Philanthropic contributions to academic medical centers from grateful patients support research, patient care, education, and capital projects. The goal of this study was to identify the ethical concerns associated with philanthropic gifts from grateful patients.
A qualitative study design was selected. Investigators conducted in-depth semi-structured interviews with 20 Department of Medicine physicians at Johns Hopkins who were identified by Development Office staff as experienced and successful in this realm—those having relationships with multiple patients who have made philanthropic contributions. Interview transcripts were independently coded by two investigators. Content analysis identified several themes related to ethical concerns.
Eighteen informants (90 %) were Associate Professors or Professors; two (10 %) were females. Four thematic domains emerged related to ethical concerns associated with philanthropy from grateful patients: (i) impact of gift on the doctor–patient relationship; (ii) gift acquisition considered beyond the physician’s professional role; (iii) justice and fairness; and (iv) vulnerability of patients. Despite acknowledging at least one of the aforementioned concerns, eleven physician informants (55 %) expressed the view that there were no ethical issues involved with grateful patient philanthropy.
In this paper, we report that physicians involved in grateful patient philanthropy are aware of, and in some cases troubled by, the ethical concerns related to this activity. Further studies could examine how best to prepare faculty for the challenges that may accompany these gifts so as to help them maintain expected professional and ethical standards when accepting grateful patient philanthropy.
philanthropy; ethics; patient care
To describe diversity programs for racial and ethnic minority faculty in U.S. medical schools and identify characteristics associated with higher faculty diversity.
The authors conducted a cross-sectional survey study of leaders of diversity programs at 106 U.S. MD-granting medical schools in 2010. Main outcome measures included African American and Latino faculty representation, with correlations to diversity program characteristics, minority medical student representation, and state demographics.
Responses were obtained from 82 of the 106 institutions (77.4%). The majority of the respondents were deans, associate and assistant deans (68.3%), members of minority ethnic/racial background (65.9% African American, 14.7% Latino), and women (63.4%). The average time in the current position was 6.7 years, with approximately 50% effort devoted to the diversity program. Most programs targeted medical trainees and faculty (63.4%). A majority of programs received monetary support from their institutions (82.9%). In bivariate analysis, none of the program characteristics measured were associated with higher than the mean minority faculty representation in 2008 (3% African American and 4.2% Latino faculty). However, minority state demographics in 2008, and proportion of minority medical students a decade earlier, were significantly associated with minority faculty representation.
Medical student diversity ten years earlier was the strongest modifiable factor associated with faculty diversity. Our results support intervening early to strengthen the minority medical student pipeline to improve faculty diversity. Schools located in states with low minority representation may need to commit additional effort to realize institutional diversity.
To determine the effect of a hospitalist-developed, continuity-centered hospitalist staffing model on patient outcomes and resource use.
The Creating Incentives and Continuity Leading to Efficiency (CICLE) staffing model was conceived by a group of hospitalists who sought to improve continuity of inpatient care. Using a retrospective, observational, pre-post study design, we compared patient-level data for all discharges from our hospitalist service from 6 months after implementation of the CICLE staffing model (September 1, 2009, through February 28, 2010; n=1585) with data from those same months in the prior year (September 1, 2008, through February 28, 2009; n=1808). We used the number of unique hospitalists who documented an encounter during the admission as a measure of continuity of care. Length of stay and hospital charges per admission constituted the measures of resource use.
The odds of having a single hospitalist for the entire hospitalization nearly doubled under the CICLE model (odds ratio, 1.87; 95% confidence interval, 1.60-2.2; P<.001). Mean length of stay decreased 7.5% (from 2.92 before to 2.70 days after initiation of the model; P<.001). Mean hospital charge per admission decreased 8.5% (from $7224.33 before to $6607.79 after initiation of the model; P<.001). Thirty-day readmission rates were not substantially affected by the CICLE model (15.0% before to 17.3% after initiation of the model; P=.08).
Improved continuity of care among hospitalists was associated with reductions in length of stay and lower health care costs. These benefits were realized without substantially affecting readmission rates. The staffing model can be achieved by reorganizing existing hospitalists and may not require the hiring of additional personnel. The CICLE staffing model is a viable option for hospitalist groups that are aiming to diminish resource use and improve quality of care.
CICLE, Combining Incentives and Continuity Leading to Efficiency; CIMS, Collaborative Inpatient Medicine Service; CM, case mix; FTE, full-time equivalent; LOS, length of stay; NPPA, nurse practitioner/physician assistant; SHM, Society of Hospital Medicine
In caring exclusively for inpatients, hospitalists are expected to perform hospital procedures. The type and frequency of procedures they perform are not well characterized.
To determine which procedures hospitalists perform; to compare procedures performed by hospitalists and non-hospitalists; and to describe factors associated with hospitalists performing inpatient procedures.
National sample of general internist members of the American College of Physicians.
We characterized respondents to a national survey of general internists as hospitalists and non-hospitalists based on time-activity criteria. We compared hospitalists and non-hospitalists in relation to how many SHM core procedures they performed. Analyses explored whether hospitalists’ demographic characteristics, practice setting, and income structure influenced the performance of procedures.
Of 1,059 respondents, 175 were classified as “hospitalists”. Eleven percent of hospitalists performed all 9 core procedures compared with 3% of non-hospitalists. Hospitalists also reported higher procedural volumes in the previous year for 7 of the 9 procedures, including lumbar puncture (median of 5 by hospitalists vs. 2 for non-hospitalists), abdominal paracentesis (5 vs. 2), thoracenteses (5 vs. 2) and central line placement (5.5 vs. 3). Performing a greater variety of core procedures was associated with total time in patient care, but not time in hospital care, year of medical school graduation, practice location, or income structure. Multivariate analysis found no independent association between demographic factors and performing all 9 core procedures.
Hospitalists perform inpatient procedures more often and at higher volumes than non-hospitalists. Yet many do not perform procedures that are designated as hospitalist “core competencies.”
hospitalists; non-hospitalists; procedures; time-activity criteria
Objective: Because many of the medical journals read by family physicians now have an electronic version, the authors conducted a survey to determine the interest of family physicians in specific features of electronic journal publications.
Setting and Participants: We surveyed 175 family physicians randomly selected from the American Academy of Family Physicians.
Results: The response rate was 63%. About half of family physicians reported good to excellent computer proficiency, and about one quarter used online journals sometimes or often. Many respondents reported high interest in having links to: an electronic medical text (48% for original articles, 56% for review articles), articles' list of references (52% for original articles, 56% for review articles), and health-related Websites (48% for original and review articles).
Conclusion: Primary care–oriented journals should consider the interests of family physicians when developing and offering electronic features for their readers.
The provision of high-quality clinical care is critical to the mission of academic and nonacademic clinical settings and is of foremost importance to academic and nonacademic physicians. Concern has been increasingly raised that the rewards systems at most academic institutions may discourage those with a passion for clinical care over research or teaching from staying in academia. In addition to the advantages afforded by academic institutions, academic physicians may perceive important challenges, disincentives, and limitations to providing excellent clinical care. To better understand these views, we conducted a qualitative study to explore the perspectives of clinical faculty in prominent departments of medicine.
Between March and May 2007, 2 investigators conducted in-depth, semistructured interviews with 24 clinically excellent internal medicine physicians at 8 academic institutions across the nation. Transcripts were independently coded by 2 investigators and compared for agreement. Content analysis was performed to identify emerging themes.
Twenty interviewees (83%) were associate professors or professors, 33% were women, and participants represented a wide range of internal medicine subspecialties. Mean time currently spent in clinical care by the physicians was 48%. Domains that emerged related to faculty's perception of clinical care in the academic setting included competing obligations, teamwork and collaboration, types of patients and productivity expectations, resources for clinical services, emphasis on discovery, and bureaucratic challenges.
Expert clinicians at academic medical centers perceive barriers to providing excellent patient care related to competing demands on their time, competing academic missions, and bureaucratic challenges. They also believe there are differences in the types of patients seen in academic settings compared with those in the private sector, that there is a “public” nature in their clinical work, that productivity expectations are likely different from those of private practitioners, and that resource allocation both facilitates and limits excellent care in the academic setting. These findings have important implications for patients, learners, and faculty and academic leaders, and suggest challenges as well as opportunities in fostering clinical medicine at academic institutions.
Many medical schools are establishing learning communities to foster cohesion among students and to strengthen relationships between students and faculty members. Emerging learning communities require nurturing and attention; this represents an opportunity wherein medical students can become involved as leaders. This study sought to understand issues related to active involvement among students who chose to become highly engaged in a newly developed learning community.
Between April and June 2008, 36 students who assumed leadership roles within the Colleges Program were queried electronically with open-ended questions about their engagement. Qualitative analysis of the written responses was independently performed by two investigators; coding was compared for agreement. Content analysis identified major themes.
35 students (97%) completed the questionnaire. Motives that emerged as reasons for getting involved included: endorsing the need for the program; excitement with the start-up; wanting to give back; commitment to institutional excellence; and collaboration with talented peers and faculty. Perceived benefits were grouped under the following domains: connecting with others; mentoring; learning new skills; and recognition. The most frequently identified drawbacks were the time commitment and the opportunity costs. Ideas for drawing medical students into new endeavors included: creating defined roles; offering a breadth of opportunities; empowering students with responsibility; and making them feel valued.
Medical students were drawn to and took on leadership roles in a medical school curricular innovation. This example may prove helpful to others hoping to engage students as leaders in learning communities at their schools or those wishing to augment student involvement in other programs.
The closure of a primary care practice and the relocation of the physicians and staff to a new office forced patients to decide whether to follow their primary care physicians (PCP) or to transfer their care elsewhere. This study explores the perspectives of the older patients affected by this change.
Setting and Participants
Two lists of patients older than 60 years from the original office were generated: (1) those who had followed their PCPs to the further practice and (2) those who chose new PCPs at an affiliated nearby clinic. One hundred forty patients from each of the two lists were randomly selected for study.
Eight months after the clinic’s closure, patients responded to an open-ended question asking patients to describe the transition. Using content analysis, two investigators independently coded all of the written responses.
Over 85% of patients in both groups had been with their original PCP for longer than 2 years. Patients that elected to transition their care to a new PCP within their community were older (75 vs 70 years) and more likely to be living alone (38% vs 18%), both p < 0.01. There was still considerable frustration associated with the clinic’s closure. Patients from both groups had variable levels of satisfaction with their new primary care arrangements. Patients who moved to the near clinic, now seeing a new physician, commented on being satisfied with the proximity of the site. On the other hand, these patients also expressed longing for the previous arrangement (the building, the staff, and especially their prior physician). Patients who transferred their care to the further clinic indicated a profound loyalty to their PCP and an appreciation of the added features at the new site. Yet, many patients still described being upset with the difficulties associated with the further distance.
The closing of this practice was difficult for this cohort of older patients. Patients’ decisions were considerably influenced by whether they imagined that convenience or their established relationship with their PCP was of a higher priority to them.
elderly; continuity; primary care; patient autonomy
Teamwork is important for improving care across transitions between providers and for increasing patient safety.
This review’s objective was to assess the characteristics and efficacy of published curricula designed to teach teamwork to medical students and house staff.
The authors searched MEDLINE, Education Resources Information Center, Excerpta Medica Database, PsychInfo, Cumulative Index of Nursing and Allied Health Literature, and Scopus for original data articles published in English between January 1980 and July 2006 that reported descriptions of teamwork training and evaluation results.
Two reviewers independently abstracted information about curricular content (using Baker’s framework of teamwork competencies), educational methods, evaluation design, outcomes measured, and results.
Thirteen studies met inclusion criteria. All curricula employed active learning methods; the majority (77%) included multidisciplinary training. Ten curricula (77%) used an uncontrolled pre/post design and 3 (23%) used controlled pre/post designs. Only 3 curricula (23%) reported outcomes beyond end of program, and only 1 (8%) >6weeks after program completion. One program evaluated a clinical outcome (patient satisfaction), which was unchanged after the intervention. The median effect size was 0.40 (interquartile range (IQR) 0.29, 0.61) for knowledge, 0.38 (IQR 0.32, 0.41) for attitudes, 0.41 (IQR 0.35, 0.49) for skills and behavior. The relationship between the number of teamwork principles taught and effect size achieved a Spearman’s correlation of .74 (p = .01) for overall effect size and .64 (p = .03) for median skills/behaviors effect size.
Reported curricula employ some sound educational principles and appear to be modestly effective in the short term. Curricula may be more effective when they address more teamwork principles.
teamwork; cooperation; medical education; curricula; medical student; house staff; resident; residency
Deficiencies in medical education research quality are widely acknowledged. Content, internal structure, and criterion validity evidence support the use of the Medical Education Research Study Quality Instrument (MERSQI) to measure education research quality, but predictive validity evidence has not been explored.
To describe the quality of manuscripts submitted to the 2008 Journal of General Internal Medicine (JGIM) medical education issue and determine whether MERSQI scores predict editorial decisions.
Design and Participants
Cross-sectional study of original, quantitative research studies submitted for publication.
Study quality measured by MERSQI scores (possible range 5–18).
Of 131 submitted manuscripts, 100 met inclusion criteria. The mean (SD) total MERSQI score was 9.6 (2.6), range 5–15.5. Most studies used single-group cross-sectional (54%) or pre-post designs (32%), were conducted at one institution (78%), and reported satisfaction or opinion outcomes (56%). Few (36%) reported validity evidence for evaluation instruments. A one-point increase in MERSQI score was associated with editorial decisions to send manuscripts for peer review versus reject without review (OR 1.31, 95%CI 1.07–1.61, p = 0.009) and to invite revisions after review versus reject after review (OR 1.29, 95%CI 1.05–1.58, p = 0.02). MERSQI scores predicted final acceptance versus rejection (OR 1.32; 95% CI 1.10–1.58, p = 0.003). The mean total MERSQI score of accepted manuscripts was significantly higher than rejected manuscripts (10.7 [2.5] versus 9.0 [2.4], p = 0.003).
MERSQI scores predicted editorial decisions and identified areas of methodological strengths and weaknesses in submitted manuscripts. Researchers, reviewers, and editors might use this instrument as a measure of methodological quality.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-008-0664-3) contains supplementary material, which is available to authorized users.
medical education research; research quality; research methods
Morbidity and Mortality (M&M) Conferences are an Accreditation Council for Graduate Medical Education (ACGME) mandated educational series that occur regularly at all institutions that have residency training programs. The potential for learning from medical errors, complications, and unanticipated outcomes is immense—provided that the focus is on education, as opposed to culpability. The education innovation described in this manuscript is the manner in which we have used the ACGME Outcome Project's 6 core competencies as the structure upon which the cases discussed at our M&M conference are framed. When presented at grand rounds in a novel format, M&M conference has not only maintained support for the quality improvement efforts in the Department, but has served to improve the educational impact of the conference.
grand rounds; Morbidity and Mortality; ACGME competencies; medical education
During clinical training, house officers frequently encounter intense experiences that may affect their personal growth. The purpose of this study was to explore processes related to personal growth during internship.
Prospective qualitative study conducted over the course of internship.
Thirty-two postgraduate year (PGY)-1 residents from 9 U.S. internal medicine training programs.
Every 8 weeks, interns responded by e-mail to an open-ended question related to personal growth. Content analysis methods were used to analyze the interns' writings to identify triggers, facilitators, and barriers related to personal growth.
Triggers for personal growth included caring for critically ill or dying patients, receiving feedback, witnessing unprofessional behavior, experiencing personal problems, and dealing with the increased responsibility of internship. Facilitators of personal growth included supportive relationships, reflection, and commitment to core values. Fatigue, lack of personal time, and overwhelming work were barriers to personal growth. The balance between facilitators and barriers may dictate the extent to which personal growth occurs.
Efforts to support personal growth during residency training include fostering supportive relationships, encouraging reflection, and recognizing interns' core values especially in association with powerful triggers.
graduate medical education; personal growth; qualitative research
Providing and eliciting high-quality feedback is valuable in medical education. Medical learners' attainment of clinical competence and professional growth can be facilitated by reliable feedback. This study's primary objective was to identify characteristics that are associated with physician teachers' proficiency with feedback.
A cohort of 363 physicians, who were either past participants of the Johns Hopkins Faculty Development Program or members of a comparison group, were surveyed by mail in July 2002. Survey questions focused on personal characteristics, professional characteristics, teaching activities, self-assessed teaching proficiencies and behaviors, and scholarly activity. The feedback scale, a composite feedback variable, was developed using factor analysis. Logistic regression models were then used to determine which faculty characteristics were independently associated with scoring highly on a dichotomized version of the feedback scale.
Two hundred and ninety-nine physicians responded (82%) of whom 262 (88%) had taught medical learners in the prior 12 months. Factor analysis revealed that the 7 questions from the survey addressing feedback clustered together to form the “feedback scale” (Cronbach's α: 0.76). Six items, representing discrete faculty responses to survey questions, were independently associated with high feedback scores: (i) frequently attempting to detect and discuss the emotional responses of learners (odds ratio [OR] = 4.6, 95% confidence interval [CI] 2.2 to 9.6), (ii) proficiency in handling conflict (OR = 3.7, 95% CI 1.5 to 9.3), (iii) frequently asking learners what they desire from the teaching interaction (OR = 3.5, 95% CI 1.7 to 7.2), (iv) having written down or reviewed professional goals in the prior year (OR = 3.2, 95% CI 1.6 to 6.4), (v) frequently working with learners to establish mutually agreed upon goals, objectives, and ground rules (OR = 2.2, 95% CI 1.1 to 4.7), and (vi) frequently letting learners figure things out themselves, even if they struggle (OR = 2.1, 95% CI 1.1 to 3.9).
Beyond providing training in specific feedback skills, programs that want to improve feedback performance among their faculty may wish to promote the teaching behaviors and proficiencies that are associated with high feedback scores identified in this study.
feedback; teaching skills; learner centeredness; medical education
The study's objectives were to determine (1) the rate at which department of medicine faculty in the United States are promoted, (2) if clinician-educators (CEs) are promoted to Associate Professor at the same rate as clinician-investigators (CIs), and (3) the variables that predict promotion.
The Prospective Study of Promotion in Academia was a part-retrospective, part-prospective (from 2000 to 2003) cohort study. Six-hundred and four Internal Medicine junior faculty across the United States who had been registered as new appointees with the Association of American Medical Colleges in 1995 were invited to participate. Twenty-one percent of these had already left their institution when the study began. One hundred and eighty-three Internal Medicine faculty from 87 institutions in 35 states enrolled. The main outcome measure was the time from appointment as Assistant Professor to promotion to Associate Professor.
Follow-up was complete for all 183 faculty. Among the faculty that achieved promotion, the estimated median time to promotion was 6.0 years (95% Conf. Int.=5.8 to 6.2). The unadjusted sixth-year promotion rate for CEs was 16%, while for CIs it was 26% (P=.002). Independent negative predictors of promotion included low amount of research time (Hazard Ratio [HR] =0.3, 95% Conf. Int.=0.2 to 0.5), having a manuscript review service (HR=0.4, 95% Conf. Int.=0.2 to 0.7), never meeting with Chairman/Chief about promotion (HR=0.4, 95% Conf. Int.=0.2 to 0.7), low job satisfaction (HR=0.5, 95% Conf. Int.=0.3 to 0.9), and working in the Northeast (HR=0.6, 95% Conf. Int.=0.4 to 1.1). Positive predictors included making between $130 and $149,000 per year (HR=1.9, 95% Conf. Int.=1.1 to 3.4), working more than 60 h/wk (HR=1.9, 95% Conf. Int.=1.1 to 3.0), having a career mentor available (HR=1.8, 95% Conf. Int.=1.1 to 2.9), and having access to a grant office (HR=1.6, 95% Conf. Int.=1.0 to 2.6).
CEs and CIs appear to be promoted at different rates. The characteristics that are independently associated with earlier promotion may be helpful for institutions and individual faculty that are committed to achieving promotion efficiently.
promotion; motivation; academic medicine
The long-term impact of longitudinal faculty development programs (FDPs) is not well understood.
To follow up past participants in the Johns Hopkins Faculty Development Program in Teaching Skills and members of a comparison group in an effort to describe the long-term impact of the program.
Design and Participants
In July 2002, we surveyed all 242 participants in the program from 1987 through 2000, and 121 members of a comparison group selected by participants as they entered the program from 1988 through 1995.
Professional characteristics, scholarly activity, teaching activity, teaching proficiency, and teaching behaviors.
Two hundred participants (83%) and 99 nonparticipants (82%) responded. When participants and nonparticipants from 1988 to 1995 were compared, participants were more likely to have taught medical students and house officers in the last year (both P<.05). Participants rated their proficiency for giving feedback more highly (P<.05). Participants scored higher than nonparticipants for 14 out of 15 behaviors related to being learner centered, building a supportive learning environment, giving and receiving feedback, and being effective leaders, half of which were statistically significant (P<.05). When remote and recent participants from 1987 through 2000 were compared with each other, few differences were found.
Participation in the longitudinal FDP was associated with continued teaching activities, desirable teaching behaviors, and higher self-assessments related to giving feedback and learner centeredness. Institutions should consider supporting faculty wishing to participate in FDPs in teaching skills.
faculty development; teaching skills; learner centeredness; feedback
Resident research has potential benefits and scholarly activity is an internal medicine residency training requirement. This study sought to learn about the resources needed and the barriers to performing scholarly work during residency from residents who had been successful.
A questionnaire was delivered to 138 internal medicine residents presenting their work at the 2002 American College of Physicians-American Society of Internal Medicine annual session. Residents were asked to comment on why they had participated in a scholarly project, the skills and resources needed to complete the project, as well as the barriers. Comparisons were made between residents who presented a research abstract and those who exhibited a clinical vignette.
Seventy-three residents (53%) completed the questionnaire. Thirty-nine residents presented a clinical vignette and 34 displayed a research abstract. Residents participated in research for a variety of reasons, including intellectual curiosity (73%), career development (60%), and to fulfill a mandatory scholarly activity requirement at their residency program (32%). The most common barriers were insufficient time (79%), inadequate research skills (45%), and lack of a research curriculum (44%). Residents who had presented research abstracts devoted more time (median, 200 vs 50 hours; P<.05) to their project than those who exhibited clinical vignettes. Sixty-nine percent of residents thought research should be a residency requirement.
The majority of respondents reported that their scholarly project was a worthwhile experience despite considerable barriers. Teaching research skills more explicitly with a focused curriculum and providing adequate protected time may enable residents to be successful.
resident research; ACGME; graduate medical education
1) To describe how internal medicine residency programs fulfill the Accreditation Council for Graduate Medical Education (ACGME) scholarly activity training requirement including the current context of resident scholarly work, and 2) to compare findings between university and nonuniversity programs.
Cross-sectional mailed survey.
ACGME-accredited internal medicine residency programs.
Internal medicine residency program directors.
Data were collected on 1) interpretation of the scholarly activity requirement, 2) support for resident scholarship, 3) scholarly activities of residents, 4) attitudes toward resident research, and 5) program characteristics. University and nonuniversity programs were compared.
The response rate was 78%. Most residents completed a topic review with presentation (median, 100%) to fulfill the requirement. Residents at nonuniversity programs were more likely to complete case reports (median, 40% vs 25%; P =.04) and present at local or regional meetings (median, 25% vs 20%; P =.01), and were just as likely to conduct hypothesis-driven research (median, 20% vs 20%; P =.75) and present nationally (median, 10% vs 5%; P =.10) as residents at university programs. Nonuniversity programs were more likely to report lack of faculty mentors (61% vs 31%; P <.001) and resident interest (55% vs 40%; P =.01) as major barriers to resident scholarship. Programs support resident scholarship through research curricula (47%), funding (46%), and protected time (32%).
Internal medicine residents complete a variety of projects to fulfill the scholarly activity requirement. Nonuniversity programs are doing as much as university programs in meeting the requirement and supporting resident scholarship despite reporting significant barriers.
ACGME; resident research; medical education; national survey
Understanding how clinician-teachers’ self-assessments compare to learners’ impressions can serve to help educators place each of these evaluations in the appropriate context. Past participants of the Johns Hopkins Faculty Development Program and other physician-teachers were surveyed in 2002 regarding their teaching skills and behaviors. We surveyed their learners to compare teacher and learner assessments of teaching proficiency, behaviors, enjoyment, and career satisfaction. In each area, learners’ ratings were statistically significantly higher than their teachers’ self-ratings. Though it is unclear whether teachers’ or learners’ assessments are a more accurate reflection of the truth, the more positive learner ratings should promote self-confidence in clinician-educators regarding their teaching abilities.
physician-teachers; teacher evaluations; self-assessments
Writing a meaningful and valuable letter of reference is not an easy task. Several factors influence the quality of any letter of reference. First, the accuracy and reliability of the writer's impressions and judgment depend on how well he knows the individual being described. Second, the writer's frame of reference, which is determined by the number of persons at the same level that he has worked with, will impact the context and significance of his beliefs and estimations. Third, the letter-writing skills of the person composing the letter will naturally affect the letter. To support the other components of a candidate's application, a letter of reference should provide specific examples of how an individual's behavior or attitude compares to a reference group and should assess “intangibles” that are hard to glean from a curriculum vitae or from test scores. This report offers suggestions that should help physicians write more informative letters of reference.
references; letter of reference; evaluation; writing
To determine what clinician-educators consider important for promotion, and what support they find helpful and useful for success.
Eighty academic medical centers in the United States.
One hundred eighty-three participants of the Prospective Study of Promotion in Academia comprising assistant professors in departments of medicine from 80 different medical schools in 35 states.
Differences between clinician-educators' and clinician-investigators' work activities, promotion preparedness, and faculty support needs.
One hundred seven (58%) of the faculty were clinician-educators (CEs), and 63 (34%) were clinician-investigators (CIs); the remaining 13 fit neither category. Participants had been in their faculty position for 4.7 years. Ninety-eight percent of CIs reported a publication expectation for promotion, and 75% of CEs also reported such an expectation. More CIs had career mentors available than CEs (68% vs 32%, P < .001). Seventy-nine percent of CIs indicated >10% protected scholarly work time, compared to only 35% of CEs (P < .001). Fifty-three percent of CIs as compared to 32% of CEs (P < .01) meet more often than yearly with their chief/chair for performance review, and more CIs have seen written promotion guidelines (72% vs 51%, P < .01). Clinician educators believed out of 11 job performance areas, research, written scholarship, and reputation were the 3 most important factors that would determine the success of their application for promotion. Both CEs and CIs sense that CIs are more likely get promoted (82% vs 79%).
Clinician educators are less familiar with promotion guidelines, meet less often with superiors for performance review, and have less protected time than CI colleagues. There is dissonance between CEs' beliefs and previously published data from promotion committee chairs in the importance given to specific aspects of job performance.
academic medical centers; mentors; medical faculty; cohort studies; socioeconomic factors; peer review
Department of medicine chairs have a critical role in the promotion of clinician-educators. Our primary objective was to determine how chairs viewed: 1) the importance of specific areas of clinician-educator performance in promotion decisions; and 2) the importance and quality of information on available measures of performance. A secondary objective was to compare the views of department chairs with those of promotion and tenure committee chairs.
In October 1997, a questionnaire was mailed to all department chairs in the United States and Canada asking them to rate the importance of 11 areas of clinician-educators' performance in evaluating them for promotion. We also asked them to rate 36 measures of performance. We compared their responses to a similar 1996 survey administered to promotion committee chairs.
One hundred fourteen of 139 department chairs (82%) responded to the survey. When considering a clinician-educator for promotion, department chairs view teaching skills and clinical skills as the most important areas of performance, as did the promotion committee chairs. Of the measures used to evaluate teaching performance, teaching awards were considered most important and rated as a high-quality measure. When evaluating a clinician-educator's clinical skills, peer and trainee evaluation were considered as the most important measures of performance, but these were rated low in quality. Patient satisfaction and objective outcome measures also were viewed as important measures that needed improvement. Promotion committee chairs placed more emphasis on productivity in publications and external grant support when compared to department chairs.
It is reassuring that both department chairs and promotion committee chairs value teaching skills and clinical skills as the most important areas of a clinician-educator's performance when evaluating for promotion. However, differences in opinion regarding the importance of several performance measures and the need for improved quality measures may represent barriers to the timely promotion of clinician-educators.
promotion criteria; clinician-educators; academic advancement
To determine the interest of academic general internists and family physicians in specific features of electronic journal publications, we surveyed 350 physicians, 175 randomly selected from each of 2 medical societies: the Society of General Internal Medicine, and the Society of Teachers of Family Medicine. The response rate was 70%. Most general internists and family physicians used online journals sometimes or often. Most general internists and family physicians reported moderate to high interest in having links from original articles, reviews, or editorials to listed references (77% to 89% of internists and 65% to 81% of family physicians) and electronic medical reference texts (73% to 78% of internists and 65% to 83% of family physicians). Less than 25% of both groups reported moderate to high interest in having links to initiate dialog with other readers or to communicate comments to the author or editor. General internists were more likely than were family physicians to have moderate to high interest in having links to appendices and supportive material (e.g., 66% of general internists versus 46% of family physicians for original articles; P < .05) and less likely to have moderate to high interest in links to health-related web sites (44% of general internists versus 69% of family physicians for original articles; P < .05). We conclude that academic general internists and family physicians have strong but not identical interests in specific features of electronic publication that primary care–oriented journals should consider.
electronic journals; primary care physicians
Physicians reading the medical literature attempt to determine whether research studies are valid. However, articles with negative results may not provide sufficient information to allow physicians to properly assess validity.
We analyzed all original research articles with negative results published in 1997 in the weekly journals BMJ, JAMA, Lancet, and New England Journal of Medicine as well as those published in the 1997 and 1998 issues of the bimonthly Annals of Internal Medicine (N = 234). Our primary objective was to quantify the proportion of studies with negative results that comment on power and present confidence intervals. Secondary outcomes were to quantify the proportion of these studies with a specified effect size and a defined primary outcome. Stratified analyses by study design were also performed.
Only 30% of the articles with negative results comment on power. The reporting of power (range: 15%-52%) and confidence intervals (range: 55–81%) varied significantly among journals. Observational studies of etiology/risk factors addressed power less frequently (15%, 95% CI, 8–21%) than did clinical trials (56%, 95% CI, 46–67%, p < 0.001). While 87% of articles with power calculations specified an effect size the authors sought to detect, a minority gave a rationale for the effect size. Only half of the studies with negative results clearly defined a primary outcome.
Prominent medical journals often provide insufficient information to assess the validity of studies with negative results.