Faculty Bibliography

Background: Diagnostic errors have a significant impact on our health care system with cognitive errors contributing to the majority of cases. Educators have theorized that interventions grounded in dual process theory (DPT) may improve the clinical reasoning (CR) process of physicians but little empirical evidence of this theory exists.
Method(s): This study was a quasi-experimental design in the New York University Internal Medicine Residency Program from June 2017- January 2018. We implemented two educational interventions in CR grounded in DPT during this 6-month period, leading to a natural experiment with three groups: no intervention (N = 25), partial intervention (received part 1, N = 23), and full intervention (received part 1 and part 2, N = 23). The educational interventions covered the concepts of DPT, impact of diagnostic errors, and case-based discussions introducing techniques to develop fast and slow thinking. We used the diagnostic thinking inventory (DTI) at baseline (a 41 item self-assessment questionnaire to assess one's approach to CR). At 6 months, participants completed a follow-up DTI and a post-survey assessing their ability to apply concepts to cases as well as workplace experiences of CR teaching. Participants who completed pre- and post-surveys were included in the analysis. Case examples were scored by two independent reviewers blinded to group status (Table). Differences between groups were analyzed using a one-way analysis of variance.
Result(s): Those in the full intervention group reported more teaching of DPT on attending rounds and in conference than the partial intervention and no intervention groups (60% often or always taught compared to 25% and 8.3%, p = 0.002; 73.3% often or always taught compared to 58.3% and 33.3%, p = 0.033, respectively). Otherwise workplace experiences were not significantly different between the groups. There was a significant difference between groups in ability to apply concepts to cases with a medium to large effect size (Table). There was also a significant difference in giving case examples in problem representation format with a large effect size (Table). There was no significant difference in change in DTI scores (mean change in score no intervention 7.0 (SD 16.3), partial intervention 8.8 (SD 9.8), full intervention 7.8 (SD 12.0), p = 0.946).
Conclusion(s): This study provides evidence that interns who participated in a CR curriculum grounded in DPT were effective in applying principles of CR in cases from their own clinical practice and supports the argument that we should be designing educational interventions in CR grounded in DPT. Subsequent studies would need to assess further impact on patient outcomes. (Figure Presented)

Transitioning medical students are anxious about their readiness-for-internship, as are their residency program directors and teaching hospital leadership responsible for care quality and patient safety. A readiness-for-internship assessment program could contribute to ensuring optimal quality and safety and be a key element in implementing competency-based, time-variable medical education. In this paper, we describe the development of the Night-onCall program (NOC), a 4-h readiness-for-internship multi-instructional method simulation event. NOC was designed and implemented over the course of 3 years to provide an authentic "night on call" experience for near graduating students and build measurements of students' readiness for this transition framed by the Association of American Medical College's Core Entrustable Professional Activities for Entering Residency. The NOC is a product of a program of research focused on questions related to enabling individualized pathways through medical training. The lessons learned and modifications made to create a feasible, acceptable, flexible, and educationally rich NOC are shared to inform the discussion about transition to residency curriculum and best practices regarding educational handoffs from undergraduate to graduate education.

BACKGROUND: The AAMC has identified 13 Entrustable Professional Activities (EPAs) that all entering residents should be expected to perform on day 1 of residency without direct supervision regardless of specialty choice. We developed an immersive, Night on call (NOC) simulation to understand the measure of entrustment of all 13 Core EPAs from the perspective of patients, nurses, attendings, and peers. METHODS: NOC is a 4-hour simulation, during which a medical student rotates through a series of authentic clinical coverage scenarios including: 4 standardized patient (SP) cases with varying degrees of complexity, each of which require first answering a call from a standardized nurse, (SN), then evaluating a SP with the SN in the room, making immediate management decisions and writing a coverage note; a phone call to an attending (Attn, an experienced clinician) to orally present (OP), and discuss the case, formulation of a clinical question and finding a best answer using digital library resources (EBM), a test of ability to recognize a pre-entrustable peer, and a handoff of 4 cases to a peer (HOff, portrayed by an senior medical student). Competency assessments were based on validated tools where available. Each rater provided an entrustment judgment. This included 9 raters providing a total of 16 entrustment judgments: 4 SPs and 3 SNs (1 rating competency and 1 rating communication each), 1 Attn based on OP, 1 peer rating based on the HOff (1 item each). Raters were trained in both case portrayal and rating reliability. This study is IRB approved. After exploring the relationships among competency measures and entrustment judgements, to test the hypothesis that NOC measures trustworthiness of our near graduates, we conducted a one-factor (entrustment) confirmatory factor analysis (CFA) with the 16-entrustment items allowing the ratings from the same raters and between raters on the same case to correlate. The CFA was conducted with a means and variance adjusted weighted-least squares estimation (WLSMV) to take the ordinal distributions of the entrustment items into account. RESULTS: 73 medical students (39 women; Age 26.5 (+2.6) years) completed NOC. The one-factor CFA model fit the data (chi² = 155.27, df = 112, p < .001, CFI = 0.97, TLI = 0.97, RMSEA = 0.07, p > 0.05). All but 2 of the 16 factor loadings were greater than 0.3, (Attn factor loading = 0.23 and the SP ratings from the first clinical case of NOC sequence (0.21)). CONCLUSIONS: A single-factor model with 16measures fit the entrustment framework within an ecologically valid simulated workplace suggesting that an individual student's clinical trustworthiness is measurable across discrete work activities. This work provides an assessment framework for the educational handoff from medical school to residency to ensure quality of care and patient safety

NEEDS AND OBJECTIVES: To address rising education costs, physician shortages, and the need for educational reform, several medical schools have developed accelerated 3-year MD programs. In 2013, NYU School of Medicine began its new 3-year MD program with guaranteed acceptance into residency upon graduation. Using the AAMC's 13 Core Entrustable Professional Activities for Entry into Residency (CEPAER) framework, we designed an immersive 4-hour simulated "Night on Call" (NOC) experience to compare performance of our first graduating cohort of fifteen 3-year MD students (3A), with third (3T) and fourth year (4T) students in the traditional 4-year MD program. SETTING AND PARTICIPANTS: 73 medical students (39 women, age 26.5 (+2.6) years; 36 '3T', 12 '3A', 25 '4T') completed an IRB-approvedNOC at our simulation center 4 weeks prior to the end of their third or final year of medical school. DESCRIPTION: We developed NOC to measure competence and entrustment across all 13 CEPAERs from the perspective of patients, nurses, and attendings. During the simulation, a medical student rotated through a series of 8 clinical coverage scenarios including: 4 standardized patient (SP) cases with varying degrees of complexity, each of which require answering a call from a standardized nurse (SN), evaluating an SP with the SN in the room, making immediate management decisions and writing a coverage note; a phone call to an experienced clinician to orally present (OP) the case; formulation of a clinical question and finding the most appropriate evidence-based medicine (EBM) answer using digital library resources; a clinical vignette (CV) to test ability to recognize a pre-entrustable peer; and a handoff (HO) of 4 cases to a peer (a senior medical student). CEPAERs assessments based on validated tools included communication, physical exam, patient education and interprofessional teamwork skills assessed by an SP and SN, and clinical reasoning based on notes, OP, EBM, CV, HO. Each rater also provided an entrustment judgment. EVALUATION: Although overall student performance improved across cases and some interesting individual performance patterns emerged, there were no significant differences across the three groups in the core competency and entrustment measures evaluated across various NOC activities. DISCUSSION/REFLECTION/LESSONS LEARNED: The 13 CEPAERs are meant to define what students should be expected to perform (without direct supervision) prior to entering residency. Our results, based on multiple rater perspectives, suggest that our cohort of 3A students is as prepared for residency as their 4T counterparts

This study examined a cohort of 227 older drivers and investigated the relationship between performance on the electronic Driver Observation Schedule (eDOS) driving task and: (1) driver characteristics; (2) functional abilities; (3) perceptions of driving comfort and abilities; and (4) self-reported driving restrictions. Participants (male: 70%; age: M = 81.53 years, SD = 3.37 years) completed a series of functional ability measures and scales on perceived driving comfort, abilities, and driving restrictions from the Year 2 Candrive/Ozcandrive assessment protocol, along with an eDOS driving task. Observations of participants' driving behaviours during the driving task were recorded for intersection negotiation, lane-changing, merging, low-speed maneuvers, and maneuver-free driving. eDOS driving task scores were high (M = 94.74; SD = 5.70) and significantly related to participants' perceived driving abilities, reported frequency of driving in challenging situations, and number of driving restrictions. Future analyses will explore potential changes in driving task scores over time.

The authors report 5 experiments that explored the role of error in motor learning. Participants practiced 4 distinct keypress sequences that varied in the amounts of advance information (i.e., choice) about which key to press next in the sequence. The amount of advance information resulted in differing levels of error during practice, which in general, was inversely related to retention performance. Although these findings support a beneficial role of error in motor learning, they also suggest that not all errors are equal in the learning process. Rather, we make a distinction between factors that induce errors that have desirable influences on learning compared to those that have undesirable effects.