Enhancing Examination Success: the Cumulative Benefits of Self-Assessment Questions and Virtual Patient Cases

PURPOSE

Research on the learning benefits of the feedback-rich formative assessment environment of virtual patient cases (VPCs) has largely been limited to single institutions and focused on discrete clinical skills or topical knowledge. To augment current understanding, we designed a multi-institutional study to explore the distinct and cumulative effects of VPC formative assessments and optional self-assessment questions (SAQs) on exam performance.

METHOD

In this correlational study, we examined the records of 1,692 students on their family medicine (FM) clerkship at 20 medical schools during the 2014-2015 academic year. Schools utilized an established online curriculum, which included family medicine VPCs, embedded formative assessments, context-rich SAQs corresponding with each VPC, and an associated comprehensive family medicine exam. We used mixed-effects modeling to relate the student VPC composite formative assessment score, SAQ completion, and SAQ performance to students' scores on the FM final examination.

RESULTS

Students scored higher on the final exam when they performed better on the VPC formative assessments, completed associated SAQs, and scored higher on those SAQs. Students' SAQ completion enhanced examination performance above that explained by engagement with the VPC formative assessments alone.

CONCLUSIONS

This large-scale, multi-institutional study furthers the body of research on the effect of formative assessments associated with VPCs on exam performance and demonstrates the added benefit of optional associated SAQs. Findings highlight opportunities for future work on the broader impact of formative assessments for learning, exploring the benefits of integrating VPCs and SAQs, and documenting effects on clinical performance and summative exam scores.

Teaching Medical Students to Help Patients Manage Their Weight: Outcomes of an Eight-School Randomized Controlled Trial

BACKGROUND

Given the rising rates of obesity there is a pressing need for medical schools to better prepare students for intervening with patients who have overweight or obesity and for prevention efforts.

OBJECTIVE

To assess the effect of a multi-modal weight management curriculum on counseling skills for health behavior change.

DESIGN

A pair-matched, group-randomized controlled trial (2015-2020) included students enrolled in eight U.S. medical schools randomized to receive either multi-modal weight management education (MME) or traditional weight management education (TE).

SETTING/PARTICIPANTS

Students from the class of 2020 (N=1305) were asked to participate in an objective structured clinical examination (OSCE) focused on weight management counseling and complete pre and post surveys. A total of 70.1% of eligible students (N=915) completed the OSCE and 69.3% (N=904) completed both surveys.

INTERVENTIONS

The MME implemented over three years included a web-based course, a role-play classroom exercise, a web-patient encounter with feedback, and an enhanced clerkship experience with preceptors trained in weight management counseling (WMC). Counseling focused on the 5As (Ask, Advise, Assess, Assist, Arrange) and patient-centeredness.

MEASUREMENTS

The outcome was student 5As WMC skills assessed using an objective measure, an OSCE, scored using a behavior checklist, and a subjective measure, student self-reported skills for performing the 5As.

RESULTS

Among MME students who completed two of three WMC components compared to those who completed none, exposure was significantly associated with higher OSCE scores and self-reported 5A skills.

LIMITATIONS

Variability in medical schools requiring participation in the WMC curriculum.

CONCLUSIONS

This trial revealed that medical students struggle with delivering weight management counseling to their patients who have overweight or obesity. Medical schools, though restrained in adding curricula, should incorporate should incorporate multiple WMC curricula components early in medical student education to provide knowledge and build confidence for supporting patients in developing individualized plans for weight management.

NIH TRIAL REGISTRY NUMBER

R01-194787.

Selected Abstracts From the Proceedings of the 2015 Society of Teachers of Family Medicine (STFM) Conference on Medical Student Education

The Society of Teachers of Family Medicine (STFM; http://www.stfm.org) is a community of professionals devoted to teaching family medicine through undergraduate, graduate, and continuing medical education. This multidisciplinary group of physicians, educators, behavioral scientists, and researchers works to further STFM's mission of improving the health of all people through education, research, patient care, and advocacy. The STFM held its 41st Conference on Medical Student Education in Atlanta, Georgia from February 5-8, 2015. The conference this year was met with record attendance and student scholarship winners. The STFM Education Committee selected 10 abstracts, of which five are presented below.

Selected Abstracts From the Proceedings of the 2017 Society of Teachers of Family Medicine Conference on Medical Student Education

The Society of Teachers of Family Medicine (STFM) is an organization made up of educators devoted to teaching family medicine to learners of all levels. This multidisciplinary group of physicians, behavioral scientists, researchers, and educators from other health professions works to further STFM's mission of improving the health of all people through education, research, patient care, and advocacy. STFM held its 43rd Conference on Medical Student Education in Anaheim, California from February 9 to 12, 2017. Abstracts for conference sessions can be viewed online.1 The conference was held concurrently with the 2017 Society of Student-Run Free Clinics Annual Conference. This partnership empowered many passionate medical students to participate in STFM sessions and present their posters. A wide variety of topics were explored by STFM conference presenters and attendees. The plenary speakers addressed physician wellness (Dike Drummond, MD), family medicine as a career (Wanda Filer, MD), and the future of family medicine (Aaron Michelfelder, MD, and Michelle Byrne, MD). The STFM Education Committee reviewed and selected eight exemplary abstracts from 22 presented educational research papers. Criteria for selection included strength of contribution to medical student education, topic of interest within and beyond family medicine, and quality of study, including well-described rationale, appropriate methods, clear results, and thoughtful conclusions. The areas covered are related to new educational methods and tools, faculty development, and interprofessional learning and assessment.

Scope of Practice and Family Medicine Match Rates: Results From a CERA Clerkship Directors' Survey

BACKGROUND AND OBJECTIVES

Family medicine clerkship directors depend on community preceptors to teach and attract medical students to family medicine. Many community preceptors do not provide the full range of family medicine services, and some are not family physicians. This study aimed to determine the types of practices in which family medicine clerkship students train and whether scope of practice is associated with family medicine Match rates.

METHODS

Data were collected as part of the 2014 Council of Academic Family Medicine Educational Research Alliance (CERA) Family Medicine Clerkship Director Survey. Clerkship directors estimated the percentage of their preceptor sites providing each of nine clinical services and the percentage of students placed with internal medicine physicians for their family medicine rotations. We devised a Scope of Practice Index (SPI) to assess scope of practice and measured the association between a clerkship's SPI and family medicine Match rate.

RESULTS

Limited scopes of practice were common. SPI was lowest in the Northeast and highest in the West. In bivariate and multivariable analyses, a lower SPI was associated with lower family medicine Match rates. Preventive gynecological care was the service most highly associated with family medicine Match rates. Family medicine Match rates were lower when programs used internal medicine sites for their family medicine rotations.

CONCLUSIONS

Many clerkship students are exposed to practices with limited scopes of family medicine practice, and this is associated with lower family medicine Match rates. These findings have implications for the specialty as preceptor scope of practice declines.

Contemporary teaching strategies of exemplary community preceptors--is technology helping?

BACKGROUND AND OBJECTIVES

Many schools rely upon community preceptors for office-based education of medical students. These preceptors struggle to balance clinical care with the learning needs of students. We aim to gain a deeper understanding of the teaching rewards and challenges of current community preceptors.

METHODS

Five schools' family medicine clerkship directors conducted in-depth interviews of two exemplary preceptors at each of their programs. Following qualitative analysis of the interviews, three directors conducted one focus group at their school. The individual and group interviews were recorded, transcribed, and analyzed using grounded theory.

RESULTS

Exemplary community preceptors described strategies to improve the learning environment and specific teaching approaches. Well-known teaching strategies such as role modeling, adjusting instruction to the learner's needs, and selecting patients appropriate for a specific student were used. They also described newer techniques such as co-learning and integrating technology, for example, accessing online, current practice guidelines together with the student. They detailed challenges to teaching, including time constraints and too much content to cover and provided advice about teaching tools.

CONCLUSIONS

While challenged by clinical demands, preceptors enjoyed teaching and found it rewarding. They used time-proven teaching strategies as well as technology and online resources to facilitate ambulatory teaching. Community preceptors continue to struggle to integrate learners and the priorities of the medical school curriculum into the clinical environment. Further development of electronic tools and other resources to support the teaching needs of preceptors may contribute to learning and help minimize preceptor burden.

Undergraduate Students’ Perspectives on Primary Care

Background and Objectives: Despite the need for more primary care physicians, the number of medical students choosing primary care careers remains lower than other specialties. While undergraduate premedical education is an essential component in the development of future physicians, little is known about undergraduate students’ perspectives on becoming primary care physicians. To better understand the early factors in career selection, we asked premed and former premed students their perceptions of primary care. Methods: Open-ended, semistructured interviews were conducted with 58 undergraduate students who represented three different groups: those who were currently premed and science majors, those who were nonscience majors and were currently premed, and those who were formerly premed. Specifically, we asked, “Why do you think there is a shortage of people who go into primary care?” Results: Undergraduates cited financial reasons, lack of “glamour,” and the career being “uninteresting.” Many believed that primary care lacked prestige, and others felt it had a negative stigma attached. Most had never even considered a career in primary care. A number of students also misunderstood what a career in primary care actually entailed. Conclusions: As early as freshman year in college, undergraduate students harbor misconceptions and negative opinions about primary care. Many of those who express interest in such a career seem to drop out of the premedical program. It is important to consider the early onset of these attitudes and a way to target this interested population when trying to address the shortage of primary care physicians.

Comparison of textbook to fmCases on family medicine clerkship exam performance

BACKGROUND AND OBJECTIVES

The use of online learning with virtual cases has become commonplace in medical education. A series of fmCASES has been developed to assist with learning for clerkship students in family medicine. It has not been shown whether this series of cases improves student learning during their clerkship compared to traditional learning modalities.

METHODS

We designed an intervention study to replace the traditional family medicine clerkship textbook with the fmCASES curriculum at one medical school. We then compared two consecutive cohorts of family medicine clerkship students by examining their performance on overall and small groups of exam questions at the end of the clerkship.

RESULTS

Data were obtained for 95% of students across the 2-year study. Overall performance on the end of clerkship exam was unchanged with the transition to fmCASES. Student performance was variable based on subject area and source of examination question.

CONCLUSIONS

Using a set of online cases to replace a traditional textbook did not change overall performance on the end-of-clerkship assessment. However, our findings suggest that students demonstrated proficiency in answering questions that came from the sources they studied from. This finding should be considered when curricula transition to greater use of online learning resources.

Opportunities and challenges in integrating electronic health records into undergraduate medical education: a national survey of clerkship directors

BACKGROUND

Few studies have reported on the utilization and the effect of electronic health records on the education of medical students.

PURPOSE

The purpose of this study was to describe the current use of electronic health records by medical students in the United States and explore the opportunities and challenges of integrating electronic health records into daily teaching of medical students.

METHODS

A survey with 24 questions regarding the use of electronic health records by medical students was developed by the Alliance for Clinical Educators and sent to clerkship directors across the United States. Both quantitative and qualitative responses were collected and analyzed to determine current access to and use of electronic health records by medical students.

RESULTS

This study found that an estimated 64% of programs currently allow student use of electronic health records, of which only two thirds allowed students to write notes within the electronic record. Overall, clerkship directors' opinions on the effects of electronic health records on medical student education were neutral, and despite acknowledging many advantages to electronic health records, there were many concerns raised regarding their use in education.

CONCLUSIONS

Medical students are using electronic health records at higher rates than physicians in practice. Although this is overall reassuring, educators have to be cautious about the limitations being placed on student's documentation in electronic health records as this can potentially have consequences on their training, and they need to explore ways to maximize the benefits of electronic health records in medical education.

Medical student documentation in electronic health records: a collaborative statement from the Alliance for Clinical Education

PURPOSE

The electronic health record (EHR) is an important advancement in health care. It facilitates improvement of health care delivery and coordination of care, but it creates special challenges for student education. This article represents a collaborative effort of the Alliance for Clinical Education (ACE), a multidisciplinary group formed in 1992. ACE recognizes the importance of medical student participation in patient care including the ability of documentation. This article proposes guidelines that can be used by educators to establish expectations on medical student documentation in EHRs.

SUMMARY

To provide the best education for medical students in the electronic era, ACE proposes to use the following as practice guidelines for medical student documentation in the EHR: (a) Students must document in the patient's chart and their notes should be reviewed for content and format, (b) students must have the opportunity to practice order entry in an EHR--in actual or simulated patient cases--prior to graduation, (c) students should be exposed to the utilization of the decision aids that typically accompany EHRs, and (d) schools must develop a set of medical student competencies related to charting in the EHR and state how they would evaluate it. This should include specific competencies to be documented at each stage, and by time of graduation. In addition, ACE recommends that accreditation bodies such as the Liaison Committee for Medical Education utilize stronger language in their educational directives standards to ensure compliance with educational principles. This will guarantee that the necessary training and resources are available to ensure that medical students have the fundamental skills for lifelong clinical practice.

CONCLUSIONS

ACE recommends that medical schools develop a clear set of competencies related to student in the EHR which medical students must achieve prior to graduation in order to ensure they are ready for clinical practice.

Clerkship directors' characteristics, scholarship, and support: a summary of published surveys from seven medical specialties

BACKGROUND

Clerkship directors (CDs) ensure that medical students achieve the core clinical skills needed to be effective physicians. Recently guidelines for time and support for U.S. CDs have been published by the Alliance for Clinical Education.

PURPOSE

This article reviews 14 published surveys of CDs in seven specialties and assesses CDs' personal characteristics, scholarship, and support for their position.

METHODS

Investigators reviewed CD surveys conducted over the last 12 years from seven different specialties. Comparisons were made of CDs demographics, departmental and school support, time allotted to the position, and publication rates.

RESULTS

Department support was generally good, but school support was often felt to be lacking. The number of publications was relatively low. Time allotted for the position was lower than the 50% recommended in all specialties.

CONCLUSIONS

Many CDs do not feel adequately supported by time or resources. Future studies need to more closely define what support is needed and what impact CD characteristics, scholarship, and resources have on medical student education.

Student attitudes: potential barriers to implementing a community medicine field activity

OBJECTIVE

Clerkship-year medical students may have complex attitudes regarding communities in which they train. Our objective was to assess medical students' attitudes following implementation of a community medicine experience in their clerkship year.

METHODS

We analyzed transcripts of audiotaped medical student group discussions following a community field activity. A multidisciplinary team coded the transcripts using content analysis techniques to identify key features of student narratives regarding students' attitudes and attributions regarding their community medicine experiences.

RESULTS

Students expressed several important perceptions regarding the community in which they conducted their field experience. These included strong insider/outsider themes, resentment that historical legacy shape the doctor-patient relationship, and concerns over personal safety and educational relevance of the activity. Some students noted improvement in understanding of patients within their communities.

CONCLUSIONS

Negative attitudes and attributions expressed by students can act as obstacles in the development of community medicine initiatives, hinder professional development if unaddressed, and have the potential to contribute to health disparities. Further work on how to incorporate community medicine training is needed.

Predoctoral directors: who are they and what do they do in these trying times?

BACKGROUND AND OBJECTIVES

Family medicine faces declining student interest and funding. Predoctoral directors will help lead efforts to overcome these challenges. Academic success will be important for predoctoral directors to be effective leaders in academic health centers. We therefore sought to describe predoctoral directors and factors associated with their academic success.

METHODS

We carried out a cross-sectional survey of all family medicine predoctoral directors at US allopathic medical schools using a Web-based questionnaire. The response rate was 82%. We measured academic success using a variable combining rank and tenure status. We used bivariate analysis and multiple linear regression analysis to identify factors associated with academic success.

RESULTS

The mean age of predoctoral directors is 47, and 45% are women. Forty-two percent are assistant professors, 36% associate professors, 20% full professors, and 33% are on a tenure track. Sixty-four percent of predoctoral programs receive Title VII funding, and 63% of predoctoral directors believe that loss of Title VII funding will adversely affect student education. Factors associated with academic success include years since residency, total publications, years as predoctoral director, male gender, state funding for predoctoral family medicine programs, and participation in an academic fellowship. Involvement in educational research was associated with number of publications.

CONCLUSIONS

Providing predoctoral directors with the skills and support needed to study their educational undertakings and publish their findings may help them achieve academic success. Medical educators must assess the effects of loss of Title VII funding on predoctoral education while seeking new sources of funding.

A gain in cultural competence through an international acupuncture elective

OBJECTIVE

This study describes an international acupuncture elective and its impact on medical students' development of cultural competence.

METHODS

Collaborating with Chinese colleagues, we created a 4-week elective that teaches medical students about acupuncture in its native cultural environment. Three focus groups were conducted to elicit students' experiences.

RESULTS

Students' reflections indicated that studying an alternative medical system in its own cultural setting helped them become open to other medical beliefs and realize the importance of culture in health care delivery. Further, being linguistically isolated allowed students to personally experience what it is like for those patients with limited language proficiency.

CONCLUSION

Studying an alternative medical system while immersed in another culture maybe an effective way to enhance cultural competence.

Testosterone treatments: why, when, and how?

Testosterone treatment is controversial for men and even more so for women. Although long-term outcome data are not available, prescriptions for testosterone are becoming more common. Testosterone is used primarily to treat symptoms of sexual dysfunction in men and women and hot flashes in women. Potential benefits include improved libido, increased bone mass, and increased sense of well-being. In individuals with human immunodeficiency virus infection or other chronic diseases, testosterone has been shown to improve mood and energy levels, even in patients with normal testosterone levels. Testosterone can be administered by injection, patch, topical gel, pill, or implant. Side effects in men include polycythemia and acne. Side effects in women include acne, hepatotoxicity, and virilization and usually only occur when testosterone is used in supraphysiologic doses. Long-term studies of the effects of testosterone on prostate cancer, breast cancer, and heart disease have not been completed. Mammograms and monitoring of prostate-specific antigen, hematocrit, and lipid levels are recommended for patients taking testosterone.

Patient characteristics associated with participation in a practice-based study of depression in late life: the Spectrum study

OBJECTIVE

An important component of generalizing study results to patients is the extent to which study participants adequately represent individuals targeted for the study. The Spectrum study of depression in older primary care patients was utilized to consider patient characteristics associated with nonparticipation.

METHOD

Interviewers utilized a validated questionnaire to screen adults aged 65 years and older for depression who presented to one of the participating primary care practices in the Baltimore, Maryland area. Screening interviews included information about sociodemographic factors, functioning, health, and attitudes about depression and its treatment in order to compare participants with persons who declined.

RESULTS

In all, 2,560 adults aged 65 years and older were screened. Comparison of the characteristics of the patients who were eligible for the study (n = 773) with patients who participated fully in the in-home evaluation (n = 355) found that the study sample included proportionately more persons who: 1) were less than 80 years old; 2) completed high school; and 3) reported two or more visits to the practice site within six months of the interview. Among patients who were depressed, no significant differences were found in the characteristics of those who met study eligibility criteria and those who agreed to participate.

CONCLUSIONS

Persons over the age of 80 years of age or those with less than a high school education may require tailored strategies for recruitment even when approached by a trained interviewer in a primary care doctor's office.

Evaluation and management of hip pain: an algorithmic approach

Start by determining whether pain is located in the anterior, lateral, or posterior hip. As the site varies, so does the etiology. Besides location, consider sudden vs insidious onset, motions and positions that reproduce pain, predisposing activities, and effect of ambulation or weight bearing. Physical examination tests that elucidate range of motion, muscle strength, and pain replication will narrow the diagnostic search. Magnetic resonance imaging is usually diagnostic if plain x-rays and conservative therapy are ineffective. Conservative measures and selective use of injection therapy are usually effective.

Diagnosis, treatment and prognosis in patients with low back pain

Patients with chronic low back pain can present a treatment dilemma for the family physician. Low back pain is one of the most common symptoms bringing patients to physicians. Despite its high prevalence, low back pain is often difficult to treat. In most patients, the pain cannot be pinpointed at a specific anatomic lesion, and plain radiographs, computed tomographic scans and magnetic resonance imaging studies are not useful. While most people with low back pain improve regardless of the type of intervention, some evidence shows that McKenzie exercises, manipulation and injection therapy are helpful for patients who do not recover spontaneously.