Teaching Physical Examination to Medical Students on Inpatient Medicine Teams: A Prospective, Mixed-Methods Descriptive Study

Exploring Ward Team Handoffs of Overnight Admissions: Key Lessons from Field Observations

BACKGROUND

The diagnostic process is a dynamic, team-based activity that is an important aspect of ward rounds in teaching hospitals. However, few studies have examined how academic ward teams operate in areas such as diagnosis in the handoff of overnight admissions during ward rounds. This study draws key lessons from team interactions in the handoff process during ward rounds.

OBJECTIVE

To describe how ward teams operate in the handoff of patients admitted overnight during ward rounds, and to characterize the role of the bedside patient evaluation in this context.

DESIGN

A qualitative ethnographic approach using field observations and documentary analysis.

PARTICIPANTS

Attending physicians, medical residents, and medical students on general medicine services in a single teaching hospital.

APPROACH

Thirty-five hours of observations were undertaken over a 4-month period. We purposively approached a diverse group of attendings who cover a range of clinical teaching experience, and obtained informed consent from all ward team members and observed patients. Thirty patient handoffs were observed across 5 ward teams with 45 team members. We conducted thematic analysis of researcher field notes and electronic health record documents using social cognitive theories to characterize the dynamic interactions occurring in the real clinical environment.

KEY RESULTS

Teams spent less time during ward rounds on verifying history and physical examination findings, performing bedside evaluations, and discussing differential diagnoses than other aspects (e.g., reviewing patient data in conference rooms) in the team handoff process of overnight admissions. Several team-based approaches to diagnosis and bedside patient evaluations were observed, including debriefing for learning and decision-making.

CONCLUSIONS

This study highlights potential strengths and missed opportunities for teaching, learning, and engaging directly with patients in the ward team handoff of patients admitted overnight. These findings may inform curriculum development, faculty training, and patient safety research.

Analysis of a Near Peer Tutoring Program to Improve Medical Students' Note Writing Skills

Problem: The ability to document a patient encounter is integral for any physician. Previous studies indicate that medical students' note writing skills are poor due to a lack of formal clinical documentation instruction. Barriers to formally teaching students how to write patient notes include the significant time burden and variability in faculty feedback. Implementing a near-peer teaching program to teach students how to write a patient note can overcome these barriers and fill this curricular gap. Intervention: Fourth year medical students who completed a Teaching in Medicine elective course were trained to provide individual feedback to 1^st and 2^nd year students on note writing as a part of their Introduction to Clinical Medicine course. In order to determine the effect of this two year, near-peer feedback program on note writing skills, we analyzed students' scores on the note writing portion of two Objective Structured Clinical Exams that took place at the end of the 2^nd and 3^rd years of medical school. Context: The near-peer feedback sessions were implemented in the Fall of 2013 during the preclinical years of the medical school curriculum. Data from students who received near-peer feedback (N = 112) were compared to a historical control group who did not receive near-peer feedback on their note writing (N = 110). Objective Structured Clinical Exam scores that were specific to note writing skills, including the history, physical exam, and differential diagnosis subscales were examined. Impact: The near-peer feedback had a positive impact on the quality of patient notes. On the end of the 2^nd year Objective Structured Clinical Exam, the near-peer feedback intervention group outperformed the no feedback group on the history and physical exam subscale scores but not on the differential diagnosis subscale score. One year later, the near-peer feedback intervention group continued to outperform the no feedback group on the physical exam subscale score, but not the history or the differential diagnosis subscale scores. Lessons Learned: Near-peer teaching improves student documentation of the history and physical exam, however only the effects on the physical exam portion persist into the clinical years of training. Writing up a differential diagnosis is a skill that develops through the clerkship experience regardless of exposure to feedback in the preclinical years. Implementing near-peer teaching in the medical school setting is feasible and can provide students with valuable learning experiences without relying on clinical faculty.

Key Attributes of a Medical Learning Community Mentor at One Medical School

PURPOSE

The purpose of this study was to discover the elements required for a successful learning community (LC) faculty member educator of medical students.

METHOD

The authors in this qualitative study evaluated six 90-min focus groups of faculty members. The groups included 31 experienced and 19 inexperienced LC faculty members at the University of Texas Southwestern Medical School. After achieving excellent interrater reliability, transcriptions of the discussions were subjected to thematic analysis using ATLAS.ti software.

RESULTS

Five major themes emerged: (1) LC faculty characteristics/competency, (2) suggested faculty development methods, (3) factors outside the LC environment influencing student relationships, (4) student attributes influencing teaching techniques, and (5) measuring and improving history and physical skills. Faculty characteristics/competency subthemes included role-modeling, mentoring, and teaching competence. Suggested faculty development methods subthemes included assessing and giving feedback to faculty, peer development, and learning from experts. Experienced LC faculty focused more attention on teaching competence and mentoring competence than inexperienced LC faculty.

DISCUSSION

The themes with the most extensive discussion among the experienced LC faculty groups may represent qualities to be sought in future mentor recruitment and faculty development. Future studies could build on this study by similarly investigating student perceptions.