Systems-based Practice Research Articles

Navigating the Roadmap for Trauma-Informed Medical Education: Application of Undergraduate Medical Education Competencies.

Trauma is common in the United States, increases risk of long-term adverse health effects, and individuals who experience it often find seeking medical care difficult. Trauma-informed care (TIC) builds trust and fosters healing relationships between clinicians and patients; however medical education has lacked consistent training in TIC. Using recently published competencies for undergraduate medical education (UME), this manuscript provides curricular examples across 8 domains to assist faculty in developing educational content. The authors identified published curricula for each of the 8 competency domains using a published search strategy and publicly available database. Inclusion criteria were published works focused on UME in the United States; abstracts and curricula not focused on UME were excluded. The authors used a consensus-based process to review 15 eligible curricula for mapping with the competencies. Of 15 published UME curricula, 11 met criteria and exemplify each of the 8 UME competency domains. Most of the available curricula fall into the Knowledge for Practice and Patient Care domains. Most were offered in the first 2 years of medical school. Competency-based medical education for TIC is new, and most current educational offerings are foundational in nature. Additional innovation is needed in the competency domains of Professionalism, Systems-Based Practice, Interprofessional Collaboration, and Personal/Professional Development. This manuscript offers a set of curricular examples that can be used to aid efforts at implementing TIC competencies in UME; future work must focus on improving assessment methods and developmental sequencing as more students are exposed to TIC principles.

Systems-Based Practice 20 Years On: Navigating the System for Better Care.

Systems-based practice (SBP) was introduced as 1 of 6 core competencies in 1999 because of its recognized importance in the quality and safety of health care provided to patients. Nearly 25 years later, faculty and learners continue to struggle with understanding and implementing this essential competency, thus hindering the medical education community's ability to most effectively teach and learn this important competency.Milestones were first introduced in 2013 as one effort to support implementation of the general competencies. However, each specialty developed its milestones independently, leading to substantial heterogeneity in the narrative descriptions of competencies including SBP. The process to create Milestones 2.0, and more specifically, the Harmonized Milestones, took this experience into account and endeavored to create a shared language for SBP across all specialties and subspecialties. The 3 subcompetencies in SBP are now patient safety and quality improvement, systems-navigation for patient-centered care (coordination of care, transitions of care, local population health), and physician's role in health care systems (components of the system, costs and resources, transitions to practice). Milestones 2.0 are also now supported by new supplemental guides that provide specific real-world examples to help learners and faculty put SBP into the context of the complex health care environment.While substantially more resources and tools are now available to aid faculty and to serve as a guide for residents and fellows, much work to effectively implement SBP remains. This commentary will explore the evolutionary history of SBP, the challenges facing implementation, and suggestions for how programs can use the new milestone resources for SBP. The academic medicine community must work together to advance this competency as an essential part of professional development.

Assessing Pediatric Rheumatology Fellow Competence in the Milestone Era: Past, Present, and Future.

Starting in 2015, pediatric rheumatology fellowship training programs were required by the Accreditation Council for Graduate Medical Education to assess fellows' academic performance within 21 subcompetencies falling under six competency domains. Each subcompetency had four or five milestone levels describing developmental progression of knowledge and skill acquisition. Milestones were standardized across all pediatric subspecialties. As part of the Milestones 2.0 revision project, the Accreditation Council for Graduate Medical Education convened a workgroup in 2022 to write pediatric rheumatology-specific milestones. Using adult rheumatology's Milestones 2.0 as a starting point, the workgroup revised the patient care and medical knowledge subcompetencies and milestones to reflect requirements and nuances of pediatric rheumatology care. Milestones within four remaining competency domains (professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice) were standardized across all pediatric subspecialties, and therefore not revised. The workgroup created a supplemental guide with explanations of the intent of each subcompetency, 25 in total, and examples for each milestone level. The new milestones are an important step forward for competency-based medical education in pediatric rheumatology. However, challenges remain. Milestone level assignment is meant to be informed by results of multiple assessment methods. The lack of pediatric rheumatology-specific assessment tools typically result in clinical competency committees determining trainee milestone levels without such collated results as the foundation of their assessments. Although further advances in pediatric rheumatology fellowship competency-based medical education are needed, Milestones 2.0 importantly establishes the first pediatric-specific rheumatology Milestones to assess fellow performance during training and help measure readiness for independent practice.

Optimizing care for patients with infectious diseases: Roles of emergency medical services and nursing

Background: Internal medicine (IM) and its subspecialties have seen a shift in care delivery, increasingly relying on nonphysician practitioners (NPPs) such as nurse practitioners (NPs) and physician assistants (PAs). This article focuses on the development of a curriculum and competency framework for advanced care practitioners (ACPs) specializing in infectious diseases (ID). Aim: To establish a comprehensive competency-based education (CBE) model for NPs and PAs in ID, aiming to enhance their skills and optimize patient care. Methods: The framework incorporates six core competencies endorsed by various regulatory and professional organizations. An interprofessional approach was utilized to develop a curriculum that addresses the educational needs of ACPs in ID practice, along with assessing Entrustable Professional Activities (EPAs). Results: The proposed guidelines outline specific clinical responsibilities and milestones for ACPs over a one-year training period. This structured approach ensures that ACPs develop competencies in patient care, medical knowledge, interpersonal skills, professionalism, and systems-based practice, allowing them to effectively manage common and complex infectious diseases. Conclusion: The integration of ACPs into infectious disease practice is vital for enhancing patient care and alleviating resident workload.

Inclusion of systems-based practice in medical education: Is it a necessity?

Abstract: Systems-based practice (SBP) is a core competency that concentrates on the foundation of health care in good medical practice. It is to be aware of the systems in which we work and to make sure to achieve the maximum outcome response in our work by remaining in the system. Compared to medical schools, fellowship programs are active in developing and evaluating SBP curricula. The Graduate Medical Education Regulation-2019 describes competency-based learning which includes designing and implementing a medical education curriculum that focuses on the desired and observable ability in real-life situations. For achieving good patient care, good medical practice is a requirement. For attaining optimal medical practice, it is important to understand how one functions within the system as a whole and how one’s actions affect all other aspects of the system. The graduating residents immediately start participating in the health-care system as a whole. Therefore, residents must be aware of the health-care systems in which they have to operate and also have the ability to provide high-quality, cost-effective medical care to the patients with the available resources. These residents should have enough exposure to SBP to efficiently work in a team. Competency-based medical education should include SBP as a competency where doctors would understand what is happening to the health-care system in which they practice, why the system is changing so rapidly, and what they can do about it.

Fostering Proficiency in Essential Skills among Emergency Medicine Residents through Simulation-Based Education

Introduction: Simulation-based education has become a crucial element within emergency medicine (EM) residency programs. Medical education places great emphasis on competency-based assessments, and high-fidelity simulation has emerged as an effective methodology to support these assessments. Objective: The Accreditation Council for Graduate Medical Education (ACGME) defines a set of core competencies that healthcare professionals must acquire to ensure the delivery of safe and effective patient care. In our study, we sought to investigate the impact of simulation-based education on the enhancement of ACGME core competencies among emergency medicine residents. Method: We conducted a prospective observational study at our institute, involving all current EM residents. Each month, we conducted a high-fidelity immersive simulation session, featuring three separate scenarios for both first year (R1) and second year (R2) residents. From August 2020 to April 2023, a total of 36 simulation sessions were conducted, encompassing 108 scenarios. To assess performance in clinical and non-technical skills, the expert faculty used our custom-designed objective structured assessment tool, the Emergency Medicine Simulation Assessment Tool (EMSAT). This tool evaluated performance across 15 sub-tasks (9 (60%) clinical and 6 (40%) non-technical skills). Each sub-task was mapped to the ACGME core competency; Patient Care (PC), Medical Knowledge (MK), Practice Based Learning (PBL), Systems Based Practice (SBP), Interpersonal and Communication Skills (ICS), and Professionalism (P). The achieved scores for each competency were converted into percentages for analysis. The data was divided into two groups. The first 18 sessions (54 scenarios) formed phase-I, while the last 18 sessions (54 scenarios) constituted phase-II. A two-tailed paired T-test was utilized to compare the two phases. Our primary outcome measure focused on the improvement observed across all six ACGME core competencies. Results: The paired T-test results revealed a significant and substantial difference in all six core competencies between phase-I and phase-II. The mean scores demonstrated a significant improvement between two phases i.e., PC (M=55.1, M=84.4), MK (M=57.2, M=83.6), PBL (M=60.5, M=88.4), SBP (M=62.2, M=89.7), ICS (M=61.8, M=89.7), and P (M=64, M=89.9). Conclusion: The implementation of high-fidelity immersive simulations in the training of emergency medicine residents yielded remarkable advancements across all six ACGME core competencies.

Career perceptions during the COVID-19 pandemic among undergraduate medical students and interns in South India

Introduction: Choosing the appropriate medical specialty as a career is one of the greatest responsibilities of a medical student. This has become a greater challenge in the aftermath of the COVID-19 pandemic. This study aims to find out whether the COVID-19 pandemic has affected the career perceptions of medical students and interns and to find out the factors influencing them. Materials and Methods: This facility-based cross-sectional study was done among medical undergraduate students and interns aged ≥18 years at a private institution. Data were collected using a semi-structured Google Form. Participants were asked to select the first, second, and third preferences of their specialties of interest before and after the onset of the COVID-19 pandemic. Results: The most preferred specialty among participants after surgery and medicine was obstetrics and gynecology before and anatomy after the outbreak of the COVID-19 pandemic. Around 158 (35.2%) participants strongly agreed/agreed that the COVID-19 pandemic had affected their career choices. This was much more significant in participants who were aged ≥23 years, those not planning to go abroad for further studies or employment, local residents, and those currently studying their final year of MBBS. As many as 257 (57.3%) participants strongly disagreed/disagreed that the current online academic training was sufficient to pursue their desired career. Conclusion: Measures need to be taken to enhance the effectiveness of online teaching methods. Career-related counseling services are essential for medical students in the postpandemic era. The following core competencies are addressed in this article: Practice-based learning and improvement, Systems-based practice, and Professionalism.

Knowledge, attitudes, and practices of dentists regarding mucormycosis as a possible orofacial manifestation of COVID-19 in postpandemic times: A cross-sectional study

Introduction: Mucormycosis, also known as black fungus, is a rare but serious fungal infection usually seen in immunocompromised hosts. There are cluster of cases being reported and diagnosed as mucormycosis in treated COVID-19 patients in the postpandemic times. The aim of the present study was to assess awareness among dentists regarding mucormycosis and other possible oral manifestations of COVID-19 in the postpandemic times and the associated complications. Materials and Methods: In the present cross-sectional study, a well-structured questionnaire composed of a total of 17 closed-ended questions was used to cover questions to assess awareness among dentists regarding the possible oral manifestations of post-COVID-19. Furthermore, statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) version 21.0 (IBM, Chicago, IL, USA), while the Chi-square test and Pearson’s correlation coefficient were used to analyze the data statistically. Results: The Chi-square test was used to analyze the association of the knowledge, attitude, and practice scores regarding COVID-19 and the academic qualification of the participants revealed that despite having sufficient information (knowledge and attitude scores), no significant difference (P = 0.7288) was observed in the practices of the participants irrespective of their academic qualification. On analyzing the data further, though, a significant positive correlation was observed between all the components of the knowledge, attitude, and practice scores of the participants (P = 0.0001) using Pearson’s correlation coefficient. Conclusion: From the findings of the present study, it could be concluded that dentists were well aware of the possible oral manifestations of COVID-19, including mucormycosis, though the possibility of increasing awareness among dentists regarding the multidisciplinary approach required for the management of deep fungal infections such as mucormycosis cannot completely be ruled out. The following core competencies are addressed in this article: Practice-based learning and improvement, Patient care and procedural skills, Systems-based practice, Medical knowledge.

The impact of playful titles and posters on learners’ interest in academic sessions: An observational study

Introduction: Academic sessions require active participation and attendance to ensure effective knowledge dissemination. In this context, we aim to investigate the influence of playful titles and posters on learners’ interest in attending educational sessions at our radiology department. Materials and Methods: A questionnaire-based survey was distributed to the department staff gauging their opinions on topics for the grand rounds of the radiology department for the academic year 2021–2022. It contains demographics, responses to “Formal” and “Playful” posters across ten pairs of radiology-related topics, and factors that could affect their attendance. Results: Forty-three department staff participated in the survey, with a mean age of 33 ± 7 years. Participants found the “Playful” posters more amusing compared to “Formal” posters. With the “Playful” posters, there were no significant differences in the agreement levels between the interest in attendance and finding the poster amusing unlike most of the “Formal” posters. There were no significant differences in participants’ interest in attendance between the “Playful” and “Formal” posters. Using linear regression analysis, the “poster interest score” was a statistically significant predictor of the “attendance score” with both styles. However, the “Formal” posters were more appropriate predictors when both analysis models were compared. Sixty-five percent of participants indicated that a topic relevant to their specialty would increase their interest in attendance, with higher agreement in older age groups. In addition, male participants preferred playful titles, those provoking curiosity and utilizing visual aids. Conclusion: The interest in posters is a strong predictor of interest in attendance, with formal posters explaining this relationship better in our cohort. Age and sex influence the preference for title presentation and playful posters. Educators should tailor their educational methods accordingly. The following core competencies are addressed in this article: Interpersonal and communication skills, Medical knowledge, Professionalism, Systems-based practice.

Systems-Based Practice in Graduate Medical Education: Evolving Toward an Ideal Future State.

Systems-based practice (SBP) was first introduced as a core competency in graduate medical education (GME) in 2002 by the Accreditation Council for Graduate Medical Education as part of the Outcomes Project. While inclusion of SBP content in GME has become increasingly common, there have also been well-documented stumbling blocks, including perceptions that SBP has eroded the amount of curricular time available for more medically focused competencies, is not relevant for some practice contexts, and is not introduced early enough in training. As a result, SBP learning experiences often feel disconnected from medical trainees' practical reality. In this commentary, the authors provide guidance regarding potential changes that may facilitate the evolution of SBP toward an ideal future state where graduates bring a systems science mindset to all aspects of their work. Specific suggestions include: (1) expanding the SBP toolbox to reflect current-day health system needs, (2) evolve the teaching methodology, (3) broadening the scope of relevant SBP content areas, and (4) emphasizing SBP as an integrated responsibility for all health care team members. Levers to enact this transformation exist and must be used to influence change at the learner, faculty, program, and clinical learning environment levels.Physicians operate within an increasingly complex health care system that highlights the intersection of health care with complex social, environmental, and relational contexts. Consequently, the role of SBP in both physician work responsibilities and educational requirements continues to expand. To meet this growing demand, GME must adapt how it supports and trains the next generation of systems thinkers, ensuring they understand how levers in the health care system directly affect health outcomes for their patients, and integrate SBP into the foundation of GME curricula in an inclusive, holistic, and unrestrained way.

Modern management of ruptured abdominal aortic aneurysm.

Ruptured abdominal aortic aneurysms (rAAA) remain one of the most clinically challenging and technically complex emergencies in contemporary vascular surgery practice. Over the past 30 years, a variety of changes surrounding the treatment of rAAA have evolved including improvements in diagnosis, development of coordinated referral networks to transfer patients more efficiently to higher volume centers, deliberate de-escalation of pre-hospital resuscitation, modification of patient and procedure selection, implementation of clinical pathways, as well as enhanced awareness of certain high-impact postoperative complications. Despite these advances, current postoperative outcomes remain sobering since morbidity and mortality rates ranging from 25%-50% persist among modern published series. Some of the most impactful variation in rAAA management has been fostered by the rapid proliferation of endovascular repair (EVAR) along with service alignment at selected centers to improve timely revascularization. Indeed, clinical care pathways and emergency response networks are now increasingly utilized which has led to improved outcomes contemporaneously. Moreover, evolution in pre- and post-operative physiologic resuscitation has also contributed to observed improvements in rAAA outcomes. Due to different developments in care provision over time, the purpose of this review is to describe the modern management of rAAA, while providing historical perspectives on patient, procedure and systems-based practice elements that have evolved care delivery paradigms in this complex group of patients.

Systems-Based Practice: Expert Perspectives on the Origin and Evolution of an Ambiguous Competency.

Systems-based practice (SBP) has been a core competency in graduate medical education in the United States since 1999, but it has been difficult to operationalize in residency programs due to its conceptual ambiguity. The authors explored the historical origin and subsequent development of the SBP competency from the perspective of individuals who were influential across critical phases of its implementation and ensuing development. The goal of this study was to elicit the history of SBP from the perspective of individuals who have expertise in it, and to use those findings to inform the current SBP construct. Between March and July 2021, 24 physicians, nurses, educators, and leaders in the field of SBP were individually interviewed about the origin and meaning of SBP as practiced in U.S. medical education using a semistructured guide. Individuals were selected based upon their influence on the origin or evolution of the SBP competency. Data were iteratively collected and analyzed using real-time analytic memos, regular adjudication sessions with the research team, and thematic analysis. Researchers identified themes from participants' perspectives and agreed upon the final results and quotations. Five themes were identified: SBP has many different definitions, SBP was intentionally designed to be vague, systems thinking was identified as the foundation of the SBP competency, the 6 core competencies established in the United States by the Accreditation Council for Graduate Medical Education were developed to be interdependent, and the SBP and practice-based learning and improvement competencies are uniquely related and synergistic. Interview data indicate that since its inception, SBP has been a nuanced and complex competency, resulting in a lack of mutually shared understanding among stakeholders. This deliberate historical examination of expert perspectives provides insight into specific areas for improving how SBP is taught and learned.

Dosimetry and effect of talocrural thrust manipulation on the range of motion in subjects with chronic ankle instability

Introduction: Chronic ankle instability (CAI) is described as the patient’s sense of an abnormal ankle, which is characterized by a combination of symptoms such as recurrent sprains, discomfort, edema, or activity avoidance. Talocrural thrust manipulation (TCTM) is a manual treatment technique that includes applying a manual push to a specific motion segment, often in the form of a joint glide. The study aimed to find out the dosimetry and effect of TCTM on the range of motion (ROM) and quality of life (QoL) in subjects with CAI. Materials and Methods: Forty subjects fulfilling the selection criteria were included in the study, with single group repeated measures design. A talocrural thrust is given to the ankle and outcomes were assessed during 1st week, 2nd week, and 3rd week after the intervention, and the scores were recorded. Results: The group was ranging from 13 to 22, with a mean and standard deviation (SD) of 16.15 ± 2.28. After 1 week, showed an increase in the range of 17–29, with a mean and SD of 22.40 ± 2.75. Similarly, for 2 weeks, the range increased to 24–32 with a mean and SD of 29.53 ± 1.71 after 2 weeks. However, the range was found to have increased to 31–34, with a mean and SD of 32.35 ± 0.70, and found to be statistically significant (P < 0.001). Conclusion: TCTM is effective in improving ROM and QoL in people who have persistent ankle instability. Talocrural thrust manipulation technique stimulates the proprioceptive awareness which is often impaired in chronic instability subjects targeting the joints with specific thrust to treat pain and dysfunction and the consistency of the movement underlying the tissues which is more crucial in identifying the restrictions of the joint. The following core competencies are addressed in this article: Medical knowledge, Patient care, Systems-based practice

Clinical profile of adverse drug reactions in patients admitted to internal medicine wards of a tertiary care hospital

Introduction: Adverse drug reactions (ADRs) are unwanted, often harmful reaction resulting from a pharmacological intervention that warrants treatment, prevention, and future precautions. ADRs are highly prevalent with 10%–20% of patients suffering from one when admitted. The aim of this study was to identify cases and provide data on the incidence, severity, causality, and preventability of ADRs in a clinical setting in various age groups. The study also aimed to identify ADR risk factors which can be used to create ADR risk prediction models for application in everyday clinical practice to proactively detect patients at risk of developing these reactions. Materials and Methods: This was an inpatient, prospective, observational cohort study in the internal medicine ward of a major tertiary care hospital. Once the institutional ethics approval was obtained, patients fulfilling the inclusion criteria were enrolled with informed consent. Their data were recorded in an ADR data form. These data were then analyzed using standardized scales to identify causality, severity, preventability, and avoidability along with specific risk factors and comparing them across age groups and drug classes. Results: One hundred and sixty-four patients were eligible and enrolled. Seventy percent of those suffering from ADRs were in the 30–60 years age group. Oral hypoglycemics and antituberculosis drugs were most commonly implicated, whereas metabolic and hepatic systems were the most frequent organ systems involved. Polypharmacy and hypertension were the most common risk factors identified. The cause of 96.3% of ADRs was probable, and 51.2% of the ADRs were categorized as severe. Nearly a fourth of the severe ADRs were categorized as life-threatening. A majority of the ADRs were treated by terminating the suspected drug, and 54% of patients recovered completely. 6.1% of the ADRs were definitely avoidable while 42.1% were unavoidable. Conclusion: This study clearly demonstrates the massive burden of ADRs, both on the patients and the hospitals. There is a dire need for a standardized, easily accessible means of mandatory reporting of ADRs, and that data need to be utilized to treat, decrease morbidity, and prevent ADRs by proactively anticipating them to ultimately improve patient care. The following core competencies are addressed in this article: Patient care, Medical knowledge, Interpersonal and communication skills, Practice-based learning and improvement, and Systems-based practice

Navigating the Global IV Contrast Shortage: The Experience of a Comprehensive Cancer Center

In March 2022, a COVID-19 associated lockdown at an intravenous (IV) contrast production facility resulted in global shortages. We report our experience as a comprehensive cancer center navigating the IV contrast shortage through the development of an IV contrast triage team. A triage prioritization system was established to serve as a guideline for ordering clinicians to reduce contrast use (Table 1). The triage team reviewed all requests and made final determination based on patient history, treatment plan, prior imaging, possible alternative modalities, and competing requests. Our institution performed a median of 194 CT studies per day. Contrast utilization as a percentage of all CTs ordered was approximately 80% prior to the shortage, nadired at 9% during peak shortage, and has since returned to pre-shortage levels. While most requests for contrast were changed to non-contrast by the ordering clinician, 132 requests were reviewed by the triage team. Fifty studies (38%) were approved by the team for contrast administration, 56 (42%) were recommended to be performed without contrast, 15 (11%) for a change in modality, and 11 (8%) were felt suitable for delay. There was overall general concordance between the recommendations of the triage team and studies conducted without significant distributional differences (χ2 = 4.004, two-tailed p = 0.2610). We did not note any instances of patient harm associated with the lack of contrast or from the utilization of an alternative imaging modality. The concept of resilience involves the development of system-based practices that allow for sustained operations during periods of sudden change, or loss of critical supplies. The effort to optimally allocate limited supply of contrast was an extensive effort across the organization including from senior leadership, IT, radiology, nursing, physicians, and APPs. Defaulting to an automatic cancelation of contrast requests, followed by review from an interdisciplinary triage team was effective in safely reducing contrast utilization. Decisions made by the team appeared to be sound without any known patient harm.

Intersectional Disparities in Emergency Medicine Residents’ Performance Assessments by Race, Ethnicity, and Sex

Previous studies have demonstrated sex-specific disparities in performance assessments among emergency medicine (EM) residents. However, less work has focused on intersectional disparities by ethnoracial identity and sex in resident performance assessments. To estimate intersectional sex-specific ethnoracial disparities in standardized EM resident assessments. This retrospective cohort study used data from the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education Milestones (Milestones) assessments to evaluate ratings for EM residents at 128 EM training programs in the US. Statistical analyses were conducted in June 2020 to January 2023. Training and assessment environments in EM residency programs across comparison groups defined by ethnoracial identity (Asian, White, or groups underrepresented in medicine [URM], ie, African American/Black, American Indian/Alaska Native, Hispanic/Latine, and Native Hawaiian/Other Pacific Islander) and sex (female/male). Mean Milestone scores (scale, 0-9) across 6 core competency domains: interpersonal and communications skills, medical knowledge, patient care, practice-based learning and improvement, professionalism, and system-based practice. Overall assessment scores were calculated as the mean of the 6 competency scores. The study sample comprised 128 ACGME-accredited programs and 16 634 assessments for 2708 EM residents of which 1913 (70.6%) were in 3-year and 795 (29.4%) in 4-year programs. Most of the residents were White (n = 2012; 74.3%), followed by Asian (n = 477; 17.6%), Hispanic or Latine (n = 213; 7.9%), African American or Black (n = 160; 5.9%), American Indian or Alaska Native (n = 24; 0.9%), and Native Hawaiian or Other Pacific Islander (n = 4; 0.1%). Approximately 14.3% (n = 386) and 34.6% (n = 936) were of URM groups and female, respectively. Compared with White male residents, URM female residents in 3-year programs were rated increasingly lower in the medical knowledge (URM female score, -0.47; 95% CI, -0.77 to -0.17), patient care (-0.18; 95% CI, -0.35 to -0.01), and practice-based learning and improvement (-0.37; 95% CI, -0.65 to -0.09) domains by postgraduate year 3 year-end assessment; URM female residents in 4-year programs were also rated lower in all 6 competencies over the assessment period. This retrospective cohort study found that URM female residents were consistently rated lower than White male residents on Milestone assessments, findings that may reflect intersectional discrimination in physician competency evaluation. Eliminating sex-specific ethnoracial disparities in resident assessments may contribute to equitable health care by removing barriers to retention and promotion of underrepresented and minoritized trainees and facilitating diversity and representation among the emergency physician workforce.

Race and Gender Differences in Pediatric Milestone Levels: A Multi-Institutional Study.

The Accreditation Council for Graduate Medical Education milestones assess resident competency in 6 domains. We hypothesized that disparities in milestones exist across race and gender in pediatric residencies. This is a retrospective, cross-sectional, multi-institutional study (3 pediatric residencies, 1446 scores; 316 residents). African American residents received the lowest scores in patient care (PC) (P = .030), medical knowledge (MK) (P = .005), practice-based learning and improvement (PBLI) (P = .003), professionalism (PROF) (P < .001), and interpersonal communication skills (ICS) (P = .005). Differences were most pronounced in PROF (African American mean 3.35 [SD .75], Asian 3.51 (.66), Hispanic 3.58 (.66), white 3.59 (.67)). Female residents received higher scores than male residents in PC (P = .002) and system-based practice (SBP) (P = .049). Female interns received higher MK scores, 2.53 (.44) versus 2.48 (.48), P = .044, but lower scores as third years, 4.00 (.43) versus 4.14 (.45), P = .030. In this study, pediatric milestones differed based on race and gender.

Virtual Visits in Medical Education: A Medical Student and Resident Perspective.

Necessitated by the COVID-19 pandemic, virtual care is now a fixture in health care delivery. Literature describes the pivot to virtual clinical education; however, less is known about the learner experience. Understanding perspectives of medical students and residents provides insight to optimize the educational experience in virtual care. Third-year medical students and general surgery residents at an academic teaching institution rated their experience of virtual clinic compared to in-person clinic through an anonymous 20-question survey. Questions were on a 5-point Likert scale with narrative opportunities and queried 4 learner objectives: patient care, systems-based practice, education, and faculty engagement. Medical student and resident responses were compared using a t-test. Lowest rated items included the ability to perform an accurate physical exam, engage with faculty, promote efficiency, and learn clinical skills. Residents gave lower ratings than medical students on all questions. There were significant differences between medical students and residents (P < .05) in actively participating in patient care, obtaining patient history, having adequate time for patient history, and facilitating efficiency. Narrative themes included faculty variability, virtual visits as additive but insufficient to replace in-person visits, and the importance of being in the same physical space or Zoom Room as faculty. Learners perceive the ability to perform a physical exam, promote efficiency, and engage with faculty to be compromised in the virtual clinic setting. Residents had less favorable perceptions of virtual clinic compared to medical students. Faculty should consider these varying learner perceptions to optimize the educational environment in virtual care.

Evaluating a Pediatric Palliative Care Elective Rotation Through Prompted Reflective Writing and Aligning With Competencies.

Background: Hospice and palliative medicine is important in the education of pediatric residents. Little is known about if and how residents' learnings during a pediatric palliative care elective fulfill core competencies and Pediatrics subcompetencies as set forth by the Accreditation Council for Graduate Medical Education (ACGME) and published subspecialty competencies for residents in pediatric hospice and palliative medicine (pHPM). Objectives: To evaluate what residents are learning on a four-week pediatric palliative care elective rotation at a single institution and how these learnings fulfill ACGME and pHPM competencies. Setting/Subjects: Prompted, written reflections were collected from residents completing a pediatric palliative care rotation at a large, urban academic center in the United States between academic years 2016-2017 and 2020-2021. Measurements: A qualitative, inductive reasoning approach was used to analyze reflections for emergent themes and codes. A deductive approach was used to map resulting codes to ACGME core competencies, Pediatric subcompetencies, and pHPM competencies. Results: Twenty-five resident reflections were collected. Inductive analysis revealed three primary themes and 102 codes. These codes were mapped to all six ACGME core competencies and mapped to most Pediatric subcompetencies with the exception of performing a physical examination, organizing and prioritizing patients, diagnostic evaluation, and community and population health. Codes mapped to most pHPM competencies with the exception of two symptom-based competencies, malignant bowel obstruction and severe fatigue. Conclusions: Residents' written reflections following a pediatric palliative care elective rotation demonstrated robust learnings that fulfill many core, specialty, and subspecialty competencies, particularly those that relate to patient- and family-centered care, communication, professionalism, and systems-based practice.

Lifestyle Medicine Intensivist Competencies: 2023 Expert Consensus Update.

The objective of this expert consensus process was to identify the competencies that lifestyle medicine (LM) Intensivists should be expected to have within their skill set. Expert panel members with experience in intensive, therapeutic lifestyle change (ITLC) updated and expanded a previously published set of competencies for this intensive LM practice, using an established process for developing consensus statements adapted for the topic. The previously published set of competencies was discussed for possible revision and expansion. Proposed changes were assessed for consensus using a modified Delphi process. The expert panel revised the original list of 34 competencies, maintaining the 6 initial proposed topics that were previously published as Specialist Competencies: (1) Practice-Based Learning and Improvement, (2) Patient Care and Procedural Skills (3) Systems-Based Practice, (4) Medical Knowledge, (5) Interpersonal and Communication Skills, and (6) Professionalism. After a series of meetings and an iterative Delphi process of voting and revision, a final set of 46 competency statements for LM Intensivists achieved consensus. These competencies define the scope of practice and desired skill set for LM Intensivists. Further, these competencies establish a standard for certification of LM Intensivists.