Letters to the Editor

The foundation has also partnered with Costs of Care to run the Teaching Value and Choosing Wisely Challenge,2 which aims to identify promising innovations and bright ideas for teaching high-value care and stewardship to medical students, trainees, and faculty. Over the past two years more than 150 entries have been submitted and a dozen winners declared. Most recently, the ABIM Foundation funded several projects3 that will foster innovations and new approaches to integrating stewardship competencies and better decision making in medical education and training. Much work is still needed until, as the authors write, resource stewardship becomes a “norm in medical practice.” I am encouraged by the growing momentum being generated by the ABIM Foundation’s programs, as well as the work of the authors and many others, to address these challenges and help prepare future clinicians to provide the best care possible for patients. Disclosures: None reported. Daniel B. Wolfson, MHSA Executive vice president and chief operating officer, ABIM Foundation, Philadelphia, Pennsylvania; [email protected].

References 1 Choosing Wisely. Costs of Care and ABIM Foundation launch teaching value in health care learning network. March 5, 2015. http://www.choosingwisely.org/resources/ updates-from-the-field/costs-of-care-andabim-foundation-launch-teaching-valuein-health-care-learning-network/. Accessed August 7, 2015. 2 ABIM Foundation. Winners named in Teaching Value and Choosing Wisely® Challenge. http://www.abimfoundation. org/News/ABIM-Foundation-News/2015/ Winners-of-Teaching-Value-Choosing-WiselyChallenge.aspx. Accessed August 7, 2015. 3 ABIM Foundation. Putting Stewardship Into Medical Education and Training grantees announced. September 10, 2015. http://www.abimfoundation.org/News/ ABIM-Foundation-News/2015/PuttingStewardship-into-Medical-Educationand-Training-Grantees-Announced.aspx. Accessed September 24, 2015.

Self-Determination Theory and Scaffolding Applied to Medical Education as a Continuum To the Editor: In a recent article in Academic Medicine, Biondi and

colleagues1 present the applicability of self-determination theory to resident supervision in postgraduate medical education. The authors expose a discrepancy in the level of autonomy in patient care that faculty think they provide and residents think they receive. The negative effect of this on the intrinsic motivation and clinical performance of residents, though not measured, is certainly implied. According to the authors, faculty are reluctant to provide autonomy to less confident and passive residents who are unable to “show” their motivation. A recent study shows how medical school graduates feel unprepared for practice because of a lack of enough independent experience in direct patient care.2 We hypothesize that this “unpreparedness” among graduate medical students is further observed during residency as uncertainty and passiveness. In order to solve this problem, we think that it is important to view medical education as a continuum. Scaffolding and its three cornerstones3 (contingency, fading, and transfer of responsibility) should be applied throughout undergraduate and postgraduate medical education. Scaffolding will look different for each learner depending not only on the level of prior knowledge and competence but also on the level of relatedness. Successful employment of scaffolding strategies customized to learner needs demands more research into individual differences in motivation and learning. This calls for a person-oriented approach in designing studies, meaning grouping students with similar motivational profiles using cluster analysis, for analyzing learning outcomes.4 Disclosures: None reported. Rashmi A. Kusurkar, MD, PhD Assistant professor and head of research in education, VUmc School of Medical Sciences, Amsterdam, the Netherlands; [email protected].

Gerda Croiset, MD, PhD Professor of medical education and director, VUmc School of Medical Sciences, Amsterdam, the Netherlands.

References 1 Biondi EA, Varade WS, Garfunkel LC, et al. Discordance between resident and faculty perceptions of resident autonomy: Can self-determination theory help interpret

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differences and guide strategies for bridging the divide? Acad Med. 2015;90:462–471. 2 Burford B, Whittle V, Vance GH. The relationship between medical student learning opportunities and preparedness for practice: A questionnaire study. BMC Med Educ. 2014;14:223. 3 Van de Pol J, Volman M, Beishuizen J. Scaffolding in teacher–student interaction: A decade of research. Educ Psychol Rev. 2010;22:271–296. 4 Kusurkar RA, Croiset G, Galindo-Garré F, Ten Cate O. Motivational profiles of medical students: Association with study effort, academic performance and exhaustion. BMC Med Educ. 2013;13:87.

Alternatives to Selling a Medical School Name To the Editor: Falit and colleagues1 have given a comprehensive outline of strategies to address the growing phenomenon of selling a medical school’s name. They helpfully list the various stakeholders involved in selling the name of a medical school, review advantages and disadvantages to the individual stakeholders, and suggest potential ways to mitigate the disadvantages. Few could argue with the authors’ ideas; however, some might question whether we should be selling medical school names in the first place. It is worth reflecting on why this is happening and whether there are other options. The reason why this phenomenon has occurred and is occurring more often now than ever before is simply because schools need funding. Medical education is expensive, as are research and clinical care: Institutions often have to deliver all three.2 We are courting donors and taking their funding for the simple reason that they have money to give. We change the names of institutions because we think these donors want something in return and we want to give them something valuable. If this logic is all perfectly flawless up to now, it is in the next step—offering the medical school name in return for the donation—that the logic fails. The evidence suggests that large donors choose their causes for a variety of reasons.3 Some give to an organization because it has sound business practices; some give because they know certain organizations are careful with their funding; some want to develop a personal relationship with the organization. Certainly some give in the expectation of public recognition, but others only give on the condition of anonymity.3 Perhaps

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Letters to the Editor

we could pursue more donors who are not seeking public recognition, or at least not such prominent public recognition. There are certainly a range of offerings that sit below the level of the medical school name. These range from sponsoring a campus building name, to sponsoring research programs, to sponsoring lecture theaters: The options are manifold. These options would command lower funding streams and require more donors to raise more money, but schools would then be less reliant on a single donor. Another strategy, of course, would be to reduce the need for funding altogether by pursuing low-cost, highvalue forms of medical education to produce low-cost, high-value doctors who would deliver low-cost, high-value care. Then we could name our medical schools after our profession’s own rich heritage—names like Flexner, Osler, Hippocrates, Galen, Lister, Fleming, Imhotep, Sushruta, Asklepios, Celsus, or Rhazes. This is the form of richness that we should pursue. Disclosures: None reported. Kieran Walsh, FRCPI Clinical director, BMJ Learning, the medical education service of the BMJ Group, London, United Kingdom; [email protected].

References 1 Falit BP, Halperin EC, Loeffler JS. Green eggs and ham: Strategies to address the growing phenomenon of selling a medical school’s name. Acad Med. 2014;89:1614–1616. 2 Walsh K, Jaye P. Cost and value in medical education. Educ Prim Care. 2013;24:391–393. 3 Center on Philanthropy at Indiana University. The 2010 Study of High Net Worth Philanthropy: Issues Driving Charitable Activities Amongst Affluent Households. Indianapolis, Ind: Center on Philanthropy; November 2010. http://agb. org/sites/default/files/legacy/u16/BAML%20 HNW%20Final.pdf. Accessed July 30, 2015.

Medical Literature: Don’t Believe Everything You Read To the Editor: Throughout medical school, internship, and residency I encountered a variety of medical papers and studies referenced by attendings, residents, and fellows. Many were from highly obscure journals and lacking sound methodology. The overriding theme was that my fellow residents and even some attendings were not all well

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versed on critical appraisal of study methodology. It became apparent that the understanding of methodology, study design, and clinical applicability was sorely lacking. As I first immersed myself in reviewing the literature in preparation for writing my own papers, I discovered numerous methodological flaws, gross errors in referencing, and, most striking, quotes obviously taken out of context. Recently, I sought more information about a statistic as referenced in a highly regarded journal. Review of the original source uncovered misquoted references and statistics reported incorrectly. Equally alarming is the frequency with which statements are quoted in ways that contradict the overall conclusions of the original source. Now, having submitted manuscripts to various journals, I am struck by the degree of variability in the peer review process and vast differences in submission requirements. There are journals that go to extreme lengths in selection of multiple expert reviewers and journals that consult a single reviewer. The commentary of an expert reviewer truly enhances and completes a manuscript and provides scrutiny for inaccuracies. In recent years, there have also been a large number of manuscript retractions for falsification and misconduct.1,2 Finally, well-regarded journals generally retain statisticians to assess the quality of statistical work, a layer of review that is often not provided by the more obscure journals. Instruction in decrypting the medical literature tends to focus on heavy statistical analysis and may scare away inexperienced readers. However, excellent templates exist for how those of us without research backgrounds can learn to examine and assess the medical literature appropriately and determine the validity of a study.3,4 In an era in which it is possible to conduct literature searches “on the fly” (often using a standard search engine), for the novice reader it is easy to believe everything you read. There must be a push in medical education—from medical students to attendings—to educate ourselves and our trainees about what is reliable evidence to be used in the practice of evidence-based medicine!

Disclosures: None reported. Adam C. Adler, MD, MS Attending physician, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; [email protected].

References 1 Nath SB, Marcus SC, Druss BG. Retractions in the research literature: Misconduct or mistakes? Med J Aust. 2006;185:152–154. 2 Woolley KL, Lew RA, Stretton S, et al. Lack of involvement of medical writers and the pharmaceutical industry in publications retracted for misconduct: A systematic, controlled, retrospective study. Curr Med Res Opin. 2011;27:1175–1182. 3 Young JM, Solomon MJ. How to critically appraise an article. Nat Clin Pract Gastroenterol Hepatol. 2009;6:82–91. 4 Barratt A, Irwig L, Glasziou P, et al. Users’ guides to the medical literature: XVII. How to use guidelines and recommendations about screening. Evidence-Based Medicine Working Group. JAMA. 1999;281:2029–2034.

The Responsibility of Academic Medicine for Reducing Football Injuries To the Editor: As a result of playing football, high school and college students die of heat prostration, dehydration, and head trauma, others are rendered paraplegic and quadriplegic, and many are sent on a pathway leading to premature dementia and death as a result of recurrent concussions—and we are all supposed to feel sanguine about this because we are reassured that there is a doctor on the sidelines during games. Concussion rates in football practice and competition exceed other sports.1 Repetitive concussions and years of playing football are associated with diminished hippocampal volume and slowed reaction time.2 Academic medicine has a responsibility to be a leader in efforts to reform the game. Academic medicine plays a significant role in facilitating football. Medical school clinical departments provide sideline physicians, do screening physicals, and practice sports medicine for football players. Advertisements link clinical practices to football: “Come see the doctors who take care of the fighting [fill in the name of the mascot] of the University of [fill in the blank].” Some college athletic departments want to be paid by the faculty

Academic Medicine, Vol. 90, No. 11 / November 2015

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Alternatives to selling a medical school name.

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