Beckman, Thomas J.

Abstract Qualitative research was originally developed within the social sciences. Medical education is a field that comprises multiple disciplines, including the social sciences, and utilizes qualitative research to gain a broader understanding of key phenomena within the field. Many clinician educators are unfamiliar with qualitative research. This article provides a primer for clinician educators who want to appraise or conduct qualitative research in medical education. This article discusses a definition and the philosophical underpinnings for qualitative research. Using the Standards for Reporting Qualitative Research as a guide, this article provides a step-wise approach for conducting and evaluating qualitative research in medical education. This review will enable the reader to understand when to utilize qualitative research in medical education and how to interpret reports using qualitative approaches.

Abstract There has been a dramatic growth of scholarly articles in medical education in recent years. Evaluating medical education research requires specific orientation to issues related to format and content. Our goal is to review the quantitative aspects of research in medical education so that clinicians may understand these articles with respect to framing the study, recognizing methodologic issues, and utilizing instruments for evaluating the quality of medical education research. This review can be used both as a tool when appraising medical education research articles and as a primer for clinicians interested in pursuing scholarship in medical education.

Background Bedside rounds (BR) have been proposed as an ideal method to promote patient-centred hospital care, but there is substantial variation in their implementation and effects. Our objectives were to describe the implementation of BR in hospital settings and determine their effect on patient-centred outcomes. Methods Data sources included Ovid MEDLINE, Ovid Embase, Scopus and Ovid Cochrane Central Registry of Clinical Trials from database inception through 28 July 2017. We included experimental studies comparing BR to another form of rounds in a hospital-based setting (ie, medical/surgical unit, intensive care unit (ICU)) and reporting a quantitative patient-reported or objectively measured clinical outcome. We used random effects models to calculate pooled Cohen's d effect size estimates for the patient knowledge and patient experience outcome domains. Results Twenty-nine studies met inclusion criteria, including 20 from adult care (17 non-ICU, 3 ICU), and nine from paediatrics (5 non-ICU, 4 ICU), the majority of which (n=23) were conducted in the USA. Thirteen studies implemented BR with cointerventions as part of a ‘bundle’. Studies most commonly reported outcomes in the domains of patient experience (n=24) and patient knowledge (n=10). We found a small, statistically significant improvement in patient experience with BR (summary Cohen’s d=0.09, 95% CI 0.04 to 0.14, p<0.001, I2=56%), but no significant association between BR and patient knowledge (Cohen’s d=0.21, 95% CI −0.004 to –0.43, p=0.054, I2=92%). Risk of bias was moderate to high, with methodological limitations most often relating to selective reporting, low adherence rates and missing data. Conclusions BR have been implemented in a variety of hospital settings, often ‘bundled’ with cointerventions. However, BR have demonstrated limited effect on patient-centred outcomes.

Purpose Self-directed learning (SDL) is part of residency training, which residents desire guidance in implementing. To characterize SDL within the clinical context, this study explored residents’ perceptions of faculty members’ role in promoting and supporting resident SDL. Method Using a constructivist grounded theory approach, the authors conducted seven focus groups with 46 internal medicine residents at the Mayo Clinic Internal Medicine Residency Program from October 2014 to January 2015. Focus group transcripts were deidentified and processed through open coding and analytic memo writing. Guided by a previously developed SDL model, data were analyzed regarding faculty member involvement in resident SDL. Themes were organized and patterns were discussed at team meetings, with constant comparison with new data. Trustworthiness was established using two member-check sessions. Results The authors identified themes within the categories of faculty guidance for SDL, SDL versus other-directed learning (ODL), and faculty archetypes for supporting SDL. Clinical teachers play a key role in facilitating resident SDL and can provide guidance at each step in the SDL process. Residents discussed the distinction between SDL and ODL, highlighting the integrated nature of learning and interplay between the two approaches to learning. Residents identified themes relating to three archetypal approaches faculty implement to support resident SDL in the clinical environment (directed, collaborative, and role model SDL), with benefits and challenges of each approach. Conclusions This study underscores the importance of external guidance for resident SDL and expands on approaches faculty members can use to support SDL in the clinical context.

Purpose To begin to quantify and understand the use of the flipped classroom (FC)—a progressive, effective, curricular model—in internal medicine (IM) education in relation to residency program and program director (PD) characteristics. Method The authors conducted a survey that included the Flipped Classroom Perception Instrument (FCPI) in 2015 regarding programs’ use and PDs’ perceptions of the FC model. Results Among the 368 IM residency programs, PDs at 227 (61.7%) responded to the survey and 206 (56.0%) completed the FCPI. Regarding how often programs used the FC model, 34 of the 206 PDs (16.5%) reported “never”; 44 (21.4%) reported “very rarely”; another 44 (21.4%) reported “somewhat rarely”; 59 (28.6%) reported “sometimes”; 16 (7.8%) reported “somewhat often”; and 9 (4.4%) reported “very often.” The mean FCPI score (standard deviation [SD]) for the in-class application factor (4.11 [0.68]) was higher (i.e., more favorable) than for the preclass activity factor (3.94 [0.65]) ( P < .001). FC perceptions (mean [SD]) were higher among younger PDs (≤ 50 years, 4.12 [0.62]; > 50 years, 3.94 [0.61]; P = .04) and women compared with men (4.28 [0.56] vs. 3.91 [0.62]; P < .001). PDs with better perceptions of FCs had higher odds of using FCs (odds ratio, 4.768; P < .001). Conclusions Most IM programs use the FC model at least to some extent, and PDs prefer the interactive in-class components over the independent preclass activities. PDs who are women and younger perceived the model more favorably.

AbstractRationale, aims and objectivesDiagnostic uncertainty is often encountered in a medical practice. Patients with ambiguous, uncertain, and undiagnosed problems are frequently referred for second opinions. Comparing referral diagnoses to final diagnoses provides an opportunity to determine how frequently final diagnoses vary and changes the direction of medical care.MethodsA retrospective study was done at a single academic medical center using a sample of 286 patients referred by physician assistants, nurse practitioners, and physicians from primary care practices from January 1, 2009 to December 31, 2010. Patients' referral and final diagnoses were compared and classified into 1 of 3 categories: referral diagnosis and final diagnosis the same, referral diagnosis better defined/refined, and referral diagnosis distinctly different from final diagnosis. Episode costs for the respective categories were calculated for the referral visit and services that occurred at our facility within the first 30 days.ResultsIn 12% (36/286) of cases, referral diagnoses were the same as final diagnoses. Final diagnoses were better defined/refined in 66% (188/286) of cases; but in 21% of cases (62/286), final diagnoses were distinctly different than referral diagnoses. Total costs for cases in category 3 (different final diagnoses) were significantly higher than costs for cases in category 1 (P = .0001) and category 2 (P = <.0001).ConclusionReferrals to advanced specialty care for undifferentiated problems are an essential component of patient care. Without adequate resources to handle undifferentiated diagnoses, a potential unintended consequence is misdiagnoses resulting in treatment delays and complications leading to more costly treatments.