For the General Internist: A Summary of Key Innovations in Medical Education
KEY WORDS: medical education; medical education-undergraduate;
medical education-graduate; review.
J Gen Intern Med
For the General Internist: A Summary of Key Innovations in Medical Education
Shobhina G. Chheda 1
Carol Bates 0
Kathel Dunn 5
Lisa L. Willett 3
0 Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
1 University of Wisconsin School of Medicine and Public Health , Madison, WI , USA
2 Section of General Internal Medicine, Yale University School of Medicine , New Haven, CT , USA
3 University of Alabama at Birmingham , Birmingham, AL , USA
4 Icahn School of Medicine at Mount Sinai , New York, NY , USA
5 National Library of Medicine , Bethesda, MD , USA
We conducted a review of published medical education articles to identify high-quality research and innovation relevant to educators in general medicine. Our review team consisted of six general internists with expertise in medical education and a professional medical librarian. We manually searched 15 journals in pairs (a total of 3062 citations) for original research articles in medical education published in 2014. Each pair of reviewers independently rated the relevance, importance, and generalizability of articles on medical education in their assigned journals using a 27-point scale (maximum of 9 points for each characteristic). From this list, each team member independently reviewed the 22 articles that received a score of 20 or higher from both initial reviewers, and for each selected article rated the quality and global relevance for the generalist educator. We included the seven toprated articles for presentation in this review, and categorized the studies into four general themes: continuity clinic scheduling, remediation, interprofessional education, and quality improvement and patient safety. We summarized key findings and identified significant limitations of each study. Further studies assessing patient outcomes are needed to strengthen the literature in medical education. This summary of relevant medical education articles can inform future research, teaching, and practice.
ducators in general medicine must stay abreast of the
current literature in order to enhance the training of a
competent clinical work force for the complexities of
twentyfirst century healthcare.1 As the number of medical education
publications increases, educators are provided with guidance
on ways to improve education for interdisciplinary teams,
remediation, clinical experiences, and quality of care.2,3 Our
aim was to conduct a structured review to identify and
summarize the most relevant, high-quality research in medical
education published in 2014 to inform general medicine
educators involved in undergraduate and graduate medical
education and faculty development.
Our team included six general internists with expertise in
medical education and a professional medical librarian (KD).
Members represented geographically and culturally diverse
academic medical centers with senior and junior roles in
undergraduate and graduate medical education leadership
and faculty development. We included clinician educators
involved in teaching, curriculum development,
implementation, assessment, and learner evaluation at all stages of medical
We manually searched issues published between January
and December 2014 by 15 major clinical journals relevant to
medical education and with an impact factor >1.0, or
published by a national organization supporting medical education
(Table 1). We considered all original medical education
research articles, which were identified by searching tables of
contents and by the following PubMed search string limited to
the journal name and publication year 2014: (education,
medical OR (medical AND (training OR trainees)) OR (clinical
AND (skills OR learning OR education))) AND journal article
Two reviewers independently reviewed all articles in their
assigned journals and rated each on relevance, importance,
and generalizability on a nine-point Likert scale (1 = worst,
9 = best; max = 27). We defined relevance as timeliness of the
topic to medical education and general internal medicine. We
defined importance as describing an advancement in the field
or providing strong evidence supporting prior literature. We
defined generalizability as the potential for application or
implementation in any institution. All seven reviewers then
read the articles scored in the top third of possible scores (score
of ≥ 20) by two reviewers, and assessed each on quality and
global appropriateness for our general internist audience. We
evaluated quality using the Medical Education Research Study
Quality Instrument (MERSQI),4 a reliable scale developed to
measure the quality of experimental, quasi-experimental, or
observational studies in medical education.5 We then
individually scored each article using a four-point subjective global
rating on its appropriateness for our audience of general
internist educators (3 = must include, 2 = strongly consider, 1 =
consider, 0 = do not include). Any reviewer with a conflict of
interest related to a study abstained from scoring and
discussion of that article.
Our goal was to present the articles most relevant for a general
medicine educator audience and with sound methodology. We
thus selected the seven articles with the highest average global
rating score that also had an average MERSQI score greater than
8.5. After final selection, we grouped the articles into four
general themes to create an organizational framework.
We reviewed 3062 titles in the issues published in 2014 from
the 15 journals we manually searched. Of these, 22 articles
received a score greater than 20 from two reviewers for
relevance, importance, and generalizability, and were considered
for inclusion. Based on average MERSQI scores from all
reviewers on these 22 articles, 20 scored above 8.5. The
average MERSQI rating was 10.5 (range 7.5 – 13.1), and the
average global rating score was 1.9 (range 0.7 – 2.7). The
seven studies with the highest global rating score from those
with MERSQI ratings above 8.5 were included and
categorized into four general themes: continuity clinic scheduling,
remediation, interprofessional education, and quality
improvement and patient safety (Table 2).
Theme 1: Continuity Clinic Scheduling
The study by Francis, et al., used data collected between
September 2010 and May 2011 from 11 community-based
and university-based residency programs in the Educational
Innovations Project Ambulatory Collaborative to assess
differences in patient satisfaction and diabetes quality of care among
three different ambulatory clinic models: (
) traditional (1–2
clinic sessions per week), (
) combination (weekly clinic
session in addition to ambulatory blocks), and (
) block (no
weekly clinic experience, with an ambulatory block rotation
every 1–3 months).6 Patient satisfaction was assessed using the
11-item Consumer Assessment of Healthcare Providers and
Systems. Resident satisfaction was assessed using the Veterans
Affairs Learners’ Perception Survey. Quality measures for
diabetes included the percentage of diabetic patients with
glycosylated hemoglobin (HbA1c) <8 %, blood pressure <130/
80 mmHg, and low-density lipoprotein (LDL) <100 mg/dL.
The traditional and block models were associated with better
patient satisfaction scores compared to the combination model,
with more patients feeling that their doctor explained things in
a way that was easy to understand (p < 0.001), listened
carefully to them (p < 0.001), gave easy-to-understand instructions
(p < 0.001), and showed respect for what they had to say
(p < 0.001). The traditional and block models were also
associated with patients reporting follow-up on test results
(p = 0.002). Overall ratings of the physician were higher for
residents in the traditional and block models than the
combination model. There was no difference between the traditional
and block models. The percentage of patients with HbA1c
<8 % was associated with higher patient satisfaction scores.
Limitations. This study did not assess whether the program
type (e.g. university- or community-based) was associated with
the clinic model. Programs were not randomized to the clinic
model, and baseline patient satisfaction with the provider was
not assessed. The authors did not examine relationships
between diabetes quality of care and the ambulatory clinic model.
Implications. This multi-institutional study demonstrated that
a traditional or block model was associated with greater
overall patient satisfaction than a combination model for continuity
clinic. Patient satisfaction was associated with some markers
of improved diabetes quality of care.
The study by Heist, et al., is a single-institution study that
evaluated the effect of changing from a traditional internal
medicine residency clinic scheduling model (1 half-day of clinic per
week) to a 4 + 1 model (4 weeks on rotation without clinic,
followed by 1 week in clinic).7 The authors compared the first
5 months of outpatient care between 23 first-year residents in the
2012–2013 academic year and 15 first-year residents in the
2011–2012 academic year. Outcomes assessed were the
percentage of time that (
) a patient was able to see their primary
) a provider saw their own patients, (
) a triage
encounter (when the patient called the clinic) was handled by
the primary provider, and (
) a provider managed his or her own
Residents had a mean of 17 clinic sessions with 525 visits in
the traditional model, compared to 22.5 clinic sessions with
Continuity Clinic Scheduling
Francis MD, et al., Determinants of Patient Satisfaction
in Internal Medicine Resident Continuity Clinics:
Findings of the Educational Innovations Project
Heist K, et al., Impact of 4 + 1 block scheduling on
patient care continuity in resident clinic
Guerrasio J, et al., Learner deficits and academic outcomes
of medical students, residents, fellows, and attending
physicians referred to a remediation program, 2006-2012
Shunk R, et al., Huddle-coaching: a dynamic intervention
for trainees and staff to support team-based care
Hoffmann TC, et al., Brief training of student clinicians
in shared decision making: a single-blind randomized
Quality Improvement and Patient Safety
Vidyarthi AR, et al., Engaging residents and fellows to
improve institution-wide quality: the first six years of a
novel financial incentive program
Starmer AJ, et al., Changes in medical errors after
implementation of a handoff program
Key Points for Practice
Traditional and block clinic scheduling models
correlated with patient satisfaction
Traditional and block clinic scheduling models
correlated with test result follow-up
Residents had more clinic sessions and saw more
of their own patients in a 4 + 1 block schedule
Patients had decreased continuity of care
Learners with deficits in clinical reasoning or
mental well-being required more faculty time
A comprehensive, tailored remediation program
for all levels results in successful remediation
A 15-minute interdisciplinary pre-clinic huddle
improves team functioning
Impact of improved team participation on patient
outcomes is unknown
A 1-hour small group intervention can improve
students’ skills and confidence in shared
Providing financial incentives to residents for
quality improvement goals resulted in achievement
of 61% of goals
Having an involved faculty mentor or high
departmental buy-in was associated with
A comprehensive handoff bundle reduces
The handoff bundle did not impact workflow
1174 visits in the 4 + 1 model, over the same time period. In
the 4 + 1 model, fewer patients saw their own provider (72 %
vs. 63 %; p = 0.008), but providers saw their own patients
more (52 % vs. 37 %; p < 0.0001). There was no difference
in resident handling of triage encounters between the two
scheduling systems. Residents followed up their own lab
results a greater percentage of time in the 4 + 1 model (91 %
vs. 76 %; p < 0.001).
Limitations. This single-site study used historical controls,
evaluated only the first 5 months of care, and included a low
number of residents. Reasons for visits were not evaluated, nor
were patient satisfaction or outcomes for management of
Implications. Residents had more clinic sessions, saw more
patients, spent a greater percentage of time seeing their own
patients, and more often followed up their patients’ lab results
in the 4 + 1 system. However, there was less continuity from
the patient perspective, which may have been due to a
decreased ability to schedule acute visits with their primary
provider. New models of continuity clinic may have
educational advantages over traditional models, but may
compromise continuity for patients.
Theme 2: Remediation
The study by Guerrasio, et al., is a single-institution study that
identified types of deficits, predictors of poor academic
outcomes, and resources required for the remediation of 151
learners (72 medical students, 65 residents, and 14 fellows/
attending physicians) over a 6-year period.8 After self-referral
(for attending physicians) or referral due to repeated poor
performance, a remediation program faculty member
conducted a semi-structured intake interview that addressed ACGME
competencies and explored medical knowledge, clinical skills,
clinical reasoning, time management/organization,
interpersonal skills, communication skills, professionalism, and
mental well-being (psychiatric diagnoses, substance abuse,
learning disabilities, and psychosocial stressors). A Bsuccess team^
was formed for the learner with a remediation specialist, and
optionally included faculty from the learner’s discipline, the
program director or student affairs dean, and/or a mental health
professional. An individualized learning plan was developed
and included deliberate practice, feedback, and reflection.
Faculty unfamiliar with students’ remediation needs conducted
independent reassessments post-remediation. Faculty who
were assigned remediation tasks kept a log to record
face-toface time spent with the learner. Learners completed a
voluntary web-based survey of their remediation experience.
Most learners had more than one deficit, with a mean (SD) of
2.14 (1.37) deficits for medical students, 1.59 (0.77) for
residents, and 1.80 (1.15) for fellows/attendings. Medical
knowledge, clinical reasoning, and professionalism were the most
common deficits identified. Difficulties with mental
wellbeing were significantly more prevalent among medical
students (p = 0.03). More men were referred (59 %; p = 0.04), and
men were more likely than women to have communication
deficits (p = 0.01) and difficulties with mental well being
(p = 0.06). The overall mean (SD) number of hours of faculty
face time required for remediation was 18.8 (23.8) h/learner.
Learners whose deficits included clinical reasoning (20 h;
p < 0.001) or mental well-being (9 h; p = 0.03) required
significantly more faculty time than learners without these deficits.
Fourteen (9 %) learners were placed on probation during
remediation; poor professionalism was the only predictor of
being placed on probation (p < 0.001). At the close of the study,
90 % of the participants were in good standing. A total of 120
(79 %) participants responded to the survey, with the majority
agreeing or strongly agreeing that the program had helped them
address challenges or gain skills that would help them succeed.
Limitations. This was a single-institution study with a
program dedicated to underperforming learners. There may
have been bias in the misclassification of deficits, and the
variability in the membership of the Bsuccess team^ may
have affected individual outcomes. Other factors that were
not identified may have also predicted faculty time required
for remediation (such as learner willingness to participate).
Implications. This is the largest and most comprehensive study
of remediation of medical learners to date. Remediation of
struggling learners requires substantial resources but can be
effective. A better understanding of the components of the
process that are most effective may be of assistance in
streamlining faculty time/efforts.
Theme 3: Interprofessional Education
The paper by Shunk, et al., reports results from a single VA
institution that developed a training program to coach trainees
and clinic staff on pre-clinic team huddle practices in (
working together as interdependent team members (team coherence),
) being physically present and participating in huddling, and
) using skills such as distributive leadership, active listening,
negotiation, and conflict resolution to support effective
teamwork.9 They developed Patient Aligned Care Teams
(PACTs), comprising a registered nurse (RN), licensed
vocational nurse (LVN), and a medical clerk working with trainee
triads consisting of two second-year internal medicine residents
and one second-year nurse practitioner student. The huddle
training program was developed with a conceptual framework
of process, relational, contextual, and organizational factors,
which were addressed by a combination of didactic
presentations, small-group skill-building, and reflective sessions
including a 1-day retreat and reinforcement through coaching.
Huddle coaches were physician and nurse practitioner
preceptors who received faculty development training. Teams were
expected to huddle for 15 minutes prior to each clinic session.
Program evaluation included feedback on the retreat and on
individual teaching sessions, huddle checklists completed by
huddle coaches, a qualitative assessment of end-of-year
interviews, and scores on a 31-item Team Development Survey
evaluating perceived team member cohesiveness,
communication, role clarity, and goals. The checklists demonstrated
improvement in attendance over time, though 65 % of
completed checklists noted the absence of at least one team
member. Qualitatively, trainees stated that they enjoyed the huddle
experience, they referred to other team members by name, and
teams became more functional over time, but that scheduling
difficulties and staff turnover negatively impacted huddles.
Team Development Survey scores improved over the course
of 6 months from a mean of 59.4 to 64.6 on a 100-point scale.
Limitations. While the evaluation of the program appears to
be positive, no statistical tests were performed to assess the
significance of trends. The generalizability of the specific team
structure may be limited, as other sites may have different staff
functions and may not have nurse practitioner trainees.
Implications. This interprofessional pre-clinic huddle training
intervention improved team coherence and participation. The
degree to which the program achieved its stated goal of
improving effective teamwork and the effect on patient outcomes
The study by Hoffman, et al., evaluates the effectiveness of
a 1-h small-group intervention in improving student
clinicians’ shared decision-making skills. This was a
two-institution, single-blinded randomized study, with 100 (93 % of
eligible) interprofessional participants, including third-year
medical students, final-year occupational therapy honors
students, and postgraduate physiotherapy students.10 Both study
arms received a book chapter on shared decision making, and
the intervention group additionally received a 1-h tutorial that
included a five-step framework for communicating evidence
and a facilitated critique of a pre-recorded modeled role-play
on shared decision making. Two weeks later, all participants
were paired and videotaped while performing role-plays of a
physician–patient encounter that required evidence-based
decision making. One author, who was blinded to group
allocation, rated the students’ role-play from the video recordings.
The primary outcome of student skills in shared decision
making was rating using the OPTION (Observing Patient
Involvement) scale and Assessing Communication about
Evidence and Patient Preferences (ACEPP) tool. The secondary
outcome, attitudes towards patient and clinical involvement in
consultations and confidence in communication with patients
about evidence, was rated using a confidence scale created by
the authors and the Patient Practitioners Orientation Scale
Mean between-group differences in post-intervention scores in
shared decision making (18.9 improvement in OPTION,
p < 0.001; 0.9-point improvement in ACEPP; p < 0.001) and
confidence in facilitating shared decision making (13.1;
p < 0.001) were better in the intervention group, with no
significant change in the caring component of the PPOS (0.08; p = 0.4).
Limitations. The study limited its follow-up to only 2 weeks
after the educational intervention. Pairs of students participated
in the role-play, and not standardized or actual patients.
Relationships between discipline and outcomes were not assessed.
Implications. The critical skill of shared decision making may
be improved using a short interprofessional small-group
Theme 4: Quality Improvement and Patient
The paper by Vidyarthi, et al., describes and evaluates the first 6
years of a quality improvement (QI) incentive program for
residents and fellows at a single institution.11 Since 2001, the
institution has had an incentive award program for non-physician
staff towards achieving patient safety and quality goals; in FY
2007, a variant of this program was added for residents and
fellows. The initial goals were Ball-program goals^ consistent
with those already established for staff, phase 2 goals were both
relevant to the strategic plan and selected through trainee surveys,
and phase 3—or Bprogram-specific goals^—were added by
interested training programs. As each goal was met, eligible
trainees would receive $400; due to the collective nature of the
all-program goals, the trainees were evaluated as one cohort.
Data were collected across 18 all-program goals in the
domains of patient satisfaction (single item from Press Ganey),
quality/safety (Joint Commission core measures from chart
abstraction, administrative databases, and Press Ganey), and
operation/utilization (such as documentation standards or lab
utilization). Trainees received a quarterly scorecard containing
data pertinent to each goal.
A total of 5275 residents and fellows participated in
allprogram goals over 6 years. In the 3 years of program-specific
goal implementation, 16 of 18 training programs (540 total
trainees) participated. Trainees received an average of $800,
achieving 11 of 18 (61 %) all-program goals and 28 of 37
(76 %) program-specific goals. An average of $724,450 per
fiscal year was paid as trainee bonuses. Trainees were more
likely to achieve goals that had an involved faculty mentor, were
perceived by trainees as having value, and had high-level
departmental buy-in. Some successful training program-specific
projects had previously been unsuccessful for the institution.
Limitations. This was not designed as a research study, and the
assessment strategy was overlaid on the program. As there was
no control arm, confounders, including the programmatic support
for QI, were not accounted for. Knowledge, skills, attitudes, and
competence in QI among trainees was not measured.
Implications. Providing financial incentives for trainees may
result in higher rates of achieving institutional QI goals.
The study by Starmer, et al., evaluated the effect of a
systems-based intervention to improve resident handoffs on
communication and patient safety in inpatient units at nine
academic pediatric residency programs in the U.S. and
Canada. No site had a handoff program at baseline.12 The
sevenelement handoff bundle (including a mnemonic as an anchor
for oral and written handoffs, a 2-h workshop on handoff and
communication skills, a 1-h role-play and simulation session
for practicing workshop skills, a computer module to allow for
independent learning, a faculty development program, direct
observation tools to provide residents feedback, and a process/
culture change campaign with sustainability materials) was
integrated into workflow and patient documentation systems
at each site for a 6-month period.
A total of 875 (95.4 %) residents participated in the study. A
comparison of 5516 pre-intervention and 5224
postintervention patient admissions showed a reduction in the rates
of medical errors (preventable failures in processes of care) of
23 % (24.5 vs. 18.8/100 admissions, p < 0.001) and a
reduction in preventable adverse events of 30 % (4.7 vs. 3.3/100
admissions, p < 0.001). No significant changes were observed
in duration of oral handoffs or resident workflow.
Limitations. This study focused on pediatric inpatient units, and
thus its applicability to other disciplines and settings is unknown.
Bundling of several educational and process changes prevents a
determination of the elements that were most impactful.
Implications. A multi-pronged handoff program addressing
miscommunication significantly reduced medical errors and
preventable adverse events, without increasing the duration of
Our review of the 2014 literature relevant to general internal
medicine educators highlights seven articles related to
continuity clinic scheduling, remediation, interprofessional education,
and quality improvement/patient safety. We present studies of
high quality and with relevance to general internist medical
educators in today’s teaching and practice environment.
We identified many articles of importance in the 2014
literature, such as those on primary care residency choice,
burnout, humanism and emotional intelligence, cost
consciousness, simulation, and clinical reasoning.13–25 Compared
to our review of the 2013 literature relevant to general
medicine educators,26 we found more multi-institutional
studies of high quality. Similar to last year, resident continuity
clinic and handoffs were areas of focus. We were encouraged
by the growing number of studies on interprofessional
education, reflecting the national shift towards collaborative
patientcentered medical homes and related care structures, but found
little evidence regarding the impact on patient
outcomes.14,16,19,25 We also found descriptive studies on use of
the milestone-based learner assessments.18 Our selection
process prioritized those most relevant, important, and
generalizable, and with greatest methodological quality, for our
audience of general internist educators.
Although we reviewed articles on a wide variety of topics
and used a structured process to identify high-impact articles
for general medicine educators, our study has limitations. We
excluded some high-quality studies because they were less
globally applicable to our general medicine educator audience.
Though we present three multi-institutional studies, the
majority of articles reviewed involved single institutions and
nonrandomized designs, introducing selection bias. We have
discussed the limitations regarding the interpretation and
scope of results for each included study. Finally, our review
team comprised educators from diverse geographical regions,
academic rank, and educational roles. However, faculty from
community-based programs and non-physician clinicians
were not represented. Article selection, therefore, may be
biased towards educators at academic medical centers.
The articles presented may help general medicine educators
stay abreast of current trends in the medical education
literature. Further studies assessing patient outcomes are needed to
strengthen the literature in medical education. The reviewed
studies may inform future research and practice of medical
Acknowledgments: All authors contributed to the selection of studies
to include in the review and to the content and revisions of the
manuscript. We would also like to acknowledge the contributions of
Briar Duffy, MD, who participated in the selection of studies to include
in this review.
Corresponding Author: Brita Roy, MD, MPH, MHS; Section of
General Internal MedicineYale University School of Medicine, PO Box
2 0 8 0 2 5 , N e w H a v e n , C T 0 6 5 2 0 - 8 0 2 5 , U S A
Compliance with Ethical Standards:
Conflict of Interest: The authors declare no conflicts of interest.
Funding and Support: None
Prior Presentations: This was previously presented as the Update in
Medical Education during the Society of General Internal Medicine 38th
Annual Meeting on April 23, 2015, in Toronto, ON, CA.
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