Resources Used to Teach the Physical Exam to Preclerkship Medical Students: Results of a National Survey

Needs assessment of essential anatomy: The perspective of adult primary care resident physicians

Curricular development and modification involve first identifying a problem and then performing a needs assessment, which can guide the design of curricular components. Pedagogical changes, coupled with reductions in curricular time for gross anatomy, pose challenges and impose restrictions within medical school curricula. In order to make anatomy education effective and efficient, it is important to determine the anatomy considered essential for medical education through a targeted needs assessment. In this study, 50 adult primary care resident physicians in family medicine (FM) and internal medicine (IM) were surveyed to assess the importance of 907 anatomical structures, or groups of structures, across all anatomical regions from a curated list based on the boldface terms in four primary anatomy texts. There were no statistically significant differences in the ratings of structures between the two groups for any anatomical region. In total, 17.0% of structures, or groups of structures, were classified as essential, 58.0% as more important, 24.4% as less important, and 0.7% as not important. FM residents rated tissues classified as skeleton, nerves, fasciae, anatomical spaces, blood vessels, lymphatics, and surface anatomy (p < 0.0001) significantly higher than IM residents, but there were no differences in the rating of muscles or organs (p > 0.0056). It was notable that 100.0% of cranial nerves were classified as essential, and 94.5% of surface anatomy structures were classified as essential or more important. It is proposed that results of this study can serve to inform curricular development and revision.

Expectations of and for Clerkship Directors 2.0: A Collaborative Statement from the Alliance for Clinical Education

This article presents an update of the collaborative statement on clerkship directors (CDs), first published in 2003, from the national undergraduate medical education organizations that comprise the Alliance for Clinical Education (ACE). The clerkship director remains an essential leader in the education of medical students on core clinical rotations, and the role of the CD has and continues to evolve. The selection of a CD should be an explicit contract between the CD, their department, and the medical school, with each party fulfilling their obligations to ensure the success of the students, the clerkship and of the CD. Educational innovations and accreditation requirements have evolved in the last two decades and therefore this article updates the 2003 standards for what is expected of a CD and provides guidelines for the resources and support to be provided.In their roles as CDs, medical student educators engage in several critical activities: administration, education/teaching, coaching, advising, and mentoring, faculty development, compliance with accreditation standards, and scholarly activity. This article describes (a) the work products that are the primary responsibility of the CD; (b) the qualifications for the CD; (c) the support structure, resources, and personnel that are necessary for the CD to accomplish their responsibilities; (d) incentives and career development for the CD; and (e) the dedicated time that should be provided for the clerkship and the CD to succeed. Given all that should rightfully be expected of a CD, a minimum of 50% of a full-time equivalent is recognized as appropriate. The complexity and needs of the clerkship now require that at least one full-time clerkship administrator (CA) be a part of the CD's team.To better reflect the current circumstances, ACE has updated its recommendations for institutions and departments to have clear standards for what is expected of the director of a clinical clerkship and have correspondingly clear guidelines as to what should be expected for CDs in the support they are provided. This work has been endorsed by each of the eight ACE member organizations.

Perspectives on the current state of pre-clerkship clinical reasoning instruction in United States medical schools: a survey of clinical skills course directors

OBJECTIVES

Clinical reasoning skills are essential for sound medical decision-making. Though many have suggested that clinical reasoning instruction should begin in pre-clerkship curricula, neither pre-clerkship clinical skills director perspectives nor extent of instruction is known. This survey study serves as part of a needs assessment for United States medical school pre-clerkship clinical reasoning curricula.

METHODS

United States medical school pre-clerkship clinical skills course directors were surveyed about perceived importance of formal instruction on clinical reasoning concepts, inclusion of these concepts in the curricula, barriers to instruction, and familiarity with clerkship curricula. Results were analyzed using descriptive and analytic statistics. Narrative comments were analyzed qualitatively for themes.

RESULTS

Of 148 directors surveyed, 102 (69%) participated and 89 (60%) completed all closed-ended items. Each clinical reasoning concept was identified as somewhat to extremely important to include in pre-clerkship curricula by 90-99% of respondents. Pre-clerkship curricula included variable degrees of formal instruction for concepts, though most respondents rated their inclusion as moderate or extensive. Perceived importance of teaching most concepts moderately correlated with the degree of inclusion in the curriculum (Spearman's rho 0.39-0.44). Curricular time constraints and lack of faculty with skills to teach these concepts were the most frequently cited barriers to instruction. Respondents indicated being somewhat 57% (n=54) to extremely 29% (n=27) familiar with clerkship curricula at their institutions.

CONCLUSIONS

This study is the first to examine pre-clerkship clinical skills course director perspectives about clinical reasoning instruction and extent of its inclusion in their curricula.

Evolving roles of clerkship directors: have expectations changed?

BACKGROUND

Physician educators directing medical student programs face increasingly more complex challenges to ensure students receive appropriate preparation to care for patients. The Alliance for Clinical Education (ACE) defined expectations of and for clerkship directors in 2003. Since then, much has changed in medical education and health care.

METHODS

ACE conducted a panel discussion at the 2016 Association of American Medical Colleges Learn Serve Lead conference, soliciting input on these expectations and the changing roles of clerkship directors. Using workshops as a cross-sectional study design, participants reacted to roles and responsibilities of clerkship directors identified in the literature using an audience response system and completing worksheets.

RESULTS

The participants represented different disciplines of medicine and ranged from clerkship directors to deans of curriculum. Essential clerkship director qualifications identified by participants included: enthusiasm, experience teaching, and clinical expertise. Essential tasks included grading and assessment and attention to accreditation standards. Participants felt clerkship directors need adequate resources, including budget oversight, full-time clerkship support, and dedicated time to be the clerkship director. To whom clerkship directors report was mixed. Clerkship directors look to their chair for career advice, and they also report to the dean to ensure educational standards are being met. Expectations to meet accreditation standards and provide exemplary educational experiences can be difficult to achieve if clerkship directors' time and resources are limited.

CONCLUSIONS

Participant responses indicated the need for a strong partnership between department chairs and the dean's office so that clerkship directors can fulfill their responsibilities. Our results indicate a need to ensure clerkship directors have the time and resources necessary to manage clinical medical student education in an increasingly complex health care environment. Further studies need to be conducted to obtain more precise data on the true amount of time they are given to do that role.

An exploratory analysis of factors contributing to resident pass rates on a national licensure OSCE in the United Arab Emirates

Purpose

To explore resident perceptions of factors contributing to pass rates on a high-stake licensing objective structured clinical exam (OSCE).

Materials and Methods

A cross-sectional survey was administered to all 51 applicants of the April 2019 internal medicine Arab Board OSCE examination in Abu Dhabi, United Arab Emirates (UAE), and included questions on preparedness, stress level, and prior educational experiences. Exposures were evaluated for correlation against Arab Board pass rates using Pearson correlation and the two-tailed significance was recorded.

Results

All 51 examinees completed the survey (100% response rate). Participants were primarily female n = 35 (67%) and all completed residency training in the UAE. Gender differences were noted, with higher pass rates for the male residents (13/35, 37% females vs. 8/16, 50% males, P < 0.05). Further, 65% (P < 0.001) of female examinees reported higher levels of anxiety than male residents. Examinees reported regular exposure during residency to clinical skills training (74%), standardized patients (71%), simulation (66%), and OSCEs (72%) but none of these educational modalities correlated with higher pass rates. Of multiple exam preparation modalities, only self-directed learning with deliberate practice, the intentional repetition of a task with feedback, was associated with higher pass rates.

Conclusion

Clinical exam skills are vital for trainees to deliver high-quality primary healthcare services. National licensure OSCEs have become the norm in the Arab world for assessing resident clinical exam skills. Our results suggest that residency programs should encourage residents' intentional deliberate practice and mastery learning in the acquisition and retention of physical examination techniques.

Incoming Interns Recognize Inadequate Physical Examination as a Cause of Patient Harm

INTRODUCTION

As providers of a large portion of the care delivered at academic health centers, medical trainees have a unique perspective on medical error. Despite data suggesting that errors in physical examination (PE) can lead to adverse patient events, we are not aware of previous studies exploring medical trainee perceptions of the relationship between patient harm and inadequate PE. We investigated whether first-year residents at a large tertiary care academic medical center perceive inadequate PE as a cause of adverse patient events.

METHODS

As part of a larger survey given to incoming interns at Thomas Jefferson University Hospital orientation (2014-2018), the authors examined the perceptions of inadequate PE and adverse patient events. We also examined other details related to PE educational experiences and self-reported PE proficiency. The survey was developed a priori by the authors and assessed for face validity by expert faculty.

RESULTS

Ninety-eight percent of respondents (695/706) reported that inadequate PE leads to adverse patient events. Seventy percent (492/706) believe that inadequate PE causes adverse events in up to 10% of all patient encounters, and 30% (214/706) reported that inadequate PE causes adverse events in greater than 10% of patient encounters. Forty-five percent of surveyed interns (319/715) had witnessed a patient safety issue as a result of an inadequate PE. Only 2% of surveyed interns (11/706) did not think patients experience adverse events because of inadequate PEs. Ninety percent of surveyed interns (643/712) reported feeling proficient in performing PE. From 2015 to 2018, 80% (486/604) indicated that they received "just enough" PE education.

CONCLUSION

Nearly all incoming interns surveyed at our institution believe that inadequate PE leads to adverse patient events, and 45% have witnessed an adverse patient event due to inadequate PE. We urge clinicians, educators, and health care administrators to consider enhanced PE skills training as an important and viable approach to medical error reduction, and as such, we propose a 5-pronged intervention for improvement, including a redesign of PE curricula, development of checklist-based assessment methods, ongoing skills training and assessment of physicians-in-practice, rigorous study of PE maneuvers, and research into whether enhanced PE skills improve patient outcomes.

Peer assessment platform of clinical skills in undergraduate medical education

Objective

The study objective was to enhance clinical skills among undergraduate students majoring in clinical medicine in performing physical examination by establishing a novel platform for peer assessment of clinical skills.

Methods

A total 126 Year 2012 students majoring in medicine and receiving traditional training were assigned to the control group, and 126 Year 2013 students receiving instruction via the peer assessment platform of clinical skills were allocated to the study group. Scores of the physical examination, paper exam, and peer assessment were compared using a t-test, and we performed linear correlation analysis of the data.

Results

Scores of the physical examination and peer assessment among Year 2013 students (the study group) were significantly higher than those in the control group. Paper exam scores in the study group were also significantly higher than those in the controls. The three assessment scores did not differ significantly according to sex.

Conclusions

The peer assessment platform can not only improve medical students’ skills and capabilities in physical examination, it can also enhance their theoretical knowledge of basic clinical principles. We determined that sex was not related to the assessment scores obtained by medical students.

Advanced physical examination training course improves medical students' confidence in physical examination

BACKGROUND

Physical examination (PE) is a basic diagnostic tool in clinical settings. It is important to enhance medical students' skills and confidence in PE.

SUBJECTS AND METHODS

Our medical students begin learning PE in the fourth medical year (M4). They undergo hands-on clinical training in the fifth medical year (M5). To improve the teaching of PE, we implemented an advanced PE training course (APETC) for M5 students. In APETC, PE skills for chest (CH), cardiovascular system (CV), and abdomen (GI) domains were demonstrated by senior specialists. Under tutors' supervision, students performed PE on selected patients with positive signs. To evaluate the effect of this training course, we designed a checklist to evaluate students' confidence level in PE before and after APETC. Average confidence scores of PE in CH, CV, and GI domains among different years and genders were compared using ANOVA tests.

RESULTS

M5 students' confidence in PE for individual items on the CH, CV, and GI checklists increased significantly after the APETC, in both 2014 and 2015 (all p < 0.0001).The average post-course confidence scores of all items in CH, CV, and GI domains increased significantly over average pre-course confidence scores. The average post-course confidence score in PE was higher in the year 2015 than that in the year 2014. Male students tended to have higher confidence scores in PE than female students.

CONCLUSION

APETC enhanced medical students' confidence in PE. Long-term effects of the training course and the impact of students' gender on learning outcomes remain to be investigated.