Abstract Effective mentoring can help individuals navigate the complex, dynamic environment of academic medicine as they work to develop meaningful and fulfilling careers. Despite robust research into the characteristics of effective mentoring relationships and successful mentoring programs, resources that support mentors and mentees in engaging in career development in academic medicine are limited. Ecological psychology, a theory focusing on how the dynamic interplay between individuals and their environment influences cognition and behavior, offers a promising framework for exploring how mentors and mentees can support positive career development outcomes. In this article, the authors introduce selected principles derived from ecological psychology and supplement these principles with practical, hypothetical examples that demonstrate the use of ecological psychology across the continuum of career development (e.g., from early to middle to late career decisions). By focusing on interactions between individuals and their environment, ecological psychology offers a valuable and practical complement to other theories and frameworks that address career development, such as social cognitive career theory and landscapes of practice. By centering on the dynamic interactions between individuals and their professional environments, ecological psychology offers mentors, mentees, and academic medical centers a practical structure for navigating the intricacies and challenges of career development in academic medicine.

Practice inquiry (PI) is a structured method of discussion that helps primary care clinicians explore uncertainty and learn from challenging cases. An understanding of what aspect of PI primary care clinicians value could guide leaders who are contemplating implementation of collaborative discussion formats in their clinical systems. We administered a survey examining clinicians' perceptions of PI in a large nationwide membership-based primary care service. Two hundred ninety-six surveys (61%, N = 296/482) were received from participants and 69 surveys (75%, N = 69/92) were received from facilitators. Most respondents (>70% across five queries) felt that PI led to enhancement of knowledge and management skills and helped them become more comfortable managing uncertainty. Colleagues in PI groups provided validation and reassurance, valuable health system information, and insights into reasoning and patient-clinician relationships. Participants and facilitators outlined ways PI sessions could be improved (eg, case follow-up) and how the organization could support PI sessions (eg, enhanced facilitator training). This is the first program evaluation of PI in a large, community primary care setting. Future directions include examining what group-level characteristics mediate PI efficacy and how clinicians and patients fare after PI discussions. Such insights could inform enhancements to the group facilitation process.

The global shortage and inequitable distribution of neurologists has led to significant gaps not only in neurology care, but also in neurology education. In order to increase access to neurology education, we developed neurology virtual morning report (NVMR), a virtual, open-access, case-based clinical reasoning conference available to learners worldwide. To evaluate NVMR's impact on participants' perception of, interest in, and confidence in neurology, we conducted a survey. Respondents represented 25 different countries of various income levels. The majority of respondents reported that NVMR decreased their perception of difficulty in understanding neurology and increased confidence in various clinical reasoning domains in neurology. Additionally, the majority of medical student participants showed an increased interest in pursuing neurology as a future specialty after participating in NVMR. NVMR represents a potential model for virtual educational conferences and highlights the opportunities digital education has to improve equitable access to neurology education.

Case-based diagnostic reasoning conferences, like morning reports, allow undergraduate medical trainees to practice diagnostic reasoning alongside senior clinicians. However, trainees have reported discomfort doing so. Peer-assisted learning offers an alternative approach. We describe the design, implementation, and evaluation of a virtual, student-only diagnostic reasoning conference that leverages peer-assisted learning. Student virtual morning report’s (VMR) design was informed by social and cognitive congruence and experience-based learning. We evaluated participant experiences using a survey focused on participant perceptions of Student VMR’s value, their methods for participation, and their preferences for Student VMR compared with VMR with more senior clinicians. 110 participants (28.9%) completed the survey. 90 participants (81.2%) reported that Student VMR was educational. Compared to VMR, participants reported being more likely to participate in Student VMR by turning on their video (50.0%), presenting a case (43.6%), verbally participating (44.5%), or participating in the chat (70.0%). Strengths included a safe learning environment to practice DR and the opportunity to engage with an international learning community. When asked whether they preferred Student VMR or non-Student VMR, most respondents (64.5%, 71/110) identified that they did not have a preference between the two. A student-focused DR conference may offer a valuable complement to, but not a replacement of, apprenticeship-based DR case conferences.

Management reasoning (MR) is a key domain of clinical reasoning that is distinct from the more heavily studied and taught diagnostic reasoning (DR). Despite MR’s importance to patient care, there are few published strategies for incorporating MR education into the clinical learning environment. In this perspective, the authors review key theories and clinical principles relevant to MR and integrate these concepts with previously described tools for teaching MR to provide frontline clinical teachers with practical, theory-informed framework for teaching MR during inpatient rounds.

Internal medicine trainees learn a variety of clinical skills from resident clinical teachers in the inpatient setting. While diagnostic reasoning (DR) is increasingly emphasized as a core competency, trainees may not feel entirely comfortable teaching it. In this perspective article, we provide a framework for teaching DR during inpatient rounds, which includes focusing on the one-liner, structuring a reasoning-focused A&P, and performing a day of discharge reflection.

The authors declare no conflict of interest.

BACKGROUND:Advance care planning allows patients to share their preferences for medical care with the aim of ensuring goal-concordant care in times of serious illness. The morbidity and mortality of the COVID-19 pandemic has increased the importance and public visibility of advance care planning. However, little is known about the frequency and quality of advance care planning documentation during the pandemic.AIM:This study examined the frequency, quality, and predictors of advance care planning documentation among hospitalized medical patients with and without COVID-19.DESIGN:This retrospective cohort analysis used multivariate logistic regression to identify factors associated with advance care planning documentation.SETTING/PARTICIPANTS:This study included all adult patients tested for COVID-19 and admitted to a tertiary medical center in San Francisco, CA during March 2020.RESULTS:Among 262 patients, 31 (11.8%) tested positive and 231 (88.2%) tested negative for SARS-CoV-2. The rate of advance care planning documentation was 38.7% in patients with COVID-19 and 46.8% in patients without COVID-19 (p = 0.45). Documentation consistently addressed code status (100% and 94.4% for COVID-positive and COVID-negative, respectively), but less often named a surrogate decision maker, discussed prognosis, or elaborated on other wishes for care. Palliative care consultation was associated with increased advance care planning documentation (OR: 6.93, p = 0.004).CONCLUSION:This study found low rates of advance care planning documentation for patients both with and without COVID-19 during an evolving global pandemic. Advance care planning documentation was associated with palliative care consultation, highlighting the importance of such consultation to ensure timely, patient-centered advance care planning.

Teaching clinical reasoning has long challenged educators because it requires familiarity with reasoning concepts, experience with describing thinking, and comfort with exposing uncertainty and error. We propose that teachers adopt the cognitive apprenticeship model and a method of disclosing uncertainty known as intellectual streaking. These approaches reflect a shift in the educator's mindset from transmitting medical knowledge to broadcasting cognition. We provide several examples to guide the adoption of these strategies and make recommendations for teachers and training programs to improve the teaching of clinical reasoning.

A 50-year-old male with a history of low back pain presented to his primary care physician with 1 week of worsening back pain. He began taking 4000 to 6000mg of acetaminophen daily for pain control. His outpatient labs were notable for a creatinine of 2.11 mg/dL (baseline 1.01 mg/dL), aspartate aminotransferase (AST) 100 U/L, alanine aminotransferase (ALT) 170 U/L, alkaline phosphatase 357 U/L, GGT 520 U/L, and total bilirubin 7.2 mg/dL. He was sent to the emergency department where he was found to have normal vital signs, abdominal distension, and bilateral lower extremity edema. No spider angiomas, palmar erythema, or distended paraumbilical veins were noted. His mental status was normal with no asterixis. Repeat labs showed a white blood cell count of 12,800 cells/uL, ALT 196 U/L, AST 140 U/L, alkaline phosphatase 461 U/L, total bilirubin 8.0 mg/dL, direct bilirubin 6.4 mg/dL, albumin 3.3 g/dL, INR 2.34, and creatinine 1.61 mg/dL. His serum acetaminophen level was less than 5 ug/mL. He was started on N-acetylcysteine infusion and admitted overnight by a covering physician and transferred to the hepatology service the next morning with a presumptive diagnosis of acetaminophen overdose.

OBJECTIVES:Participation in case-based diagnostic reasoning (DR) conferences has previously been limited to those who can attend in-person. Technological advances have enabled these conferences to migrate to virtual platforms, creating an opportunity to improve access and promote learner participation. We describe the design and evaluation of virtual morning report (VMR), a novel case-based DR conference that aimed to expand access to these conferences, leverage a virtual platform to create new opportunities for learner participation, and improve learner confidence in performing DR. METHODS:VMR took place on a videoconferencing platform. Participants included health professions students, post-graduate trainees, and practitioners. In designing VMR, we adapted concepts from the experience-based model of learning to design opportunities for learner participation. Teaching strategies were informed by information-processing and situativity theories. We evaluated learner experiences in VMR using a survey with open and closed-ended questions. Survey items focused on accessing case-based teaching conferences outside of VMR, participant perceptions of the educational value of VMR, and VMR's impact on participants' confidence in performing DR. We used thematic analysis to manually code open-ended responses and identify themes. RESULTS:203 participants (30.2%) completed the survey. 141 respondents (69.5%) reported they did not otherwise have access to a DR conference. The majority of participants reported increased confidence performing DR. Respondents highlighted that VMR supplemented their education, created a supportive learning environment, and offered a sense of community. CONCLUSIONS:VMR can expand access to DR education, create new opportunities for learner participation, and improve learner confidence in performing DR.

Introduction To advance in their clinical roles, residents must earn supervisors’ trust. Research on supervisor trust in the inpatient setting has identified learner, supervisor, relationship, context, and task factors that influence trust. However, trust in the continuity clinic setting, where resident roles, relationships, and context differ, is not well understood. We aimed to explore how preceptors in the continuity clinic setting develop trust in internal medicine residents and how trust influences supervision. Methods In this qualitative study, we conducted semi-structured interviews with faculty preceptors from two continuity clinic sites in an internal medicine residency program at an urban academic medical center in the United States from August 2018–June 2020. We analyzed transcripts using thematic analysis with sensitizing concepts related to the theoretical framework of the five factors of trust. Results Sixteen preceptors participated. We identified four key drivers of trust and supervision in the continuity clinic setting: 1) longitudinal resident-preceptor-patient relationships, 2) direct observations of continuity clinic skills, 3) resident attitude towards their primary care physician role, and 4) challenging context and task factors influencing supervision. Preceptors shared challenges to determining trust stemming from incomplete knowledge about patients and limited opportunities to directly observe and supervise between-visit care. Discussion The continuity clinic setting offers unique supports and challenges to trust development and trust-supervision alignment. Maximizing resident-preceptor-patient continuity, promoting direct observation, and improving preceptor supervision of residents’ provision of between-visit care may improve resident continuity clinic learning and patient care.

1.Describe frequency and quality of ACP documentation among patients with confirmed or suspected COVID-19.2.Recognize palliative care consultation is associated with increased ACP documentation. Advanced care planning (ACP) supports individuals in understanding and expressing their personal values for medical care in times of serious illness. (1) The COVID-19 pandemic has increased the urgency of ACP discussions, as those infected have high rates of ICU admission, mechanical ventilation, and increased mortality. (2) No prior research has studied the frequency, quality, and factors associated with ACP documentation among patients suspected of having COVID-19. We assessed the frequency and quality of ACP documentation in hospitalized patients positive for COVID-19 compared with those who tested negative. We conducted structured chart reviews on all adults tested for COVID-19 who were admitted to a 600-bed academic tertiary care center in San Francisco, CA between March 1–31, 2020. Multivariate logistic regression was performed to identify factors associated with ACP documentation. 29 patients were diagnosed with COVID-19, while 229 patients tested negative. Demographic data was statistically similar between the two groups. 37.9% of patients with COVID-19 had documentation in a centralized ACP navigator in the EMR, compared to 46.3% of COVID-negative patients (p=0.43). ACP documentation for COVID-19 patients centered around code status (n=11, 100%), rather than prognosis (n=0, 0%) or other wishes (n=3, 27%). For all patients, palliative care consultation was associated with significantly higher odds of ACP documentation (OR 11.51, CI 2.92-77.35, p=0.002). Hospitalized patients with COVID-19 had low rates of ACP documentation, albeit similar to those testing negative. While future studies are needed to explore underlying factors, proposed explanations include PPE requirements, visitor restrictions, clinical uncertainty regarding prognosis, and racial and ethnic disparities. Palliative care consultation was associated with increased ACP documentation across all patients. These findings highlight the importance of palliative care involvement in the care of patients with COVID-19 to ensure timely ACP discussions.

Medical EducationVolume 54, Issue 9 p. 851-852 MEDICAL EDUCATION ADAPTATIONS Virtual Morning Report during COVID-19: A novel model for case-based teaching conferences H. Moses Murdock, Corresponding Author H. Moses Murdock [email protected] orcid.org/0000-0003-4098-8968 Correspondence H. Moses Murdock, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. Email: [email protected]Search for more papers by this authorJohn C. Penner, John C. Penner orcid.org/0000-0002-7021-9409 Search for more papers by this authorStephenie Le, Stephenie LeSearch for more papers by this authorSaman Nematollahi, Saman NematollahiSearch for more papers by this author H. Moses Murdock, Corresponding Author H. Moses Murdock [email protected] orcid.org/0000-0003-4098-8968 Correspondence H. Moses Murdock, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. Email: [email protected]Search for more papers by this authorJohn C. Penner, John C. Penner orcid.org/0000-0002-7021-9409 Search for more papers by this authorStephenie Le, Stephenie LeSearch for more papers by this authorSaman Nematollahi, Saman NematollahiSearch for more papers by this author First published: 13 May 2020 https://doi.org/10.1111/medu.14226Citations: 47Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. REFERENCE 1 The Clinical Problem Solvers. Virtual Morning Report. [website]. The Clinical Problem Solvers; 2020. https://clinicalproblemsolving.com/learn-live/. Accessed May 29, 2020. Google Scholar Citing Literature Volume54, Issue9September 2020Pages 851-852 This article also appears in:Medical Education Adaptations ReferencesRelatedInformation

BACKGROUND:Although coaching programs have become a prominent piece of graduate medical education, they have yet to become an integral part of undergraduate medical education. A handful of medical schools have utilized longitudinal coaching experiences as a method for professional identity formation, developing emotional intelligence and leadership.OBJECTIVE:We developed A Whole New Doctor (AWND), a medical student leadership development and coaching program at Georgetown University, with the aim of fostering resilience, leadership, and emotional intelligence at the nascent stage of physician training. To our knowledge, ours is the only program that is largely student-managed and uses certified executive coaches in the medical student population.METHODS:Cohort 1 of AWND started in October 2016. For each cohort, we hold a kickoff workshop that is highly interactive, fast-paced and covers coaching, complex thinking, reflective writing, and a coaching panel for Q&A. Following the workshop, students work with coaches individually to address self-identified weaknesses, tensions, and areas of conflict. We believe the program's student-driven nature provides a new structural approach to professional development and leadership programs, offering students a simultaneously reflective and growth-oriented opportunity to develop essential non-technical skills for physician leaders.RESULTS:Of the 132 students in the program, 107 have worked with one of our coaches (81%). Student testimonials have been uniformly positive with students remarking on an increased sense of presence, improvements in communication, and more specific direction in their careers.CONCLUSION:Our pilot coaching program has received positive feedback from students early in their medical training. It will be important to further scale the program to reach an increasing number of students and quantitatively evaluate participants for the long-term effects of our interventions.