Are medical students trained in cross-cover?

Consensus-Derived Recommended Skills for Transition to Residency Courses

PURPOSE

Transition to residency (TTR) courses facilitate the medical student-residency transition and are an integral part of senior medical student training. The authors established a common set of skills for TTR courses, and an expected level of entrustment students should demonstrate in each skill on TTR course completion.

METHOD

A modified Delphi approach was used with 3 survey iterations between 2020 and 2022 to establish skills to be included in a TTR course. Nine TTR experts suggested general candidate skills and conducted a literature search to ensure no vital skills were missed. A stakeholder panel was solicited from email lists of TTR educators, residency program directors, and residents at the panelists' institutions. Consensus was defined as more than 75% of participants selecting a positive inclusion response. An entrustment questionnaire asked panelists to assign a level of expected entrustment to each skill, with 1 indicating observation only and 6 indicating perform independently.

RESULTS

The stakeholder panel initially consisted of 118 respondents with representation across educational contexts and clinical specialties. Response rates were 54% in iteration 2, 42% in iteration 3, and 33% on the entrustment questionnaire. After 3 iterations, 54 skills met consensus and were consolidated into 37 final skills categorized into 18 clinical skills (e.g., assessment and management of inpatient concerns), 14 communication skills (e.g., delivering serious news or having difficult conversations), 4 personal and professional skills (e.g., prioritization of clinical tasks), and 1 procedural skill (mask ventilation). Median entrustment levels were reported for all skills, with 19 skills having a level of expected entrustment of 4 (perform independently and have all findings double-checked).

CONCLUSIONS

These consensus skills can serve as the foundation of a standardized national TTR curriculum framework. Entrustment guidance may help educational leaders optimize training and allocation of resources for TTR curriculum development and implementation.

Can Incoming Interns Be Entrusted to Recognize Medical Emergencies? Implementation of a Vignette-Based Cross-Cover Assessment

BACKGROUND

Interns must recognize urgent clinical situations and know when to seek assistance. However, assessing this skill is challenging.

OBJECTIVE

We explored whether graduating medical students could determine urgency of medical cross-cover scenarios and what factors were associated with this ability.

METHODS

Sixty senior medical students enrolled in an internal medicine residency preparation course, and 28 experts were invited to take an assessment using 4 clinical vignette handoffs, each with 5 to 6 cross-cover scenarios. Respondents were asked whether they would evaluate the patient at bedside and notify their supervising resident. They were asked to rate their comfort managing the scenario, rate the urgency (1=low, 2=moderate, 3=high), and take a medical knowledge quiz. Student performance was categorized based on stratification of clinical urgency-those who underestimated (fourth quartile), accurately estimated (second and third quartile), and overestimated (first quartile) urgency. We examined differences between groups in medical knowledge, action, and confidence using analysis of variance and post-hoc Tukey Honestly Significant Difference test.

RESULTS

Fifty-eight students (96.7%) and 22 experts (78.6%) participated. Clear differentiation emerged between students' ability to estimate urgency on the 3-point urgency scale (lowest quartile: 2.15±0.11; mid-quartiles: 2.38±0.07; upper quartile: 2.61±0.10, respectively). Students who underestimated urgency were less likely to notify their supervising resident (P=.001) and less likely to evaluate a patient at bedside (P=.01). There was no difference in quiz score or comfort level.

CONCLUSIONS

Incoming interns vary in their abilities to recognize urgent scenarios, independent of medical knowledge and confidence.

Transitioning from university to postgraduate medical training: A narrative review of work readiness of medical graduates

CONTEXT

Work readiness is often described in terms of the clinical competence medical graduates bring to day 1 of internship. Despite being increasingly viewed as a key graduate outcome, work readiness has remained poorly defined.

OBJECTIVE

This narrative review draws on the international literature to explore how different research methods provide differing insight into what constitutes work readiness of medical graduates. From this, we explored contributory factors and developed a conceptual framework to better understand work readiness.

METHODS

Databases were searched using the terms including "ready," "readiness," "preparedness," "medical graduates," "intern," and "junior doctor." Information was summarized using a textual description template that included information on study setting, participants, methodologies, limitations, and key result areas (including measures/themes and study conclusions). Consensus discussions between authors led to the naming and understanding of the key themes.

RESULTS

Seventy studies were included in the review. Study participants included final-year medical students (n = 20), junior doctors early in internship (n = 24), and junior doctors late in internship or postgraduate year 2 and above (n = 23). Most studies explored work readiness through the retrospective self-report of the students and/or junior doctor participants. Quantitative research methods elaborated on key skills-based competencies, whereas qualitative research methods provided insight into key contextual and individual characteristics that contributed to preparedness.

CONCLUSIONS

Different research methods provided insight into competencies, as well as individual and contextual aspects, associated with preparedness for practice. The transition from university to clinical practice is significant and requires personal capability and confidence, as well as a supportive training context. Enabling students to engage authentically in clinical environments enhanced preparedness by promoting understanding of role and responsibility. Individual resilience is important, but contextual factors, including provision of adequate support and feedback, can enhance or subtract from feeling prepared. We propose a novel conceptual framework for better understanding work readiness.

Handoffs and Nurse Calls: Overnight Call Simulation for Fourth-Year Medical Students

INTRODUCTION

Interns must be able to give and receive handoffs and use handoff information to respond to calls from nursing staff regarding patient concerns. Medical students may not receive adequate instruction in these tasks and often feel unprepared in this aspect of transitioning to residency. This program simulated an overnight call experience for fourth-year medical students emphasizing handoffs, nurse calls, and medical emergency response.

METHODS

The program utilized a combination of traditional didactics and simulated handoffs, nurse calls, and patient scenarios to allow groups of fourth-year medical students to independently manage a simulated overnight call. The program was designed for students as part of a larger Transition to Residency capstone course.

RESULTS

We ran four sessions over 3 years, with a total of 105 medical student participants. All students reported increased confidence or comfort in their ability to manage handoffs and respond to nurse calls. Students reported that the sessions were helpful and realistic.

DISCUSSION

This program provided fourth-year medical students with a realistic and useful opportunity to simulate handoffs and response to nurse calls, which increased their confidence and comfort. Minor changes were made between iterations of the course with continued positive feedback from medical students. The course is generalizable and can be adapted to the needs and resources of different institutions.

Cross-Cover Curriculum for Senior Medical Students

INTRODUCTION

Cross-cover, the process by which a nonprimary team physician cares for patients, usually during afternoons, evenings, and weekends, is common in academic medical centers. With the advent of residency duty-hour restrictions, cross-cover care has increased, making education in effective cross-coverage an urgent need.

METHODS

We implemented a cross-cover didactic activity composed of 18 interactive cases with 29 senior medical students enrolled in an internal medicine residency preparation course. The curriculum was facilitated by one faculty member and one senior medical resident and utilized think-pair-share learning techniques to discuss an approach to a range of common (both urgent and routine) cross-cover scenarios. We analyzed confidence and feelings of preparedness pre- and postintervention. We also examined differences in medical knowledge based on two multiple-choice written cross-cover cases that addressed both medical management and triage.

RESULTS

This curriculum significantly improved feelings of confidence (from 1.8 to 3.2, p < .0001), reduced anxiety (from 4.5 to 4.1, p < .03), and improved performance in clinical case scenarios (from 82% to 89%, p < .02).

DISCUSSION

This curriculum covered not only the important medical aspects of cross-cover care (e.g., diagnostics and management) but also equally important roles of cross-cover, such as how to effectively triage cross-cover scenarios. The curriculum was well received by students.

Inpatient Cross-Cover Consensus Recommendations for Medical and Surgical Residents: A Delphi Analysis

BACKGROUND

Residents regularly care for hospitalized patients for whom they are not the primary provider (cross-cover), often without guidance.

OBJECTIVE

We identified and defined components of safe cross-cover care.

METHODS

Sixty medical and surgical faculty physicians and chief residents from the Midwest were invited to participate in a Delphi study analyzing the appropriateness of cross-covering residents evaluating patients at bedside, deferring issues to the primary team, documenting a note, contacting the attending, and communicating with nurses. The first survey was free text, and responses were categorized. In the second survey, physicians rated categorized responses based on appropriateness using a 5-point Likert scale. High consensus was defined as ≥ 80% agreement, approaching consensus as 51% to 79% agreement, and nonconsensus as ≤ 50% agreement. Results were analyzed by specialty and cross-cover experience in the past year using Pearson χ² test or Fisher exact test.

RESULTS

Forty respondents (67%) completed the first survey and 30 (50%) completed the second. Responses led to 46 categories. Twenty-eight items (60%) achieved high consensus, 8 (17%) approached consensus, and 10 (22%) did not achieve consensus, with no difference based on specialty or experience. Responses with 100% consensus included: residents should evaluate a patient at bedside whenever asked by the nurse; documentation should occur for change in level of care, death, code, or rapid response team activation; and physician-nurse communication should be respectful and closed loop.

CONCLUSIONS

This regional physician panel reached consensus on 28 elements important in cross-cover care, which can be used for training and future studies.