Publications by authors named "Eva Aagaard"

69 Publications

Educational leadership in the time of a pandemic: Lessons from two institutions.

FASEB Bioadv 2021 Mar 30;3(3):182-188. Epub 2020 Dec 30.

University of Colorado Anschutz Medical Campus Aurora CO USA.

Over the course of a few weeks in March, COVID-19 upended the daily lives of Americans. Academic Medical Centers became a center-point for the response to the virus. Leaders within academic medical centers faced twin challenges of responding to the needs of the patients we serve while managing radical changes within their own institutions, including the educational mission. In this article, we describe some key themes identified and lessons learned as educational leaders during this time. We draw from the experiences of two institutions- one public and one private. These lessons learned fall into the broad categories of leadership decision-making and communication and included the importance of principled decision-making, a connected leadership team, and effective communication both within leadership and to the broader institutional community. The consequences of these responses resulted in a renewed recognition for us as educational leaders of the interdependence of our tripartide academic fates, the importance of academic medical centers as anchor institutions and advocates for our community, and the resilience and ingenuity of our students. We provide examples of these lessons and themes and make recommendations for how to approach educational decision-making in the "new normal" of living with COVID-19 for the immediate future.
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http://dx.doi.org/10.1096/fba.2020-00113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944866PMC
March 2021

Curriculum renewal in the time of COVID-19: The Washington University School of Medicine Story.

FASEB Bioadv 2021 Mar 22;3(3):143-149. Epub 2020 Dec 22.

Division of General Medicine Department of Medicine and Office of Education Washington University School of Medicine St Louis MO USA.

Washington University School of Medicine began a curriculum renewal process in 2017 with a goal of implementing the Gateway Curriculum in 2020. In this article, we describe the vision of this curriculum and the infrastructure that was built to support it. We also describe the impact of COVID-19 on the legacy curriculum and the Gateway Curriculum as well as the lessons learned to date.
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http://dx.doi.org/10.1096/fba.2020-00095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944873PMC
March 2021

Washington University School of Medicine.

Acad Med 2020 Sep;95(9S A Snapshot of Medical Student Education in the United States and Canada: Reports From 145 Schools):S285-S290

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http://dx.doi.org/10.1097/ACM.0000000000003385DOI Listing
September 2020

Managing medical curricula during the pandemic-A special collection.

FASEB Bioadv 2021 Feb 14;3(2):108-109. Epub 2020 Dec 14.

Department of Cell Biology & Physiology Washington University School of Medicine St. Louis MO USA.

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http://dx.doi.org/10.1096/fba.2020-00108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7876700PMC
February 2021

Student Response Initiatives: A Case Study of COVID-19 at Washington University.

Med Sci Educ 2021 Feb 9:1-5. Epub 2021 Feb 9.

Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO USA.

The COVID-19 pandemic disrupted medical education worldwide, leading medical students to organize response initiatives. This paper summarizes the Washington University Medical Student COVID-19 Response (WUMS-CR) and shares lessons to guide future initiatives. We used a three-principle framework of community needs assessment, faculty mentorship, and partnership with pre-existing organizations to address needs in St. Louis, including contact tracing and childcare. In total, over 12,000 h were volunteered across 15+ projects. Overall, student response initiatives should use appropriate frameworks to guide projects and should capitalize on volunteer participation, speed and flexibility, and the diversity of student interests and skills for maximal impact.
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http://dx.doi.org/10.1007/s40670-021-01225-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872507PMC
February 2021

Washington University School of Medicine in St. Louis Case Study: A Process for Understanding and Addressing Bias in Clerkship Grading.

Acad Med 2020 12;95(12S Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments):S131-S135

E.M. Aagaard is professor of medicine, Carol B and Jerome T Loeb Professor of Medical Education, and senior associate dean for education, Washington University School of Medicine in St. Louis, St. Louis, Missouri.

In 2018, in response to a news story featuring the Icahn School of Medicine's decision to eliminate its chapter of Alpha Omega Alpha (AOA) due to perceived racial inequities, students at Washington University School of Medicine in St. Louis (WUSM) brought similar concerns to leadership. WUSM leadership evaluated whether students' race, ethnicity, and gender were associated with their receipt of honors in the 6 core clerkships, key determinants of AOA selection. In preliminary analysis of the school's data, statistically significant racial and ethnic disparities were associated with receipt of honors in each clerkship. Leaders shared these findings with the WUSM community along with a clear message that such discrepancies are unacceptable to the school. An effort to further analyze what lay behind the findings as well as to identify steps to resolve the problem was launched. Using a quality improvement framework, data from focus groups and student surveys were analyzed and 2 overarching themes emerged. Students perceived that both assessment and the learning environment impacted racial/ethnic disparities in clerkship grades. In multivariable logistic regression models, shelf exam scores (a part of student assessment) were found to be associated with receipt of honors in each clerkship; in some (but not all) clerkships, shelf exam scores attenuated the effect of race/ethnicity on receipt of honors, so that when the shelf scores were added to the model, the race/ethnicity effect was no longer significant. This case study describes WUSM's process to understand and address bias in clerkship grading and AOA nomination so that other medical schools might benefit from what has been learned.
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http://dx.doi.org/10.1097/ACM.0000000000003702DOI Listing
December 2020

A BEME realist synthesis review of the effectiveness of teaching strategies used in the clinical setting on the development of clinical skills among health professionals: BEME Guide No. 61.

Med Teach 2020 06 21;42(6):604-615. Epub 2020 Jan 21.

Department of Medicine, University of Colorado Anschutz, Aurora, CO, USA.

Literature describing the effectiveness of teaching strategies in the clinical setting is limited. This realist synthesis review focuses on understanding the effectiveness of teaching strategies used in the clinical setting. We searched ten databases for English language publications between 1 January 1970 and 31 May 2017 reporting effective teaching strategies, used in a clinical setting, of non-procedural skills. After screening, we used consensus to determine inclusion and employed a standardised instrument to capture study populations, methodology, and outcomes. We summarised what strategies worked, for whom, and in what settings. The initial search netted 53,642 references after de-duplication; 2037 were retained after title and abstract review. Full text review was done on 82 references, with ultimate inclusion of 25 publications. Three specific teaching strategies demonstrated impact on educational outcomes: the One Minute Preceptor (OMP), SNAPPS, and concept mapping. Most of the literature involves physician trainees in an ambulatory environment. All three have been shown to improve skills in the domains of medical knowledge and clinical reasoning. Apart from the OMP, SNAPPS, and concept mapping, which target the formation of clinical knowledge and reasoning skills, the literature establishing effective teaching strategies in the clinical setting is sparse.
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http://dx.doi.org/10.1080/0142159X.2019.1708294DOI Listing
June 2020

Effect of individualized feedback on learning curves in EGD and colonoscopy: a cluster randomized controlled trial.

Gastrointest Endosc 2020 04 9;91(4):882-893.e4. Epub 2019 Nov 9.

Division of Gastroenterology, University of Texas Health San Antonio, San Antonio, Texas, USA.

Background And Aims: Gastroenterology fellowships need to ensure that trainees achieve competence in upper endoscopy (EGD) and colonoscopy. Because the impact of structured feedback remains unknown in endoscopy training, this study compared the effect of structured feedback with standard feedback on trainee learning curves for EGD and colonoscopy.

Methods: In this multicenter, cluster, randomized controlled trial, trainees received either individualized quarterly learning curves or feedback standard to their fellowship. Assessment was performed in all trainees using the Assessment of Competency in Endoscopy tool on 5 consecutive procedures after every 25 EGDs and colonoscopies. Individual learning curves were created using cumulative sum (CUSUM) analysis. The primary outcome was the mean CUSUM score in overall technical and overall cognitive skills.

Results: In all, 13 programs including 132 trainees participated. The intervention arm (6 programs, 51 trainees) contributed 558 EGD and 600 colonoscopy assessments. The control arm (7 programs, 81 trainees) provided 305 EGD and 468 colonoscopy assessments. For EGD, the intervention arm (-.7 [standard deviation {SD}, 1.3]) had a superior mean CUSUM score in overall cognitive skills compared with the control arm (1.6 [SD, .8], P = .03) but not in overall technical skills (intervention, -.26 [SD, 1.4]; control, 1.76 [SD, .7]; P = .06). For colonoscopy, no differences were found between the 2 arms in overall cognitive skills (intervention, -.7 [SD, 1.3]; control, .7 [SD, 1.3]; P = .95) or overall technical skills (intervention, .1 [SD, 1.5]; control, -.1 [SD, 1.5]; P = .77).

Conclusions: Quarterly feedback in the form of individualized learning curves did not affect learning curves for EGD and colonoscopy in a clinically meaningful manner. (Clinical trial registration number: NCT02891304.).
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http://dx.doi.org/10.1016/j.gie.2019.10.032DOI Listing
April 2020

Time Given to Trainees to Attempt Cannulation During Endoscopic Retrograde Cholangiopancreatography Varies by Training Program and Is Not Associated With Competence.

Clin Gastroenterol Hepatol 2020 12 4;18(13):3040-3042.e1. Epub 2019 Oct 4.

Department of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado. Electronic address:

Advanced endoscopy training programs (AETPs) were developed as a result of the lack of comprehensive endoscopic retrograde cholangiopancreatography (ERCP) training during gastroenterology fellowships. There is no standardized curriculum for AETPs and the influence of program- and trainer-associated factors on trainee competence in ERCP has not been investigated adequately. In prior work, we showed that advanced endoscopy trainees (AETs) achieve ERCP competence at varying rates. The aims of this study were to measure the variability in time given to AETs to attempt cannulation between AETPs and throughout the 1-year training period, and to determine the association between AET cannulation time and AET competence at the end of training.
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http://dx.doi.org/10.1016/j.cgh.2019.09.039DOI Listing
December 2020

The Evolution of Resident Remedial Teaching at One Institution.

Acad Med 2019 12;94(12):1891-1894

J. Guerrasio was professor, Division of Hospital Medicine, Department of Medicine, and director for remediation, University of Colorado School of Medicine, Aurora, Colorado, at the time of writing. She is currently in private practice at David L. Mellman, MD, PLLC, and working as a consultant, Denver, Colorado. E. Brooks is assistant professor, Department of Community and Behavioral Health, University of Colorado School of Public Health, Aurora, Colorado. C.M. Rumack is professor, Department of Radiology, and associate dean for graduate medical education, University of Colorado School of Medicine, Aurora, Colorado. E.M. Aagaard is professor, Division of Medical Education, Department of Medicine, and senior associate dean for education, Washington University School of Medicine in St. Louis, St. Louis, Missouri.

Residency program directors and teaching faculty invest an enormous amount of time, energy, and resources in providing underperforming at-risk learners with remedial teaching. A remediation program was created and centralized at the University of Colorado School of Medicine in 2006 and 2012, respectively, that consolidated expertise in and resources for learner assessment and individualized teaching for struggling learners, particularly those placed on probation or receiving letters of warning (called focused review letters) from their residency programs. Since the implementation of the program, the authors have observed a decrease in the number of residents being placed on probation, and, of those on probation, more are graduating and obtaining board certification. In this Article, the authors aim to describe the development and outcomes of the program and to explore possible reasons for the improved outcomes.
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http://dx.doi.org/10.1097/ACM.0000000000002894DOI Listing
December 2019

Moving Toward Summative Competency Assessment to Individualize the Postclerkship Phase.

Acad Med 2019 12;94(12):1858-1864

M.G. Keeley is assistant dean for student affairs, director of the fourth-year program, and professor of pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia; ORCID: https://orcid.org/0000-0001-8602-2638. M.E. Gusic is senior advisor in educational affairs and professor of medical education, University of Virginia School of Medicine, Charlottesville, Virginia. H.K. Morgan is associate professor of learning health sciences and associate professor of obstetrics and gynecology, University of Michigan Medical School, Ann Arbor, Michigan. E.M. Aagaard is senior associate dean for education and professor of medicine, Washington University School of Medicine, St. Louis, Missouri. S.A. Santen is senior associate dean for assessment, evaluation, and scholarship and professor of emergency medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia.

In the move toward competency-based medical education, leaders have called for standardization of learning outcomes and individualization of the learning process. Significant progress has been made in establishing defined expectations for the knowledge, skills, attitudes, and behaviors required for successful transition to residency training, but individualization of educational processes to assist learners in reaching these competencies has been predominantly conceptual to date. The traditional time-based structure of medical education has posed a challenge to individualization within the curriculum and has led to more attention on innovations that facilitate transition from medical school to residency. However, a shift of focus to the clerkship-to-postclerkship transition point in the undergraduate curriculum provides an opportunity to determine how longitudinal competency-based assessments can be used to facilitate intentional and individualized structuring of the long-debated fourth year.This Perspective demonstrates how 2 institutions-the University of Virginia School of Medicine and the University of Michigan Medical School-are using competency assessments and applying standardized outcomes in decisions about individualization of the postclerkship learning process. One institution assesses Core Entrustable Professional Activities for Entering Residency, whereas the other has incorporated Accreditation Council for Graduate Medical Education core competencies and student career interests to determine degrees of flexibility in the postclerkship phase. Individualization in addition to continued assessment of performance presents an opportunity for intentional use of curriculum time to develop each student to be competently prepared for the transition to residency.
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http://dx.doi.org/10.1097/ACM.0000000000002830DOI Listing
December 2019

A Guide for Increasing Scholarship for Medical Educators.

J Gen Intern Med 2019 07;34(7):1348-1351

Washington University School of Medicine, St. Louis, MO, USA.

Disseminating scholarly work as a clinician educator is critical to furthering new knowledge in medical education, creating an evidence base for new practices, and increasing the likelihood of promotion. Knowing how to initiate scholarship and develop habits to support it, however, may not be clear. This perspective is designed to help readers choose and narrow their focus of scholarly interest, garner mentors, find potential project funding, and identify outside support through involvement with national organizations, collaborators, and faculty development programs. By incorporating these suggestions into their daily work, educators can find ways to connect their clinical and educational interests and make their daily work count toward scholarship.
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http://dx.doi.org/10.1007/s11606-019-04948-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6614218PMC
July 2019

Transformation and Innovation at the Nexus of Health Systems and Medical Education.

J Gen Intern Med 2019 05;34(5):645-646

Washington University School of Medicine, St. Louis, MO, USA.

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http://dx.doi.org/10.1007/s11606-019-04926-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502911PMC
May 2019

Health Education Advanced Leadership for Zimbabwe (Healz): Developing the Infrastructure to Support Curriculum Reform.

Ann Glob Health 2018 04 30;84(1):176-182. Epub 2018 Apr 30.

Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, ZW.

An economic crisis in Zimbabwe from 1999-2009 resulted in a shortage of faculty at the University of Zimbabwe College of Health Sciences (UZCHS) and declining enrollment and graduation rates. To improve proficiency and retention of graduates, the college sought to develop a competency-based curriculum using evidence-based educational methodologies. Achievement of this goal required a cadre of highly qualified educators to lead the curriculum review and innovation processes. The Health Education Advanced Leadership for Zimbabwe (HEALZ) program was established in 2012 to rapidly develop the needed faculty leadership. HEALZ is a one-year program of rigorous coursework delivered face-to-face in three intensive one-week sessions. Between sessions, scholars engage with mentors to conduct a needs assessment and to develop, implement, and evaluate a competency-based curriculum. Forty scholars completed training from 2012-15. All participants reported they were satisfied or extremely satisfied with the training after each week. Pre-post surveys identified significant knowledge gains in all key content domains. The program garnered significant organizational support. Scholars showed significant variation in progress toward implementing and evaluating their curricula as well as the quality of the work demonstrated by program end. Interviews of scholars and UZCHS leaders revealed important impacts of the program on the quality and culture of medical education at the college.
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http://dx.doi.org/10.29024/aogh.19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6748278PMC
April 2018

Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees.

Gastrointest Endosc 2019 06 7;89(6):1160-1168.e9. Epub 2019 Feb 7.

University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.

Background And Aims: Minimum EUS and ERCP volumes that should be offered per trainee in "high quality" advanced endoscopy training programs (AETPs) are not established. We aimed to define the number of procedures required by an "average" advanced endoscopy trainee (AET) to achieve competence in technical and cognitive EUS and ERCP tasks to help structure AETPs.

Methods: American Society for Gastrointestinal Endoscopy (ASGE)-recognized AETPs were invited to participate; AETs were graded on every fifth EUS and ERCP examination using a validated tool. Grading for each skill was done using a 4-point scoring system, and learning curves using cumulative sum analysis for overall, technical, and cognitive components of EUS and ERCP were shared with AETs and trainers quarterly. Generalized linear mixed-effects models with a random intercept for each AET were used to generate aggregate learning curves, allowing us to use data from all AETs to estimate the average learning experience for trainees.

Results: Among 62 invited AETPs, 37 AETs from 32 AETPs participated. Most AETs reported hands-on EUS (52%, median 20 cases) and ERCP (68%, median 50 cases) experience before starting an AETP. The median number of EUS and ERCPs performed per AET was 400 (range, 200-750) and 361 (range, 250-650), respectively. Overall, 2616 examinations were graded (EUS, 1277; ERCP-biliary, 1143; pancreatic, 196). Most graded EUS examinations were performed for pancreatobiliary indications (69.9%) and ERCP examinations for ASGE biliary grade of difficulty 1 (72.1%). The average AET achieved competence in core EUS and ERCP skills at approximately 225 and 250 cases, respectively. However, overall technical competence was achieved for grade 2 ERCP at about 300 cases.

Conclusion: The thresholds provided for an average AET to achieve competence in EUS and ERCP may be used by the ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training. (Clinical trial registration number: NCT02509416.).
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http://dx.doi.org/10.1016/j.gie.2019.01.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6527477PMC
June 2019

Long-Term Outcomes of a Simulation-Based Remediation for Residents and Faculty With Unprofessional Behavior.

J Grad Med Educ 2018 Dec;10(6):693-697

Background: There are few studies describing remediation for unprofessional behavior in residents and faculty and none that assess the long-term impact of remediation.

Objective: We implemented a simulation-based personalized remediation program for unprofessional behavior in residents and faculty and collected assessments from participants and referring supervisors.

Methods: Residents and faculty were referred for unprofessional behaviors, including aggressive, condescending, and argumentative communication styles as well as an inability to read social cues. We had standardized patients recreate the scenarios that triggered the unprofessional behavior. After each scenario, participants reviewed a videotape of their performance, participated in guided self-reflection and feedback, and then iteratively practiced skills. In 2017, about 2 to 4 years after the intervention, we conducted structured phenomenological qualitative interviews until thematic saturation was reached. Transcripts were analyzed inductively for themes by 2 reviewers (J.G. and research assistant).

Results: Requests for interviews were sent to 16 residents, 8 faculty members, and 24 supervisors, including program directors. Nine remediation participants (38%) and 19 referring supervisors (79%) were interviewed. Sixteen supervisors reported no recurrence of unprofessional behavior in participants 2 to 4 years after the intervention, and participants identified behavioral strategies to reduce unprofessional behavior. Participants and respective supervisors reported similar themes of behavior changes that resulted in improved professional interaction with others.

Conclusions: A simulation-based personalized remediation program for unprofessional behavior, where faculty and residents practice behaviors with guided feedback, can lead to sustained positive behavior change in participants.
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http://dx.doi.org/10.4300/JGME-D-18-00263.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6314358PMC
December 2018

Practical Implications of Compassionate Off-Ramps for Medical Students.

Acad Med 2019 05;94(5):619-622

E.M. Aagaard is Carol B. and Jerome T. Loeb Professor of Medical Education and senior associate dean for education, Washington University School of Medicine in St. Louis, St. Louis, Missouri; ORCID: https://orcid.org/0000-0002-5773-0923. L. Moscoso is associate professor of pediatrics and associate dean for student affairs, Washington University School of Medicine in St. Louis, St. Louis, Missouri.

Attrition from medical school remains uncommon even when a medical student performs poorly, has a change in interests, or experiences an unexpected life event that alters his/her ability to succeed as a physician. In this issue, Bellini and colleagues describe the scope of this problem and make recommendations to support the implementation of compassionate off-ramps for students. These recommendations include enabling ongoing assessment of commitment to career path via a professional identity formation curriculum; implementing competency-based education and training to identify struggling learners; using career advisors and coaches who understand alternative career pathways; providing credit or credentials for competencies already achieved; requiring financial counseling and supporting debt forgiveness; and requiring schools to report on their remediation programs and handling of debt. In this Invited Commentary, the authors describe a representative student-a composite of several students they have counseled whose medical school paths have been impacted by poor performance, unanticipated life events and stressors, changing career interests, and/or physical and mental health issues-who may have benefited from these recommendations. The authors elaborate on Bellini and colleagues' recommendations and describe what they think would be necessary to ensure that the recommendations effectively meet the goal of providing compassionate off-ramps for students in need. The authors describe the potential impact of the recommendations on the representative and similar students. Although this impacts a small proportion of students, the recommendations would help schools achieve the moral imperatives of humanistic care for students while honoring the social contract of the medical profession.
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http://dx.doi.org/10.1097/ACM.0000000000002569DOI Listing
May 2019

Leadership Observation and Feedback Tool: A Novel Instrument for Assessment of Clinical Leadership Skills.

J Grad Med Educ 2018 Oct;10(5):573-582

Background : While leadership training is increasingly incorporated into residency education, existing assessment tools to provide feedback on leadership skills are only applicable in limited contexts.

Objective : We developed an instrument, the Leadership Observation and Feedback Tool (LOFT), for assessing clinical leadership.

Methods : We used an iterative process to develop the tool, beginning with adapting the Leadership Practices Inventory to create an open-ended survey for identification of clinical leadership behaviors. We presented these to leadership experts who defined essential behaviors through a modified Delphi approach. In May 2014 we tested the resulting 29-item tool among residents in the internal medicine and pediatrics departments at 2 academic medical centers. We analyzed instrument performance using Cronbach's alpha, interrater reliability using intraclass correlation coefficients (ICCs), and item performance using linear-by-linear test comparisons of responses by postgraduate year, site, and specialty.

Results : A total of 377 (of 526, 72%) team members completed the LOFT for 95 (of 519, 18%) residents. Overall ratings were high-only 14% scored at the novice level. Cronbach's alpha was 0.79, and the ICC ranged from 0.20 to 0.79. Linear-by-linear test comparisons revealed significant differences between postgraduate year groups for some items, but no significant differences by site or specialty. Acceptability and usefulness ratings by respondents were high.

Conclusions : Despite a rigorous approach to instrument design, we were unable to collect convincing validity evidence for our instrument. The tool may still have some usefulness for providing formative feedback to residents on their clinical leadership skills.
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http://dx.doi.org/10.4300/JGME-D-18-00113.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194892PMC
October 2018

Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice.

Gastroenterology 2018 11 26;155(5):1483-1494.e7. Epub 2018 Jul 26.

University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background & Aims: It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence.

Methods: We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs.

Results: By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate).

Conclusions: In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.
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http://dx.doi.org/10.1053/j.gastro.2018.07.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6504935PMC
November 2018

Development of a neonatal curriculum for medical students in Zimbabwe - a cross sectional survey.

BMC Med Educ 2018 May 2;18(1):90. Epub 2018 May 2.

Department of Pediatrics and Child Health, University of Zimbabwe College of Health Sciences, P.O.Box A178, Mazoe Street, Avondale, Harare, Zimbabwe.

Background: Calls have been made to reassess the curricula of medical schools throughout the world to adopt competence-based programs that address the healthcare needs of society. Zimbabwe is a country characterized by a high neonatal mortality rate of 24 per 1000 live births. The current research sought to determine the content and appropriate teaching strategies needed to guide the development of an undergraduate neonatal curriculum map for medical students at the University of Zimbabwe College of Health Sciences.

Methods: We surveyed faculty (n = 8) and non-faculty pediatricians (n = 5), senior resident medical officers (N = 26) using a self-administered questionnaire, and completed one focus group discussion with midwives (n = 11). We asked respondents their expectations regarding knowledge, psychomotor skills, competencies, and teaching strategies in a basic newborn curriculum for medical students. Relevant policy and curricula documents were reviewed to assess newborn health needs and the current training. A group of faculty educationists (n = 11) collated and finalized the findings from the document review, survey, and focus group using descriptive statistics and thematic analysis.

Results: The document review revealed three key neonatal health objectives according to the current national maternal and neonatal health road map. These objectives are to be met using a four tier approach comprising (i) family planning (ii) focused antenatal care (iii) clean and safe delivery and (iv) basic and comprehensive emergency obstetric & neonatal care. Existing curriculum has 15 newborn topics taught in lecture style during the pediatric rotations, and five newborn care skills to be learned through observation. The existing curriculum is silent on desired competencies. In the current study 19 cognitive areas, 17 psychomotor skills and six competency domains were identified for an ideal neonatal curriculum for undergraduate students. A combination of teaching strategies including classroom, simulation and a clinical rotation were recommended.

Conclusion: This study revealed a significant gap between the existing neonatal curriculum and the ideal curriculum as recommended by broad stakeholders in the context of national health care needs. Next steps are to complete the development and implementation of the proposed curriculum map to better align with the ideal state.
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http://dx.doi.org/10.1186/s12909-018-1194-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5932895PMC
May 2018

Medical Education Partnership Initiative (MEPI) in Zimbabwe: Outcomes and Challenges.

Glob Health Sci Pract 2018 03 30;6(1):82-92. Epub 2018 Mar 30.

Division of Infectious Diseases, University of Colorado, Aurora, Denver, CO, USA.

Background: Sub-Saharan Africa has an inadequate number of health professionals, leading to a reduced capacity to respond to health challenges, including HIV/AIDS. From 2010 to 2015, the Medical Education Partnership Initiative (MEPI)-sponsored by the U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR) and the National Institutes of Health (NIH)-was enthusiastically taken up by the University of Zimbabwe College of Health Sciences (UZCHS) and 12 other sub-Saharan African universities to develop models of training to improve medical education and research capacity. In this article, we describe the outcomes and challenges of MEPI in Zimbabwe.

Methods: UZCHS in partnership with the University of Colorado, Denver; Stanford University; University of Cape Town; University College London; and King's College London designed the Novel Education Clinical Trainees and Researchers (NECTAR) program and 2 linked awards addressing cardiovascular disease and mental health to pursue MEPI objectives. A range of medical education and research capacity-focused programs were implemented, including faculty development, research support, mentored scholars, visiting professors, community-based education, information and technology support, cross-cutting curricula, and collaboration with partner universities and the ministries of health and education. We analyzed quantitative and qualitative data from several data sources, including annual surveys of faculty, students, and other stakeholders; workshop exit surveys; and key informant interviews with NECTAR administrators and leaders and the UZCHS dean.

Findings: Improved Internet connectivity and electronic resource availability were early successes of NECTAR. Over the 5-year period, 69% (115 of 166) of faculty members attended at least 1 of 15 faculty development workshops. Forty-one faculty members underwent 1-year advanced faculty development training in medical education and leadership. Thirty-three mentored research scholars were trained under NECTAR, and 52 and 12 in cardiovascular and mental health programs, respectively. Twelve MEPI scholars had joined faculty by 2015. Full-time faculty grew by 36% (122 to 166), annual postgraduate and medical student enrollment increased by 61% (75 to 121) and 71% (123 to 210), respectively. To institutionalize and sustain MEPI innovations, the Research Support Center and the Department of Health Professions Education were established at UZCHS.

Conclusion: MEPI has synergistically revitalized medical education, research capacity, and leadership at UZCHS. Investments in creating a new research center, health professions education department, and, programs have laid the foundation to help sustain faculty development and research capacity in the country.
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http://dx.doi.org/10.9745/GHSP-D-17-00052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878082PMC
March 2018

Evaluating the Impact of the Medical Education Partnership Initiative at the University of Zimbabwe College of Health Sciences Using the Most Significant Change Technique.

Acad Med 2017 09;92(9):1264-1268

S.C. Connors is associate director, The Evaluation Center, School of Education and Human Development, University of Colorado Denver, Denver, Colorado.S. Nyaude is monitoring and evaluation specialist, Regional Office for Southern Africa, Humanist Institute for Co-operation with Developing Countries (Hivos), Harare, Zimbabwe.A. Challender is education coordinator, Colorado Family Medicine Residencies, Denver, Colorado.E. Aagaard is professor of medicine, Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.C. Velez is senior evaluation specialist, The Evaluation Center, School of Education and Human Development, University of Colorado Denver, Denver, Colorado.J. Hakim is professor of medicine, Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.

Problem: In medical education, evaluating outcomes from programs intended to transform attitudes or influence career trajectories using conventional methods of monitoring is often difficult. To address this problem, the authors adapted the most significant change (MSC) technique to gain a more comprehensive understanding of the impact of the Medical Education Partnership Initiative (MEPI) program at the University of Zimbabwe College of Health Sciences.

Approach: In 2014-2015, the authors applied the MSC to systematically examine the personal significance and level of positive transformation that individuals attributed to their MEPI participation. Interviews were conducted with 28 participants nominated by program leaders. The authors coded results inductively for prevalent themes in participants' stories and prepared profiles with representative quotes to place the stories in context. Stakeholders selected 9 themes and 18 stories to illustrate the most significant changes.

Outcomes: Six themes (or outcomes) were expected, as they aligned with MEPI goals-becoming a better teacher, becoming a better clinician, increased interest in teaching, increased interest in research, new career pathways (including commitment to practice in Zimbabwe), and improved research skills. Three themes were unexpected-increased confidence, expanded interprofessional networks, and improved interpersonal interactions.

Next Steps: The authors found the MSC to be a useful and systematic evaluation approach for large, complex, and transformative initiatives like MEPI. The MSC seemed to encourage participant reflection, support values inquiry by program leaders, and provide insights into the personal and cultural impacts of MEPI. Additional trial applications of the MSC technique in academic medicine are warranted.
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http://dx.doi.org/10.1097/ACM.0000000000001519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5580049PMC
September 2017

Resident and Preceptor Perceptions of Preceptor Integration Into Resident Clinic Scheduling Templates.

J Grad Med Educ 2017 Aug;9(4):497-502

Background : Some internal medicine residency programs on X+Y schedules have modified clinic preceptor schedules to mimic those of the resident cohort (resident matched). This is in contrast to a traditional model, in which preceptors supervise on the same half-day each week.

Objective : We assessed preceptor and resident perceptions of the 2 precepting models.

Methods : We surveyed 44 preceptors and 97 residents at 3 clinic sites in 2 academic medical centers. Two clinics used the resident-matched model, and 1 used a traditional model. Surveys were completed at 6 months and 1 year. We assessed resident and preceptor perceptions in 5 domains: relationships between residents and preceptors; preceptor familiarity with complex patients; preceptor ability to assess milestone achievements; ability to follow up on results; and quality of care.

Results : There was no difference in perceptions of interpersonal relationships or satisfaction with patient care. Preceptors in the resident-matched schedule reported they were more familiar with complex patients at both 6 months and 1 year, and felt more comfortable evaluating residents' milestone achievements at 6 months, but not at 1 year. At 1 year, residents in the resident-matched model perceived preceptors were more familiar with complex patients than residents in the traditional model. The ability to discuss patient results between clinic weeks was low in both models.

Conclusions : The resident-matched model increased resident and preceptor perceptions of familiarity with complex patients and early preceptor perceptions of comfort in assessment of milestone achievements.
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http://dx.doi.org/10.4300/JGME-D-16-00609.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5559247PMC
August 2017

The Impact of an Academy of Medical Educators on the Culture of an American Health Sciences Campus.

Acad Med 2017 08;92(8):1145-1150

J. Corral is assistant professor, Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado.G. Guiton is associate professor, Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado.E. Aagaard is professor, Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado.

Purpose: During the last two decades in the United States, academies of medical educators (AMEs) have proliferated as formal organizations within faculties of health professions education to recognize teaching excellence, support faculty development, and encourage scholarly activity. AMEs have been effective at rewarding faculty for educational excellence and providing faculty development. However, the impact of an AME on campus culture remains unclear.

Method: A qualitative case study asked, How has an AME shaped organizational culture? The authors investigated the University of Colorado health sciences campus AME given its clear mandate to impact organizational culture. The authors interviewed a purposeful sample of 26 AME members and non-AME campus faculty and educational leaders during the 2014-2015 academic year. Two reviewers employed content analysis to code the transcripts.

Results: The AME has positively impacted organizational culture by being a symbol of institutional commitment to the educational mission, and by asserting education as an evidence-based practice. At the faculty member level, the AME's impact includes creating a home and community for educators to network. Individual faculty influence departments and programs across campus through teaching and interpersonal connections. However, the AME has not impacted all of campus, due to only reaching self-identified educators, and the siloed nature of departments on campus.

Conclusions: Although limited to a single campus and an early established AME, this study contributes significant insight by describing how an AME as a structural unit impacts individual faculty members, who in turn impact organizational campus culture regarding the educational mission.
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http://dx.doi.org/10.1097/ACM.0000000000001508DOI Listing
August 2017

The SGIM TEACH Program: A Curriculum for Teachers of Clinical Medicine.

J Gen Intern Med 2017 Aug 13;32(8):948-952. Epub 2017 Apr 13.

Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.

Background: Demand for faculty with teaching expertise is increasing as medical education is becoming well established as a career pathway. Junior faculty may be expected to take on teaching responsibilities with minimal training in teaching skills.

Aim: To address the faculty development needs of junior clinician-educators with teaching responsibilities and those changing their career focus to include teaching.

Setting: Sessions at two Society of General Internal Medicine (SGIM) annual meetings combined with local coaching and online learning during the intervening year.

Participants: Eighty-nine faculty scholars in four consecutive annual cohorts from 2013 to 2016.

Program Description: Scholars participate in a full-day core teaching course as well as selective workshops at the annual meetings. Between meetings they receive direct observation and feedback on their teaching from a local coach and participate in an online discussion group.

Program Evaluation: Sessions were evaluated using a post-session survey. Overall content rating was 4.48 (out of 5). Eighty-nine percent of participants completed all requirements. Of these, 100% agreed that they had gained valuable knowledge and skills.

Discussion: The TEACH certificate program provides inexperienced faculty teachers an opportunity to develop core skills. Satisfaction is high. Future research should focus on the impact that this and similar programs have on teaching skills.
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http://dx.doi.org/10.1007/s11606-017-4053-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5515791PMC
August 2017

Toward an Optimal Pedagogy for Teamwork.

Acad Med 2017 10;92(10):1378-1381

M.A. Earnest is professor of medicine and division head, General Internal Medicine Division, University of Colorado School of Medicine, Denver, Colorado. J. Williams is assistant professor of pediatrics and training director of child psychology, University of Colorado School of Medicine, Denver, Colorado. E.M. Aagaard is professor of medicine and associate dean for educational strategy, University of Colorado School of Medicine, Denver, Colorado.

Teamwork and collaboration are increasingly listed as core competencies for undergraduate health professions education. Despite the clear mandate for teamwork training, the optimal method for providing that training is much less certain. In this Perspective, the authors propose a three-level classification of pedagogical approaches to teamwork training based on the presence of two key learning factors: interdependent work and explicit training in teamwork. In this classification framework, level 1-minimal team learning-is where learners work in small groups but neither of the key learning factors is present. Level 2-implicit team learning-engages learners in interdependent learning activities but does not include an explicit focus on teamwork. Level 3-explicit team learning-creates environments where teams work interdependently toward common goals and are given explicit instruction and practice in teamwork. The authors provide examples that demonstrate each level. They then propose that the third level of team learning, explicit team learning, represents a best practice approach in teaching teamwork, highlighting their experience with an explicit team learning course at the University of Colorado Anschutz Medical Campus. Finally, they discuss several challenges to implementing explicit team-learning-based curricula: the lack of a common teamwork model on which to anchor such a curriculum; the question of whether the knowledge, skills, and attitudes acquired during training would be transferable to the authentic clinical environment; and effectively evaluating the impact of explicit team learning.
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http://dx.doi.org/10.1097/ACM.0000000000001670DOI Listing
October 2017

Academic Remediation: Why Early Identification and Intervention Matters.

Acad Radiol 2017 06 23;24(6):730-733. Epub 2017 Mar 23.

Department of Internal Medicine.

At our institution, we have developed a remediation team of strong, focused experts who help us with struggling learners in making the diagnosis and then coaching on their milestone deficits. It is key for all program directors to recognize struggling residents because early recognition and intervention gives the resident the best chance of success.
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http://dx.doi.org/10.1016/j.acra.2016.12.022DOI Listing
June 2017

Attending rounds: What do the all-star teachers do?

Med Teach 2017 Jan 12;39(1):100-104. Epub 2016 Nov 12.

a University of Colorado School of Medicine , Aurora , CO , USA.

Aim: To examine differences in the types of teaching activities performed during rounds between the most effective and least effective inpatient teaching attendings.

Methods: Participants included 56 attending physicians supervising 279 trainees. Trained observers accompanied teams during rounds and recorded the frequencies of educational activities that occurred. Students and residents then rated their satisfaction with the teaching on rounds.

Results: Attending physicians with the highest learner satisfaction scores performed significantly more teaching activities per patient than attending physicians who were rated as average or less-effective (2.1 vs. 1.4 vs. 1.5; p = .03). There were significant differences in the frequencies of 3 out of the 9 specific teaching activities observed, including answering specific patient-care related questions (77% vs. 66% vs. 47%; p = .003), teaching on learner chosen topics (8% vs. 2% vs. 2%; p = .02), and providing feedback (31% vs. 10% vs. 0.1%; p = .001).

Conclusions: Specific categories of teaching activities-patient-specific teaching, teaching on learner-identified topics, and providing real-time feedback-are performed more frequently by the highest-rated attending physicians, which can guide faculty development.
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http://dx.doi.org/10.1080/0142159X.2017.1248914DOI Listing
January 2017

How Residents Develop Trust in Interns: A Multi-Institutional Mixed-Methods Study.

Acad Med 2016 Oct;91(10):1406-1415

L. Sheu is chief resident in internal medicine, University of California, San Francisco School of Medicine, San Francisco, California.P.S. O'Sullivan is professor of medicine, University of California, San Francisco School of Medicine, San Francisco, California.E.M. Aagaard is professor of medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.D. Tad-y is assistant professor of medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.H.E. Harrell is professor of medicine, Department of Medicine, University of Florida College of Medicine, Gainesville, Florida.J.R. Kogan is associate professor of medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.J. Nixon is professor of medicine and pediatrics, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota.H. Hollander is professor of medicine, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California.K.E. Hauer is professor of medicine, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California.

Purpose: Although residents trust interns to provide patient care, little is known about how trust forms.

Method: Using a multi-institutional mixed-methods study design, the authors interviewed (March-September 2014) internal medicine (IM) residents in their second or third postgraduate year at a single institution to address how they develop trust in interns. Transcript analysis using grounded theory yielded a model for resident trust. Authors tested (January-March 2015) the model with residents from five IM programs using a two-section quantitative survey (38 items; 31 rated 0 = not at all to 100 = very much; 7 rated 0 = strongly disagree to 100 = strongly agree) to identify influences on how residents form trust.

Results: Qualitative analysis of 29 interviews yielded 14 themes within five previously identified factors of trust (resident, intern, relationship, task, and context). Of 478 residents, 376 (78.7%) completed the survey. Factor analysis yielded 11 factors that influence trust. Respondents rated interns' characteristics (reliability, competence, and propensity to make errors) highest when indicating importance to trust (respective means 86.3 [standard deviation = 9.7], 76.4 [12.9], and 75.8 [20.0]). They also rated contextual factors highly as influencing trust (access to an electronic medical record, duty hours, and patient characteristics; respective means 79.8 [15.3], 73.1 [14.4], and 71.9 [20.0]).

Conclusions: Residents form trust based on primarily intern- and context-specific factors. Residents appear to consider trust in a way that prioritizes interns' execution of essential patient care tasks safely within the complexities and constraints of the hospital environment.
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http://dx.doi.org/10.1097/ACM.0000000000001164DOI Listing
October 2016

The Residency Application Process--Burden and Consequences.

N Engl J Med 2016 Jan;374(4):303-5

From the Department of Medicine, Division of General Internal Medicine (E.M.A.), and the Department of Otolaryngology (M.A.), University of Colorado School of Medicine, Aurora.

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http://dx.doi.org/10.1056/NEJMp1510394DOI Listing
January 2016
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