Christine

Hi Gang:

I know most of you are not into this stuff....

But Christine asked me to promote your link and business for her.

Why not?

Take a look:

PsychicHealerChristine.com 

Cleansing the mind. 

Intuitive Insights.

http://www.psychichealerchristine.com/







Marc

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The ultimate resident evaluation

It comes as no shock to me, and probably many other current and former program directors, that a recent study showed faculty overall performance evaluations of residents do not correlate with their scores on the yearly American Board of Surgery in Training Examination.

According to the JAMA Surgery paper, faculty evaluations encompassed technical skill and the six core competencies—medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and system-based practice.

The paper analyzed data for 150 residents at different levels of training over 4 years and also found that even faculty evaluations of the category medical knowledge couldn’t predict who would get a good or a bad score on the test.

It’s great to know that at the authors’ institution, the average annual evaluation scores ranged from just over 75 to 100 with means and medians both slightly above 92—like Garrison Keillor’s mythical Lake Wobegon, “where all the women are strong, all the men are good looking, and all the children are above average.”

Medical knowledge can be measured, but the other parameters are so subjective that they border on meaningless. They remind me of the infamous “smiley face” numerical pain scale that means different things to different patients.

Some examples. Earlier this year, I wrote about the difficulty defining professionalism. Using a numerical scale, how can you rate one resident as more professional than another?

And I always had trouble ranking one resident over another in system-based practice. It might be better to rate system-based practice on a binary scale; that is, can a resident define the term or not?

Big business is having trouble evaluating employees too. The evaluation process at General Electric was examined by Quartz. At GE, the annual review is not effective for managing people or improving performance. “It leads to a tendency…to focus excessively on process over outcomes” and is “an exercise in paperwork and bureaucracy instead of an agent of change.”

Note that the JAMA Surgery study accumulated 1131 evals. Even if that was only virtual paperwork, it’s much work for little value, but at least there was a lot of data to show a site visitor from the Residency Review Committee.

A New Yorker article noted that consulting firm Deloitte’s evaluation process involves consensus meetings ending with managers marking on a 5-point scale how strongly they agree with two statements: “Given what I know of this person’s performance, and if it were my money, I would award this person the highest possible compensation increase and bonus;” and “Given what I know of this person’s performance, I would always want him or her on my team.” And they must answer yes or no to two more: “This person is at risk for low performance,” and “This person is ready for promotion today.”

Maybe we should adopt a modification of Deloitte’s system for our resident evaluations. Faculty must respond yes or no to this statement: “I would let this resident operate on me.” If the answer is “no,” why should we let that resident operate on anyone?

This post originally appeared on Physicians Weekly.

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Applicants want to be a resident but don’t write good Here’s help

Thanks to a spammer trying to comment on some of my posts, I have been introduced to the world of online personal statement services.

On a website called internalmedicineresidency.biz, $54.09 (discounted to $43.27 if you order by June 30) will get you a 275-word personal statement. As the website points out, “Coming up with a personal statement internal medicine of this quality is far from easy, but it’s what our professional service is here to help you achieve.”

Under the heading “How to create a killer statement, item #2 is “Argue why you suit for the course.”

The site offers a sample personal statement that begins, “I’ve always admired those who work in the health care industry not only because my mother was one but the fact that these people are the ones who care for our well being.”

In case you are after bigger game, the same company offers similar services for obtaining a neurosurgical residency. This site says, “Getting a neurosurgery residency can give your career a boost which can have a positive effect at your future in this field.”

I must agree that if you want to become a neurosurgeon, failure to obtain a neurosurgical residency position is a definite disadvantage. In fact, I think it would pretty much preclude your becoming a neurosurgeon.

It may be more difficult to obtain a neurosurgical residency than one in internal medicine, but the price for a neurosurgery personal statement, at a mere $27.19, is much lower.

For some reason when you click on the Sample tab, the site displays a “Pre Med Personal Statement” followed by this paragraph:

Pre Med personal statement writing is nowadays proven as beneficial using online services. Nowadays, students are showing more interest for the pre-med programs because of its value and prospective value for the future medicine studies. There is a great competition every year for this program and thousands of students applying every year too. Here, it is indicating, how important it is to add your application with a personal statement. If you fail to satiate this factor, then admission success is hard to expect. Our service is definitely wise option here to come up with a neurosurgery residency personal statement and any winning personal statement.

If that doesn’t convince you to try this service, I don’t know what will.

A USMLE Forum lists 18 other websites that provide personal statement writing services. I wish I had time to check out all of them.

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Should resident promotion decisions be based on a written exam

A few days ago, some surgeons on Twitter discussed the role of the American Board of Surgery In-Training Examination, a test which is given every year in January.

The test was designed to assess residents knowledge and give them an idea of where their studying should be focused. However, many general surgery program directors (PDs) use the test results in other ways. Some impose remediation programs on residents with low scores and even base resident promotion or retention on them. Some even demand that all residents in their programs maintain scores above the 50th percentile.

The Residency Review Committee (RRC) for Surgery frowns upon these practices and states in its program requirements (Section V.A.2.e) that residents knowledge should be monitored "by use of a formal exam such as the American Board of Surgery In Training Examination (ABSITE) or other cognitive exams. Test results should not be the sole criterion of resident knowledge, and should not be used as the sole criterion for promotion to a subsequent PG [postgraduate year] level."

The problem for program directors is that the RRC also mandates (Section V.C.2.c) that "as one measure of evaluating program effectiveness" 65% of a residency programs graduates must pass both the American Board of Surgerys Qualifying Examination (written) and Certifying Examination (oral) on their first attempts. I have said before that the "65% on the first attempt rule" does not seem evidence-based.

Does performance on the ABSITE predict performance on the boards examinations?

A recent paper by the staff of the American Board of Surgery states, "Although the ABSITE does not have a direct effect on board certification, it has been shown to be predictive of ABS Qualifying Examination performance." The authors cited three references.

The best is a 2010 Archives of Surgery paper that analyzed 607 graduates of 17 programs from the western US. It found "On multivariable analysis, scoring below the 35th percentile on the ABSITE at any time during residency was associated with an increased risk of failing both examinations (odds ratio, 0.23 [95% confidence interval, 0.08-0.68] for the qualifying examination and 0.35 [0.20-0.61] for the certifying examination)."

Note: The boards paper found that ABSITE scores do not correlate with passing the certifying (oral) exam. This makes sense because the oral exam is more about judgment and situational thinking than recall of facts.

A systematic review of 26 papers, published online in the Journal of Surgical Education, showed that "Structured reading programs and setting clear expectations with mandatory remedial programs were consistently effective in improving ABSITE performance, whereas the effect of didactic teaching conferences and problem-based learning groups was mixed."

However, its not so simple. Structured reading and mandatory remedial programs will only work if the deficient resident is committed to succeeding, an attitude that is not always present. [See "grit."]

A brilliant post of mine from two years ago pointed out that program size has a lot to do with being able to maintain a better than 65% board passage rate on the first attempt. Using a simple statistical fact, I explained why smaller programs may be much more likely to fail to meet the 65% standard.

A resident who, despite attempts at remediation, has single digit ABSITE percentile scores over two or three years creates a serious dilemma for the director of a small program. Should the PD keep the resident in the program which can ill afford to graduate a resident with a high risk of failure on the written board examination or dismiss the resident and try to find a competent replacement from a very small pool of available candidates?

Having been there, I can tell you its not an easy decision.

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Can you define professionalism

A while ago, I wrote about a medical student whose school tried to dismiss him just prior to graduation for unprofessional behavior.

A judge ruled that the school could not do so because it had tolerated some similar behavior earlier in his medical school career and had not considered it important enough to mention in his letters of recommendation.

In that post, I said, "Professionalism is difficult to define, especially when trying to do so in a courtroom."

In the comments section, a medical student wrote that he had been given a two-week suspension for unprofessional behavior for silencing his phone during an exam.

Another commenter told of several students who were caught colluding on a take-home final exam in statistics. Their punishment was that they had to agree to do their residencies at the medical school. [Digression: What does that say about the school?]

The Accreditation Council for Graduate Medical Education defines professionalism, one of its six core competencies, as follows:

"Professionalism—Demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles."

Im always a bit confused when the definition of a term contains the term itself, and this is no exception.

Three internal medicine foundations combined to publish a somewhat clearer definition that is two pages long, but does not mention specific behaviors like cheating on a test, falsifying a medical record, or being arrested for driving under the influence of alcohol.

The American Board of Internal Medicine Foundation produced this "Word Cloud," which is supposed to help one better understand what professionalism is. But all it did was remind me why I hate word clouds.



It is said to depict "words physicians most associate with medical professionalism."

If you are having trouble reading some of them, I can help. Here are a few: "empathize, compassion, respect, responsibility, ethics, integrity, caring, honor."

Those sound pretty good, but here are some more: "tougher, smoker, diet, sick, job, prevent, financial, good insurance, disease, death." What do those words have to do with medical professionalism?

Since we have trouble defining professionalism, we can hardly blame the judge in the case I wrote about before for ruling in the students favor.

He said, "Although courts should give almost complete deference to university judgments regarding academic issues, the same deference does not follow university character judgments, especially on character judgments only distantly related to medical education."

I disagree with the last part of his statement. I think character judgments are strongly related to medical education, but how are medical schools and residency programs supposed to teach professionalism and assess whether their trainees possess it, if it is so ill-defined?

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