Unsupervised Practice Research Articles

Resident Performance Evaluations May Be Biased Toward Whites

Resident Performance Evaluations May Be Biased Toward Whites

Training Generations of Clinician Educators: Applying the Novel Clinician Educator Milestones to Faculty Development

Training Generations of Clinician Educators: Applying the Novel Clinician Educator Milestones to Faculty Development

Fitting In While Standing Out: Professional Identity Formation, Imposter Syndrome, and Burnout in Early-Career Faculty Physicians.

Professional identity formation (PIF) is a dynamic process by which an individual internalizes the core values and beliefs of a specific profession. Within medical education, PIF begins in medical school and continues throughout training and practice. Transitions affect PIF, with a critical transition occurring between medical training and unsupervised practice. This study aims to characterize PIF during the transition from resident to early-career faculty physician and explores the relationship between PIF and burnout during this transition. The authors conducted a qualitative study using constructivist grounded theory. They conducted semistructured interviews with early-career faculty physicians (defined as practicing for ≤ 5 years) from the Department of Medicine, Mayo Clinic. Deidentified interview transcripts were processed through open and axial coding. The authors organized themes and identified relationships between themes that were refined through discussion and constant comparison with newly collected data. During data analysis, the authors identified self-determination theory, with the concepts of autonomy, competence, and relatedness, as a framework to support the organization and analysis of the data. Eleven early-career faculty physicians participated in the interviews. Their PIF was characterized by the dual desires to fit in and stand out. Striving for these desires was characterized by imposter syndrome, driving physicians to question their decision making and overall competence. Participants associated imposter syndrome and academic pressures with burnout. Autonomy support by the institution to pursue opportunities important for career development helped mitigate burnout and support PIF. Early-career faculty physicians face identity challenges when transitioning from training to unsupervised practice, including striving to fit in and stand out. They link this tension to imposter syndrome, which they associated with burnout. Institutional awareness and support, including addressing structural and cultural contributors to imposter syndrome, are paramount as new faculty explore their identities and navigate new challenges.

Evaluation Evolution: Designing Optimal Evaluations to Enhance Learning in Nephrology Fellowship.

Evaluations serve as the backbone of any educational program and can be broadly divided into formative and summative evaluations. Formative evaluations are "just in time" evaluations focused on informing the learning process, whereas summative evaluations compare fellows to a preset standard to determine their readiness for unsupervised practice. In the nephrology fellowship programs, evaluations assess competence in the framework of ACGME Milestones 2.0. A variety of learning venues, evaluators, and tools should be incorporated into the measurement process. It is important to determine which milestones can be best assessed in each education venue to decrease the burden of assessment fatigue. Additionally, programs can diversify the evaluators to include nurses, medical students, peers, and program coordinators in addition to faculty to provide a well-rounded assessment of the fellows and share the assessment burden. Lastly, the evaluation data should be presented to fellows in a format where it can inform goal setting. The evaluation system needs to evolve along with the changes being made in curriculum design. This will help to make fellowship learning effective and efficient.

Predicting Performance at Graduation From Early ACGME Milestone Ratings: Longitudinal Learning Analytics in Professionalism and Communication in Vascular Surgery

Program directors in surgical disciplines need more tools from the ACGME to help them use Milestone ratings to improve trainees' performance. This is especially true in competencies that are notoriously difficult to measure, such as professionalism (PROF) and interpersonal and communication skills (ICS). It is now widely understood that skills in these two areas have direct impact on patient care outcomes. This study investigated the potential for generating early predictors of final Milestone ratings within the PROF and ICS competency categories. This retrospective cohort study utilized Milestone ratings from all ACGME-accredited vascular surgery training programs, covering residents and fellows who completed training in June 2019. The outcome measure studied was the rate of achieving the recommended graduation target of Milestone Level 4 (possible range: 1-5), while the predictors were the Milestone ratings attained at earlier stages of training. Predictive probability values (PPVs) were calculated for each of the 3 PROF and two ICS sub-competencies to estimate the probability of trainees not reaching the recommended graduation target based on their previous Milestone ratings. All ACGME-accredited vascular surgery training programs within the United States. All trainees completing a 2 year vascular surgery fellowship (VSF) in June 2019 (n = 119) or a 5 year integrated vascular surgery residency (IVSR) in June 2019 (n = 52) were included in the analyses. The overall rate of failing to achieve the recommended graduation target across all PROF and ICS sub-competencies ranged from 7.7% to 21.8% of all trainees. For trainees with a Milestone rating at ≤ 2.5 with 1 year remaining in their training program, the predictive probability of not achieving the recommended graduation target ranged from 37.0% to 71.5% across sub-competencies, with the highest risks observed under PROF for "Administrative Tasks" (71.5%) and under ICS for "Communication with the Healthcare Team" (56.7%). As many as 1 in 4 vascular surgery trainees did not achieve the ACGME vascular surgery Milestones targets for graduation in at least one of the PROF and ICS sub-competencies. Biannual ACGME Milestone assessment ratings of PROF and ICS during early training can be used to predict achievement of competency targets at time of graduation. Early clues to problems in PROF and ICS enable programs to address potential deficits early in training to ensure competency in these essential non-technical skills prior to entering unsupervised practice.

An Examination of the Associations Among USMLE Step 3 Scores and the Likelihood of Disciplinary Action in Practice.

As the last examination in the United States Medical Licensing Examination (USMLE) sequence, Step 3 provides a safeguard before physicians enter into unsupervised practice. There is, however, little validity research focusing on Step 3 scores beyond examining its associations with other educational and professional assessments thought to cover similar content. This study examines the associations between Step 3 scores and subsequent receipt of disciplinary action taken by state medical boards for problematic behavior in practice. It analyzes Step 3 total, Step 3 computer-based case simulation (CCS), and Step 3 multiple-choice question (MCQ) scores. The final sample included 275,392 board-certified physicians who graduated from MD-granting medical schools and who passed Step 3 between 2000 and 2017. Cross-classified multilevel logistic regression models were used to examine the effects of Step 3 scores on the likelihood of receiving a disciplinary action, controlling for other USMLE scores and accounting for jurisdiction and specialty. Results showed that physicians with higher Step 3 total, CCS, and MCQ scores tended to have lower chances of receiving a disciplinary action, after accounting for other USMLE scores. Specifically, a 1-standard-deviation increase in Step 3 total, CCS, and MCQ score was associated with a 23%, 11%, and 17% decrease in the odds of receiving a disciplinary action, respectively. The effect of Step 2 CK score on the likelihood of receiving a disciplinary action was statistically significant, while the effect of Step 1 score became statistically nonsignificant when other Step scores were included in the analysis. Physicians who perform better on Step 3 are less likely to receive a disciplinary action from a state medical board for problematic behavior in practice. These findings provide some validity evidence for the use of Step 3 scores when making medical licensure decisions in the United States.

Development of entrustable professional activities for post-doctorate pediatric dentistry education.

To identify the core components of pediatric dentistry defining entrustable professional activities (EPAs) representing the profession. Potential core components of pediatric dentistry and corresponding domains were identified through review of literature and existing pediatric dentistry standards. A modified Delphi technique was utilized to rate these candidate EPAs to achieve consensus around prioritized EPAs. Eleven participants participated in all three rounds of the Delphi. After three rounds, 16 candidate EPAs reached consensus for pediatric dentistry. Each EPA fell into one of four domains: "assessment and planning," "provision of care," "behavior guidance," and "professional development." An original candidate EPA focused on non-pharmacological behavior guidance was deemed too broad by the Delphi. This EPA was subsequently developed into three separate components on nitrous oxide analgesia, moderate sedation, and general anesthesia. Prioritized EPAs will help define the essential activities of the profession and provide a framework for creating assessments to ensure that graduating pediatric residents are ready for unsupervised practice.

Integrating training, practice, and reflection within a new model for Canadian medical licensure: a concept paper prepared for the Medical Council of Canada.

In 2020 the Medical Council of Canada created a task force to make recommendations on the modernization of its practices for granting licensure to medical trainees. This task force solicited papers on this topic from subject matter experts. As outlined within this Concept Paper, our proposal would shift licensure away from the traditional focus on high-stakes summative exams in a way that integrates training, clinical practice, and reflection. Specifically, we propose a model of graduated licensure that would have three stages including: a trainee license for trainees that have demonstrated adequate medical knowledge to begin training as a closely supervised resident, a transition to practice license for trainees that have compiled a reflective educational portfolio demonstrating the clinical competence required to begin independent practice with limitations and support, and a fully independent license for unsupervised practice for attendings that have demonstrated competence through a reflective portfolio of clinical analytics. This proposal was reviewed by a diverse group of 30 trainees, practitioners, and administrators in medical education. Their feedback was analyzed and summarized to provide an overview of the likely reception that this proposal would receive from the medical education community.

Pediatric powered mobility training: powered wheelchair versus simulator-based practice

ABSTRACT Many children with physical disabilities lack independent mobility. Powered mobility can be a viable option, but to become proficient drivers, children need opportunities to practice. As is often the case, practice powered wheelchairs are scarce and direct therapy hours dedicated to powered mobility are often limited. Hence, alternative options are needed to enable safe, unsupervised practice. Simulator-based learning has been shown to be an effective training method for powered mobility and other skill-based tasks for adults. The goal of this study was to compare two training methods of powered mobility, powered wheelchair (control group) versus simulator-based (experimental group) practice to determine whether simulation is a feasible and effective method for youth. Method Participants included 30 children and adolescents (23 males, 13 females) with cerebral palsy and other neuromuscular diseases, aged 6–18. Data were collected and compared at baseline and after 12 weeks of home-based practice via a powered wheelchair or a simulator. Powered mobility ability was determined by the Powered Mobility Program (PMP), the Israel Ministry of Health’s Powered Mobility Proficiency Test (PM-PT) and the Assessment of Learning Powered Mobility (ALP). Results All participants practiced for the required amount of time and both groups reported a similar user experience. Both groups achieved significant improvement following the practice period as assessed by the PMP and PM-PT assessments, with no significant differences between them. A significant improvement was found in the ALP assessment outcomes for the powered wheelchair group only. Conclusions This is the first study, to our knowledge, that compares two different wheelchair training methods. Simulator-based practice is an effective training option for powered mobility for children with physical disabilities aged 6–18 years old, demonstrating that it is possible to provide driving skill practice opportunities safe, controlled environments.

To Boost or Not to Boost Residents and Fellows-That Is the Question.

To Boost or Not to Boost Residents and Fellows-That Is the Question.

Overextending: A Qualitative Study of Trainees Learning at the Edge of Evolving Expertise.

The challenge of graduate medical education is to prepare physicians for unsupervised practice while ensuring patient safety. Current approaches may inadequately prepare physicians due to limited opportunities for autonomy. Recent work on how trainees gain autonomy shows that they actively influence their supervisors' entrustment decisions. If program directors more clearly understand how trainees experience increasing independence, they may better sensitize trainees to the deliberations they will face during patient care. The authors sought to explore how trainees experience lessening supervision as their clinical training advances. Using constructivist grounded theory, the authors recruited trainees from various specialties and training levels via email and conducted 17 semi-structured interviews from 2019 to 2020 to solicit clinical experiences during which their perceived autonomy changed. Through constant comparison and iterative analysis, key themes and conceptual relationships were identified. Seventeen trainees from 4 specialties described novel clinical situations that required "overextending," or going beyond their perceived edge of evolving expertise. This move represented a spectrum based on perceived locus of control, from deliberate overextending driven by trainees, to forced overextending driven by external factors. Trainee judgments about whether or not to overextend were distilled into key questions: (1) Can I do it? (2) Must I do it? (3) Do I want to do it? and (4) Is it safe to do it? More advanced trainees posed a fifth question: (5) Am I missing something? Decisions to move into the realm of uncertainty about capabilities carried weight for trainees. In making deliberative judgments about overextending, they attempted to balance training needs, capability, urgency, and patient safety.

Things We Do for No Reason™: Toxic quizzing in medical education.

Things We Do for No Reason™: Toxic quizzing in medical education.

The effect of continuous at-home training of minimally invasive surgical skills on skill retention

BackgroundSkill deterioration of minimally invasive surgical (MIS) skills may be prevented by continuous training. The aim of this study is to evaluate whether unsupervised continuous at-home training of MIS skills results in better skill retention compared to no training.MethodsMedical doctors followed a two-week interval training for two MIS tasks (precise peg transfer and interrupted suture with knot tying), ending with a baseline test. They were randomly assigned to the no-practice group or continuous-practice group. The latter practiced unsupervised at home every two weeks during the study period. Skill retention was measured after three and six months on both tasks by the total time needed, distance traveled by instruments and LS-CAT score (8 best possible score and > 40 worst score).ResultsA total of 38 participants were included. No significant differences in performance were found at pre-test or baseline. At six months the no-practice group needed more time for the suturing task (309 s vs. 196 s at baseline, p = 0.010) and the LS-CAT score was significantly worse (30 vs. 20 at baseline, p < 0.0001). The continuous-practice group performed the suturing task significantly better than the no-practice group at both three and six months (17 vs. 25, p < 0.001 and 17 vs. 30, p < 0.001) and faster as well (p = 0.034 and p = 0.001).ConclusionThis study shows a skill decay after only a few months of non-use and shows better skill retention after continuous unsupervised at-home practice of MIS skills. This indicates an added value of regular at-home practice of surgical skills.

Approaching Training-Practice Gaps After the Transition: A Practice Proposal for Supervision After Training.

Transitions within medical, veterinarian, and other health professional training, from classroom to workplace, between undergraduate, postgraduate, fellowship phases, and to unsupervised clinical practice, are often stressful. Endeavors to alleviate inadequate connections between phases have typically focused on preparation of learners for a next phase. Yet, while some of these efforts show results, they cannot obliviate transitional gaps. If reformulated as ‘not completely ready to assume the expected responsibilities in the next phase’, transitions may reflect intrinsic problems in a training trajectory. Indeed, the nature of classroom teaching and even skills training for example, will never fully reflect the true context of clinical training. In various stages of clinical training, the supervision provided to trainees, particularly medical residents, has increased over the past decades. This addresses calls for enhanced patient safety, but may inadequately prepare trainees for unsupervised practice. Transitions often evolve around the question how much support or supervision incoming trainees or junior professionals require. We propose to consider receiving incoming trainees and new employees in clinical workplaces with a conversation about required supervision for discrete tasks, or entrustable professional activities (EPAs). EPAs lend themselves for the question: “At what level of supervision will you be able to carry out this task?”. This question can be answered by both the trainee or junior employee and the supervisor or employer and can lead to agreement about specified supervision for a defined period of time. We expect that this “supported autonomy tool” could alleviate stress and enhance continued development after transitions.

Lost in Transit: Implications and Insights for Making Medical Task Trainer Prototypes with an Open Source Hardware Paradigm

AbstractThis paper presents an open-source novel intravenous cannulation task trainer developed during the Covid- 19 pandemic for unsupervised clinical skill practice. Multiple user errors were uncovered when observing 13 registered nurses using the task trainer during a two-hour unsupervised skill training session. These insights raise the question of how OSH needs to share more than just device descriptions and assembly instructions- as designs are being shared only in its current state of an ongoing project, sharing insights, user errors and test results should be encouraged and prioritized.

A novel dashboard for improving the efficiency of a general surgery residency Clinical Competency Committee meeting

The 2020 Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education in Surgery requires that the program director (PD) or designee, with input from the Clinical Competency Committee (CCC), provide at least semi-annual as well as annual evaluations of each resident. These evaluations are to assess their advancement toward unsupervised practice based on 18 milestones within the six domains of physician competency and other relevant feedback and data.

Repeated low doses of LSD in healthy adults: A placebo-controlled, dose-response study.

The resurgence of interest in using psychedelic drugs, including lysergic acid diethylamide (LSD), in psychiatry has drawn attention to the medically unsupervised practice of 'microdosing'. Thousands of users claim that very low doses of LSD, taken at 3-4-day intervals, improve mood and cognitive function., However, few controlled studies have described the effects of the drug when taken in this way. Here, in a double-blind controlled study, we studied the effects of four repeated doses of LSD tartrate (13 or 26 μg) or placebo, administered to healthy adults at 3-4day intervals, on mood, cognitive performance and responses to emotional tasks. Participants were randomly assigned to one of three drug conditions: placebo (N = 18), 13 μg LSD (N = 19), or 26 μg LSD (N = 19). They attended four 5-hour drug-administration sessions separated by 3-4days, followed by a drug-free follow-up session 3-4days after the last session. LSD (26 μg) produced modest subjective effects including increased ratings of 'feeling a drug effect' and both stimulant-like and LSD-like effects, but the drug did not improve mood or affect performance on psychomotor or most emotional tasks. No residual effects were detected on mood or task performance on the drug-free follow-up session. We conclude that within the context of a controlled setting and a limited number of administrations, repeated low doses of LSD are safe, but produce negligible changes in mood or cognition in healthy volunteers.

Patient involvement in assessment of postgraduate medical learners: A scoping review.

Competency-based assessment of learners may benefit from a more holistic, inclusive, approach for determining readiness for unsupervised practice. However, despite movements towards greater patient partnership in health care generally, inclusion of patients in postgraduate medical learners' assessment is largely absent. We conducted a scoping review to map the nature, extent and range of literature examining the inclusion (or exclusion) of patients within the assessment of postgraduate medical learners. Guided by Arskey and O'Malley's framework and informed by Levac et al. and Thomas et al., we searched two databases (MEDLINE® and Embase®) from inception until February 2021 using subheadings related to assessment, patients and postgraduate learners. Data analysis examined characteristics regarding the nature and factor influencing patient involvement in assessment. We identified 41 papers spanning four decades. Some literature suggests patients are willing to be engaged in assessment, however choose not to engage when, for example, language barriers may exist. When stratified by specialty or clinical setting, the influence of factors such as gender, race, ethnicity or medical condition seems to remain consistent. Patients may participate in assessment as a stand-alone group or part of a multi-source feedback process. Patients generally provided high ratings but commented on the observed professional behaviours and communication skills in comparison with physicians who focused on medical expertise. Factors that influence patient involvement in assessment are multifactorial including patients' willingness themselves, language and reading-comprehension challenges and available resources for training programmes to facilitate the integration of patient assessments. These barriers however are not insurmountable. While understudied, research examining patient involvement in assessment is increasing; however, our review suggests that the extent which the unique insights will be taken up in postgraduate medical education may be dependent on assessment systems readiness and, in particular, physician readiness to partner with patients in this way.

Evolution of Post Graduate Curricula in Pakistan

Evolution of Post Graduate Curricula in Pakistan

THE NATIONAL LICENSING EXAMINATION: A COMPARISON WITH OTHER MAJOR MEDICAL LICENSING EXAMINATIONS AND PRACTICAL SUGGESTIONS FOR WIDER ACCEPTANCE

THE NATIONAL LICENSING EXAMINATION: A COMPARISON WITH OTHER MAJOR MEDICAL LICENSING EXAMINATIONS AND PRACTICAL SUGGESTIONS FOR WIDER ACCEPTANCE