Graduate Medical Education Core Competencies Research Articles

Family Medicine Resident Remediation Compared Across Two CERA Studies.

From 2020 to 2022, multiple medical schools transitioned from teaching patient care directly to online electives. Family medicine program directors reported on these learners' abilities to meet the Accreditation Council of Graduate Medical Education (ACGME) core competencies during residency. The authors hypothesized an increased need for medical knowledge remediation in the 2023 Council of Academic Family Medicine Educational Research Alliance (CERA) study. Using the 2017 and 2023 CERA studies, the authors evaluated which factors were associated with residents requiring remediation, residents completing remediation, the duration of remediation, and the most remediated core competency. Compared to 2017, the percentage of residents who successfully remediated in the 2023 study increased (P=.006), while remediation duration stayed unchanged at 6 to 12 months. The top ACGME core competency needing remediation remained professionalism in both studies (2017: 38.1%; 2023: 45.1%; P=.10) with medical knowledge being second most common (2017: 30.2%; 2023: 25.2%; P=.20). We found no associations between non-U.S. medical graduate percentage, core faculty remediation training, professionalism training, or didactic hours and the number of residents undergoing remediation, the percentage of residents remediating successfully, or the most common competency remediated. Program director gender, degree, race, years of experience, underrepresented in medicine status, and remediation training were not associated with any resident remediation variables studied. Professionalism remains the top core competency requiring remediation. We found no associations between resident, program, training, or program director factors and the core competency requiring remediation, the number of residents needing remediation, or the percentage of residents who completed remediation.

Prioritizing Health Literacy Educational Objectives for Pediatric Residents – A Delphi Study

ObjectiveChildren of caregivers with limited health literacy are at risk of poorer health outcomes. Thus, health literacy-informed communication tools are critical to achieving a more equitable health system. However, there is no agreement on the health literacy skills pediatric residents should attain. We used Delphi methodology to establish consensus on health literacy objectives to inform development of a pediatric resident curriculum. MethodsOur Delphi panel participated in three rounds of anonymous surveys to rank the importance of health literacy objectives in pediatric resident education. Consensus was defined as ≥70% of panelists identifying an objective as essential or 100% agreeing an objective was recommended or essential. ResultsThirteen pediatric health literacy experts comprised a racially, geographically, and professionally-diverse panel. After three survey rounds, 27 of the initial 65 objectives met consensus. All final objectives aligned with Accreditation Council for Graduate Medical Education (ACGME) core competencies. ConclusionsA panel of pediatric health literacy experts established consensus on health literacy objectives specific to pediatric resident training. These prioritized objectives align with ACGME core competencies, as well as evidence-based strategies like teach-back, and newer considerations like addressing organizational health literacy. They should inform future health literacy curricula and assessment within pediatric residency programs.

Scaled performance on the Vascular Qualifying Examination does not correlate with Vascular Certifying Examination first attempt pass in a national cohort of residents and fellows

BackgroundSpecialty board certification is an important indicator of surgeon competence and necessary for residency and fellowship programs to maintain accreditation by the Accreditation Council for Graduate Medical Education. Thus, identification of trainees at risk of board certification failure is important for both vascular surgery graduates and their parent program. We sought to examine the correlation of Vascular Qualifying Examination (VQE) performance on first-time pass achievement of the Vascular Certifying Examination (VCE). MethodsWe used American Board of Surgery data to examine predictive associations of a national longitudinal cohort of all vascular surgery integrated residents (VIRs) and vascular surgery fellows (VSFs) who completed the VQE and VCE from 2016 through 2021. Descriptive statistics were used to examine trends. We used χ2 tests to examine proportional group differences. Predictive associations between VQE scaled score performance and first-time pass achievement on subsequent VCE attempts were examined using logistic regression. ResultsVQE scaled score performance and VCE pass rates were obtained for all VIRs and VSFs (n = 579; 175 residents and 404 fellows) from 151 programs (48 residency and 103 fellowship) during the study period. First-attempt pass rate for the VQE was 96% in the study cohort, and first-attempt pass rate for the VCE was 94%. There were no significant differences in pass-fail rates in VQE and VCE for VIR and VSF candidates (P = .210 and P = .116, respectively). Trainee scaled score performance on the VQE was not predictive of subsequent first-attempt pass achievement on VCE (odds ratio, 1.00; 95% confidence interval, 1.00-1.01; P = .077). Stratified subgroup analyses by VIR and VSF cohorts also showed no significant predictive first-attempt VCE pass achievement (P = .190 and P = .094, respectively). ConclusionsIn this national cohort of vascular trainees taking the VQE and VCE, VQE performance was not predictive of subsequent VCE first-time pass achievement. This finding highlights the necessity to identify other measures of trainee competence to indicate the preparedness of trainees for board certification examinations. Furthermore, this may be reflective of the ability to assess distinctive competencies between the two examinations, with the VQE focused on medical knowledge and the VCE on clinical judgment and interpersonal communication skills, thus broadening assessment of the Accreditation Council for Graduate Medical Education core competencies to ensure certification of vascular surgeons possessing both the knowledge and judgment necessary to maintain high-quality standards within our specialty.

Teaching Frailty to Medical Residents: A Needs Assessment Among Geriatrics Faculty.

Knowledge of frailty is essential for meeting the Accreditation Council for Graduate Medical Education core competencies for US trainees. The UK General Medical Council requires that frailty be included in undergraduate and graduate medical education curricula. Trainees are expected to appropriately modify care plans and help make patient-centered decisions, while incorporating diagnostic uncertainty, such as frailty, in older adults. Little is known about current needs for frailty instruction in graduate medical education in the US and beyond. We sought to capture faculty perceptions on how frailty should be defined and identified, and what aspects and level of detail should be taught to residents. The authors developed a 4-item short response questionnaire, and faculty had the option to respond via electronic survey or via semi-structured interviews. Respondents included 24 fellowship-trained geriatricians based at 6 different academic medical centers in a single urban metropolitan area. An invitation to participate in either an electronic survey or semi-structured virtual interview was e-mailed to 30 geriatricians affiliated with an academic multi-campus Geriatric Medicine fellowship. Responses were transcribed and coded independently by two authors. Responses were received from 24 geriatricians via a combination of digital questionnaires (n=18) and semi-structured online interviews (n=6), for a response rate of 80%. Responses revealed significant diversity of opinion on how to define and identify frailty and how these concepts should be taught. As frailty is increasingly incorporated into clinical practice, consensus is needed on how to define and teach frailty to residents.

Virtual Learning and Assessment in Rheumatology Fellowship Training: Objective Structured Clinical Examination Revisited.

With the onset of the COVID-19 pandemic, an annual multi-institutional face-to-face rheumatology objective structured clinical examination (ROSCE) was transformed into a virtual format. The educational goals of the virtual ROSCE (vROSCE) were to reproduce the educational value of the previous in-person ROSCE, providing a valuable formative assessment of rheumatology training activities encompassing the 6 Accreditation Council for Graduate Medical Education (ACGME) core competencies for fellows-in-training (FITs). This article describes the novel design, feasibility, and stakeholder value of a vROSCE. Through an established collaboration of 5 rheumatology fellowship training programs, in February 2021, a vROSCE was created and conducted using a Zoom platform. Station development included learning objectives, FIT instructions, faculty proctor instructions, and a checklist by which to provide structured formative feedback. An anonymous, optional web-based survey was sent to FIT participants to evaluate the experience. Twenty-three rheumatology FITs from 5 institutions successfully rotated through 6 stations in the vROSCE. Immediate feedback was given to each FIT using standardized rubrics structured around ACGME core competencies. A total of 65% of FITs (15 of 23) responded to the survey, and 93% of survey respondents agreed or strongly agreed that the vROSCE was a helpful educational activity and identified individualized opportunities for improvement. A vROSCE is an innovative, feasible, valuable, and well-received educational technology tool. The vROSCE enriched rheumatology FITs' education and offered collaborative learning experiences across institutions.

Acute Pulmonary Edema and NSTEMI.

Emergency medicine residents and medical students on emergency medicine rotation. Acute pulmonary edema is a common and potentially fatal presentation in the emergency department. More than 1 million patients are admitted annually with a diagnosis of pulmonary edema secondary to cardiac causes.1 Pulmonary edema is broadly split into two main categories: cardiogenic and noncardiogenic. Cardiogenic pulmonary edema is characterized by acute dyspnea caused by the accumulation of fluid within the lung's interstitial and/or alveolar spaces, which is the result of acutely elevated cardiac filling pressures.2 Noncardiogenic pulmonary edema is characterized by fluid accumulation within the alveolar space in the absence of elevated pulmonary capillary wedge pressure.2 These patients often present critically ill, and rapid identification and aggressive management is paramount in caring for patients with pulmonary edema. Dyspnea is the most common presentation with a sensitivity of 89% but a low specificity of 51%.3 Workup of pulmonary edema often includes laboratory testing, electrocardiogram (EKG), chest x-ray (CXR), and often bedside ultrasound (US) and echocardiography.4 Pulmonary edema management depends on the etiology but is often focused on preload and afterload reduction. Diuretics, nitrates, and optimizing ventilatory support through non-invasive and invasive strategies are the mainstay of treatment. At the end of this practice oral boards case, the learner will:1) recognize unstable vital signs (VS) and intervene to stabilize ventilation and oxygenation, 2) demonstrate the ability to obtain a complete medical history including the important characteristics of chest pain, 3) demonstrate an appropriate exam on a patient, 4) order the appropriate evaluation studies for a patient with complaints of dyspnea, 5) interpret the results of diagnostic evaluation and diagnose Non- ST elevation myocardial infarction (NSTEMI) and pulmonary edema, 6) order appropriate management of pulmonary edema and NSTEMI, and 6) demonstrate effective communication with patient and family members. Practice oral boards. Immediate Feedback was solicited from the learners and observers participating in the case both by verbal discussion and completion of a rating for the case following the debriefing. The efficacy of the educational content was assessed by comparing scoring measures across residents based on the training year. Scoring measures of the American College of Graduate Medical Education (ACGME) core competencies were performed using a scale from 1 - 8, 1-4 being unacceptable performance and 5 - 8 being acceptable. Efficacy was assumed based on full completion of the case by the residents who acted as practice oral board candidates, and a debriefing session followed to discuss the key components of the case. This case was presented to twelve Emergency Medicine Residents, seven PGY 1 and five PGY 2 at a relatively new residency program. The overall average score for the residents was 5.62. The PGY 1 Residents' average on the case was 5.56, and the average for the PGY 2 Residents was slightly better at 5.70. The slight improvement noted by the PGY 2 Residents is likely attributable to more clinical experience; however, both classes did not have any prior exposure to the oral board format until this simulated experience. Six residents completed all critical actions in the case. Of those who missed a critical action, failing to diagnose NSTEMI and consulting cardiology were the most common. All learners found educational value in the case with an overall rating of 4.83 (1-5 Likert scale, 5 being excellent). Acute pulmonary edema and NSTEMI are common diagnoses that will be frequently encountered for most emergency physicians. This case highlights the need for early identification and aggressive management of the patient presenting with respiratory distress. The differential for respiratory distress is large, but most learners were able to quickly identify pulmonary edema based on the exam findings of jugular vein distention (JVD), rales, and lower extremity edema. Most learners quickly escalated to a non-rebreather mask and ultimately to BPAP (bilevel positive airway pressure) without requesting to intubate the patient. There was notable variation in the approach to administering nitrates, but most ordered an intravenous (IV) nitroglycerin (NTG) drip and requested pharmacy assistance in dosing. Diuretics were ordered by all the learners, but some were hesitant to start early because they felt the effect would be delayed. Some of the residents did not identify ischemic changes on the EKG at first glance but did request to review a second time when the troponin result was positive. All residents gave aspirin after noting the positive troponin, but not all were able to make a clear diagnosis of NSTEMI or consult cardiology. Although the case was relatively straightforward, residents enjoyed early diagnosis and aggressive management of the patient with impending respiratory failure. Many residents are asking for an ultrasound early in the workup of this patient presenting in respiratory distress. Although not a critical action in this case, it highlights the emphasis placed on ultrasonography in the current emergency medicine curriculum. Pulmonary Edema, Cardiovascular emergencies, NSTEMI.

The Role of Graduate Medical Education in the Fight Against Health Misinformation.

The Role of Graduate Medical Education in the Fight Against Health Misinformation.

The Association Between USMLE Step 2 Clinical Knowledge Scores and Residency Performance: A Systematic Review and Meta-Analysis.

With the change in Step 1 score reporting, Step 2 Clinical Knowledge (CK) may become a pivotal factor in resident selection. This systematic review and meta-analysis seeks to synthesize existing observational studies that assess the relationship between Step 2 CK scores and measures of resident performance. The authors searched MEDLINE, Web of Science, and Scopus databases using terms related to Step 2 CK in 2021. Two researchers identified studies investigating the association between Step 2 CK and measures of resident performance and included studies if they contained a bivariate analysis examining Step 2 CK scores' association with an outcome of interest: in-training examination (ITE) scores, board certification examination (BCE) scores, select Accreditation Council for Graduate Medical Education (ACGME) core competency assessments, overall resident performance evaluations, or other subjective measures of performance. For outcomes that were investigated by 3 or more studies, pooled effect sizes were estimated with random-effects models. Among 1,355 potential studies, 68 met inclusion criteria and 43 were able to be pooled. There was a moderate positive correlation between Step 2 CK and ITE scores (0.52, 95% CI 0.45-0.59, P < .01). There was a moderate positive correlation between Step 2 CK and ITE scores for both nonsurgical (0.59, 95% CI 0.51-0.66, P < .01) and surgical specialties (0.41, 95% CI 0.33-0.48, P < .01). There was a very weak positive correlation between Step 2 CK scores and subjective measures of resident performance (0.19, 95% CI 0.13-0.25, P < .01). This study found Step 2 CK scores have a statistically significant moderate positive association with future examination scores and a statistically significant weak positive correlation with subjective measures of resident performance. These findings are increasingly relevant as Step 2 CK scores will likely become more important in resident selection.

Competency-Based Frameworks in Medical School Education Programs: A Thematic Analysis of the Academic Medicine Snapshots, 2020.

Educational program objectives (EPOs) provide the foundation for a medical school's curriculum. In recent years, the Liaison Committee on Medical Education (LCME) endorsed an outcomes-based approach to objectives, to embrace the movement toward competency-based medical education (CBME). The purpose of this study was to explore the CBME frameworks used by medical schools in formulating their EPOs. A secondary aim was to determine factors related to the selection of specific frameworks. The authors performed a quantitative content analysis of entries to the 2020 Academic Medicine Snapshot. Publicly available data gathered included demographic features of each program (e.g., year founded, accreditation status, affiliation, etc.), participation in national medical education consortia, and presence of specific CBME frameworks identified in EPOs. Descriptive statistics were used to examine trends in frameworks used by medical schools. Bivariate comparisons between factors and frameworks were conducted using chi-square tests. Logistic regression was used to examine factors predicting use of more recently developed CBME frameworks. A total of 135 institutions submitted Snapshots (RR = 88%). All institutions endorsed 1 or more CBME frameworks, with 37% endorsing 2 and 20% endorsing 3 or more. The most common was the Accreditation Council for Graduate Medical Education core competencies (63%). In addition to published frameworks, 36% of institutions developed their own competencies. Schools with pending LCME visits were 2.61 times more likely to use a more recently developed curricular framework, P = .022. Medical schools in the United States have embraced the CBME movement through incorporation of competency-based frameworks in their EPOs. While it is encouraging that CBME frameworks have been integrated in medical school EPOs, the variability and use of multiple frameworks identifies the pressing need for a unified CBME framework in undergraduate medical education.

Developing Medical Student Competencies, Clinical Skills, and Self-Efficacy With an Emergency Medical Responder Certification Course

IntroductionPrevious studies have claimed gap year clinical experiences before medical school matriculation increase student self-efficacy and clinical confidence. At the University of Central Florida College of Medicine, 41 first-year medical students participated in a new certification course to become emergency medical responders before beginning their coursework. This study describes the results of a follow-up study that aims to investigate the impact the course had on student competency, self-efficacy, and clinical efficacy and if the course would prepare students similarly to previous clinical experience.MethodsFirst-year medical students completed a 30-question survey consisting of a Likert scale and free-response questions. Questions were based on the Accreditation Council for Graduate Medical Education core competencies: medical knowledge, practice-based learning and improvement, systems-based practice, patient care, professionalism, and interpersonal and communication skills. Questions on the perceived benefit of the emergency medical responder course and previous clinical experiences were also included. Responses were separated based on participation in the emergency medical responder course and prior clinical experience. Two-tail Welch’s t-tests were performed on the data to determine significance.ResultsOf 98 responses: 20.4% (20/98) of participants of the emergency medical responder course had previous clinical experience, 21.5% (21/98) of participants of the course had no clinical experience, 26.5% (26/98) did not participate in the course but had previous clinical experience, and 31.6% (31/98) did not participate in the course nor had previous clinical experience. Students with previous clinical experience reported the emergency medical responder course improved both their patient care skills and performance in courses that emphasized patient interviewing and physical exams. Students with clinical experience had significantly higher medical knowledge (p < 0.1) and professionalism (p < 0.1) Likert scores. Eighty-seven percent of students agreed the course had a positive impact on their patient care skills.ConclusionLarger sample size is needed to make stronger conclusions; however, the responses show the emergency medical responder course had a positive subjective impact on students with previous medical experience. Previous clinical experience leads to the most positive subjective reporting of competencies such as medical knowledge and professionalism. Early clinical exposure, such as an emergency medical responder certification course, may improve self-efficacy and patient care skills for medical students with no previous clinical experience.

Nontechnical skills for the surgery clerkship in the operating room based on adult learning principles in Taiwan.

Medical education has traditionally been rooted in the teaching of medical knowledge and surgical technique in the operating room, with little attention to the nontechnical skills (NTS) that include situational awareness, decision-making, teamwork and communication, and leadership. Under the guidance of adult learning principles, the aim of this study is to evaluate the learning outcomes of the NTS program for the surgery clerkship in the operation room in Taiwan. Self-directed learning principles were practiced during this 2-week subspecialty rotation. The learners were randomly divided into two groups: the control group (the learners and teachers deciding together what should be learnt) and the intervention group (the same as the control group and the formal NTS program implemented during the second week). A 12-item quantitative questionnaire including both the 6-item Accreditation Council for Graduate Medical Education (ACGME) Core Competencies and the 6-item adult learning characteristics was completed twice: before and after rotation. From Oct 2020 to May 2021, 16 medical students received NTS training and 16 were training-naïve. For those undergoing NTS training, six core competencies significantly improved on a 6-point scale. Moreover, total score differences (post-training - pre-training) in core competency had significant correlations to the differences in adult learning characteristics (r=0.648, p=0.007). The NTS program could be feasibly integrated into core objectives of the basic surgical clerkships, with the improvement in adult learning motivation in the learners helping to facilitate NTS training under the competency-based surgical training program.

Association Between Resident Race and Ethnicity and Clinical Performance Assessment Scores in Graduate Medical Education.

To assess the association between internal medicine (IM) residents' race/ethnicity and clinical performance assessments. The authors conducted a cross-sectional analysis of clinical performance assessment scores at 6 U.S. IM residency programs from 2016 to 2017. Residents underrepresented in medicine (URiM) were identified using self-reported race/ethnicity. Standardized scores were calculated for Accreditation Council for Graduate Medical Education core competencies. Cross-classified mixed-effects regression assessed the association between race/ethnicity and competency scores, adjusting for rotation time of year and setting; resident gender, postgraduate year, and IM In-Training Examination percentile rank; and faculty gender, rank, and specialty. Data included 3,600 evaluations by 605 faculty of 703 residents, including 94 (13.4%) URiM residents. Resident race/ethnicity was associated with competency scores, with lower scores for URiM residents (difference in adjusted standardized scores between URiM and non-URiM residents, mean [standard error]) in medical knowledge (-0.123 [0.05], P = .021), systems-based practice (-0.179 [0.05], P = .005), practice-based learning and improvement (-0.112 [0.05], P = .032), professionalism (-0.116 [0.06], P = .036), and interpersonal and communication skills (-0.113 [0.06], P = .044). Translating this to a 1 to 5 scale in 0.5 increments, URiM resident ratings were 0.07 to 0.12 points lower than non-URiM resident ratings in these 5 competencies. The interaction with faculty gender was notable in professionalism (difference between URiM and non-URiM for men faculty -0.199 [0.06] vs women faculty -0.014 [0.07], P = .01) with men more than women faculty rating URiM residents lower than non-URiM residents. Using the 1 to 5 scale, men faculty rated URiM residents 0.13 points lower than non-URiM residents in professionalism. Resident race/ethnicity was associated with assessment scores to the disadvantage of URiM residents. This may reflect bias in faculty assessment, effects of a noninclusive learning environment, or structural inequities in assessment.

Pediatric Emergency Medicine Fellowship Procedural Sedation Training: Consensus Educational Guidelines.

Pediatric procedural sedation (PPS) is a core clinical competency of pediatric emergency medicine (PEM) fellowship training mandated by both the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. Neither of these certifying bodies, however, offers specific guidance with regard to attaining and evaluating proficiency in trainees. Recent publications have revealed inconsistency in educational approaches, attending oversight, PPS service rotation experiences, and evaluation practices among PEM fellowship programs. A select group of PEM experts in PPS, PEM fellowship directors, PEM physicians with educational roles locally and nationally, PEM fellows, and recent PEM fellowship graduates collaborated to address this opportunity for improvement. This consensus driven educational guideline was developed to outline PPS core topics, evaluation methodology, and resources to create or modify a PPS curriculum for PEM fellowship programs. This curriculum was developed to map to fellowship Accreditation Council for Graduate Medical Education core competencies and to use multiple modes of dissemination to meet the needs of diverse programs and learners. Implementation and utilization of a standardized PPS curriculum as outlined in this educational guideline will equip PEM fellows with a comprehensive PPS knowledge base. Pediatric emergency medicine fellows should graduate with the competence and confidence to deliver safe and effective PPS care. Future study after implementation of the guideline is warranted to determine its efficacy.

Effect of resident and assessor gender on entrustment-based observational assessment in an internal medicine residency program

Background: Implicit gender bias leads to differences in assessment. Studies examining gender differences in resident milestone assessment data demonstrate variable results. The purpose of this study was to determine if observational entrustment scores differ by resident and assessor gender in a program of assessment based on discrete, observable skills. Methods: We analyzed overall entrustment scores and entrustment scores by Accreditation Council for Graduate Medical Education (ACGME) core competency for 238 residents (49% female) from 396 assessors (38% female) in one internal medicine residency program from July 2012 to June 2019. We conducted analyses at 1-12 months, 1-36 months, 1-6 months, 7-12 months, and 31-36 months. We used linear mixed-effect models to assess the role of resident and assessor gender, with resident-specific and assessor-specific random effect to account for repeated measures. Results: Statistically significant interactions existed between resident and assessor gender for overall entrustment at 1-12 months (p &lt; 0.001), 1-36 months (p&lt; 0.001), 1-6 months (p&lt;0.001), 7-12 months (p=0.04), and 31-36 months (p&lt;0.001). However, group differences were not statistically significant. In several instances an interaction was significant between resident and assessor gender by ACGME core competency, but there were no statistically significant group differences for all competencies at any time point. When applicable, subsequent analysis of main effect of resident or assessor gender independently of one another revealed no statistically significant differences. Conclusions: No significant differences in entrustment scores were found based on resident or assessor gender in our large, robust entrustment-based program of assessment. Determining the reasons for our findings may help identify ways to mitigate gender bias in assessment.

Efficacy of an Online Blended Learning Curriculum to Improve Medical Student Urologic Education.

ObjectiveDuring the COVID-19 pandemic, limitations on in-person medical school clerkships created a deficit in urologic learning opportunities. We sought to develop and evaluate a blended curriculum of interactive online modules with small-group discussion to enhance the educational experience for medical students in urology.Materials and MethodsWe created a curriculum of four online case-based urology modules. Between July and October 2020, 14 fourth-year medical students completed the modules. Students answered questions on a discussion board and engaged in asynchronous dialogue with 16 physicians, in addition to a weekly live review session. Students and physicians completed anonymous surveys to assess satisfaction and perceived learning outcomes, with questions scored on a 5-point Likert scale.ResultsThirteen students (93% response rate) and 12 physicians (75% response rate) completed the survey. Overall, 12/13 students and 11/12 physicians “strongly agree” or “somewhat agree” that the modules improved the rotation. Students and physicians perceived that the modules were effective for learning/teaching foundational knowledge (average ratings 4.8 and 4.5, respectively) and facilitating performance assessment (4.4 and 4.0). Students reported high learning scores across multiple Accreditation Council for Graduate Medical Education core competencies, and 12/13 students found the modules fun/engaging. The majority of students (12/13) and physicians (10/12) felt that the online modules should be incorporated into future urology electives.ConclusionsA blended learning curriculum utilizing online modules is an effective tool for enhancing urologic education, improving perceived learning outcomes and facilitating performance assessment.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40670-021-01427-3.

Training fellows in neonatal tele-resuscitation using a simulation-based mastery learning model

BackgroundNeonatal tele-resuscitation uses real-time, audio–video telemedicine to connect neonatologists with community hospital care teams during advanced neonatal resuscitations. While telemedicine continues to expand, best practices for training fellows in tele-resuscitation are not known. ObjectiveWe aimed to develop a neonatal tele-resuscitation curriculum using a simulation-based mastery learning model that provides neonatal-perinatal medicine (NPM) fellows with the knowledge, skills, and behaviors needed to lead tele-resuscitations. MethodsUsing technology-enhanced simulation education and a mastery learning model, we developed a longitudinal pilot tele-resuscitation curriculum. From 07/2018 to 03/2021, NPM fellows participated in the curriculum, which included individualized telemedicine learning, observing and leading simulated tele-resuscitations, and finally, performing clinical (non-simulated) tele-resuscitations. A performance assessment tool was developed to assess competency through eight questions mapped to the Accreditation Council for Graduate Medical Education (ACGME) core competencies, with responses on a 1 to 5 scale (1 = critical deficiencies; 5 = competence of an expert). ResultsFour NPM fellows participated in the curriculum, progressing through the curriculum at an individualized pace. Median scores on the three learning modules were 96–100%. Fellows participated in variable number of simulated tele-resuscitations based on when mastery was achieved (2–3 supervised simulations per fellow, 1–4 unsupervised simulations per fellow). In total, eighteen simulated tele-resuscitations (eight unsupervised, 10 supervised) and one clinical tele-resuscitation were conducted. Twenty-five performance assessments were completed. Assessment scores across the ACGME competencies were consistently high, with mean scores ranging from 4.2-4.6, with 4 equating to ‘ready for unsupervised practice’ and 5 equating to ‘competence of an expert’. ConclusionsAs telemedicine use continues to expand, curricula that improve learners’ comfort with and proficiency in tele-resuscitation are essential. A simulation-based mastery learning model may be one approach that affords learners gradual exposure to and mastery of complex tele-resuscitation skills and behaviors.

Development and Implementation of an Online Virtual Teaching Curriculum for the Continuity of Undergraduate Medical Education in Surgical Anatomy.

Despite the significant reform medical education has witnessed over the past decade,1,2 the coronavirus disease of 2019 (COVID-19) pandemic has kindled change that will persist for generations to come.3 Recommendations recently made by the Association of American Medical Colleges have advocated for the withdrawal of medical students from all clinical rotations at the height of the COVID-19 pandemic, and, more recently, for the cancellation of all in-person visiting rotations.3,4 In response, plastic surgeons have continued to innovate and address these educational challenges. The American Society of Plastic Surgeons now provides interested medical students with free access to its online Education Network, a program that offers over 90 educational modules on an array of essential plastic surgery topics.3 A recent report in the Journal describes the development of virtual plastic surgery subinternships for senior medical students unable to complete in-person rotations, with objectives that remain in line with Accreditation Council for Graduate Medical Education core competencies.4 However, and despite these notable efforts, there remains a paucity of attention targeted toward the continuity of medical education in surgical anatomy, a topic that remains particularly relevant as an essential competency for senior medical students before beginning postgraduate training in plastic surgery. To address this educational disparity, our group developed and implemented an online virtual anatomy teaching curriculum designed to help keep medical students up to date, prepared, and on-track for surgical rotations ahead. Topics covered thus far include the thorax, brachial plexus, forearm, hand, anterior abdominal wall, back, and lower extremity, with upcoming sessions scheduled for head and neck, craniofacial, intraabdominal, and pelvic anatomy. These sessions were designed not to replace core anatomy teaching, but rather to help reinforce essential concepts and discuss different surgical techniques, medical abnormalities, and clinically relevant variations, thus simulating and complementing intraoperative and clinical learning. [See Video (online), which shows a short segment from a breast anatomy lecture (image courtesy of Jad Abi-Rafeh).] Our initiative has so far amassed interest from 227 medical students; the majority of them (80 percent) are in their second and third years of medical training. Most recently, 68 percent of participants attended from our local institution, with the remainder representing local and international trainees from the United States, Canada, Mexico, Colombia, Indonesia, and The Netherlands. With the support of Plastic and Reconstructive Surgery’s social medial channels, interest from international attendees continues to grow. Through before-and-after tests administered to participants, a significant improvement in average test scores was observed following virtual learning (from 46 percent to 76 percent; p < 0.05), with retention of knowledge subsequently established at 2-week follow-up. All sessions are recorded in real time and remain available for future reference by all participants. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video.","caption":"This video shows a short segment from a breast anatomy lecture (image courtesy of Jad Abi-Rafeh).","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_syjxjg45"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} The role of virtual teaching resources in plastic surgery education continues to grow, with notable advantages established for both trainees and educators alike.3 Advancements in the field of simulation and virtual teaching in plastic surgery have complemented timely transitions to competency-based training curricula.5 Plastic surgeons must continue innovating and responding to evolving educational challenges to help foster excellence in our field. Thus, it is the authors’ wish that through this correspondence, the validity, efficacy, and reliability of virtual training platforms in surgical education is demonstrated, to help address evolving educational challenges and training the next generation of surgeons, during the time of the COVID-19 pandemic, and beyond. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No funding was received for this work. Jad Abi-Rafeh, M.Sc.Faculty of Medicine Tyler Safran, M.D.Mirko S. Gilardino, M.D., M.Sc.Division of Plastic and Reconstructive SurgeryMcGill UniversityMontreal, Quebec, Canada

To the Editor: Holistic Assessment of Research Accolades in Medical Trainees.

The article “Reporting of USMLE Step 1 as Pass/Fail: A Benefit for Residency Programs and Those Underrepresented in Medicine?” evoked our interest.1 The authors describe the potential benefits of the United States Medical Licensing Examination (USMLE) Step 1 transitioning to a pass/fail examination for students underrepresented in medicine (UiM). No longer relying on an applicant's USMLE Step 1 score for screening purposes may emphasize holistic review of their residency application; however, the authors comment on the potential for other traditional metrics (ie, a 3-digit USMLE Step 2 score or number of authored publications) to take the place of a pass/fail USMLE Step 1 examination. We wish to further challenge the residency application process on its use of research accolades for candidate assessment following this transition.The number of publications by residency applicants has steadily increased in some specialties—what Wadhwa et al called the applicant's “arms race.”2 Without a 3-digit USMLE Step 1 score, an applicant's research accolades will heavily factor into the calculus of their clinical potential in the eyes of the residency program director. This is especially poignant considering program directors must look for proxies for USMLE Step 1 scores, and prior research has linked scholarly productivity with future academic achievement.3 Will the inability to be categorized by score result in further inflation of residency program research requirements?The added pressure to begin searching earlier for extracurricular projects, especially those that will result in publication, may have unforeseen consequences to those UiM applicants. For example, the increased weight on research experience in an applicant's assessment may disadvantage UiM students from schools without progressive curricula that allow longitudinal research experience, a factor known to increase the rate of first authorship.4 Considering the lack of diversity in the medical workforce mentioned by Romero et al, physicians UiM may not be easily accessible as research mentors for applicants UiM seeking mentor congruency. Lastly, consider that extra emphasis on performing research will result in time lost to other important activities for the physician-in-training, such as studying, volunteering, advocacy projects, and self-care.In their holistic review of applicants, we urge residency programs to seek value in research experiences that do not result in abstracts, presentations, or publication—the current currency of academia. The very qualities that a robust research experience affords an applicant are qualities that sometimes may not even be developed without a “failed” experience: resilience, self-reflection, and perseverance, to name a few. While research that results in publication and/or presentation should continue to be rewarded, a research experience without either to show for it should be given a ladder to stand on in comparison.Institutions with a strong focus on recruiting academically productive residents from all backgrounds may be benefited by creating a deliberate space in the application process for reflection on the qualities an applicant has developed in the process of unfinished projects. For example, programs may standardize asking: How many research projects have gone according to plan? What was learned from a failed project, and how will you avoid similar difficulties as a future physician-scientist? Similar questions asked could help to base admissions decisions on personal attributes, rather than maintaining medical education prestige hierarchies related to research funding.5 Furthermore, encouraging reflection on research failure would help illustrate an applicant's ability to investigate, evaluate, and improve their patient care practices, part of the 6 Accreditation Council for Graduate Medical Education core competencies.

To the Editor: Professionalism in Residency Feedback.

A slew of negative reviews, mostly in the form of complaints on the emergency medicine (EM) monthly rotation evaluations, has been an early warning sign to us that our residency culture is threatened. A culture of complaining poses not only an immediate risk to the work environment of the emergency department, but also a longer-range risk to the development and application of the Accreditation Council for Graduate Medical Education (ACGME) core competency and subsequent subcompetencies in professionalism. As a soon-to-be graduating resident who will be pursuing a fellowship in administration in similar teaching hospitals, and a current core faculty member in EM, the topics of culture and how culture change can influence the acquisition of the ACGME core competencies in medical training are of keen interest to us. Therefore, we found the article by Seehusen, “Understanding Unprofessionalism in Residents,” to be highly relevant to this quandary.1Seehusen provides 3 main questions to guide a program toward the underlying cause of a fallout in professionalism. The question most salient to our situation and most easily answered is: “Does the resident understand professional expectations?” In our case, we are using the overall tone of recent evaluations as guiding feedback that many residents do not understand each component of this expectation, particularly as it refers to the ACGME definitions of professional accountability and continued professional growth. Seehusen reasons that professionalism is a learned skill, so residents “cannot be expected to be fully proficient in professional behaviors.”1 Therefore, it seems reasonable that to foster a more concrete sense of accountability and professional growth, the question wording on the EM evaluation should be reviewed and modified to encourage more solution-oriented responses.Although data are sparse, studies do show that changing the wording of questionnaires can result in an overall increase in the number of comments and obtainable action items, as well as a modulatory effect in valence (from negative to positive for example).2,3 One study even showed that modification in how an evaluation was worded in the context of descriptive systems can lead to positive physical changes in health utility.4The language of an evaluation carries powerful implications, and we believe that changing the wording of our EM rotation evaluation will help to make the professionalism expectations more apparent as suggested by Seehusen, improving evaluation scores, and fundamentally, the EM rotation.

Gender bias in resident evaluations: Natural language processing and competency evaluation.

Research shows that female trainees experience evaluation penalties for gender non-conforming behaviour during medical training. Studies of medical education evaluations and performance scores do reflect a gender bias, though studies are of varying methodology and results have not been consistent. We sought to examine the differences in word use, competency themes and length within written evaluations of internal medicine residents at scale, considering the impact of both faculty and resident gender. We hypothesised that female internal medicine residents receive more negative feedback, and different thematic feedback than male residents. This study utilised a corpus of 3864 individual responses to positive and negative questions over the course of six years (2012-2018) within Yale University School of Medicine's internal medicine residency. Researchers developed a sentiment model to assess the valence of evaluation responses. We then used natural language processing (NLP) to evaluate whether female versus male residents received more positive or negative feedback and if that feedback focussed on different Accreditation Council for Graduate Medical Education (ACGME) core competencies based on their gender. Evaluator-evaluatee gender dyad was analysed to see how it impacted quantity and quality of feedback. We found that female and male residents did not have substantively different numbers of positive or negative comments. While certain competencies were discussed more than others, gender did not seem to influence which competencies were discussed. Neither gender trainee received more written feedback, though female evaluators tended to write longer evaluations. We conclude that when examined at scale, quantitative gender differences are not as prevalent as has been seen in qualitative work. We suggest that further investigation of linguistic phenomena (such as context) is warranted to reconcile this finding with prior work.