accreditation. After controlling for covariates, the odds of passing Step 2 CS for those from accredited schools were 1.3 times greater for the global group, 2.4 times greater for the Caribbean group, and 1.1 times greater for the non-Caribbean group compared to individuals from nonaccredited schools. In phase two, the expert panel unanimously agreed on 14 essential standards that should be required by accrediting agencies to ensure the quality of physicians. Of the accreditation systems in 18 countries that were analyzed for inclusion of the criteria, four systems, used in 10 countries, were given a grade of A (included 80% or more of the essential standards), and eight systems, used in eight countries, were given a grade of B (included less than 80% of the essential standards). The IMGs attending medical schools accredited by a system that received a grade of A performed better on Step 1 and Step 2 CS as compared to IMGs attending medical schools that are accredited by a system receiving a grade of B. For Step 2 CK, the results were reversed. Certain essential standards were associated with better performance for all three examinations. Discussion The purpose of this study was to investigate the USMLE performance of graduates of international medical schools who voluntarily seek ECFMG certification based on variables related to the accreditation of their medical education programs. In this study, for the self-selected population who took examinations during the study period, accreditation was associated with better performance in specific regions and for some examinations. Of the three examinations, the existence of a system of accreditation had the strongest association with Step 1 performance for the global and Caribbean groups. Many accreditation criteria are directly related to aspects of the preclinical phase of education. The association between accreditation and Step 2 CS was positive for all three groups of students/graduates, although systems of accreditation may have less direct impact on student performance on clinical examinations as students' experiences in the clinical phase are likely more varied. Of the three groups, the existence of accreditation systems had the greatest associated with examination performance in the Caribbean, an important finding considering the large numbers of IMGs educated in this region seeking ECFMG certification and ultimately treating U.S. patients. The quality of accrediting agencies, as determined by the number of essential elements utilized in the systems, was positively associated with performance for Step 1 and Step 2 CS, but not Step 2 CK. The finding supporting the importance of a high-quality accreditation system on Step 2 CS performance is important due to the purpose of this examination in evaluating a physician's skills in a real world setting. This study lends some support to the value of accreditation. Due to the substantial resources needed to design and implement accreditation processes, these results provide some positive evidence beyond face validity, especially in the Caribbean region, that quality assurance oversight of educational programs is associated with the production of more highly skilled physicians, which in turn should improve the health care of patients in the United States and around the world. / Public Health

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