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1.  Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety 
Long working hours and sleep deprivation have been a facet of physician training in the US since the advent of the modern residency system. However, the scientific evidence linking fatigue with deficits in human performance, accidents and errors in industries from aeronautics to medicine, nuclear power, and transportation has mounted over the last 40 years. This evidence has also spawned regulations to help ensure public safety across safety-sensitive industries, with the notable exception of medicine.
In late 2007, at the behest of the US Congress, the Institute of Medicine embarked on a year-long examination of the scientific evidence linking resident physician sleep deprivation with clinical performance deficits and medical errors. The Institute of Medicine’s report, entitled “Resident duty hours: Enhancing sleep, supervision and safety”, published in January 2009, recommended new limits on resident physician work hours and workload, increased supervision, a heightened focus on resident physician safety, training in structured handovers and quality improvement, more rigorous external oversight of work hours and other aspects of residency training, and the identification of expanded funding sources necessary to implement the recommended reforms successfully and protect the public and resident physicians themselves from preventable harm.
Given that resident physicians comprise almost a quarter of all physicians who work in hospitals, and that taxpayers, through Medicare and Medicaid, fund graduate medical education, the public has a deep investment in physician training. Patients expect to receive safe, high-quality care in the nation’s teaching hospitals. Because it is their safety that is at issue, their voices should be central in policy decisions affecting patient safety. It is likewise important to integrate the perspectives of resident physicians, policy makers, and other constituencies in designing new policies. However, since its release, discussion of the Institute of Medicine report has been largely confined to the medical education community, led by the Accreditation Council for Graduate Medical Education (ACGME).
To begin gathering these perspectives and developing a plan to implement safer work hours for resident physicians, a conference entitled “Enhancing sleep, supervision and safety: What will it take to implement the Institute of Medicine recommendations?” was held at Harvard Medical School on June 17–18, 2010. This White Paper is a product of a diverse group of 26 representative stakeholders bringing relevant new information and innovative practices to bear on a critical patient safety problem. Given that our conference included experts from across disciplines with diverse perspectives and interests, not every recommendation was endorsed by each invited conference participant. However, every recommendation made here was endorsed by the majority of the group, and many were endorsed unanimously. Conference members participated in the process, reviewed the final product, and provided input before publication. Participants provided their individual perspectives, which do not necessarily represent the formal views of any organization.
In September 2010 the ACGME issued new rules to go into effect on July 1, 2011. Unfortunately, they stop considerably short of the Institute of Medicine’s recommendations and those endorsed by this conference. In particular, the ACGME only applied the limitation of 16 hours to first-year resident physicans. Thus, it is clear that policymakers, hospital administrators, and residency program directors who wish to implement safer health care systems must go far beyond what the ACGME will require. We hope this White Paper will serve as a guide and provide encouragement for that effort.
Resident physician workload and supervision
By the end of training, a resident physician should be able to practice independently. Yet much of resident physicians’ time is dominated by tasks with little educational value. The caseload can be so great that inadequate reflective time is left for learning based on clinical experiences. In addition, supervision is often vaguely defined and discontinuous. Medical malpractice data indicate that resident physicians are frequently named in lawsuits, most often for lack of supervision. The recommendations are: The ACGME should adjust resident physicians workload requirements to optimize educational value. Resident physicians as well as faculty should be involved in work redesign that eliminates nonessential and noneducational activity from resident physician dutiesMechanisms should be developed for identifying in real time when a resident physician’s workload is excessive, and processes developed to activate additional providersTeamwork should be actively encouraged in delivery of patient care. Historically, much of medical training has focused on individual knowledge, skills, and responsibility. As health care delivery has become more complex, it will be essential to train resident and attending physicians in effective teamwork that emphasizes collective responsibility for patient care and recognizes the signs, both individual and systemic, of a schedule and working conditions that are too demanding to be safeHospitals should embrace the opportunities that resident physician training redesign offers. Hospitals should recognize and act on the potential benefits of work redesign, eg, increased efficiency, reduced costs, improved quality of care, and resident physician and attending job satisfactionAttending physicians should supervise all hospital admissions. Resident physicians should directly discuss all admissions with attending physicians. Attending physicians should be both cognizant of and have input into the care patients are to receive upon admission to the hospitalInhouse supervision should be required for all critical care services, including emergency rooms, intensive care units, and trauma services. Resident physicians should not be left unsupervised to care for critically ill patients. In settings in which the acuity is high, physicians who have completed residency should provide direct supervision for resident physicians. Supervising physicians should always be physically in the hospital for supervision of resident physicians who care for critically ill patientsThe ACGME should explicitly define “good” supervision by specialty and by year of training. Explicit requirements for intensity and level of training for supervision of specific clinical scenarios should be providedCenters for Medicare and Medicaid Services (CMS) should use graduate medical education funding to provide incentives to programs with proven, effective levels of supervision. Although this action would require federal legislation, reimbursement rules would help to ensure that hospitals pay attention to the importance of good supervision and require it from their training programs
Resident physician work hours
Although the IOM “Sleep, supervision and safety” report provides a comprehensive review and discussion of all aspects of graduate medical education training, the report’s focal point is its recommendations regarding the hours that resident physicians are currently required to work. A considerable body of scientific evidence, much of it cited by the Institute of Medicine report, describes deteriorating performance in fatigued humans, as well as specific studies on resident physician fatigue and preventable medical errors.
The question before this conference was what work redesign and cultural changes are needed to reform work hours as recommended by the Institute of Medicine’s evidence-based report? Extensive scientific data demonstrate that shifts exceeding 12–16 hours without sleep are unsafe. Several principles should be followed in efforts to reduce consecutive hours below this level and achieve safer work schedules. The recommendations are: Limit resident physician work hours to 12–16 hour maximum shiftsA minimum of 10 hours off duty should be scheduled between shiftsResident physician input into work redesign should be actively solicitedSchedules should be designed that adhere to principles of sleep and circadian science; this includes careful consideration of the effects of multiple consecutive night shifts, and provision of adequate time off after night work, as specified in the IOM reportResident physicians should not be scheduled up to the maximum permissible limits; emergencies frequently occur that require resident physicians to stay longer than their scheduled shifts, and this should be anticipated in scheduling resident physicians’ work shiftsHospitals should anticipate the need for iterative improvement as new schedules are initiated; be prepared to learn from the initial phase-in, and change the plan as neededAs resident physician work hours are redesigned, attending physicians should also be considered; a potential consequence of resident physician work hour reduction and increased supervisory requirements may be an increase in work for attending physicians; this should be carefully monitored, and adjustments to attending physician work schedules made as needed to prevent unsafe work hours or working conditions for this group“Home call” should be brought under the overall limits of working hours; work load and hours should be monitored in each residency program to ensure that resident physicians and fellows on home call are getting sufficient sleepMedicare funding for graduate medical education in each hospital should be linked with adherence to the Institute of Medicine limits on resident physician work hours
Moonlighting by resident physicians
The Institute of Medicine report recommended including external as well as internal moonlighting in working hour limits. The recommendation is: All moonlighting work hours should be included in the ACGME working hour limits and actively monitored. Hospitals should formalize a moonlighting policy and establish systems for actively monitoring resident physician moonlighting
Safety of resident physicians
The “Sleep, supervision and safety” report also addresses fatigue-related harm done to resident physicians themselves. The report focuses on two main sources of physical injury to resident physicians impaired by fatigue, ie, needle-stick exposure to blood-borne pathogens and motor vehicle crashes. Providing safe transportation home for resident physicians is a logistical and financial challenge for hospitals. Educating physicians at all levels on the dangers of fatigue is clearly required to change driving behavior so that safe hospital-funded transport home is used effectively. Fatigue-related injury prevention (including not driving while drowsy) should be taught in medical school and during residency, and reinforced with attending physicians; hospitals and residency programs must be informed that resident physicians’ ability to judge their own level of impairment is impaired when they are sleep deprived; hence, leaving decisions about the capacity to drive to impaired resident physicians is not recommendedHospitals should provide transportation to all resident physicians who report feeling too tired to drive safely; in addition, although consecutive work should not exceed 16 hours, hospitals should provide transportation for all resident physicians who, because of unforeseen reasons or emergencies, work for longer than consecutive 24 hours; transportation under these circumstances should be automatically provided to house staff, and should not rely on self-identification or request
Training in effective handovers and quality improvement
Handover practice for resident physicians, attendings, and other health care providers has long been identified as a weak link in patient safety throughout health care settings. Policies to improve handovers of care must be tailored to fit the appropriate clinical scenario, recognizing that information overload can also be a problem. At the heart of improving handovers is the organizational effort to improve quality, an effort in which resident physicians have typically been insufficiently engaged. The recommendations are: Hospitals should train attending and resident physicians in effective handovers of careHospitals should create uniform processes for handovers that are tailored to meet each clinical setting; all handovers should be done verbally and face-to-face, but should also utilize written toolsWhen possible, hospitals should integrate hand-over tools into their electronic medical records (EMR) systems; these systems should be standardized to the extent possible across residency programs in a hospital, but may be tailored to the needs of specific programs and services; federal government should help subsidize adoption of electronic medical records by hospitals to improve signoutWhen feasible, handovers should be a team effort including nurses, patients, and familiesHospitals should include residents in their quality improvement and patient safety efforts; the ACGME should specify in their core competency requirements that resident physicians work on quality improvement projects; likewise, the Joint Commission should require that resident physicians be included in quality improvement and patient safety programs at teaching hospitals; hospital administrators and residency program directors should create opportunities for resident physicians to become involved in ongoing quality improvement projects and root cause analysis teams; feedback on successful quality improvement interventions should be shared with resident physicians and broadly disseminatedQuality improvement/patient safety concepts should be integral to the medical school curriculum; medical school deans should elevate the topics of patient safety, quality improvement, and teamwork; these concepts should be integrated throughout the medical school curriculum and reinforced throughout residency; mastery of these concepts by medical students should be tested on the United States Medical Licensing Examination (USMLE) stepsFederal government should support involvement of resident physicians in quality improvement efforts; initiatives to improve quality by including resident physicians in quality improvement projects should be financially supported by the Department of Health and Human Services
Monitoring and oversight of the ACGME
While the ACGME is a key stakeholder in residency training, external voices are essential to ensure that public interests are heard in the development and monitoring of standards. Consequently, the Institute of Medicine report recommended external oversight and monitoring through the Joint Commission and Centers for Medicare and Medicaid Services (CMS). The recommendations are: Make comprehensive fatigue management a Joint Commission National Patient Safety Goal; fatigue is a safety concern not only for resident physicians, but also for nurses, attending physicians, and other health care workers; the Joint Commission should seek to ensure that all health care workers, not just resident physicians, are working as safely as possibleFederal government, including the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, should encourage development of comprehensive fatigue management programs which all health systems would eventually be required to implementMake ACGME compliance with working hours a “ condition of participation” for reimbursement of direct and indirect graduate medical education costs; financial incentives will greatly increase the adoption of and compliance with ACGME standards
Future financial support for implementation
The Institute of Medicine’s report estimates that $1.7 billion (in 2008 dollars) would be needed to implement its recommendations. Twenty-five percent of that amount ($376 million) will be required just to bring hospitals into compliance with the existing 2003 ACGME rules. Downstream savings to the health care system could potentially result from safer care, but these benefits typically do not accrue to hospitals and residency programs, who have been asked historically to bear the burden of residency reform costs. The recommendations are: The Institute of Medicine should convene a panel of stakeholders, including private and public funders of health care and graduate medical education, to lay down the concrete steps necessary to identify and allocate the resources needed to implement the recommendations contained in the IOM “Resident duty hours: Enhancing sleep, supervision and safety” report. Conference participants suggested several approaches to engage public and private support for this initiativeEfforts to find additional funding to implement the Institute of Medicine recommendations should focus more broadly on patient safety and health care delivery reform; policy efforts focused narrowly upon resident physician work hours are less likely to succeed than broad patient safety initiatives that include residency redesign as a key componentHospitals should view the Institute of Medicine recommendations as an opportunity to begin resident physician work redesign projects as the core of a business model that embraces safety and ultimately saves resourcesBoth the Secretary of Health and Human Services and the Director of the Centers for Medicare and Medicaid Services should take the Institute of Medicine recommendations into consideration when promulgating rules for innovation grantsThe National Health Care Workforce Commission should consider the Institute of Medicine recommendations when analyzing the nation’s physician workforce needs
Recommendations for future research
Conference participants concurred that convening the stakeholders and agreeing on a research agenda was key. Some observed that some sectors within the medical education community have been reluctant to act on the data. Several logical funders for future research were identified. But above all agencies, Centers for Medicare and Medicaid Services is the only stakeholder that funds graduate medical education upstream and will reap savings downstream if preventable medical errors are reduced as a result of reform of resident physician work hours.
doi:10.2147/NSS.S19649
PMCID: PMC3630963  PMID: 23616719
resident; hospital; working hours; safety
2.  The Utility of Letters of Recommendation in Predicting Resident Success: Can the ACGME Competencies Help? 
Background
The Accreditation Council for Graduate Medical Education (ACGME) core competencies are used to assess resident performance, and recently similar competencies have become an accepted framework for evaluating medical student achievements as well. However, the utility of incorporating the competencies into the resident application has not yet been assessed.
Purpose
The objective of this study was to examine letters of recommendation (LORs) to identify ACGME competency–based themes that might help distinguish the least successful from the most successful residents.
Methods
Residents entering a university-based residency program from 1994 to 2004 were retrospectively evaluated by faculty and ranked in 4 groups according to perceived level of success. Applications from residents in the highest and lowest groups were abstracted. LORs were qualitatively reviewed and analyzed for 9 themes (6 ACGME core competencies and 3 additional performance measures). The mean number of times each theme was mentioned was calculated for each student. Groups were compared using the χ2 test and the Student t test.
Results
Seventy-five residents were eligible for analysis, and 29 residents were ranked in the highest and lowest groups. Baseline demographics and number of LORs did not differ between the two groups. Successful residents had statistically significantly more comments about excellence in the competency areas of patient care, medical knowledge, and interpersonal and communication skills.
Conclusion
LORs can provide useful clues to differentiate between students who are likely to become the least versus the most successful residency program graduates. Greater usage of the ACGME core competencies within LORs may be beneficial.
doi:10.4300/JGME-D-11-00010.1
PMCID: PMC3179231  PMID: 22942969
3.  Needs Assessment for Electrosurgery Training of Residents and Faculty in Obstetrics and Gynecology 
Background and Objectives:
Effective application of electrosurgical techniques requires knowledge of energy sources and electric circuits to produce desired tissue effects. A lack of electrosurgery knowledge may negatively affect patient outcomes and safety. Our objective was to survey obstetrics-gynecology trainees and faculty to assess their basic knowledge of electrosurgery concepts as a needs assessment for formal electrosurgery training.
Methods:
We performed an observational study with a sample of convenience at 2 academic hospitals (Beth Israel Deaconess Medical Center and Mount Auburn Hospital). Grand rounds dedicated to electrosurgery teaching were conducted at each department of obstetrics and gynecology, where a short electrosurgery multiple-choice examination was administered to attendees.
Results:
The face validity of the test content was obtained from a gynecologic electrosurgery specialist. Forty-four individuals completed the examination. Test scores were analyzed by level of training to investigate whether scores positively correlated with more advanced career stages. The median test score was 45.5% among all participants (interquartile range, 36.4%–54.5%). Senior residents scored the highest (median score, 54.5%), followed by attendings (median score, 45.5%), junior residents and fellows (median score in both groups, 36.4%), and medical students (median score, 27.3%).
Conclusion:
Although surgeons have used electrosurgery for nearly a century, it remains poorly understood by most obstetrician-gynecologists. Senior residents, attendings, junior residents, and medical students all show a general deficiency in electrosurgery comprehension. This study suggests that there is a need for formal electrosurgery training. A standardized electrosurgery curriculum with a workshop component demonstrating clinically useful concepts essential for safe surgical practice is advised.
doi:10.4293/JSLS.2014.00293
PMCID: PMC4154422  PMID: 25392632
Electrosurgery; Surgical curriculum; Surgical teaching
4.  Subspecialty and Gender of Obstetrics and Gynecology Faculty in Department-Based Leadership Roles 
Obstetrics and gynecology  2015;125(2):471-476.
Objective
To characterize the cohort who may become senior leaders in obstetrics and gynecology by examining the gender and subspecialty of faculty in academic department administrative and educational leadership roles.
Methods
This is an observational study conducted through websites of U.S. obstetrics and gynecology residency programs accredited in 2012-2013.
Results
In obstetrics and gynecology departmental administrative leadership roles, women comprised 20.4% of chairs, 36.1% of vice chairs, and 29.6% of division directors. Among educational leaders, women comprised 31.9% of fellowship directors, 47.3% of residency directors and 66.1% of medical student clerkship directors. Chairs were most likely to be maternal–fetal medicine faculty (38.2%), followed by specialists in general obstetrics and gynecology (21.8%), reproductive endocrinologists (15.6%), and gynecologic oncologists (14.7%). Among chairs, 32.9% are male maternal–fetal medicine specialists. Family planning had the highest representation of women (80.0%) among division directors, while reproductive endocrinology and infertility had the lowest (15.8%).
The largest proportion of women chairs, vice chairs, residency program directors, and medical student clerkship directors were specialists in general obstetrics and gynecology.
Conclusion
Women remained under-represented in the departmental leadership roles of chair, vice chair, division director, and fellowship director. Representation of women was closer to parity among residency program directors, where women held just under half of positions. Nearly one in three department chairs was a male maternal–fetal medicine specialist. Compared to subspecialist leaders, specialist leaders in general obstetrics and gynecology were more likely to be women.
doi:10.1097/AOG.0000000000000628
PMCID: PMC4304882  PMID: 25568998
5.  Successfully Matching Into Surgical Specialties: An Analysis of National Resident Matching Program Data 
Objective
We explored the impact that attributes of US medical school seniors have on their success in matching to a surgical residency, in order to analyze trends for National Resident Matching Program (NRMP) match outcomes in surgical specialties between 2007 and 2009.
Methods
Using Electronic Residency Application Service data and NRMP outcomes, we analyzed medical students' attributes and their effect in successfully matching students into residency positions in surgery, otolaryngology, orthopedic surgery, plastic surgery, and obstetrics and gynecology. Attributes analyzed included self-reported United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, Alpha Omega Alpha (AOA) Honor Medical Society membership, research experience, additional graduate degree status, and graduation from a top 40 National Institutes of Health (NIH)–funded medical school. Odds ratios were calculated for each criterion, and 95% confidence intervals were used to determine significance.
Results
Between 2007 and 2009, the number of surgical specialty residency positions increased by 86, and the number of applicants increased by 34. Membership in AOA, USMLE Step 1 and Step 2 scores, research experience, and graduation from a top 40 NIH-funded medical school frequently had a significant impact on residents successfully matching into many specialties, while additional graduate degrees had no effect on matching into surgical specialties (range 0.64 to 1.2).
Conclusions
Although the statistical significance varied across specialties, higher USMLE Step 1 and Step 2 scores, AOA membership, research experience, and graduation from a top 40 NIH-funded medical school generally had a positive impact on match success to surgical residency for US allopathic seniors. Test preparation and seeking research experience during undergraduate medical education may be effective approaches for increasing the likelihood of success for US seniors matching into a surgical specialty.
doi:10.4300/JGME-D-09-00020.1
PMCID: PMC2951766  PMID: 21976075
6.  Residents as Role Models: The Effect of the Obstetrics and Gynecology Clerkship on Medical Students' Career Interest 
Background
Medical students' choice of residency specialty is based in part on their clerkship experience. Postclerkship interest in a particular specialty is associated with the students' choice to pursue a career in that field. But, many medical students have a poor perception of their obstetrics and gynecology clerkships.
Objective
To determine whether fourth-year medical students' perceptions of teaching quality and quantity and amount of experiential learning during the obstetrics-gynecology clerkship helped determine their interest in obstetrics-gynecology as a career choice.
Methods
We distributed an anonymous, self-administered survey to all third-year medical students rotating through their required obstetrics and gynecology clerkship from November 2006 to May 2007. We performed bivariate analysis and used χ2 analysis to explore factors associated with general interest in obstetrics and gynecology and interest in pursuing obstetrics and gynecology as a career.
Results
Eighty-one students (N  =  91, 89% response rate) participated. Postclerkship career interest in obstetrics and gynecology was associated with perceptions that the residents behaved professionally (P < .0001) and that the students were treated as part of a team (P  =  .008). Having clear expectations on labor and delivery procedures (P  =  .014) was associated with postclerkship career interest. Specific hands-on experiences were not statistically associated with postclerkship career interest. However, performing more speculum examinations in the operating room trended toward having some influence (P  =  .068). Although more women than men were interested in obstetrics and gynecology as a career both before (P  =  .027) and after (P  =  .014) the clerkship, men were more likely to increase their level of career interest during the clerkship (P  =  .024).
Conclusions
Clerkship factors associated with greater postclerkship interest include higher satisfaction with resident professional behavior and students' sense of inclusion in the clinical team. Obstetrics and gynecology programs need to emphasize to residents their role as educators and professional role models for medical students.
doi:10.4300/JGME-D-09-00070.1
PMCID: PMC2951771  PMID: 21976080
7.  Visiting medical student elective and clerkship programs: a survey of US and Puerto Rico allopathic medical schools 
BMC Medical Education  2010;10:41.
Background
No published reports of studies have provided aggregate data on visiting medical student (VMS) programs at allopathic medical schools.
Methods
During 2006, a paper survey was mailed to all 129 allopathic medical schools in the United States and Puerto Rico using a list obtained from the Association of American Medical Colleges. Contents of the survey items were based on existing literature and expert opinion and addressed various topics related to VMS programs, including organizational aspects, program objectives, and practical issues. Responses to the survey items were yes-or-no, multiple-choice, fill-in-the-blank, and free-text responses. Data related to the survey responses were summarized using descriptive statistics.
Results
Representatives of 76 schools (59%) responded to the survey. Of these, 73 (96%) reported their schools had VMS programs. The most common reason for having a VMS program was "recruitment for residency programs" (90%). "Desire to do a residency at our institution" was ranked as the leading reason visiting medical students choose to do electives or clerkships. In descending order, the most popular rotations were in internal medicine, orthopedic surgery, emergency medicine, and pediatrics. All VMS programs allowed fourth-year medical students, and approximately half (58%) allowed international medical students. The most common eligibility requirements were documentation of immunizations (92%), previous clinical experience (85%), and successful completion of United States Medical Licensing Examination Step 1 (51%). Of the programs that required clinical experience, 82% required 33 weeks or more. Most institutions (96%) gave priority for electives and clerkships to their own students over visiting students, and a majority (78%) reported that visiting students were evaluated no differently than their own students. During academic year 2006-2007, the number of new resident physicians who were former visiting medical students ranged widely among the responding institutions (range, 0-76).
Conclusions
Medical schools' leading reason for having VMS programs is recruitment into residency programs and the most commonly cited reason students participate in these programs is to secure residency positions. However, further research is needed regarding factors that determine the effectiveness of VMS programs in residency program recruitment and the development of more universal standards for VMS eligibility requirements and assessment.
doi:10.1186/1472-6920-10-41
PMCID: PMC2893187  PMID: 20529301
8.  Can enriching emotional intelligence improve medical students’ proactivity and adaptability during OB/GYN clerkships? 
Objectives
The purpose of this pilot study was to examine our hypothesis that enriching workplace emotional intelligence through resident coaches could improve third-year medical students’ adaptability and proactivity on the Obstetrics and Gynecology clerkship.
Methods
An observational pilot study was conducted in a teaching hospital. Fourteen 3rd year medical students from two cohorts of clerkships were randomly divided into two groups, and equally assigned to trained resident coaches and untrained resident coaches. Data was collected through onsite naturalistic observation of students’ adaptability and proactivity in clinical settings using a checklist with a 4-point Likert scale (1=poor to 4=excellent). Wilcoxon rank-sum test was used to compare the differences between these two groups.
Results
A total of 280 data points were collected through onsite observations conducted by investigators. All (n=14) students’ adaptability and proactivity performance significantly improved from an average of 3.04 to 3.45 (p=0.014) over 6-week clerkship. Overall, students with trained resident coaches adapted significantly faster and were more proactive in the obstetrics and gynecology clinical setting than the students with untrained coaches (3.31 vs. 3.24, p=0.019).
Conclusions
Findings from our pilot study supported our hypothesis that enriching workplace emotional intelligence knowledge through resident coaches was able to help medical students adapt into obstetrics and gynecology clinical settings faster and become more proactive in learning. Clerkship programs can incorporate the concept of a resident coach in their curriculum to help bridge medical students into clinical settings and to help them engage in self-directed learning throughout the rotation.
doi:10.5116/ijme.5658.0a6b
PMCID: PMC4695392  PMID: 26708233
Emotional intelligence; obstetrics and gynecology; resident coach; clerkship
9.  Should Osteopathic Students Applying to Allopathic Emergency Medicine Programs Take the USMLE Exam? 
Introduction
Board scores are an important aspect of an emergency medicine (EM) residency application. Residency directors use these standardized tests to objectively evaluate an applicant’s potential and help decide whether to interview a candidate. While allopathic (MD) students take the United States Medical Licensing Examination (USMLE), osteopathic (DO) students take the Comprehensive Osteopathic Medical Licensing Examination (COMLEX). It is difficult to compare these scores. Previous literature proposed an equation to predict USMLE based on COMLEX. Recent analyses suggested this may no longer be accurate. DO students applying to allopathic programs frequently ask whether they should take USMLE to overcome this potential disadvantage. The objective of the study is to compare the likelihood to match of DO applicants who reported USMLE to those who did not, and to clarify how important program directors consider it is whether or not an osteopathic applicant reported a USMLE score.
Methods
We conducted a review of Electronic Residency Application Service (ERAS) and National Resident Matching Program (NRMP) data for 2010–2011 in conjunction with a survey of EM residency programs. We reviewed the number of allopathic and osteopathic applicants, the number of osteopathic applicants who reported a USMLE score, and the percentage of successful match. We compared the percentage of osteopathic applicants who reported a USMLE score who matched compared to those who did not report USMLE. We also surveyed allopathic EM residency programs to understand how important it is that osteopathic (DO) students take USMLE.
Results
There were 1,482 MD students ranked EM programs; 1,277 (86%, 95% CI 84.3–87.9) matched. There were 350 DO students ranked EM programs; 181 (52%, 95% CI 46.4–57.0) matched (difference=34%, 95% CI 29.8–39.0, p<0.0001). There were 208 DO students reported USMLE; 126 (61%, 95% CI 53.6–67.2) matched. 142 did not report USMLE; 55 (39%, 95% CI 30.7–47.3) matched (difference=22%, 95% CI 11.2–32.5, p<0.0001). Survey results: 39% of program directors reported that it is extremely important that osteopathic students take USMLE, 38% stated it is somewhat important, and 22% responded not at all important.
Conclusion
DO students who reported USMLE were more likely to match. DO students applying to allopathic EM programs should consider taking USMLE to improve their chances of a successful match.
doi:10.5811/westjem.2013.8.16169
PMCID: PMC3935778  PMID: 24578773
10.  Residents as Medical Student Mentors During an Obstetrics and Gynecology Clerkship 
Background
Resident physicians provide much of the clinical teaching for medical students during their clerkship rotations, but often receive no formal preparation or structure for teaching and mentoring students.
Objective
We sought to evaluate a medical student mentoring program (MSMP) for students during their obstetrics and gynecology clerkship at a midwestern teaching hospital during the 2013–2014 academic year.
Methods
A senior resident physician was assigned 1 to 2 medical students for a 6-week rotation. Students were provided MSMP information during clerkship orientation; residents were given information on MSMP requirements and were randomly assigned to students. We surveyed students and residents about their experience with the MSMP.
Results
Of 49 eligible medical students, 43 (88%) completed postsurveys. All students reported not having a mentoring program on other clerkships. Postclerkship, students indicated that they would participate in the MSMP again (32 of 38, 84%), and felt that having a mentor on other clerkships (30 of 36, 83%) would be beneficial. Students reported receiving educational (20 of 41, 49%) and procedural (33 of 41, 80%) instruction, personal development feedback (23 of 41, 56%), and career advice (14 of 41, 34%) from resident mentors. Out of a total of 45 possible surveys by residents, 17 (38%) were completed. Residents did not feel burdened by students (14 of 17, 82%), and all responded that they would participate in the MSMP again.
Conclusions
Feedback from medical students suggests that a mentoring program during clerkships may provide potential benefits for their careers and in 1-on-1 instruction.
doi:10.4300/JGME-D-14-00667.1
PMCID: PMC4597953  PMID: 26457148
11.  Subtest Scores From the In-Training Examination: An Evaluation Tool for an Obstetric-Anesthesia Rotation 
Objective
To evaluate resident performance in the obstetric-anesthesia rotation using resident portfolios and their In-Training Examination scores, which are provided by the American Board of Anesthesiology/American Society of Anesthesiologists.
Methods
We reviewed academic portfolios for second- and third-year anesthesiology residents at a single institution from 2006–2008 to examine United States Medical Licensing Exam Step 1 and 2 scores, grade for obstetrics-gynecology in medical school, and performance on the In-Training Examination. Faculty evaluation of medical knowledge and correlations for the various scores were obtained.
Results
We examined scores for 43 residents. The subtest score for obstetric anesthesia increased after completing a rotation in obstetric anesthesia, 26.1 ± 10.3 versus 36.3 ± 10.6 (P  =  .02). The subtest score correlated with United States Medical Licensing Exam Step 2, r  =  0.46 (P  =  .027) but not with United States Medical Licensing Exam Step 1 or with the grade obtained in medical school. There was no correlation between faculty evaluations of medical knowledge and resident subtest scores in obstetric anesthesia.
Conclusions
Subtest scores in obstetric anesthesia are valid and provide a tool for the assessment of the educational program of a rotation. Knowledge as assessed by a faculty member is different from the knowledge assessed on a written examination. Both methods can help provide a more complete assessment of the resident and the rotation.
doi:10.4300/JGME-D-09-00066.1
PMCID: PMC2941385  PMID: 21975629
12.  Selecting the best and brightest: A comparison of residency match processes in the United States and Canada 
Plastic Surgery  2015;23(4):225-230.
Plastic surgery remains a competitive field, with many candidates applying to a limited number of residency programs in Canada and the United States annually. However, Canadian programs de-emphasize academic measures and use distinctly different criteria that are less objective than their American counterparts. This survey-based study compared and contrasted the two systems, and sought to determine the characteristics and aptitudes best suited to successful residency in plastic surgery.
BACKGROUND:
Selecting candidates for plastic surgery residency training remains a challenge. In the United States, academic measures (United States Medical Licensing Exam Step I scores, medical school class rank and publications) are used as primary criteria for candidate selection for residency. In contrast, Canadian medical education de-emphasizes academic measures by using a pass-fail grading system. As a result, choosing residents from many qualified applicants may pose a challenge for Canadian programs without objective measures of academic success.
METHODS:
A 25-question online survey was distributed to program directors of Canadian plastic surgery residency-training programs. Program directors commented on number of yearly residents and applicants; application sections (ranked in importance using a Likert scale); interview invitation and rank-order list determination; and their satisfaction with the selection process.
RESULTS:
Ten Canadian plastic surgery program directors responded (90.9% response rate). The most important application components determining invitation to interview were letters of reference from a plastic surgeon (mean importance of 5.0 on the Likert scale), clinical electives in plastic surgery (mean 4.6) and electives with their program (mean 4.5). Applicants invited for interview were assessed on the quality of their responses to questions, maturity and personality. The majority of program directors agreed that a clinical elective with their program was important for consideration on their rank-order list. Program directors were neutral on their satisfaction with the selection process.
CONCLUSION:
Canadian plastic surgery residency programs emphasize clinical electives with their program and letters of reference from colleagues when selecting applicants for interviews. In contrast to their American counterparts, Canadian program directors rely on clinical interactions with prospective residents in the absence of objective academic measures.
PMCID: PMC4664135  PMID: 26665135
Medical education; Plastic surgery; Residency; Selection
13.  Impact of the Medical Liability Crisis on Postresidency Training and Practice Decisions in Obstetrics-Gynecology 
Introduction
The liability crisis may affect residency graduates' practice decisions, yet structured liability education during residency is still inadequate. The objective of this study was to determine the influence of medical liability on practice decisions and to evaluate the adequacy of current medical liability curricula.
Methods
All fourth-year residents (n  =  1274) in 264 Accreditation Council for Graduate Medical Education–accredited allopathic and 25 osteopathic US obstetrics and gynecology residency training programs were asked to participate in a survey about postgraduate plans and formal education during residency regarding liability issues in 2006. Programs were identified by the Council on Resident Education in Obstetrics and Gynecology directory and the American College of Osteopathic Obstetricians and Gynecologists residency program registry. Outcome measures were the reported influence of liability/malpractice concerns on postresidency practice decision making and the incidence of formal education in liability/malpractice issues during residency.
Results
A total of 506 of 1274 respondents (39.7%) returned surveys. Women were more likely than men to report “region of the country” (P  =  .02) and “paid malpractice insurance as a salaried employee” (P  =  .03) as a major influence. Of the respondents, 123 (24.3%) planned fellowship training, and 229 (45.3%) were considering limiting practice. More than 20% had been named in a lawsuit. Respondents cited Pennsylvania, Florida, and New York as locations to avoid. In response to questions about medical liability education, 54.3% reported formal education on risk management, and 65.2% indicated they had not received training on “next steps” after a lawsuit.
Discussion
Residents identify liability-related issues as major influences when making choices about practice after training. Structured education on matters of medical liability during residency is still inadequate.
doi:10.4300/JGME-D-11-00135.1
PMCID: PMC3399611  PMID: 23730440
14.  Evaluation of Infectious Disease Knowledge in Obstetrics and Gynecology and the Effects of Varying Durations of Training 
Objective: The amount, origin, and resources of infectious disease knowledge in the field ofobstetrics and gynecology were investigated. If this knowledge is lacking, the exact length of the specific infectious disease training during residency should be defined to meet the ever-increasing knowledge required in training.
Methods: A 50-question test was developed by one faculty member utilizing questions that incorporated the basic sciences of microbiology and pharmacology and clinical knowledge of infectious diseases in the area of obstetrics and gynecology. Multiple choice and matching questions were structured so as to ascertain the source of the knowledge, including medical school curriculum, recent journal articles, and clinical experience.
Results: The test was given yearly to all students and residents on the Obstetric and Gynecology Service over a period of 2 year's. The questions were the same for each group, but were reshuffled each exam period. Three hundred and seven tests were properly administered and recorded. There was no statistical improvement in any successive year’s scores unless specific infectious disease training occurred. Increasing improvement in scores was noted, with an increasing duration of infectious disease training specific for obstetrics and gynecology, beginning at 2 weeks (22% improvement), 4 weeks (30% improvement), and 6 weeks (31% improvement) (P = .05–.001). Basic science questions were most frequently answered correctly by medical students and early residents, while correctly answered clinical questions correlated with increasing clinical experience except in the area of ambulatory care.
Conclusions: The infectious disease knowledge of residents in obstetrics and gynecology can be improved with 4 weeks of intensive training. Re-exposure to basic science knowledge and improved training in ambulatory care in this resident group appear to be necessary. This test or similar tests can be helpful in defining areas of deficiencies and their possible remedies.
doi:10.1155/S1064744993000274
PMCID: PMC2364306  PMID: 18475330
15.  Evaluating Professionalism, Practice-Based Learning and Improvement, and Systems-Based Practice: Utilization of a Compliance Form and Correlation with Conflict Styles 
Objective
The purpose of this article was to develop and determine the utility of a compliance form in evaluating and teaching the Accreditation Council for Graduate Medical Education competencies of professionalism, practice-based learning and improvement, and systems-based practice.
Methods
In 2006, we introduced a 17-item compliance form in an obstetrics and gynecology residency program. The form prospectively monitored residents on attendance at required activities (5 items), accountability of required obligations (9 items), and completion of assigned projects (3 items). Scores were compared to faculty evaluations of residents, resident status as a contributor or a concerning resident, and to the residents' conflict styles, using the Thomas-Kilmann Conflict MODE Instrument.
Results
Our analysis of 18 residents for academic year 2007–2008 showed a mean (standard error of mean) of 577 (65.3) for postgraduate year (PGY)-1, 692 (42.4) for PGY-2, 535 (23.3) for PGY-3, and 651.6 (37.4) for PGY-4. Non-Hispanic white residents had significantly higher scores on compliance, faculty evaluations on interpersonal and communication skills, and competence in systems-based practice. Contributing residents had significantly higher scores on compliance compared with concerning residents. Senior residents had significantly higher accountability scores compared with junior residents, and junior residents had increased project completion scores. Attendance scores increased and accountability scores decreased significantly between the first and second 6 months of the academic year. There were positive correlations between compliance scores with competing and collaborating conflict styles, and significant negative correlations between compliance with avoiding and accommodating conflict styles.
Conclusions
Maintaining a compliance form allows residents and residency programs to focus on issues that affect performance and facilitate assessment of the ACGME competencies. Postgraduate year, behavior, and conflict styles appear to be associated with compliance. A lack of association with faculty evaluations suggests measurement of different perceptions of residents' behavior.
doi:10.4300/JGME-D-10-00048.1
PMCID: PMC2951784  PMID: 21976093
16.  Using a Commercially Available Web-Based Evaluation System to Enhance Residents' Teaching 
Background
Residents-as-teachers (RATs) programs have been shown to improve trainees' teaching skills, yet these decline over time.
Intervention
We adapted a commercial Web-based system to maintain resident teaching skills through reflection and deliberate practice and assessed the system's ability to (1) prevent deterioration of resident teaching skills and (2) provide information to improve residents' teaching skills and teaching program quality.
Methods
Ten first-year obstetrics-gynecology (Ob-Gyn) residents participated in a RATs program. Following the program, they used a commercial evaluation system to complete self-assessments of their teaching encounters with medical students. Students also evaluated the residents. To assess the system's effectiveness, we compared these residents to historical controls with an Objective Structured Teaching Examination (OSTE) and analyzed the ratings and the free text comments of residents and students to explore teaching challenges and improve the RATs program.
Results
The intervention group outscored the control group on the OSTE (mean score ± SD  =  81 ± 8 versus 74 ± 7; P  =  .05, using a 2-tailed Student t-test). Rating scale analysis showed resident self-assessments were consistently lower than student evaluations, with the difference reaching statistical significance in 3 of 6 skills (P < .05). Comments revealed that residents most valued using innovative teaching techniques, while students most valued a positive educational climate and interpersonal connections with residents. Recommended targets for RATs program improvement included teaching feedback, time-limited teaching, and modeling professionalism behaviors.
Conclusions
Our novel electronic Web-based reinforcement system shows promise in preventing deterioration of resident teaching skills learned during an Ob-Gyn RATs program. The system also was effective in gaining resident and student insights to improve RATs programs. Because our intervention was built upon a commercially available program, our approach could prove useful to the large population of current subscribers.
doi:10.4300/JGME-D-11-00018.1
PMCID: PMC3312536  PMID: 23451309
17.  Alton Ochsner Medical Foundation's Combined Family Practice and Internal Medicine Residency Program 
The Ochsner Journal  2000;2(4):228-232.
The impact of managed care in the 1990s and the need for more broadly trained primary care physicians led the American Board of Internal Medicine and the American Board of Family Practice to explore ways to collaboratively train primary care physicians. One proposed solution was a combined residency incorporating the training curriculums of both boards in an integrated fashion. In 1995, the Alton Ochsner Medical Foundation Combined Family Practice and Internal Medicine Residency Program was one of the first to be approved by the two boards. The first residents began training in July 1996. Due to overlap in curriculums, completion for both boards is possible in 48 months as opposed to the 72 months a consecutive approach would require. The first graduates completed the program in July 2000.
The combined residents rotate on both the Family Practice inpatient service and the General Internal Medicine wards and participate in continuity care clinics and precepting in both core programs. Facilities for the program involve only existing clinics and administrative personnel. Residents serve as primary care physicians for a mixed ethnic, middle-class patient population atOchsner's New Orleans East satellite clinic, provide longitudinal obstetric and pediatric care at an inner city clinic, and complete a rural primary care rotation. Inservice examination scores have been consistently high with several combined residents scoring at the top United States level on both examinations. The program has matched with our highest ranked students over each year of the program despite a marked decline in US graduates entering primary care fields. Graduates of the combined program are ideal staff for either medical schools or residency programs of either core program.
While this residency is in its early stages, both boards have mandated an indepth evaluation to determine the quality and outcomes of training. The results of a recent survey of current Ochsner residents assessing their perceptions of the combined program were encouraging. We plan to track our graduates and compare them with recent graduates of the two core programs in order to document long-term impact.
PMCID: PMC3117509  PMID: 21765701
18.  Out-of-Match Residency Offers: The Possible Extent and Implications of Prematching in Graduate Medical Education 
Background
When the data from the National Resident Matching Program (NRMP) are used to analyze trends in medical students' career preferences, positions offered outside the match are omitted. The purpose of the study was to evaluate the extent and nature of out-of-match residency offers.
Methods
We obtained total resident complements and postgraduate year-1 positions offered in 7 specialties in 2007 and compared these with the 2007 NRMP match data. We compared the percentage of positions offered outside the match to “success” in matching United States medical doctors (USMDs) and to the availability of fellowship positions, using the Spearman rank order test (SROT).
Results
A total of 18 030 postgraduate year-1 positions were offered in 9 specialty areas. Of 15 205 positions offered in the match, 54% were taken by USMDs. The percentage of outside-the-match offers was found to vary by specialty, from 7% in obstetrics-gynecology to 23% in internal medicine, and was inversely correlated with the specialty's “success” in matching USMDs (SROT  =  −0.87). The 3 nonprocedural primary care specialties (internal medicine, family medicine, and pediatrics) accounted for 10 091 (46.2%) of the 21 845 total positions offered in the match, with 4401 (43.6%) offered almost entirely to non-USMDs. Another 2467 positions were offered outside the match, resulting in 6868 positions offered to non-USMDs (55% of all primary care positions). In internal medicine, the percentage of outside-the-match offers was significantly and inversely associated with the availability of intrainstitutional fellowship programs (P < .0001). Prematching of independent applicants was significantly higher in primary care than in procedural-lifestyle programs (P < .0001).
Conclusion
The NRMP's match data do not account for positions filled outside the match, a finding that appears to be significant. In 2007, 1 in 5 positions in primary care was offered outside the match.
doi:10.4300/JGME-D-09-00053.1
PMCID: PMC2951768  PMID: 21976077
19.  "Making the grade:" noncognitive predictors of medical students' clinical clerkship grades. 
OBJECTIVES: Because clinical clerkship grades are associated with resident selection and performance and are largely based on residents'/attendings' subjective ratings, it is important to identify variables associated with clinical clerkship grades. METHODS: U.S. medical students who completed > or =1 of the following required clinical clerkships--internal medicine, surgery, obstetrics/gynecology, pediatrics, neurology and psychiatry--were invited to participate in an anonymous online survey, which inquired about demographics, degree program, perceived quality of clerkship experiences, assertiveness, reticence and clerkship grades. RESULTS: A total of 2395 medical students (55% women; 57% whites) from 105 schools responded. Multivariable logistic regression models identified factors independently associated with receiving lower clerkship grades (high pass/pass or B/C) compared with the highest grade (honors or A). Students reporting higher quality of clerkship experiences were less likely to report lower grades in all clerkships. Older students more likely reported lower grades in internal medicine (P = 0.02) and neurology (P < 0.001). Underrepresented minorities more likely reported lower grades in all clerkships (P < 0.001); Asians more likely reported lower grades in obstetrics/gynecology (P = 0.007), pediatrics (P = 0.01) and neurology (P = 0.01). Men more likely reported lower grades in obstetrics/gynecology (P < 0.001) and psychiatry (P = 0.004). Students reporting greater reticence more likely reported lower grades in internal medicine (P = 0.02), pediatrics (P = 0.02) and psychiatry (P < 0.05). Students reporting greater assertiveness less likely reported lower grades in all clerkships (P < 0.03) except IM. CONCLUSIONS: The independent associations between lower clerkship grades and nonwhite race, male gender, older age, lower quality of clerkship experiences, and being less assertive and more reticent are concerning and merit further investigation.
PMCID: PMC2574397  PMID: 17987918
20.  Asking for a Commitment: Violations during the 2007 Match and the Effect on Applicant Rank Lists 
Introduction
Applicants to residency face a number of difficult questions during the interview process, one of which is when a program asks for a commitment to rank the program highly. The regulations governing the National Resident Matching Program (NRMP) match explicitly forbid any residency programs asking for a commitment.
Methods
We conducted a cross-sectional survey of applicants from U.S. medical schools to five specialties during the 2006–2007 interview season using the Electronic Residency Application Service of the Association of American Medical Colleges. Applicants were asked to recall being asked to provide any sort of commitment (verbal or otherwise) to rank a program highly. Surveys were sent after rank lists were submitted, but before match day. We analyzed data using descriptive statistics and logistic regression.
Results
There were 7,028 unique responses out of 11,983 surveys sent for a response rate of 58.6%. Of those who identified their specialty (emergency medicine, internal medicine, obstetrics and gynecology [OBGYN], general surgery and orthopedics), there were 6,303 unique responders. Overall 19.6% (1380/7028) of all respondents were asked to commit to a program. Orthopedics had the highest overall prevalence at 28.9% (372/474), followed by OBGYN (23.7%; 180/759), general surgery (21.7%; 190/876), internal medicine (18.3%; 601/3278), and finally, emergency medicine (15.4%; 141/916). Of those responding, 38.4% stated such questions made them less likely to rank the program.
Conclusion
Applicants to residencies are being asked questions expressly forbidden by the NRMP. Among the five specialties surveyed, orthopedics and OBGYN had the highest incidence of this violation. Asking for a commitment makes applicants less likely to rank a program highly.
doi:10.5811/westjem.2015.1.24462
PMCID: PMC4380392  PMID: 25834683
21.  Factors affecting residency rank-listing: A Maxdiff survey of graduating Canadian medical students 
BMC Medical Education  2011;11:61.
Background
In Canada, graduating medical students consider many factors, including geographic, social, and academic, when ranking residency programs through the Canadian Residency Matching Service (CaRMS). The relative significance of these factors is poorly studied in Canada. It is also unknown how students differentiate between their top program choices. This survey study addresses the influence of various factors on applicant decision making.
Methods
Graduating medical students from all six Ontario medical schools were invited to participate in an online survey available for three weeks prior to the CaRMS match day in 2010. Max-Diff discrete choice scaling, multiple choice, and drop-list style questions were employed. The Max-Diff data was analyzed using a scaled simple count method. Data for how students distinguish between top programs was analyzed as percentages. Comparisons were made between male and female applicants as well as between family medicine and specialist applicants; statistical significance was determined by the Mann-Whitney test.
Results
In total, 339 of 819 (41.4%) eligible students responded. The variety of clinical experiences and resident morale were weighed heavily in choosing a residency program; whereas financial incentives and parental leave attitudes had low influence. Major reasons that applicants selected their first choice program over their second choice included the distance to relatives and desirability of the city. Both genders had similar priorities when selecting programs. Family medicine applicants rated the variety of clinical experiences more importantly; whereas specialty applicants emphasized academic factors more.
Conclusions
Graduating medical students consider program characteristics such as the variety of clinical experiences and resident morale heavily in terms of overall priority. However, differentiation between their top two choice programs is often dependent on social/geographic factors. The results of this survey will contribute to a better understanding of the CaRMS decision making process for both junior medical students and residency program directors.
doi:10.1186/1472-6920-11-61
PMCID: PMC3170644  PMID: 21867513
22.  The Importance of International Medical Rotations in Selection of an Otolaryngology Residency 
Background
The objective of this study was to determine the extent of interest in international electives among prospective otolaryngology residents and to determine whether the availability of international electives affected students' interest in ranking a particular residency program.
Methods
A 3-part survey was given to all medical students enrolled in the 2008 otolaryngology match via the Electronic Residency Application Service. Part 1 elicited demographic information. Part 2 explored general interest in international rotations. Part 3 involved ranking several factors affecting students' choice of residency programs. This survey was developed at our institution, with no formal validation. Participation was anonymous and voluntary.
Results
A total of 307 students entered the otolaryngology match, and 55 surveys (18%) were completed. Twenty-five of 55 students (55%) had completed an international elective during or prior to medical school, and 51 of 55 respondents (93%) had a “strong” or “very strong” desire to participate in an international elective during residency; 48 of 55 students (87%) had a “strong” or “very strong” desire to participate in international surgical missions after residency. Future practice goals had no correlation with interest in international rotations, either during or after residency training. Respondents ranked 8 factors that had an impact on residency program selection in the following order of importance: operative experience, location, lifestyle, research opportunities, didactics, international electives, prestige of program, and salary.
Conclusion
Interest in international medicine among prospective otolaryngologists was high in this subset of respondents but did not appear to affect residency program selection.
doi:10.4300/JGME-D-10-00185.1
PMCID: PMC3179233  PMID: 22942976
23.  Teaching Error Disclosure to Residents: A Curricular Innovation and Pilot Study 
Objective
To compare change in obstetrics and gynecology residents' self-efficacy in disclosing medical errors after a formal educational session.
Methods
This was a retrospective postintervention survey to assess change in perceived preparedness to disclose medical errors. We used a 4-hour educational seminar that included a didactic component (30 minutes) and experiential learning with a trained facilitator (3 hours). Change in self-efficacy was measured using a 5-point Likert-type scale (1 is lowest, and 5 is highest) and was compared using sign test (α  =  .05).
Results
In our pilot study, 13 of 15 residents reported having previously participated in error disclosure. After the session, residents considered themselves more prepared for the following: to know what to include in and how to introduce error discussions, to deal with a patient's emotional reaction, to respond to a patient's questions regarding how an error occurred, and to recognize one's own emotions when discussing medical errors. Residents believed that they would be likely to use the skills learned in the remainder of residency and in their future career.
Conclusions
This curriculum was associated with improvement in self-efficacy regarding error disclosure. Given the unique malpractice issues that obstetricians/gynecologists face, it seems particularly useful for residents to learn these skills early in their career. In addition, this topic represents an ideal educational opportunity for residencies to improve patient care and to address other core competencies in resident education such as communication skills and professionalism.
doi:10.4300/01.01.0019
PMCID: PMC2931195  PMID: 21975717
24.  What Are We Telling Our Students? A National Survey of Clerkship Directors' Advice for Students Applying to Internal Medicine Residency 
Background
Little is known about the advice fourth-year medical students receive from their advisors as they prepare to apply for residency training.
Objective
We collected information on recommendations given to medical students preparing to apply to internal medicine residencies regarding fourth-year schedules and application strategies.
Methods
Clerkship Directors in Internal Medicine conducted its annual member survey in June 2013. We analyzed responses on student advising using descriptive and comparative statistics, and free-text responses using content analysis.
Results
Of 124 members, 94 (76%) responded, and 83 (88%) advised fourth-year medical students. Nearly half (45%) advised an average of more than 20 students a year. Advisors encouraged students to take a medicine subinternship (Likert scale mean 4.84 [1, strongly discourage, to 5, strongly encourage], SD = 0.61); a critical care rotation (4.38, SD = 0.79); and a medicine specialty clinical rotation (4.01, SD = 0.80). Advisors reported they thought fourth-year students should spend a mean of 6.5 months doing clinical rotations (range 1–10, SD = 1.91). They recommended highest academic quartile students apply to a median of 10 programs (range 1–30) and lowest quartile students apply to 15 programs (range 3–100). Top recommendations involved maximizing student competitiveness, valuing program fit over reputation, and recognizing key decision points in the application process.
Conclusions
Undergraduate medical advisors recommended specific strategies to enhance students' competitiveness in the Match and to prepare them for residency. The results can inform program directors and encourage dialogue between undergraduate medical education and graduate medical education on how to best utilize the fourth year.
doi:10.4300/JGME-D-14-00552.1
PMCID: PMC4597948  PMID: 26457143
25.  Are Away Rotations Critical for a Successful Match in Orthopaedic Surgery? 
Surveys have suggested one of the most important determinants of orthopaedic resident selection is completion of an orthopaedic clerkship at the program director’s institution. The purpose of this study was to further elucidate the significance of visiting externships on the resident selection process. We retrospectively reviewed data for all medical students applying for orthopaedic surgery residency from six medical schools between 2006 and 2008, for a total of 143 applicants. Univariate and multivariate regression analyses were used to compare students who matched successfully versus those who did not in terms of number of away rotations, United States Medical Licensing Examination® scores, class rank, and other objective factors. Of the 143 medical students, 19 did not match in orthopaedics (13.3%), whereas the remaining 124 matched. On multiple logistic regression analysis, whether a student did more than one home rotation, how many away rotations a student performed, and United States Medical Licensing Examination® Step 1 score were factors in the odds of match success. Orthopaedic surgery is one of the most competitive specialties in medicine; the away rotation remains an important factor in match success.
doi:10.1007/s11999-009-0920-9
PMCID: PMC2772936  PMID: 19582529

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