Recent Publications by CFE Educators

Current controversies in medical education associated with professionalism, including disagreements about curriculum, pedagogy, and assessment, are rooted in part in the differing frameworks that are used to address professionalism. Three dominant frameworks, which have evolved in the medical education community, are described. The oldest framework is virtue based and focuses on the inner habits of the heart, the development of moral character and reasoning, plus humanistic qualities of caring and compassion: The good physician is a person of character. The second framework is behavior based, which emphasizes milestones, competencies, and measurement of observable behaviors: The good physician is a person who consistently demonstrates competence in performing patient care tasks. The third framework is identity formation, with a focus on identity development and socialization into a community of practice: The good physician integrates into his or her identity a set of values and dispositions consonant with the physician community and aspires to a professional identity reflected in the very best physicians. Although each professionalism framework is useful and valid, the field of medical education is currently engaged in several different discourses resulting in misunderstanding and differing recommendations for strategies to facilitate professionalism. In this article, the assumptions and contributions of each framework are described to provide greater insight into the nature of professionalism. By examining each discourse in detail, underlying commonalities and differences can be highlighted to assist educators in more effectively creating professionalism curricula, pedagogy, and assessment.

BACKGROUND 

Rater-based judgments are widely used in graduate medical education to provide more meaningful assessments, despite concerns about rater reliability.

OBJECTIVE 

We introduced a statistical modeling technique that corresponds to the new rater reliability framework, and present a case example to provide an illustration of the utility of this new approach to assessing rater reliability.

METHODS 

We used mixed-effects models to simultaneously incorporate random effects for raters and systematic effects of rater role as fixed effects. Study data are clinical performance ratings collected from medical school graduates who were evaluated for their readiness for supervised clinical practice in authentic simulation settings at 2 medical schools in the Netherlands and Germany.

RESULTS 

The medical schools recruited a maximum of 30 graduates out of 60 (50%) and 180 (17%) eligible candidates, respectively. Clinician raters (n = 25) for the study were selected based on their level of expertise and experience. Graduates were assessed on 7 facets of competence (FOCs) that are considered important in supervisors' entrustment decisions across the 5 cases used. Rater role was significantly associated with 2 FOCs: (1) teamwork and collegiality, and (2) verbal communication with colleagues/supervisors. For another 2 FOCs, rater variability was only partially explained by the role of the rater (a proxy for the amount of direct interaction with the trainee).

CONCLUSIONS 

Consideration of raters as meaningfully idiosyncratic provides a new framework to explore their influence on assessment scores, which goes beyond considering them as random sources of variability.

BACKGROUND

Screening, brief intervention, and referral to treatment (SBIRT) is a practical means to address substance misuse in primary care. Important barriers to implementing SBIRT include adequacy of training and provider confidence as well as logistical hurdles and time constraints. A faculty development initiative aimed at increasing SBIRT knowledge and treatment of substance use disorders (SUDs) should lead to increased use of SBIRT by faculty and the residents they teach. This study examined how a faculty development program to promote SBIRT influenced faculty practice and resident teaching.

METHODS

This was a cross-sectional study of faculty exposed to multiple SBIRT educational interventions over a 5-year period in an academic faculty-resident general medicine practice. Participants completed a brief online survey followed by a semistructured interview. Quantitative responses were examined descriptively. Qualitative questions were reviewed to identify key themes.

RESULTS

Fifteen of 29 faculty (52%) completed the survey and 13 (45%) completed the interviews regarding faculty development interventions. Faculty thought that SBIRT was an important skill and had confidence in screening for substance use disorders, although confidence in making treatment referrals and prescribing pharmacotherapy were rated lower. Many faculty reported screening more frequently for SUDs after attending faculty development sessions. However, several reported that the training did not improve their SBIRT teaching to residents during clinic precepting sessions. To improve uptake of SBIRT, a majority of faculty recommended electronic health record (EHR) alerts.

CONCLUSIONS

SBIRT is a highly valued set of skills, and training may enhance rates of screening for substance misuse. However, participants did not report a substantial change in SBIRT teaching as a result of faculty development. In the future, small, targeted faculty development sessions, potentially involving strategies for using the electronic health record (EHR), may be an effective way to enhance primary care SBIRT skills.

BACKGROUND

Catecholamine excess in patients with pheochromocytoma often results in impaired glucose tolerance, leading to diabetes mellitus. Little data are available on the long-term effect of surgery on diabetes.

OBJECTIVE

The primary aim of this study was to determine the likelihood of diabetes cure after surgery, while secondary objectives were to determine risk factors for development of diabetes preoperatively and persistence of diabetes postoperatively.

METHODS

All patients undergoing surgery for pheochromocytoma from 1996 to 2015 were retrospectively reviewed to identify those with a preoperative diagnosis of diabetes. Demographic and diabetes-specific data were collected. Median follow-up was 52.1 months.

RESULTS

Overall, 153 patients underwent surgery. Diabetes was seen in 36 (23.4%) patients. Eight patients met the exclusion criteria and were removed from the final analysis, while 22 (78.6%) patients had complete resolution of diabetes. Four patients remained on medication with improved control. Overall, 93.0% of patients had improvement of their diabetes; two patients did not improve. Patients with large, symptomatic tumors were more likely to develop preoperative diabetes, and diabetes was more likely to persist in patients who had an elevated body mass index (BMI).

CONCLUSIONS

Diabetes was found concurrently with pheochromocytoma in 23% of patients, more often in those with large, symptomatic tumors. The majority of patients had long-term resolution of diabetes after successful resection; however, some patients may continue to require treatment of diabetes after operation, especially those with a higher BMI.

Disability measures in multiple sclerosis (MS) rely heavily on ambulatory function, and current metrics fail to capture potentially important variability in walking behavior. We sought to determine whether remote step count monitoring using a consumer-friendly accelerometer (Fitbit Flex) can enhance MS disability assessment. 99 adults with relapsing or progressive MS able to walk ≥2-min were prospectively recruited. At 4 weeks, study retention was 97% and median Fitbit use was 97% of days. Substudy validation resulted in high interclass correlations between Fitbit, ActiGraph and manual step count tally during a 2-minute walk test, and between Fitbit and ActiGraph (ICC = 0.76) during 7-day home monitoring. Over 4 weeks of continuous monitoring, daily steps were lower in progressive versus relapsing MS (mean difference 2546 steps, p  0.01). Lower average daily step count was associated with greater disability on the Expanded Disability Status Scale (EDSS) (p  0.001). Within each EDSS category, substantial variability in step count was apparent (i.e., EDSS = 6.0 range 1097-7152). Step count demonstrated moderate-strong correlations with other walking measures. Lower average daily step count is associated with greater MS disability and captures important variability in real-world walking activity otherwise masked by standard disability scales, including the EDSS. These results support remote step count monitoring as an exploratory outcome in MS trials.

BACKGROUND

Internet searches are an increasingly used tool in medical research. To date, no studies have examined Google search data in relation to common gastrointestinal symptoms.

AIMS

The aim of this study was to compare trends in Internet search volume with clinical datasets for common gastrointestinal symptoms.

METHODS

Using Google Trends, we recorded relative changes in volume of searches related to dysphagia, vomiting, and diarrhea in the USA between January 2008 and January 2011. We queried the National Inpatient Sample (NIS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) during this time period and identified cases related to these symptoms. We assessed the correlation between Google Trends and these two clinical datasets, as well as examined seasonal variation trends.

RESULTS

Changes to Google search volume for all three symptoms correlated significantly with changes to NIS output (dysphagia: r = 0.5, P = 0.002; diarrhea: r = 0.79, P  0.001; vomiting: r = 0.76, P  0.001). Both Google and NIS data showed that the prevalence of all three symptoms rose during the time period studied. On the other hand, the NHAMCS data trends during this time period did not correlate well with either the NIS or the Google data for any of the three symptoms studied. Both the NIS and Google data showed modest seasonal variation.

CONCLUSIONS

Changes to the population burden of chronic GI symptoms may be tracked by monitoring changes to Google search engine query volume over time. These data demonstrate that the prevalence of common GI symptoms is rising over time.