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Grade Inflation in the Internal Medicine Clerkship: A national Survey

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    Grade Inflation in the Internal Medicine Clerkship: A national Survey Grade Inflation in the Internal Medicine Clerkship: A national Survey Document Transcript

    • This article was downloaded by: [UPSTATE Medical University Health Sciences Library] On: 04 March 2013, At: 06:49 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20 Grade Inflation in the Internal Medicine Clerkship: A National Survey Sara B. Fazio a , Klara K. Papp b , Dario M. Torre c & Thomas M. DeFer d a Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA b Department of General Sciences, Case Western Reserve University, Cleveland, Ohio, USA c Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA d Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA To cite this article: Sara B. Fazio , Klara K. Papp , Dario M. Torre & Thomas M. DeFer (2013): Grade Inflation in the Internal Medicine Clerkship: A National Survey, Teaching and Learning in Medicine: An International Journal, 25:1, 71-76 To link to this article: http://dx.doi.org/10.1080/10401334.2012.741541 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
    • Teaching and Learning in Medicine, 25(1), 71–76 Copyright C 2013, Taylor & Francis Group, LLC ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2012.741541 Grade Inflation in the Internal Medicine Clerkship: A National Survey Sara B. Fazio Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA Klara K. Papp Department of General Sciences, Case Western Reserve University, Cleveland, Ohio, USA Dario M. Torre Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA Thomas M. DeFer Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA Background: Grade inflation is a growing concern, but the de- gree to which it continues to exist in 3rd-year internal medicine (IM) clerkships is unknown. Purpose: The authors sought to de- termine the degree to which grade inflation is perceived to exist in IM clerkships in North American medical schools. Methods: A national survey of all Clerkship Directors in Internal Medicine members was administered in 2009. The authors assessed key as- pects of grading. Results: Response rate was 64%. Fifty-five per- cent of respondents agreed that grade inflation exists in the Internal Medicine clerkship at their school. Seventy-eight percent reported it as a serious/somewhat serious problem, and 38% noted students have passed the IM clerkship at their school who should have failed. Conclusions: A majority of clerkship directors report that grade inflation still exists. In addition, many note students who passed despite the clerkship director believing they should have failed. In- terventions should be developed to address both of these problems. BACKGROUND The assessment and evaluation of medical students in their clinical years is a critical part of the educational process, with real-time implications for competencies achieved and need for These data were presented at the October 2010 national Clerkship Directors in Internal Medicine meeting in San Antonio, Texas. We ac- knowledge the AAIM staff for their help in creating an online survey, as well as in survey distribution, collection, and data entry. We also thank the CDIM Research Committee for assistance with data extraction and methods, and CDIM membership for responding to the survey. Correspondence may be sent to Sara B. Fazio, Division of Gen- eral Internal Medicine/E-CC631H, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA. E-mail: sfazio@bidmc.harvard.edu remediation. Accurate student evaluation also has a downstream effect on residency programs that will eventually employ the students as house officers, and most important has implications for the patients whom they will treat. There is a general sense that clerkship grading is challeng- ing, poorly standardized, and often subjective.1 At the same time, an increasing national awareness has developed over the past decade that grade inflation may be more of a problem than was previously appreciated.2 Grade inflation may be defined as the occurrence of “an upward shift in students’ grade point av- erage without a similar rise in achievement,”3 compression of all grades at the top,4 or assigning a higher grade to achieve- ment previously assigned a lower grade. There has been a robust discussion in the education community as to whether the phe- nomenon truly exists and, if so, what its consequences are, which has played out in academia as well as the lay press.5 Trends in grade inflation reported at American colleges and universities demonstrate clear differences between public and private uni- versities with the occurrence of higher grade inflation at private when compared to public schools.2 In medical education, there is limited literature available on the topic of grade inflation, but what does exist suggests that it is not a problem limited to one discipline.6–9 In 1996, Speer, Solomon, and Fincher administered a survey to all 125 Liaison Committee on Medical Education–accredited medical school in- ternal medicine clerkship directors, with a 66% response rate.10 Forty-eight percent of respondents reported that grade infla- tion existed in their courses, whereas, of greater concern, 43% reported that some students passed who should have failed. Ac- cording to their data, between 1987 and 1995, there was a sig- nificant increase in the number of students receiving the highest grade (21.67–25.23%), and a significant decrease in the number 71 Downloadedby[UPSTATEMedicalUniversityHealthSciencesLibrary]at06:4904March2013
    • 72 S. B. FAZIO, K. K. PAPP, D. M. TORRE, T. M. DEFER of students receiving the lowest passing grade (42.41–39.05%). Cacamese, Elnicki, and Speer compiled data from the 2004 na- tional Clerkship Directors in Internal Medicine (CDIM) member survey regarding grade inflation in the medicine subinternship. The majority of clerkship directors again reported that grade in- flation existed, with 18% of those surveyed reporting that they had passed a student whom they thought should have failed.11 Furthermore, greater than 50% of subinternship students across the country received the highest grade. Internal medicine is not alone in facing this problem. Roman and Trevino reported that more than 60% of students received the highest grade in their psychiatry clerkship.8 Takayama et al. reported data from the Medical School Performance Evaluations between 2004 and 2005, finding that the range of grade distributions was perhaps the most striking; in internal medicine clerkships, 30% of stu- dents across the country had received the highest grade, but this ranged from a low of 1% to a high of 76% at one institu- tion.12 Many reasons have been cited for the existence of grade inflation in both the general education and medical education literature.10–11,13–14 Among them are a fear of litigation on the part of faculty, concern over negative student-rendered faculty evaluations, a growing sense of entitlement among students, and lack of faculty time to dedicate toward the process of assess- ment. Both the Speer and Cacamese studies called for faculty development to improve the process of grading and evaluation. Over the ensuing years, undergraduate medical education has undergone many changes to adapt to a new educational environ- ment in the setting of increasing use of technology, duty hours reform, and a variety of curricular innovations. We sought to determine the degree to which the perception of grade inflation still existed over a decade after the initial study of 3rd-year inter- nal medicine clerkships was performed, as well as to determine reasons for which it might still exist and to better understand the type of methods that clerkship directors were currently using to assess student performance. We developed a series of survey questions that were administered to a national organization of clerkship directors. METHODS In June 2009, CDIM surveyed its U.S. and Canadian institu- tional members. A total of 107 of 143 (75%) medical school- associated Departments of Medicine in North America have institutional members in CDIM. We sent all CDIM institutional members an e-mail message with a cover letter linked to the online, confidential survey. Nonrespondents were contacted up to three additional times by e-mail and once by telephone. Par- ticipants were blinded to any specific hypothesis of the study. The Institutional Review Board (IRB) at Case Western Reserve University determined that the CDIM survey research protocol did not fit the definition of human subjects’ research per 45 CFR 46.102, and therefore the protocol did not require exemp- tion status, further IRB review, or IRB approval. No incentive was provided for participation. As part of the annual CDIM survey process, a call for ques- tions was issued to CDIM members in the fall of 2008. Questions were reviewed, organized, and edited by members of the CDIM Research Committee. Questions were then presented to CDIM Council and revised to their final format. There were 127 total survey items; five of the items dealt specifically with the topic of grade inflation. The five survey questions included frequency of criterion versus norm-referenced grading systems, the forms of assessment utilized in clerkships, the degree to which grade inflation existed at each medical school, whether any students had passed who should have failed, and the top factors clerkship directors believed were contributors to grade inflation. Many of the same questions were used that had been posed to the national group of clerkship directors by Speer et al. a decade previously with minor modifications.10 Due to space constraints, all of these questions could not be included. We asked if the grading system on the internal medicine clerkship was criterion referenced (with no quotas on final grade distribution, the grade thus being based on achievement of specific criteria only); norm referenced (where the grade distribution is predetermined by the school, with a specific rec- ommended distribution (e.g., 15% Honors, 50% High Pass, 25% Satisfactory, etc.); or a combination of the two. We then inquired which methods of evaluation were used in their clerkship and whether they were used in a formative fashion only, or if they contribute to the final grade, and if so, by what percentage. Choices included clinical evaluations, National Board of Medical Examiners subject exams, faculty- developed written examinations, observed structured clinical exams (OSCEs), and direct observations of clinical skills (such as with a clinical evaluation exercise [CEX] or mini-CEX).15 We also asked for the degree of agreement with the following statements: “At my medical school, students have passed the internal medicine clerkship who should have failed,” “Grade inflation exists in the internal medicine clerkship at my medical school,” and “Grade inflation is more of a problem in other clerkships than in internal medicine.” Finally we posed two additional questions regarding how serious a problem grade inflation was thought to be and what the top three factors were that contribute most to grade inflation from a list of 15 possibilities. Anonymized data were analyzed. Descriptive statistics were used to summarize responses. Due to relatively small sample sizes, Fisher’s exact test was used to determine whether the dif- ferences between categorical data were significant. Four ques- tions required rating on a 5-point scale (strongly disagree to strongly agree). These data were dichotomized by combining strongly disagree and disagree as well as strongly agree and agree. Fisher’s exact test was to determine the significance be- tween agreement or disagreement as well as differences between public/private school, criterion/normative grading system, and clerkship director age at or older than 45 years versus younger than 45 years. The level of significance was set at an alpha of .05. Downloadedby[UPSTATEMedicalUniversityHealthSciencesLibrary]at06:4904March2013
    • GRADE INFLATION: A NATIONAL SURVEY 73 TABLE 1 Forms of evaluation used by Internal Medicine clerkships from responses to Clerkship Directors in Internal Medicine National Survey 2009 N (%) Grading System Criterion 37 (54) Normative 13 (19) Combination 18 (27) Use Clinical Evaluations 69 (100) Formative Only 2 (3) Pass/Fail Only 9 (13) Contributes, on Average, to Final Grade 61% Use NBME Subject Exam 63 (91) Formative Only 2 (3) Pass/Fail Only 8 (13) Contributes, on Average, to Final Grade 25% Use an In-House Exam 21 (30) Formative Only 3 (14) Pass/Fail Only 4 (19) Contributes, on Average, to Final Grade 17% Use an OSCE 34 (49) Formative Only 8 (24) Pass/Fail Only 10 (30) Contributes, on Average, to Final Grade 16% Formal Direct Observation of Clinical Skillsa 50 (73) Formative Only 27 (54) Pass/Fail Only 21 (42) Contributes, on Average, to Final Grade 15% Note. N = 69 respondents. NBME = National Board of Medical Examiners; OSCE = Objective Structured Clinical Examination. a For example, mini-clinical evaluation exercise, observed history and physical or other clinical work. RESULTS Of the 107 CDIM institutional members queried, 64% com- pleted the survey. General information and details about types of evaluation used at different medical schools are presented in Table 1. Fifty-eight percent were from public or state institutions (including the military), and 42% represented private schools. Forty-four percent of clerkship directors were younger than 45. Fifty-four percent of schools had criterion-referenced grading systems, 19% had normative-referenced systems, and 27% de- scribed a combination of the two. The distribution did not vary based on public/state versus private designation. There were no significant differences in respondent gender, geographic distri- bution, or type of institution (public vs. private) between those who did (n = 69) and did not (n = 38) respond to the survey. The forms of student evaluation utilized were not mutually exclusive. Most clerkship directors use multiple evaluation mea- sures. All, 100% of respondents, use clinical evaluations in their clerkships. The percentage of the grade that these evaluations represent was < 50% for 23%, 50–74% for 50%, and 75–100% for 27%. Three of 69 survey respondents did not respond to the latter question. Ninety-one percent of respondents use the National Board of Medical Examiners subject examination as a means of student assessment. For the majority of respondents this represents 20 to 25% of the final grade; two clerkships reported using it for formative purposes only. Thirty percent of schools use an in- house (faculty-developed) written exam; the majority do not use resulting scores to determine grades but rather as a means of self-assessment. Forty-nine percent use an OSCE; most use OSCE results for grade determination, with a range of 5 to 35%, though for the majority of respondents it represented 10 to 15% of the grade. Seventy-two percent use some form of direct observation, with the majority using it for formative purposes only. None of the responses varied significantly by public versus private school, age of the clerkship director, or type of grading system (Table 1). Other formal means of evaluation reported included (in order of frequency) formal write-ups/note review, oral examinations, small-group participation/attendance, portfolios, preceptor eval- uations, evidenced-based medicine exercises, Simulated Inter- nal Medicine Patient Learning Experience (SIMPLE) cases,16 midterm quizzes, radiology exams, pretests, clinical reasoning exercise, and assessment of professionalism. Table 2 presents data regarding clerkship directors’ assess- ment of grade inflation. Fifty-five percent of respondents agreed or strongly agreed that grade inflation exists in the internal medicine clerkship at their school, whereas 23% did not be- lieve it was a problem in their clerkship. Seventy-eight percent reported that, in general, grade inflation is a serious or some- what serious problem. Those who agreed or strongly agreed that grade inflation existed at their own school compared with those who disagreed or strongly disagreed were much more likely to report it as a serious or somewhat serious problem (97% vs. 50%, p < .001). Forty-one percent of respondents agreed or strongly agreed that grade inflation is more of a problem in other clerkships at their school than their own, whereas 26% disagreed or strongly disagreed. Thirty-eight percent agreed or strongly agreed that students have passed the internal medicine clerkship at their school who should have failed, whereas 41% disagreed or strongly disagreed (Figure 1). Of note, only 19% strongly disagreed with this statement. There were no signifi- cant differences in responses by public versus private school, age of the clerkship director, or type of grading system. In terms of defining the top factors contributing to grade inflation, responses can be grouped into six categories: stu- dent factors, consequences to faculty, residency recruitment, performance standards, evaluation issues, and remediation fac- tors. Student factors and evaluation issues were most commonly cited. Twenty-seven percent reported to avoid dealing with un- happy/angry/upset students, 17% indicated because there is lit- tle formalized training in evaluation, 14% chose clinical eval- uations are subjective in nature, and 11% noted to help the Downloadedby[UPSTATEMedicalUniversityHealthSciencesLibrary]at06:4904March2013
    • 74 S. B. FAZIO, K. K. PAPP, D. M. TORRE, T. M. DEFER TABLE 2 Clerkship directors’ assessment of grade inflation from Clerkship Directors in Internal Medicine National Survey 2009 Survey Question N (%) Select the statement that best describes your opinion about grade inflation A Serious/Somewhat Serious Problem 54 (78) Definitely/Probably not a Big Problem 6 (9) Neutral 9 (13) Grade inflation exists in the IM clerkship at my medical school Agree/Strongly Agree 38 (55) Disagree/Strongly Disagree 16 (23) Neutral 15 (22) Grade inflation is more of a problem in other clerkships at my medical school than in IM Agree/Strongly Agree 28 (41) Disagree/Strongly Disagree 18 (26) Neutral 23 (33) At my school students have passed the IM clerkship who should have failed Agree/Strongly Agree 26 (38) Disagree/Strongly Disagree 29 (42) Neutral 14 (20) Note. N = 69 respondents. IM = internal medicine. a Not all clerkship directors responded to each item. FIG. 1. Breakdown of responses to the statement, “At my medical school, students have passed the Internal Medicine clerkship who should have failed” from 2009 CDIM National Survey. (Color figure available online). students get the best possible residency. In addition, 6% each of respondents chose the following three reasons: fear of negative consequence to the evaluator, evaluators do not have enough time to properly assess students, and to improve students’ self- esteem and encourage them to improve. CONCLUSIONS Defensible and fair grading process during medical school is necessary to ensure transparency in the residency application process as well as to ensure that students who have not met a min- imum threshold for competency do not graduate until they do. An association between 3rd-year clerkship grades and internship ratings by program directors in professionalism and knowledge has been demonstrated to exist,17 suggesting that 3rd-year per- formance may have some ability to predict the quality of the practicing physician. The ability to properly assess student per- formance, particularly for those who have not meet minimum competency requirements, is therefore critical. The majority of clerkship directors at North American medical schools reported that grade inflation exists in the internal medicine clerkship at their school and that they consider this to be a significant prob- lem. Unfortunately, little has changed over the past 13 years, as Speer et al.10 in 1996–1997 found that 48% of clerkship direc- tors thought grade inflation existed in their clerkship (compared with 55% in our study; Table 3). What is more concerning is TABLE 3 Comparison of clerkship director assessments about grade inflation between 1996–1997 and 2009 Clerkship Directors in Internal Medicine surveys 1996–199710 2009 No. of Respondents 83 (66%) 69 (64%) Grade inflation exists in the IM clerkship at my medical school Agree/Strongly Agree 48% 55% Disagree/Strongly Agree 37% 23% At my school students have passed the IM clerkship who should have failed Agree/Strongly Agree 43% 38% Disagree/Strongly Agree 45% 42% Grade inflation is more of a problem in other clerkships at my medical school than in IM Agree/Strongly Agree 60% 41% Disagree/Strongly Agreea 26% Assessment of Grade Inflation Serious/Somewhat Serious Problemb 78% Probably Not a Big Problemb 9% Definitely Not a Problemb 0% Note. IM = internal medicine. a Data not published. b Question not asked on the 1996–1997 survey. Downloadedby[UPSTATEMedicalUniversityHealthSciencesLibrary]at06:4904March2013
    • GRADE INFLATION: A NATIONAL SURVEY 75 that 38% of our respondents reported that students had passed the internal medicine clerkship who should have failed. Factors that were cited as potential reasons for grade inflation included student issues, consequences for faculty, effect on resi- dency recruitment, changing performance standards, evaluation concerns, and lack of proper remediation. The most common reason chosen was to avoid dealing with an “angry or upset” student. Our study did not explore the reasons for avoidance of the angry student being a reason for grade inflation. Potential reasons include fear of poor evaluations, which have implica- tions for faculty promotion as well as academic recognition and awards, and legal repercussions, particularly when inadequate documentation exists. This would be a fruitful area for further research. The lack of formalized training in evaluation was the next most common reason, identifying a clear need for enhanced faculty development. In particular, the individuals who are fill- ing out the evaluations are most often teaching attendings and residents, and not the clerkship director; thus being able to solicit reliable and effective data on student performance is an impor- tant aspect of ensuring that clerkship director grading is accu- rate. Kassebaum and Eaglen have reported that the majority of a student’s grade is based on composite recollections of their case presentations, write-ups and discussion only, with little regard to higher cognitive or interpersonal skills.18 Finally, it cannot be ig- nored that the top academic selection criteria for residency pro- grams are based on clinical performance, with the highest rank being given to grades in core clerkships.19 Particularly given that more institutions have reverted to a pass/fail system for the preclinical years,20 this may create pressure on faculty to award higher grades to assist their students in residency placement. Adding multiple methods of assessment to the clerkship, such as direct observation of interviewing and physical exam skills, oral exams and OSCEs may result in a more reliable and valid assignment of grades, as Roman and Trevino found in their study of a psychiatry clerkship.8 Similarly, Schmahmann, Neal, and MacMore found that adding a bedside examination exercise was a useful means of assessing clinical skills and differentiating student performance.6 A variety of assessment methods were reported in our survey, but some clerkships use more than others. Difficulty in delivering negative feedback was cited as the number one reason for grade inflation among subinternship directors in the 2004 CDIM survey.11 In fact, a study from the surgical education literature demonstrated that giving face-to-face feedback actually resulted in more grade inflation, presumably because faculty are not comfortable with giving negative feedback in person.14 The “failure to fail” the incompetent trainee was further addressed by Dudek, Marks, and Regehr, who ascribed this in part to lack of documentation, lack of knowledge of what to document, and lack of remediation options.21 Others have noted that evaluators and students often form a personal relationship, which makes it difficult to render a negative evaluation.22 This further underscores the need for enhanced faculty development in giving effective and truthful feedback as a part of the evaluative process. The mechanism by which evaluation occurs also bears closer examination. Battistone et al. studied the use of regularly sched- uled, formal evaluation and feedback sessions, coupled with behavioral descriptors which describe progressive development from “reporter” to “interpreter” to “manager/educator” (R-I-M- E).23 The authors found that in contrast to a purely numeric rat- ing system on an evaluation form, such “descriptive evaluations” were distributed more normally and with a greater range across the scale of possible grades. Subsequent research established the feasibility of implementing such a system, using descriptive vocabulary, beyond the institution at which it was developed.24 In addition, more explicit descriptors may help decrease grade inflation, though many would assert that expanding the rating form does not solve the underlying problem.9,25 Williams, Dun- nington, and Klamen recommended maximizing the number of raters, encouraging immediate recording of observations, and creation of clinical performance rating norms.25 There are several limitations to our study. The survey re- sponse rate (64%) was slightly lower than in prior years, though no different from the 1997 survey (66%), which first broached the topic of grade inflation in the internal medicine clerkship. Given limitations in space, because this was a subset of a larger CDIM survey, data about the actual percentage of grades at each institution were unable to be collected; thus the analysis is based upon the subjective reports of clerkship directors. In addition, the term “grade inflation” may mean different things to differ- ent people and is somewhat subjectively defined; a definition was not provided in the questionnaire. Finally, it is difficult to interpret the number of respondents who reported that a student passed who should have failed without knowing how common an occurrence this was; for example, had it only happened once over the course of 15 years or on more than one occasion? It is also important to more precisely identify the source(s) of grade inflation; does it exist at the level of the individual faculty mem- ber completing a clinical evaluation, does the inflation occur at the level of the clerkship director assigning grades, or is it prompted at the level of the dean’s office and/or central admin- istration of the medical school? A follow-up survey is planned to address many of these issues. We have identified that the majority of internal medicine clerkship directors report that grade inflation is a serious prob- lem, with more than one third specifically noting that students had passed the clerkship who should have failed. This is an unacceptably high number given what is at stake. We have a responsibility to the student and society to identify those who are not competent. In addition, grade inflation occurs at the other end of the spectrum, where the clerkship director may feel pressure to give a higher grade to help students secure the best possible residency slots. It is clear that faculty development and support will be critical in effecting a change. In addition, change can only happen as part of an overall culture shift. As such, a first step may be to call for greater transparency in reporting grade distributions in Medical Student Performance Evaluations across the board, as a number of schools still do not Downloadedby[UPSTATEMedicalUniversityHealthSciencesLibrary]at06:4904March2013
    • 76 S. B. FAZIO, K. K. PAPP, D. M. TORRE, T. M. DEFER release this data. At the departmental level, giving each faculty member a “report card” of where they fall on the spectrum of evaluations might be helpful in raising awareness. Given that 100% of respondents used clinical evaluations in their assess- ment, it is clear that a more robust sampling of performance is needed, along with uniform criteria for grading included in faculty development sessions, which should be utilized across all institutions. Some schools are attempting to transition to a core teaching faculty system to better systematize this pro- cess.25 Multiple assessments to document student performance are important, particularly in the setting of a student who is not performing adequately, as they will serve to strengthen the documentation to support a failing grade. Further studies are needed to better delineate the significance of the problem, and to begin to highlight solutions. REFERENCES 1. 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The feasibility and acceptability of implementing formal evaluation sessions and using descriptive vocabulary to assess student performance on a clinical clerkship. Teaching and Learning in Medicine 2002;14:5–10. 25. Williams RG, Dunnington GL, Klamen DL. Forecasting residents’ performance—partly cloudy. Academic Medicine 2005;80:415–22. 26. Weinberger SE, Smith LG, Collier VU. Redesigning training for internal medicine. Annals of Internal Medicine 2006;144:927–32. Downloadedby[UPSTATEMedicalUniversityHealthSciencesLibrary]at06:4904March2013