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Journal: Academic medicine : journal of the Association of American Medical Colleges

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Most medical students use Wikipedia as an information source, yet medical schools do not train students to improve Wikipedia or use it critically.

Concepts: Education, University, College

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PURPOSE: To explore the mentor-mentee relationship with a focus on determining the characteristics of effective mentors and mentees and understanding the factors influencing successful and failed mentoring relationships. METHOD: The authors completed a qualitative study through the Departments of Medicine at the University of Toronto Faculty of Medicine and the University of California, San Francisco, School of Medicine between March 2010 and January 2011. They conducted individual, semistructured interviews with faculty members from different career streams and ranks and analyzed transcripts of the interviews, drawing on grounded theory. RESULTS: The authors completed interviews with 54 faculty members and identified a number of themes, including the characteristics of effective mentors and mentees, actions of effective mentors, characteristics of successful and failed mentoring relationships, and tactics for successful mentoring relationships. Successful mentoring relationships were characterized by reciprocity, mutual respect, clear expectations, personal connection, and shared values. Failed mentoring relationships were characterized by poor communication, lack of commitment, personality differences, perceived (or real) competition, conflicts of interest, and the mentor’s lack of experience. CONCLUSIONS: Successful mentorship is vital to career success and satisfaction for both mentors and mentees. Yet challenges continue to inhibit faculty members from receiving effective mentorship. Given the importance of mentorship on faculty members' careers, future studies must address the association between a failed mentoring relationship and a faculty member’s career success, how to assess different approaches to mediating failed mentoring relationships, and how to evaluate strategies for effective mentorship throughout a faculty member’s career.

Concepts: Qualitative research, Grounded theory, Coaching, Success, Alternative education, Youth mentoring, Mentorship, Maybach Foundation

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PURPOSE: To understand the nature of excellent clinicians at an academic health science center by exploring how and why excellent clinicians achieve high performance. METHOD: From 2008 to 2010, the authors conducted a qualitative study using a grounded theory approach. Members of the Clinical Advisory Committee in the Department of Pediatrics at the University of Toronto nominated peers whom they saw as excellent clinicians. The authors then conducted in-depth interviews with the most frequently nominated clinicians. They audio-recorded and transcribed the interviews and coded the transcripts to identify emergent themes. RESULTS: From interviews with 13 peer-nominated, excellent clinicians, a model emerged. Dominant themes fell into three categories: (1) core philosophy, (2) deliberate activities, and (3) everyday practice. Excellent clinicians are driven by a core philosophy defined by high intrinsic motivation and passion for patient care and humility. They refine their clinical skills through two deliberate activities-reflective clinical practice and scholarship. Their high performance in everyday practice is characterized by clinical skills and cognitive ability, people skills, engagement, and adaptability. CONCLUSIONS: A rich theory emerged explaining how excellent clinicians, driven by a core philosophy and engaged in deliberate activities, achieve high performance in everyday practice. This theory of the nature of excellent clinicians provides a holistic perspective of individual performance, informs medical education, supports faculty career development, and promotes clinical excellence in the culture of academic medicine.

Concepts: Health care, Scientific method, Psychology, Medicine, Clinical trial, Educational psychology, Qualitative research, Grounded theory

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PURPOSE: Despite the importance of leadership in interprofessional health care teams, little is understood about how it is enacted. The literature emphasizes a collaborative approach of shared leadership, but this may be challenging for clinicians working within the traditionally hierarchical health care system. METHOD: Using case study methodology, the authors collected observation and interview data from five interprofessional health care teams working at teaching hospitals in urban Ontario, Canada. They interviewed 46 health care providers and conducted 139 hours of observation from January 2008 through June 2009. RESULTS: Although the members of the interprofessional teams agreed about the importance of collaborative leadership and discussed ways in which their teams tried to achieve it, evidence indicated that the actual enactment of collaborative leadership was a challenge. The participating physicians indicated a belief that their teams functioned nonhierarchically, but reports from the nonphysician clinicians and the authors' observation data revealed that hierarchical behaviors persisted, even from those who most vehemently denied the presence of hierarchies on their teams. CONCLUSIONS: A collaborative approach to leadership may be challenging for interprofessional teams embedded in traditional health care, education, and medical-legal systems that reinforce the idea that physicians sit at the top of the hierarchy. By openly recognizing and discussing the tensions between traditional and interprofessional discourses of collaborative leadership, it may be possible to help interprofessional teams, physicians and clinicians alike, work together more effectively.

Concepts: Health care, Medicine, Healthcare, Hospital, Hierarchy, Methodology, Heterarchy, Maslow's hierarchy of needs

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Effective leadership is critical for optimizing cost, access, and quality in health care. Creating a pipeline of effective health care leaders requires developing leadership competencies that differ from the usual criteria of clinical and scientific excellence by which physicians have traditionally been promoted to leadership positions. Specific competencies that differentiate effective leaders from average leaders, especially emotional intelligence and its component abilities, are essential for effective leadership.Adopting a long-standing practice from successful corporations, some health care institutions, medical societies, and business schools now offer leadership programs that address these differentiating leadership competencies. The author draws on experience with such programs through the Cleveland Clinic Academy to provide recommendations for health care leadership training and to identify unanswered questions about such programs.The author recommends that such training should be broadly available to all health care leadership communities (i.e., nurses, administrators, and physicians). A progressive curriculum, starting with foundational concepts and extending to coaching and feedback opportunities through experiential learning, recognizes the challenge of becoming an effective leader and the long time line needed to do so. Linking leadership courses to continuing medical education and to graduate credit opportunities is appealing to participants. Other recommendations focus on the importance of current leaders' involvement in nominating emerging leaders for participation, embedding leadership development discussions in faculty’s professional reviews, and blending discussion of frameworks and theory with practical, experiential lessons. The author identifies questions about the benefits of formal health care leadership training that remain to be answered.

Concepts: Health care, Medicine, Clinical trial, Skill, Management, Positive psychology, Leadership, Leadership development

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PURPOSE: To determine, through a 10-year review, (1) the prevalence of residents in difficulty, (2) characteristics of these residents, (3) areas of residents' weakness, and (4) outcomes of residents who undergo remediation. METHOD: A retrospective review of resident records for the University of Toronto Faculty of Medicine’s (UT-FOM) Board of Examiners for Postgraduate Programs (BOE-PG) was done from July 1, 1999 to June 30, 2009 using predetermined data elements entered into a standardized form and analyzed for trends and significance. Outcomes for residents in difficulty were tracked through university registration systems and licensure databases. RESULTS: During 10 years, 103 UT-FOM residents were referred to the BOE-PG, representing 3% of all residents enrolled. The annual prevalence of residents referred to the BOE-PG ranged from 0.2% to 1.5%. The CanMEDS framework was used to classify areas of residents' weaknesses and organize remediation plans. All 100 residents studied had either medical expertise (85%) or professionalism (15%) weaknesses or both. Residents had difficulties with an average of 2.6 CanMEDS Roles, with highest frequencies of Medical Expert (85%) Professional (51%), Communicator (49%), Manager (43%), and Collaborator (20%). Often, there were multiple remediation periods, with an average of six months' duration. Usually, remediation was successful; 78% completed residency education, 17% were unsuccessful, and 5% remained in training. CONCLUSION: Residents in difficulty have multiple areas of weakness. The CanMEDS framework is an effective approach to classifying problems and designing remediation plans. Successful completion of residency education after remediation is the most common outcome.

Concepts: Retrospective, Physician, Management, Medical school, Outcome, Resident

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Competency-based education requires individualization of instruction. Mastery learning, an instructional approach requiring learners to achieve a defined proficiency before proceeding to the next instructional objective, offers one approach to individualization. The authors sought to summarize the quantitative outcomes of mastery learning simulation-based medical education (SBME) in comparison with no intervention and nonmastery instruction, and to determine what features of mastery SBME make it effective.

Concepts: Psychology, Medicine, Systematic review, Educational psychology, Medical school, Meta-analysis

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PURPOSE: The clinical reasoning literature focuses on how physicians reason while making decisions, rather than on what they reason about while performing their clinical tasks. In an attempt to provide a common language for discussing, teaching, and researching clinical reasoning, the authors undertook the task of developing a unified list of physicians' reasoning tasks, or what they reason about, during clinical encounters. METHOD: The authors compiled an initial list of 20 reasoning tasks based on the literature from four content areas-clinical reasoning, communications, medical errors, and clinical guidelines. In the summer and fall of 2010, they surveyed a purposive sample of 46 international experts in clinical reasoning and communications. From the results of the first survey, the authors refined their list of reasoning tasks, then resurveyed 22 of the original participants. From the results of the second survey, they further refined their list and validated the inclusion of the reasoning tasks. RESULTS: Twenty-four of 46 (52%) and 15 of 22 (65%) participants completed the first- and second-round surveys, respectively. Following the second-round survey, the authors' list included 24 reasoning tasks, and a clinical example corresponding to each, that fell into four broad categories: framing the encounter (3), diagnosis (8), management (11), and self-reflection (2). CONCLUSIONS: The development of this unified list represents a first step in offering a vocabulary for discussing, reflecting on, teaching, and studying physicians' reasoning tasks during clinical encounters.

Concepts: Psychology, Physician, Cognition, Medical diagnosis, Logic, Reasoning, Reason, Conclusion

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Annually affecting over 18 million people worldwide, sepsis is common, deadly, and costly. Despite significant effort by the Surviving Sepsis Campaign and other initiatives, sepsis remains underrecognized and undertreated.

Concepts: Sepsis, Surviving Sepsis Campaign, Business game, Simulations and games in economics education