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OBJECTIVE: Communication and interpersonal skills (CIS) are essential elements of competency-based education. We examined defensible CIS passing levels for medical students completing basic sciences (second-year students) and clinical training (fourth-year students), using five standard setting methods. METHODS: A 14-item CIS scale was used. Data from second-year (n = 190) and fourth-year (n = 170) students were analyzed using descriptive statistics and generalizability studies. Fifteen judges defined borderline CIS performance. Cut scores and fail rates from five standard setting methods (Angoff, Borderline-Group, Borderline-Regression, Contrasting-Groups, and Normative methods) were examined. RESULTS: CIS performance was similar during second-year (Mean = 74%, SD = 6%) and fourth-year (Mean = 72%, SD = 5%) students. Judges using the Angoff method expected greater competence at the fourth-year level, as reflected in the Angoff cut scores (second-year = 53% with 0% fail, fourth-year = 66% with 10% fail). Cut scores from the remaining methods did not differentiate between training levels. We found evidence of case specificity. CONCLUSION: Performance on CIS may be case specific. Passing standards for communication skills may require employing approaches such as the Angoff method that are sensitive to expectations of learner performance for different levels of training, competencies, and milestone levels. PRACTICE IMPLICATIONS: Institutions that want to encourage continued growth in CIS should apply appropriate standard setting methods.

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PROBLEM: Studies have documented performance on the United States Medical Licensing Examination® (USMLE) Step 1 exam as an important factor that residency program directors consider when deciding which applicants to interview and rank. Therefore, success on this exam, though only one aspect of applicant evaluation, is important in determining future career prospects for medical students. Unfortunately, mean test scores at the University of Illinois College of Medicine at Chicago (UIC) have historically been below the national average. INTERVENTION: This retrospective and quasi-experimental mixed-methods study describes the development, evaluation, and effects of a student-initiated USMLE Step 1 preparatory program at UIC. The program provided second year students with First Aid for the USMLE Step 1 at the beginning of the academic year, as well as a six month subscription to the USMLE World question bank midyear. In addition, optional peer review sessions covering basic sciences and organ systems were taught by high-performing upperclassmen. The goals of the program were to raise mean USMLE Step 1 exam scores and increase the percentage of students passing the exam on their first time. CONTEXT: The program premiered during the 2012-13 academic year. Data from this cohort as well as four others (N = 830; 2010-2014 examinees) were gathered. Performances between preintervention (2010-12 examinees) and postintervention (2013-14 examinees) cohorts of students were compared. Focus groups and interviews with staff and students were conducted, recorded, and analyzed to investigate the impact that the program had on student interactions and perceptions of the learning environment. OUTCOME: There was a significant difference in exam performance pre- versus postintervention, with average USMLE Step 1 scores improving by 8.82 points following the implementation of the student-initiated program, t(5.61) = 828, p < .001. The average first-attempt pass rate also increased significantly by 8%, χ2(1) = 23.13, p < .001. Taking age, sex, Medical College Admission Test® scores, and undergraduate grade point average into account, students who participated in the program scored 6.57 points higher than students who did not participate in the program (R2 = 0.3), F(5, 886) = 76.71, p < .01, and had higher odds of passing USMLE Step 1 (odds ratio = 3.08, SE = 1.07, p < .01). Students and staff commented on the sense of community and empowerment the program created as well as the unique student-driven nature of the program. LESSONS LEARNED: This study demonstrates the efficacy of a student-initiated curriculum and provides guidance for development and implementation of examination preparatory efforts at other institutions.

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BACKGROUND: Geriatric patients account for a growing proportion of dermatology clinic visits. Although their biopsychosocial needs differ from those of younger adults, there are no geriatrics training requirements for dermatology residency programs. OBJECTIVE: This study explored the state of geriatrics education in dermatology programs in 2016. METHODS: This constructivist study employed cross-sectional, mixed-methods analysis with triangulation of semistructured interviews, surveys, and commonly used curricular materials. We used purposive sampling of 5 US academic allopathic dermatology programs of different sizes, geographic locations, and institutional resources. Participants were interviewed about informal curricula, barriers, and suggestions for improving geriatrics education, and they also completed a survey about the geriatrics topics that should be taught. The constant comparative method with grounded theory was used for qualitative analysis. We identified formal geriatrics curricular content by electronically searching and counting relevant key texts. RESULTS: Fourteen of 17 participants (82%) agreed to be interviewed, and 10 of 14 (71%) responded to the survey. Themes of what should be taught included diagnosing and managing skin diseases common in older adults, holistic treatment, cosmetic dermatology, benign skin aging, and the basic science of aging. Topics currently covered that could be expanded included communication, systems-based challenges, ethical issues, safe prescribing, quality improvement, and elder abuse. Cosmetic dermatology was the most commonly taught formal geriatrics curricular topic. CONCLUSIONS: There were discrepancies among topics participants felt were important to teach about geriatric dermatology and curricular coverage of these areas. We identified challenges for expanding geriatrics curricula and potential solutions.

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OBJECTIVES: Increased emphasis is being placed worldwide on accreditation of undergraduate medical education programmes, and costs of participation in accreditation continue to rise. The primary purposes of accreditation are to ensure the quality of medical education and to promote quality improvement. Student performance data as indicators of the impact of accreditation have important limitations. The purpose of this study was to evaluate the impact of accreditation using an innovative marker: the processes implemented at medical schools as a result of accreditation. This conceptual model suggests that accreditation drives medical schools to implement and strengthen processes that support quality in medical education. METHODS: In this qualitative study, conducted in 2015-2016, interviews and focus group discussions with deans, undergraduate medical education deans and faculty leaders at 13 of the 17 Canadian medical schools were used to elicit perspectives about processes influenced by accreditation; the method of constant comparative analysis associated with grounded theory was used to generate themes of processes. Perceived negative consequences of accreditation on medical education programmes were also explored. RESULTS: Nine themes representing processes reported as resulting from accreditation were identified. These processes related to: (i) governance, (ii) data collection and analysis, (iii) monitoring, (iv) documentation, (v) creation and revision of policies and procedures, (vi) continuous quality improvement, (vii) faculty members' engagement, (viii) academic accountability and (ix) curriculum reforms. Themes representing negative consequences of accreditation included (i) costs, (ii) staff and faculty members' morale and feelings, (iii) school reputation and (iv) standards. The identified processes, given their nature, appear likely to be associated with improvement of quality in medical education. These results help justify the costs associated with accreditation. CONCLUSIONS: This study uses an innovative marker, medical schools' processes, to evaluate the impact of accreditation. Results provide evidence that accreditation-related activities steer medical education programmes towards establishment of processes likely to be associated with improved quality in medical education.

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BACKGROUND: Providing residents with formative operative feedback is one of the ongoing challenges in modern surgical education. This is highlighted by the recent American Board of Surgery requirement for formal operative assessments. A flexible and adaptable procedure feedback process may allow attending surgeons to provide qualitative and quantitative feedback to residents while encouraging surgeons-in-training to critically reflect on their own performance. STUDY DESIGN: We designed and implemented a flexible feedback process in which residents initiated a postoperative feedback discussion and completed a Procedure Feedback Form (PFF) with their supervising attending surgeon. Comparisons were made between the quantitative and qualitative assessments of attending and resident surgeons. Free text statements describing strengths and weaknesses were analyzed using grounded theory with constant comparison. RESULTS: We identified 346 assessments of 48 surgery residents performing 38 different cases. There was good inter-rater reliability between resident and attending surgeons' quantitative assessment, Goodman and Kruskal gamma > 0.65. Key themes identified on qualitative analysis included flow, technique, synthesis/decision, outcomes, knowledge, and communication/attitudes. Subthematic analysis demonstrated that our novel debriefing procedure was easily adaptable to a wide variety of clinical settings and grew more individualized for senior learners. CONCLUSIONS: This procedure feedback process is easily adaptable to a wide variety of cases and supports resident self-reflection. The process grows in nuance and complexity with the learner and may serve as a guide for a flexible and widely applicable postoperative feedback process.

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BACKGROUND: Resident training in pediatrics currently entails similar training for all residents in a fragmented curriculum with relatively little attention to the career plans of individual residents. OBJECTIVES: To explore strengths and gaps in training for residents planning a career in primary care pediatrics and to present strategies for addressing the gaps. METHODS: Surveys were sent to all graduates of the University of Colorado Denver Pediatric Residency Program (2003-2006) 3 years after completion of training. Respondents were asked to evaluate aspects of their training, using a 5-point Likert scale and evaluating each item ranging from "not at all well prepared" to "extremely well prepared" for their future career. In addition, focus groups were conducted with practitioners in 8 pediatric practices in Colorado. Sessions were transcribed and hand coded by 2 independent coders. RESULTS: Survey data identified training in behavior and development (mean score, 3.72), quality improvement and patient safety strategies (mean, 3.57), and practice management (mean, 2.46) as the weakest aspects of training. Focus groups identified deficiencies in training in mental health, practice management, behavioral medicine, and orthopedics. Deficiencies noted in curriculum structure were lack of residents' long-term continuity of relationships with patients; the need for additional training in knowledge, skills, and attitudes needed for primary care (perhaps even a fourth year of training); and a training structure that facilitates greater resident autonomy to foster development of clinical capability and self-confidence. CONCLUSIONS: Important gaps were identified in the primary care training of pediatric residents. These data support the need to develop more career-focused training.

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PURPOSE: To examine the organizational structure of educational technology units within U.S. and Canadian medical schools in order to (1) identify organization models that support educational technology, (2) describe key attributes of these models, and (3) discuss the strengths and challenges associated with these models. METHOD: The authors distributed a survey to 88 schools that had previously provided information on their educational technology services and infrastructure. The authors developed the survey through a series of pilots and, then, from the data for each respondent school, created concept maps, which were used to identify organizational models. The authors conducted analyses to determine differences among models. The authors coded the comments about organizational models and identified themes. RESULTS: The authors received adequate data for analysis from 61 schools (69%). Four models for educational technology organizations emerged: (1) centralized units located in the school of medicine, (2) centralized units located at the health science center, (3) centralized units at the comprehensive university, and (4) no centralized unit (Dispersed Model). The majority (75%) of schools relied on some type of centralized organization. Whereas few organization attributes proved to be statistically significant, the centralized models have more resources devoted to educational technology and a closer alignment with the academic mission than the Dispersed Model. CONCLUSIONS: Medical schools primarily use central models. The authors recommend that schools structuring their educational technology resources consider exploration of a central model because of its focused use of resources to improve teaching and learning.

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Interest in conducting problem-based learning (PBL) on-line has increased to meet student and physician schedules. Little research describes skills needed to facilitate PBL on-line. In this paper we studied teaching presence in asynchronous PBL groups. Two raters, with average inter-rater agreements of 0.80, used an existing code to measure teaching presence in 62 PBL case discussions facilitated by one instructor over five years. This instructor was selected because of consistently high teaching evaluations. Messages sent by the instructor in the on-line PBL discussion were coded into three categories: instructional design and organization, facilitating discourse and direct instruction. Instructional design indicators were most frequent averaging 22.5 (SD = 5.6)/discussion. Facilitating discourse and direct instruction were comparable, 19.5(SD = 7.4) and 19.5 (SD = 6.7), respectively. Messages and indicators of teacher presence rose across time with a decline during subsequent PBL cases with the same group.

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PURPOSE: To describe the current educational technology infrastructure and services provided by North American allopathic medical schools that are members of the Association of American Medical Colleges (AAMC), to present information needed for institutional benchmarking. METHOD: A Web-based survey instrument was developed and administered in the fall of 2004 by the authors, sent to representatives of 137 medical schools and completed by representatives of 88, a response rate of 64%. Schools were given scores for infrastructure and services provided. Data were analyzed with one-way analyses of variance, chi-square, and correlation coefficients. RESULTS: There was no difference in the number of infrastructure features or services offered based on region of the country, public versus private schools, or size of graduating class. Schools implemented 3.0 (SD = 1.5) of 6 infrastructure items and offered 11.6 (SD = 4.1) of 22 services. Over 90% of schools had wireless access (97%), used online course materials for undergraduate medical education (97%), course management system for graduate medical education (95%) and online teaching evaluations (90%). Use of services differed across the undergraduate, graduate, and continuing medical education continuum. Outside of e-portfolios for undergraduates, the least-offered services were for services to graduate and continuing medical education. CONCLUSIONS: The results of this survey provide a benchmark for the level of services and infrastructure currently supporting educational technology by AAMC-member allopathic medical schools.

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PURPOSE: To determine whether critical thinking in problem-based learning (PBL) group discourse differed according to case modality. METHOD: The study was conducted in 2000 in the Department of Pediatrics at the University of Colorado School of Medicine in Denver. Third-year medical students on their pediatrics clerkship were divided into three groups: face-to-face with a text case, face-to-face with a digital video case, and virtual with a digital video case. Twenty-four groups were divided among the three case modalities. Using an existing coding scheme, each distinct codable unit of discourse was placed into one of 35 indicators reflective of five critical-thinking stages. For each group's discourse, a critical-thinking ratio was calculated for each of the stages. The Kruskal-Wallis test was used to compare the critical-thinking ratios for each stage across the three modalities. Residual conversation to indicate processes occurring within the group was also coded. RESULTS: A content analysis of the transcripts of 13 of the 24 group discussions occurred. The virtual groups had the highest critical-thinking ratio. Except for the problem-identification stage, the video groups had higher ratios that the text groups did. CONCLUSIONS: This exploratory study examined how the mode of case presentation affected the critical thinking of groups using the PBL format. Students who learned in a virtual modality with a digital video case engaged in more critical thinking. The data suggest that the video enhanced critical thinking in both face-to-face and virtual PBL groups.

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OBJECTIVE: Our purpose is to present findings regarding student attitudes towards a virtual PBL program used to standardize their pediatric clinical experience. DESCRIPTION: With funding provided by the Fund for the Improvement of Post-Secondary Education, we developed Project LIVE (Learning through Interactive Video Education), a CD-ROM/Web hybrid program that uses digital video cases to conduct "virtual" problem-based learning groups with students doing a clinical rotation in a remote setting. Cases were progressively disclosed by videos of patient/physician encounters on a CD-ROM. Groups of five students and a faculty facilitator collaborated, teaching each other within the discussion section of the program. We conducted a multifaceted evaluation of Project LIVE to study the impact of case modality or distance on student learning and attitudes. We placed students in one of three groups (1) a face-to-face group with a paper case (FFT), (2) a face-to-face group with a video case (FFV), and (3) a virtual group (VG) with the digital video case. We then studied student attitudes about the three teaching formats. Over a six-month period three education specialists, who were not a part of the development team, conducted eight focus groups lasting one hour to assess student attitudes about Project LIVE. No one from the project team was present during these groups, and an independent evaluator analyzed the notes taken by each focus group leader. DISCUSSION: Trends across the groups included the following: (1) Authenticity (video)-Students reported that the authenticity of the case was a critical feature and that, "seeing (videos) made learning more memorable." Virtual and FFV groups reported more confidence in their ability to recognize abnormal findings in their patients. "You can't expect to teach clinical exam skills with a piece of paper." (2) Use of time-Students from all groups believed the cases were a good use of their time and improved their ability to solve clinical problems. They said it gave them an opportunity to "get away from just doing and focus on learning." However, the virtual groups complained of the lack of "a barometer for how much is too much" time. Some students reported spending an average of eight to ten hours per case over the period of a week. (In contrast, face-to-face groups met for three hours.) (3) Modeling clinical reasoning-Students believed the cases were valuable in structuring their knowledge, conceptualizing how to handle difficult situations, distinguishing abnormal from normal physical examination findings, and collaborating with their peers and their mentor to develop critical thinking. "It forced us to be logical" and ". how to think through the process-it mimics the real setting." (4) Technical support-The responsiveness of the Project LIVE staff was essential in assisting students in troubleshooting problems. (5) Distance component-Students preferred to work through the cases in face-to-face groups but agreed that the virtual experience is "good if you are in the middle of nowhere." This program was enjoyed by students and gave us an approach to standardizing experiences across multiple clinical sites.

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