Diagnostic Reasoning across the Medical Education Continuum.

We aimed to study linguistic and non-linguistic elements of diagnostic reasoning across the continuum of medical education. We performed semi-structured interviews of premedical students, first year medical students, third year medical students, second year internal medicine residents, and experienced faculty (ten each) as they diagnosed three common causes of dyspnea. A second observer recorded emotional tone.

A multisite, multistakeholder validation of the Accreditation Council for Graduate Medical Education competencies.

Purpose: The Accreditation Council for Graduate Medical Education's (ACGME's) six-competency framework has not been validated across multiple stakeholders and sites. The objective of this study was to perform a multisite validation with five stakeholder groups.

Method: This was a cross-sectional, observational study carried out from October to December, 2011, in the internal medicine residency continuity clinics of eight internal medicine residency programs in the Pacific Northwest, including a VA, two academic medical centers, a military medical center, and four private hospitals.

Developing a Cultural Consensus Analysis Based on the Internal Medicine Milestones (M-CCA).

A national task force identified domains and developmental milestones from the national competencies for resident training. Cultural Consensus Analysis (CCA) is a standard anthropological technique that can identify value conflicts. We created a CCA based on the internal medicine milestones (M-CCA) in 3 steps: converted the 38 domains into active statements; reduced the total number to 12 by summarizing and combining; and simplified the wording.

Toward an ecological perspective of resident teaching clinic.

Teaching clinic managers struggle to convert performance data into meaningful behavioral change in their trainees, and quality improvement measures in medicine have had modest results. This may be due to several factors including clinical performance being based more on team function than individual action, models of best practice that are over-simplified for real patients with multiple chronic diseases, and local features that influence behavior but are not aligned with core values. Many are looking for a new conceptual structure to guide them.

Developing and validating a conceptual model of recurring problems in teaching clinic.

Recurrent problems in medical teaching clinic are common and difficult to address because of complex interpersonal dynamics. To minimize this difficulty, we developed a conceptual model that simplifies problems and identifies the root cause of tension between groups in clinic. We used recursive analysis and modeling of the data from a larger multi-site, multi-method study of problems in teaching clinic.

Testing the exportability of a tool for detecting operational problems in VA teaching clinics.

Background: Recurrent operational problems in teaching clinics may be caused by the different medical preferences of patients, residents, faculty, and administrators. These preference differences can be identified by cultural consensus analysis (CCA), a standard anthropologic tool.

Objective: This study tests the exportability of a unique CCA tool to identify site-specific operational problems at 5 different VA teaching clinics.

A qualitative study of resident learning in ambulatory clinic. The importance of exposure to 'breakdown' in settings that support effective response.

Qualitative analysis of a large ethnographic database from observations of a resident teaching clinic revealed three important findings. The first finding was that breakdown, a situation where an 'actor' (such as a person or the group) is not achieving expected effectiveness, was the most important category because of its frequency and explanatory power. The next finding was that exposure to breakdown was a necessary ingredient for reflective learning.

Cultural consensus analysis as a tool for clinic improvements.

Some problems in clinic function recur because of unexpected value differences between patients, faculty, and residents. Cultural consensus analysis (CCA) is a method used by anthropologists to identify groups with shared values. After conducting an ethnographic study and using focus groups, we developed and validated a CCA tool for use in clinics.