2014 ACR/ARHP Annual Meeting: Medical Education Trends

BOSTON—Pore over the thousands of articles published in medical education journals in just one year, and you begin to spot common threads. What we read most often on the page or screen helps us track trends in physician training and education models worldwide, said speakers at the ACR/ARHP Annual Meeting in Boston.

In his Nov. 16, 2014, lecture, Medical Education: The Year in Review, Andrew R. Hoellein, MD, MS, FACP, presented findings from the hottest topics in physician training based on a PubMed scan of thousands of articles and related citations. Dr. Hoellein, an associate professor of medicine at the University of Kentucky College of Medicine in Lexington, identified the most popular medical education subjects in 2014. These included longitudinal integrated clerkships, patient safety training, teaching hospitals, clinical competency and learning culture. He presented intriguing and even amusing observations about factors that influence the success of various education models.

Patient-Centeredness

The longitudinal integrated clerkship (LIC) model of medical education focuses on trainees developing close and continuous contact with cohorts of patients, said Dr. Hoellein. “In this model, students feel a sense of duty to patients and practice more patient advocacy due to this contact,” he said.

LICs have both skeptics and supporters, said Dr. Hoellein. Skeptics point to no long-term outcomes to support the extra cost associated with these programs, and supporters say LICs create “strong bonds with mentors and patients” that rotation-based clerkships may not offer, he said.

One study published in the journal, Academic Medicine, in 2014 compared academic performance between students in both types of programs at the University of Calgary in Alberta, Canada.¹ The Calgary researchers found that there was no difference in evaluation scores measuring medical knowledge, clinical performance, or clinical skills, he said. In a follow-up on the original cohort of the Cambridge model, survey results showed that LIC-trained students scored higher on the Patient-Practitioner Orientation Scale (PPOS), measuring clinical acumen and human sensitivity, than traditionally trained students at Harvard Medical School.

“Patient-centeredness endures in LIC graduates,” said Dr. Hoellein. “Over time, the PPOS score differences remained. LIC graduates felt better prepared to understand the role of patients and their families in care, and better prepared to be the patient’s advocate.”

Education methods aimed at improving patient safety, specifically patient-centered simulation training, was another hot topic in 2014 medical literature, Dr. Hoellein said. Mayo Clinic education researcher David A. Cook, MD, published a meta-analysis of 592 studies on patient-centered simulation training in medical education and found an overabundance of evidence to support its use.²

“Clearly, we have an excess of evidence on this topic,” said Dr. Hoellein. Some authors may be unaware of existing studies, or they may wish to publish their own findings. “Some replication is necessary, but at some point, it may no longer be needed. We need to recognize what’s been happening in the past, but we need to stop wasting time and dollars on unimportant research questions or on those already answered.”

Hospitalist services at teaching hospitals was another common topic among published medical education articles in 2014, said Dr. Hoellein. One study published in the Journal of General Internal Medicine compared three different types of hospitalist services at academic medical centers: hospitalists, hospitalist-preceptors and academician-preceptors.³ Having a hospitalist alone translated to the lowest readmission rate of the three but higher cumulative costs. Centers with a hospitalist-preceptor recorded the shortest length of stays for patients and may be the best approach for teaching hospitals, Dr. Hoellein said.

Patient care transition, or handovers of cases, is an important time for ensuring patient safety, said Dr. Hoellein. Studies analyzing handovers were a popular topic in 2014’s medical education literature, including methods for effectively conducting handovers from overnight to morning staff reduce omission of clinically relevant issues.

“I think morning is the most hectic, chaotic time for handover,” Dr. Hoellein noted. In an article published in the Journal of the American Medical Association Internal Medicine, Canadian researchers analyzed morning handover practices at two Toronto academic medical centers.⁴ They concluded that providing a dedicated time and distraction-free setting, such as a conference room rather than a crowded hallway, would reduce omissions by on-call trainees during handovers, he said.

Competency Influencers

Knowledge of musculoskeletal anatomy is lacking among rheumatologists and rheumatology fellows, affecting diagnostic competency, according to an article published in Arthritis Care & Research in 2014.⁵

When 170 participants in rheumatology workshops completed practical anatomy tests, rheumatology fellows scored the highest, perhaps due to musculoskeletal ultrasound training. Older, more experienced rheumatologists also did well, said Dr. Hoellein. “However, musculoskeletal knowledge is still suboptimal, especially of the hand,” he noted. Better foundation of anatomy knowledge may also save costs over the long term, he said. “A physical exam is still the cheapest lab test.”

Salient distracting clinical features presenting early in complex cases may also lower competency, Dr. Hoellein said based on findings published in Academic Medicine in 2014.⁶ The study found that distracting clinical features presenting near the end of cases did not adversely affect diagnostic accuracy. Residents may latch onto a certain diagnosis early and overlook the big picture. “Sometimes, premature closure happens. But we usually have time to make an accurate diagnosis,” Dr. Hoellein said.

Sleepy residents may also exhibit lower clinical competency and risk patient safety, said Dr. Hoellein. In 2011, new regulations require shorter duty shifts to improve patient safety, trainee quality of life and the overall quality of medical education, he said. A study published in the Journal of General Internal Medicine in 2014 analyzed perceptions of these changes based on 237 surveys from internal medicine program directors.7 The authors found that shorter working hours improved resident quality of life, but increased the workload of program directors.

Medical students may view charismatic or good-looking instructors as more effective teachers, according to a study published in Medical Education.8 Researchers gave 48 first-year medical students audiotapes of teachers presenting educational material, accompanied by photographs of either attractive or unattractive individuals. Students rated each teacher’s effectiveness using a ratings scale.

“In just two minutes, a student could predict if this was a good preceptor or not,” said Dr. Hoellein. Charisma and intellect increased teaching effectiveness ratings scores, but perceived physical attractiveness also influenced higher ratings. “So if you give a talk, do really well in the first two minutes! But remember that charisma can carry you no matter what you look like.”

Susan Bernstein is a freelance medical journalist based in Atlanta.

References

1. Myhre DL, Woloschuk W, Jackson W, et al. Academic performance of longitudinal integrated clerkship versus rotation-based clerkship students: A matched cohort study. Acad Med. 2014 Feb;89(2):292–295.
2. Cook DA. How much evidence does it take? A cumulative meta-analysis of outcomes of simulation-based education. Med Educ. 2014 Aug;48(8):750–760.
3. Chin DL, Wilson MH, Bang H, et al. Comparing patient outcomes of academician-preceptors, hospitalist-preceptors, and hospitalists on internal medicine services in an academic medical center. J Gen Intern Med. 2014 Dec;29(12):1672–1678.
4. Devlin MK, Kozil NK, Kiss A, et al. Morning handover of on-call issues: Opportunities for improvement. JAMA Intern Med. 2014 Sept;174(9):1479–1485.
5. Navarro-Zarza JE, Hernandez-Diaz C, Saavedra MA, et al. Preworkshop of musculoskeletal anatomy of rheumatology fellows and rheumatologists of seven North, Central and South American countries. Arthritis Care Res. 2014 Feb;66(2):270–276.
6. Mamede S, van Gog T, van den Berge K, et al. Why do doctors make mistakes? A study of the role of salient distracting clinical features. Acad Med. 2014 Jan;89(1):114–120.