Examining the Validity of Milestone-Based Medical Resident Ratings

Improving the Use of Oral Case Presentations

There are other steps that are also now being proposed to improve training. Scholars are suggesting that oral case presentation in medical education could be used to assess clinical competence and teach clinical reasoning.

Even though oral case presentations are widely used, they could be used more effectively as tools for structured teaching and assessment, according to the authors of a Viewpoint in JAMA.²  Part of the problem is that oral case presentations in medical education lack standardization.

“Medical educators can achieve greater effectiveness in using case presentations for teaching by doing 3 things: first by telling trainees more clearly what expectations they have for presentation format and content; second, they should use probing questions to check for understanding; and third they should model how they think through a case to help trainees understand their clinical reasoning,” said viewpoint author Rodrigo Cavalcanti, MD, associate professor of internal medicine at the University of Toronto in Canada.

He would like to see more formative evaluation based on oral case presentations in which the assessment of the trainee’s performance is designed to help improve performance, similar to what a sports coach might do.

“When watching someone play, coaches focus on giving tips on how to perform the task better. Presentations happen on a daily basis in every teaching hospital for almost every trainee,” Dr Cavalcanti told Endocrinology Advisor.

Co-author Lindsay Melvin, MD, also from the University of Toronto, said the main barriers have to do with time constraints for the clinical teacher. Teaching clinicians are under pressure to be efficient and are faced with competing demands of providing care.

“Improvements need to start by acknowledging these two important tasks and recognizing the value of each of them. Clinical care is paramount. Teaching also needs to be rewarded for its contributions to the new generation of physicians.” Dr. Melvin said in an interview. 

What About Teaching High-Value Care?

Two medical ethics scholars are urging careful consideration of how the concept of high-value care should be integrated in medical education.³ 

In another Viewpoint published in JAMA, the authors noted that if primacy of patient welfare is to truly remain fundamental to the profession, then there needs to be a commitment to this principle. Further, it should be the most critical ethical value instilled in cultivating professional identity, according to the authors.³

The researchers contend that if “value” is considered the ratio of health benefits achieved per unit of cost, value can be increased in several ways. This could be accomplished by increasing health benefits, decreasing costs, or accepting less health benefit as a trade-off for cost savings. However, teaching approaches that overemphasize cost savings could risk causing trainees to lose sight of individual patient welfare or create unintended consequences for subsequent bedside decision-making.³

Co-author Matthew DeCamp, MD, PhD, assistant professor of medicine at the Johns Hopkins University School of Medicine in Baltimore, said physicians must sometimes balance ethical tension between cost saving and patient welfare. He noted the best way to do this has not been settled among ethics scholars and practicing physicians. This lack of consensus could lead to inexperienced medical trainees misunderstanding their duty.

“From the standpoint of ethics, ensuring that the effects of medical training on professional identity formation are captured is key.  We sometimes think of evaluating ethics and professionalism as a separate domain from the rest of medical training,” said Dr DeCamp, who is also a faculty member at the Johns Hopkins Berman Institute of Bioethics. 

He explained that ethics and value have to be evaluated together. For example, with the growing popularity of high-value care education, it would be important to evaluate the impact of high value care education on not just costs and quality but also on how medical trainees understand their identity and ethical obligations as health professionals. 

“In the high-value care domain, there may be teachers with a keen understanding of value-based health care but less understanding of medical professionalism or vice versa,” Dr DeCamp told Endocrinology Advisor. 

However, he said this problem is not insurmountable, if educators are given the time and resources to design and evaluate curricula together rather than as separate units. He and his co-author contend that ambiguity regarding the primacy of patient welfare in high-value care education risks patient distrust and societal backlash.  

References

1. Hauer KE,  Vandergrift J,  Hess B, et al. Correlations between ratings on the resident annual evaluation summary and the internal medicine milestones and association with ABIM certification examination scores among US internal medicine residents, 2013-2014. JAMA. 2016; 316(21):2253-2262. doi:10.1001/jama.2016.17357.
2. Melvin L, Cavalcanti RB. The oral case presentation: A key tool for assessment and teaching in competency-based medical education. JAMA. 2016;316(21):2187-2188. doi:10.1001/jama.2016.16415.
3. DeCamp M, Riggs KR. Navigating ethical tensions in high-value care education. JAMA. 2016; 316(21):2189-2190. doi:10.1001/jama.2016.17488. 

This article originally appeared on Endocrinology Advisor