Publications by authors named "Eva M Aagaard"

39 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

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

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

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

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

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

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

Association of Characteristics, Deficits, and Outcomes of Residents Placed on Probation at One Institution, 2002-2012.

Acad Med 2016 Mar;91(3):382-7

J. Guerrasio is associate professor, Division of General Internal Medicine, Department of Internal Medicine, and director for remediation, University of Colorado School of Medicine, Aurora, 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. A. Christensen is director of finance and administration, Office of Graduate Medical Education, University of Colorado School of Medicine, Aurora, Colorado. E.M. Aagaard is professor, Division of General Internal Medicine, Department of Internal Medicine, and associate dean for educational strategy, University of Colorado School of Medicine, Aurora, Colorado.

Purpose: To describe the population of residents placed on probation, identify learner characteristics associated with being placed on probation, and describe immediate and long-term career outcomes for those placed on probation as compared with matched controls.

Method: The authors collected data for residents at the University of Colorado School of Medicine placed on probation from July 2002 to June 2012, including postgraduate year placed on probation, deficits identified, mandated evaluation for physical and mental health, duration of probation, disability accommodations requested, and number of additional training months required. They were retrospectively compared with 102 controls matched for specialty, matriculation, and postgraduate year. Variables assessed included demographics, academic performance, license status, specialty, state board certification, and board citations.

Results: Of 3,091 residents, 3.3% were placed on probation (88 residents; 14 fellows). Compared with controls, those on probation were more likely to be international medical graduates, married, not Caucasian, older (all P < .001), male (P = .01), to have transferred from another graduate medical education training program, and to have taken time off between medical school and residency (all P < .001). Among those currently in practice, 53 (63.9%) were board certified compared with 93 (100%) of the controls. Placement on probation was associated with failure to graduate and lack of board certification. All 7 graduates cited by state medical boards were in the probation group.

Conclusions: Further research is needed to understand these associations and to determine whether changes in curricula or remediation programs may alter these outcomes.
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http://dx.doi.org/10.1097/ACM.0000000000000879DOI Listing
March 2016

The impact of exposure to shift-based schedules on medical students.

Med Educ Online 2015 19;20:27434. Epub 2015 Jun 19.

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

Background: With new resident duty-hour regulations, resident work schedules have progressively transitioned towards shift-based systems, sometimes resulting in increased team fragmentation. We hypothesized that exposure to shift-based schedules and subsequent team fragmentation would negatively affect medical student experiences during their third-year internal medicine clerkship.

Design: As part of a larger national study on duty-hour reform, 67 of 150 eligible third-year medical students completed surveys about career choice, teaching and supervision, assessment, patient care, well-being, and attractiveness of a career in internal medicine after completing their internal medicine clerkship. Students who rotated to hospitals with shift-based systems were compared to those who did not. Non-demographic variables used a five-point Likert scale. Chi-squared and Fisher's exact tests were used to assess the relationships between exposure to shift-based schedules and student responses. Questions with univariate p ≤ 0.1 were included in multivariable logistic regression models.

Results: Thirty-six students (54%) were exposed to shift-based schedules. Students exposed to shift-based schedules were less likely to perceive that their attendings were committed to teaching (odds ratio [OR] 0.35, 95% confidence interval [CI]: 0.13-0.90, p = 0.01) or perceive that residents had sufficient exposure to assess their performance (OR 0.29, 95% CI: 0.09-0.91, p = 0.03). However, those students were more likely to feel their interns were able to observe them at the bedside (OR 1.89, 95% CI: 1.08-3.13, p = 0.02) and had sufficient exposure to assess their performance (OR 3.00, 95% CI: 1.01-8.86, p = 0.05).

Conclusions: These findings suggest that shift-based schedules designed in response to duty-hour reform may have important broader implications for the teaching environment.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4475685PMC
http://dx.doi.org/10.3402/meo.v20.27434DOI Listing
February 2016

Methods and outcomes for the remediation of clinical reasoning.

J Gen Intern Med 2014 Dec;29(12):1607-14

Division of General Internal Medicine, University of Colorado School of Medicine, 12401 East 17th Ave, Mail Code F782, Aurora, CO, 80045, USA,

Introduction: There is no widely accepted structured, evidence based strategy for the remediation of clinical reasoning skills.

Aim: To assess the effectiveness of a standardized clinical reasoning remediation plan for medical learners at various stages of training.

Setting: Learners enrolled in the University of Colorado School of Medicine Remediation Program.

Program Description: From 2006 to 2012, the learner remediation program received 151 referrals. Referrals were made by medical student clerkship directors, residency and fellowship program directors, and through self-referrals. Each learner's deficiencies were identified using a standardized assessment process; 53 were noted to have clinical reasoning deficits. The authors developed and implemented a ten-step clinical reasoning remediation plan for each of these individuals, whose subsequent performance was independently assessed by unbiased faculty and senior trainees. Participant demographics, faculty time invested, and learner outcomes were tracked.

Program Evaluation: Prevalence of clinical reasoning deficits did not differ by level of training of the remediating individual (p = 0.49). Overall, the mean amount of faculty time required for remediation was 29.6 h (SD = 29.3), with a median of 18 h (IQR 5-39) and a range of 2-100 h. Fifty-one of the 53 (96%) passed the post remediation reassessment. Thirty-eight (72%) learners either graduated from their original program or continue to practice in good standing. Four (8%) additional residents who were placed on probation and five (9%) who transferred to another program have since graduated.

Discussion: The ten-step remediation plan proved to be successful for the majority of learners struggling with clinical reasoning based on reassessment and limited subsequent educational outcomes. Next steps include implementing the program at other institutions to assess generalizability and tracking long-term outcomes on clinical care.
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http://dx.doi.org/10.1007/s11606-014-2955-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242871PMC
December 2014

Innovations to enhance the quality of health professions education at the University of Zimbabwe College of Health Sciences--NECTAR program.

Acad Med 2014 Aug;89(8 Suppl):S88-92

Dr. Ndhlovu is senior lecturer, Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe. Dr. Nathoo is professor of pediatrics, Department of Pediatrics, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe. Dr. Borok is associate professor of medicine, Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe. Dr. Chidzonga is professor of oral and maxillofacial surgery, Department of Dentistry, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe. Dr. Aagaard is professor of medicine, Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado. Dr. Connors is associate director, Evaluation Center, School of Education and Human Development, University of Colorado, Denver, Colorado. Dr. Barry is professor of medicine, Department of Medicine, and senior associate dean for global health, Stanford University, Palo Alto, California. Dr. Campbell is professor of medicine, Department of Medicine, Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado. Dr. Hakim is professor of medicine, Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.

The University of Zimbabwe College of Health Sciences (UZCHS) is Zimbabwe's premier health professions training institution. However, several concerns were raised during the past decade over the quality of health education at UZCHS. The number of faculty and students declined markedly until 2010, when there was a medical student intake of 147 while the faculty comprised only 122 (39%) of a possible 314 positions. The economic and political crises that the country experienced from 1999 to 2009 compounded the difficulties faced by the institution by limiting the availability of resources. The Medical Education Partnership Initiative funding opportunity has given UZCHS the stimulus to embark on reforms to improve the quality of health education it offers. UZCHS, in partnership with the University of Colorado School of Medicine, the University of Colorado Denver Evaluation Center, and Stanford University, designed the Novel Education Clinical Trainees and Researchers (NECTAR) program to implement a series of health education innovations to meet this challenge. Between 2010 and 2013, innovations that have positively affected the quality of health professions education at UZCHS include the launch of comprehensive faculty development programs and mentored clinical and research programs for postgraduate students. A competency-based curriculum reform process has been initiated, a health professions department has been established, and the Research Support Center has been strengthened, providing critical resources to institutionalize health education and research implementation at the college. A core group of faculty trained in medical education has been assembled, helping to ensure the sustainability of these NECTAR activities.
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http://dx.doi.org/10.1097/ACM.0000000000000336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4174276PMC
August 2014

Failure to fail: the institutional perspective.

Med Teach 2014 Sep 20;36(9):799-803. Epub 2014 May 20.

University of Colorado School of Medicine , USA.

Purpose: To determine institutional barriers to placing failing students on probation, dismissing students.

Methods: An online survey study was distributed to Student Affairs Deans or the equivalent at allopathic (MD) and osteopathic (DO) medical schools, and physician assistant (PA) and nurse practitioner (NP) schools across the United States. Nineteen (40%) of the 48 schools responded: six MD, four DO, five PA and four NP. The survey contained demographic questions and questions regarding probation and dismissal. Themes were independently coded and combined via consensus based on grounded theory. The survey was distributed until saturation of qualitative responses were achieved.

Results: Respondents identified variations in the use of probation and dismissal and a wide range of barriers, with the greatest emphasis on legal concerns. Respondents felt that students were graduating who should not be allowed to graduate, and that the likelihood of a student being placed on probation or being terminated was highly variable.

Discussion: Our results suggest that institution culture at heath professions schools across the United States may represent an obstacle in placing failing learners on probation and dismissing learners who should not graduate. Additional studies are needed to prove if these concerns are founded or merely fears.
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http://dx.doi.org/10.3109/0142159X.2014.910295DOI Listing
September 2014

Feasibility and sustainability of an interactive team-based learning method for medical education during a severe faculty shortage in Zimbabwe.

BMC Med Educ 2014 Mar 28;14:63. Epub 2014 Mar 28.

Department of Medicine, University of Colorado School of Medicine, 12631 E 17th Ave Campus Box B178, Aurora, CO 80045, USA.

Background: In 2010, in the midst of the human immunodeficiency virus (HIV) epidemic in Zimbabwe, 69% of faculty positions in the Department of Medicine of the University of Zimbabwe College of Health Sciences (UZ-CHS) were vacant. To address the ongoing need to train highly skilled HIV clinicians with only a limited number of faculty, we developed and implemented a course for final-year medical students focused on HIV care using team-based learning (TBL) methods.

Methods: A competency-based HIV curriculum was developed and delivered to final-year medical students in 10 TBL sessions as part of a 12 week clinical medicine attachment. A questionnaire was administered to the students after completion of the course to assess their perception of TBL and self-perceived knowledge gained in HIV care. Two cohorts of students completed the survey in separate academic years, 2011 and 2012. Descriptive analysis of survey results was performed.

Results: Ninety-six of 120 students (80%) completed surveys. One hundred percent of respondents agreed that TBL was an effective way to learn about HIV and 66% strongly agreed. The majority of respondents agreed that TBL was more stimulating than a lecture course (94%), fostered enthusiasm for the course material (91%), and improved teamwork (96%). Students perceived improvements in knowledge gained across all of the HIV subjects covered, especially in challenging applied clinical topics, such as management of HIV antiretroviral failure (88% with at least a "large improvement") and HIV-tuberculosis co-infection (80% with at least a "large improvement").

Conclusions: TBL is feasible as part of medical education in an African setting. TBL is a promising way to teach challenging clinical topics in a stimulating and interactive learning environment in a low-income country setting with a high ratio of students to teachers.
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http://dx.doi.org/10.1186/1472-6920-14-63DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3972960PMC
March 2014

Learner deficits and academic outcomes of medical students, residents, fellows, and attending physicians referred to a remediation program, 2006-2012.

Acad Med 2014 Feb;89(2):352-8

Dr. Guerrasio is associate professor, Department of Internal Medicine, remediation consultant, and remediation program director, University of Colorado School of Medicine, Aurora, Colorado. Dr. Garrity is associate dean of medical student affairs, University of Colorado School of Medicine, Aurora, Colorado. Dr. Aagaard is associate professor, Department of Internal Medicine, and assistant dean of lifelong learning, University of Colorado School of Medicine, Aurora, Colorado.

Purpose: To identify deficit types and predictors of poor academic outcomes among students, residents, fellows, and physicians referred to the University of Colorado School of Medicine's remediation program.

Method: During 2006-2012, 151 learners were referred. After a standardized assessment process, program faculty developed individualized learning plans that incorporated deliberate practice, feedback, and reflection, followed by independent reassessment. The authors collected data on training levels, identified deficits, remediation plan details, outcomes, and faculty time invested. They examined relationships between gender, training level, and specific deficits. They analyzed faculty time by deficit and explored predictors of negative outcomes.

Results: Most learners had more than one deficit; medical knowledge, clinical reasoning, and professionalism were most common. Medical students were more likely than others to have mental well-being issues (P = .03), whereas the prevalence of professionalism deficits increased steadily as training level increased. Men struggled more than women with communication (P = .01) and mental well-being. Poor professionalism was the only predictor of probationary status (P < .001), and probation was a predictor of other negative outcomes (P < .0001). Remediation of clinical reasoning and mental well-being deficits required significantly more faculty time (P < .001 and P = .03, respectively). Per hour, faculty face time reduced the odds of probation by 3.1% (95% CI, 0.09-0.63) and all negative outcomes by 2.6% (95% CI, 0.96-0.99).

Conclusions: Remediation required substantial resources but was successful for 90% of learners. Future studies should compare remediation strategies and assess how to optimize faculty time.
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http://dx.doi.org/10.1097/ACM.0000000000000122DOI Listing
February 2014

Patient, resident physician, and visit factors associated with documentation of sexual history in the outpatient setting.

J Gen Intern Med 2011 Aug 27;26(8):887-93. Epub 2011 Apr 27.

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

Background: Providers need an accurate sexual history for appropriate screening and counseling, but data on the patient, visit, and physician factors associated with sexual history-taking are limited.

Objectives: To assess patient, resident physician, and visit factors associated with documentation of a sexual history at health care maintenance (HCM) visits.

Design: Retrospective cross-sectional chart review.

Participants: Review of all HCM clinic notes (n = 360) by 26 internal medicine residents from February to August of 2007 at two university-based outpatient clinics.

Measurements: Documentation of sexual history and patient, resident, and visit factors were abstracted using structured tools. We employed a generalized estimating equations method to control for correlation between patients within residents. We performed multivariate analysis of the factors significantly associated with the outcome of documentation of at least one component of a sexual history.

Key Results: Among 360 charts reviewed, 25% documented at least one component of a sexual history with a mean percent by resident of 23% (SD = 18%). Factors positively associated with documentation were: concern about sexually transmitted infection (referent: no concern; OR = 4.2 [95% CI = 1.3-13.2]); genitourinary or abdominal complaint (referent: no complaint; OR = 4.3 [2.2-8.5]); performance of other HCM (referent: no HCM performed; OR = 3.2 [1.5-7.0]), and birth control use (referent: no birth control; OR = 3.0 [1.1, 7.8]). Factors negatively associated with documentation were: age groups 46-55, 56-65, and >65 (referent: 18-25; ORs = 0.1, 0.1, and 0.2 [0.0-0.6, 0.0-0.4, and 0.1-0.6]), and no specified marital status (referent: married; OR = 0.5 [0.3-0.8]).

Conclusions: Our findings highlight the need for an emphasis on documentation of a sexual history by internal medicine residents during routine HCM visits, especially in older and asymptomatic patients, to ensure adequate screening and counseling.
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http://dx.doi.org/10.1007/s11606-011-1711-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3138976PMC
August 2011

Modest impact of a brief curricular intervention on poor documentation of sexual history in university-based resident internal medicine clinics.

J Sex Med 2010 Oct;7(10):3315-21

Department of Medicine, University of Colorado Denver, Aurora, CO 80045, USA.

Introduction: Providers need an accurate sexual history for appropriate screening and counseling. While curricula on sexual history taking have been described, the impact of such interventions on resident physician performance of the sexual history remains unknown.

Aims: Our aims were to assess the rates of documentation of sexual histories, the rates of documentation of specific components of the sexual history, and the impact of a teaching intervention on this documentation by Internal Medicine residents.

Methods: The study design was a teaching intervention with a pre- and postintervention chart review. Participants included postgraduate years two (PGY-2) and three (PGY-3) Internal Medicine residents (N=25) at two university-based outpatient continuity clinics. Residents received an educational intervention consisting of three 30-minute, case-based sessions in the fall of 2007.

Main Outcome Measures: We reviewed charts from health-care maintenance visits pre- and postintervention. We analyzed within resident pre- and postrates of sexual history taking and the number of sexual history components documented using paired t-tests.

Results: In total, we reviewed 369 pre- and 260 postintervention charts. The mean number of charts per resident was 14.8 (range 8-29) pre-intervention and 10.4 (range 3-25) postintervention. The mean documentation rate per resident for one or more components of sexual history pre- and postintervention were 22.5% (standard deviation [SD]=18.1%) and 31.7% (SD=20.4%), respectively, P<0.01. The most frequently documented components of sexual history were current sexual activity, number of current sexual partners, and gender of current sexual partner. The least documented components were history of specific sexually transmitted infections, gender of sexual partners over lifetime, and sexual behaviors.

Conclusion: An educational intervention modestly improved documentation of sexual histories by Internal Medicine residents. Future studies should examine the effects of more comprehensive educational interventions and the impact of such interventions on physician behavior or patient care outcomes.
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http://dx.doi.org/10.1111/j.1743-6109.2010.01883.xDOI Listing
October 2010
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