Does Delaying the United States Medical Licensing Examination Step 1 to After Clerkships Affect Student Performance on Clerkship Subject Examinations?

Phenomenon: Schools are considering the optimal timing of Step 1 of the United States Medical Licensing Examination (USMLE). Two primary reasons for moving Step 1 after the core clerkships are to promote deeper, more integrated basic science learning in clinical contexts and to better prepare students for the increasingly clinical focus of Step 1. Positioning Step 1 after the core clerkships leverages a major national assessment to drive learning, encouraging students to deepen their basic science knowledge while in the clinical setting. Previous studies demonstrated small increases in Step 1 scores, reductions in failure rates, and similar Step 2 Clinical Knowledge scores when Step 1 was after the clerkships. Some schools that have moved Step 1 reported declines in clinical subject examination (CSE) performance. This may be due to shortened pre-clerkship curricula, the absence of the Step 1 study period for knowledge consolidation, or exposure to fewer National Board of Medical Examiners type questions prior to taking CSEs. This multi-institutional study aimed to determine whether student performance on CSEs was affected by moving Step 1 after the core clerkships. Approach: CSE scores for students from eight schools that moved Step 1 after core clerkships between 2012 and 2016 were analyzed in a pre-post format. Hierarchical linear modeling was used to quantify the effect of the curriculum on CSE performance. Additional analysis determined if clerkship order impacted clinical subject exam performance and whether the curriculum change resulted in more students scoring in the lowest percentiles (as defined as below the national fifth percentile) before and after the curricular change. Findings: After moving Step 1 to after the clerkships, collectively these eight schools demonstrated statistically significant lower performance on four CSEs (Medicine, Neurology, Pediatrics, and Surgery) but not Obstetrics/Gynecology or Psychiatry. Comparing performance within the three years pre and post Step 1 change, differences across all clerkships ranged from 0.3 to -2.0 points, with an average difference of -1.1. CSE performance in clerkships taken early in the sequence was more affected by the curricular change, and differences gradually disappeared with subsequent examinations. Medicine and Neurology showed the largest average differences between curricular-group when taken early in the clinical year. Finally, there was a slightly higher chance of scoring below the national fifth percentile in four of the clinical subject exams (Medicine, Neurology, Pediatrics, and Psychiatry) for the cohort with Step 1 after the clerkships. Insights: Moving Step 1 after core clerkships had a small impact on CSE scores overall, with decreased scores for exams early in the clerkship sequence and an increased number of students below the fifth percentile. Score differences have minor effects on clerkship grades, but overall the size of the effect is unlikely to be educationally meaningful. Schools can use a variety of mitigation strategies to address CSE performance and Step 1 preparation in the clerkship phase.

Strategies From 11 U.S. Medical Schools for Integrating Basic Science Into Core Clerkships

Calls for curricular reform in medical schools and enhanced integration of basic and clinical science have resulted in a shift toward preclerkship curricula that enhance the clinical relevance of foundational science instruction and provide students with earlier immersion in the clinical environment. These reforms have resulted in shortened preclerkship curricula, yet the promise of integrated basic science education into clerkships has not been sufficiently realized because of barriers such as the nature of clinical practice, time constraints, and limited faculty knowledge. As personalized medicine requires that physicians have a more nuanced understanding of basic science, this is cause for alarm. To address this problem, several schools have developed instructional and assessment strategies to better integrate basic science into the clinical curriculum. In this article, faculty and deans from 11 U.S. medical schools discuss the strategies they implemented and the lessons they learned to provide guidance to other schools seeking to enhance basic science education during clerkships. The strategies include program-level interventions (e.g., longitudinal sessions dedicated to basic science during clerkships, weeks of lessons dedicated to basic science interspersed in clerkships), clerkship-level interventions (e.g., case-based learning with online modules, multidisciplinary clerkship dedicated to applied science), bedside-level interventions (e.g., basic science teaching scripts, self-directed learning), and changes to formative and summative assessments (e.g., spaced repetition/leveraging test-enhanced learning, developing customized examinations). The authors discovered that: interventions were more successful when buy-in from faculty and students was considered, central oversight by curricular committees collaborating with faculty was key, and some integration efforts may require schools to provide significant resources. All schools administered the United States Medical Licensing Examination Step 1 exam to students after clerkship, with positive outcomes. The authors have demonstrated that it is feasible to incorporate basic science into clinical clerkships, but certain challenges remain.

The Clumsy Horse: A Professional Development Tool for Facilitators of Self-Directed, Case-Based Learning

INTRODUCTION

With the constant evolution of science and advancing technology, future physicians must learn to navigate an ever-changing health care environment by continuous learning throughout their professional careers. Lifelong, self-directed learning is a critical component of medical education to ensure future physicians are adept at identifying knowledge gaps and seeking, analyzing, and communicating new information. To train faculty who teach case-based, self-directed learning, we designed the Clumsy Horse Case.

METHODS

The Clumsy Horse Case was created as part of a faculty development program for facilitators of a new case-based, self-directed curriculum known as Patient-Centered Education (PaCE) Cases. An unfamiliar veterinary medicine case was designed to level the playing field for faculty from different specialty areas in order to provide an authentic self-directed learning experience. To determine effectiveness, faculty participants completed a standardized eight-question evaluation survey after the Clumsy Horse Case session, and facilitators received student feedback at the end of each semester via a standard faculty evaluation form.

RESULTS

Student ratings indicated that faculty were adequately prepared to be effective facilitators. The Clumsy Horse Case was an integral part of facilitator preparation and provided an engaging learning experience for over 60 faculty. Survey ratings and comments from faculty participants indicated a high level of engagement and satisfaction with the learning experience.

DISCUSSION

The Clumsy Horse Case is generalizable for developing faculty in any curriculum with a case-based, self-directed learning component. It can be modified to fit any school's curriculum and integrated into a professional development program.

Proteomic analysis of cytochromes P450: a mass spectrometry approach

In human, the CYP (cytochrome P450) superfamily comprises 57 genes arranged in 18 families and 42 subfamiles. These genes encode for enzymes involved in the metabolism of drugs, foreign chemicals, fatty acids, eicosanoids and cholesterol. Additionally, they play roles in bile acid biosynthesis, steroid synthesis and metabolism, and vitamin D3 synthesis and metabolism. Mutations in many CYP genes cause inborn errors of metabolism and contribute to increased risk of cancer. MS provides a convenient method for the identification and quantification of CYP enzymes, and in the present paper we will review the current state of the technology for such an analysis.

Distorted perceptions of competence and incompetence are more than regression effects

Students inaccurately assess their own skills, especially high- or low-performers on exams. This study assessed whether regression effects account for this observation. After completing the Infection and Immunity course final exam (IIF), second year medical students (N = 143) estimated their performance on the IIF in terms of percent correct and percentile rank. Second year grade point averages (M2GPAs) were combined with the IIF results to form five subgroups: 1 = true-low (lowest third on both IIF and M2GPA, 2 = false-low (lowest third on IIF only), 3 = middle (neither lowest nor highest third on IIF), 4 = false-high (highest third on IIF only), 5 = true-high (highest third on IIF and M2GPA). The false-low and false-high groups were considered more susceptible to regression effects due to likely group misclassification. Differences between self-assessment and actual performance within each group and between the five groups were used to estimate what portion of observed differences is due to general tendencies versus regression effects. Results found that students accurately assessed their percent correct, but inaccurately assessed their percentile rank. No statistically significant differences existed between the true and false-low subgroups nor the true- and false-high subgroups. Percentages of mean differences suggest that while regression effects resulted in 50-75% over/under-estimates of scores by students who were misclassified, when they were merged with the true-low/high groups, they do not account for more than 14% of low performer over-estimates of their performance and high performer under-estimates of their performance. Accurate percent correct assessments and distorted percentile rank assessments are challenges in using instructional methods dependent on student self-assessments of their learning needs. Identifying and helping students with distorted perceptions of their test performances may be a key issue in such instructional approaches.

Evidence-based medicine: answering questions of diagnosis

Using medical evidence to effectively guide medical practice is an important skill for all physicians to learn. The purpose of this article is to understand how to ask and evaluate questions of diagnosis, and then apply this knowledge to the new diagnostic test of CT colonography to demonstrate its applicability. Sackett and colleagues have developed a step-wise approach to answering questions of diagnosis: Step1: Define a clinical question and its four components: Patient, intervention, comparison and outcome. Step 2: Find the evidence that will help answer the question. PubMed Clinical Queries is an efficient database to accomplish this step. Step 3: Assess whether this evidence is valid and important. A quick review of the methods and results section will help to answer these two questions. Step 4: Apply the evidence to the patient. This step includes: assessing whether the test can be used; determining if it will help the patient; finding whether the study patients are similar to the patient in question; determining a pretest probability; and deciding if the test will change one's management of the patient. A relatively new diagnostic test, CT colonography, is explored as a scenario in which the steps presented by Sackett et al.1 can be helpful. A patient who is interested in completing a CT colonography instead of a colonoscopy is the basis of the discussion. Because a CT colonography does not detect polyps of less than 10 mm accurately, many patient are not likely to prefer this test over a colonoscopy. Evidence-based medicine is an effective strategy for finding, evaluating, and critically appraising diagnostic tests, treatment and application. This skill will help physicians interpret and explain the medical information patients read or hear about.

Integrating the art and science of medical practice: innovations in teaching medical communication skills

BACKGROUND AND OBJECTIVES

This paper describes the content and methods used to teach communication skills in Undergraduate Medical Education for the 21st Century (UME-21) schools and provides suggestions for future efforts.

METHODS

Faculty leaders of curriculum projects at UME-21 schools provided reports describing new communication curriculum projects. Reports were reviewed and analyzed, curriculum content and methods were categorized into themes, and findings were confirmed through phone interviews with lead faculty at each participating school.

RESULTS

Curriculum projects were designed to improve medical students' communication skills during the clerkship years at 12 participating UME-21 schools. These skills were addressed through a variety of teaching methods and applied in interactions with patients, health teams, and community members. Curricular themes included conflict resolution, delivery of bad news, addressing patient preferences for end-of-life care, patient and community health education, communicating with families, and working effectively with patients from diverse backgrounds. Students' communication skill competencies were assessed through a variety of methods including objective structured clinical examinations, focused observation and feedback, and debriefing sessions based on recall, audiotapes, or videotapes of encounters.

CONCLUSIONS

Opportunities for students to develop, apply, and refine their communication skills can be embedded throughout the medical school curricula. Our findings illustrate the variety of methods that may be used to teach and evaluate medical students' communication skill competencies. Future challenges include development of comprehensive longitudinal curricula, practical teaching methods, valid evaluation tools, and faculty development.

Prescribing oral contraceptives for women older than 35 years of age

This paper addresses the use of combined oral contraceptives in women older than 35 years of age, including the potential risks and benefits, pretreatment assessment, common side effects and their management, appropriate follow-up, and diagnosis of menopause. The case-based discussion also focuses on issues that pertain to women who smoke, have hypertension, or have dyslipidemia.

Can specialists and generalists teach clinical skills to second-year medical students with equal effectiveness?

PURPOSE

To compare the effectiveness of specialists and generalists as small-group leaders teaching basic physical examination skills to preclinical medical students.

METHOD

Specialists and generalists were randomly assigned to teach physical examination skills to 69 groups of second-year students (n = 288). At the conclusion of the course, the specialist- and generalist-led groups were compared using three measures: students' scores on an objective structured clinical exam (OSCE), students' evaluations of their small-group leaders, and leaders' self-evaluations of confidence in teaching.

RESULTS

OSCE scores did not differ between students taught by specialists and generalists (93.5% and 93.8% respectively, p = NS). Students' evaluations of their leaders were similar for nine characteristics rated on a seven-point scale (7 = strongly agree/outstanding; range of results for specialists: 6.20-6.62, for generalists 6.34-6.75, p = NS). Leaders expressed similar levels of confidence (on a seven-point scale; 7 = very confident) in their abilities to teach the neurologic exam (specialists 5.52, generalists 6.19, mean effect size difference 0.44, p = NS) and complete history and physical exam (6.03 and 6.53, mean effect size difference 0.43, p = NS). Specialists were significantly less confident in teaching the cardiovascular exam (5.80 and 6.50, mean effect size difference 0.51, p <.05) and pulmonary exam (5.56 and 6.60, mean effect size difference, 0.80, p <.01).

CONCLUSIONS

Specialists and generalists can teach preclinical medical students with equal effectiveness as rated by the students and the students' scores on the OSCE examination, but specialists do not rate themselves as confident as do generalists to teach some skills.

Activation of the rod G-protein Gt by the thrombin receptor (PAR1) expressed in Sf9 cells

Functional coupling of the human thrombin receptor PAR1 (protease-activated receptor 1) with the retinal rod G-protein transducin (Gt, a member of the Gi family) was studied in a reconstituted system of membranes from Sf9 cells expressing the thrombin receptor and purified Gt from bovine rod outer segments. TRAP6-agonist-activated PAR1 interacts productively with the distant G-protein. Agonist-dependent Gt activation was measured using a real-time fluorimetric GTP[S]-binding assay and membranes from Sf9 cells. To characterize nucleotide-exchange catalysis by PAR1, we analyzed dependence on nucleotides, temperature and pH. Activation was inhibited by low GDP concentrations (IC50 = 5.2 +/- 1.5 microM at 5 microM GTP[S]), indicating that receptor-Gt coupling, followed by instantaneous GDP release, is rate limiting under the conditions (25 degrees C). Arrhenius plots of the temperature dependence reflect an apparent Ea of 60 +/- 3.5 kJ.mol-1. Evaluation of the pH/rate profiles of Gt activation indicates that the activating conformation of the receptor is determined by protonation of a titratable group with an apparent pKa of 6.4. This supports the idea that the active state of agonist-bound PAR1 depends on forced protonation, indicating possible analogies to the scheme established for rhodopsin.

Precepting preclinical students

Preclinical preceptors have an opportunity to imprint students with good clinical work habits, professionalism, and excitement for medical education. While attention to the multiple roles of the preclinical preceptor can add responsibilities to a busy physician's day, the chance to influence the development of future physicians is deeply gratifying.

[Focal and diffuse lesions in dynamic MR-mammography of healthy probands]

PURPOSE

To evaluate the range of normal contrast enhancement behaviour in dynamic MR mammography of healthy breast parenchyma, and to reduce false-positive results caused by incidental contrast enhancing lesions.

MATERIALS AND METHODS

We performed a prospective two-armed study on 20 healthy premenopausal volunteers who were examined four times within one month (Group 1) or during four consecutive months (Group 2). Incidence, prevalence, morphology, and contrast enhancement pattern of lesions were evaluated.

RESULTS

82% (9/11 of Group 1) and 78% (7/9 of Group 2) showed at least one of a total of 60 contrast enhancing lesions. In 54% or 33% (Group 1 or 2), lesions with enhancement velocity beyond the malignancy threshold were found. 72% or 75% of lesions resolved completely during follow-ups. 69% of lesions were focal with irregular border. Time/signal intensity diagrams were almost always not suspicious; no wash-out phenomenon was seen.

CONCLUSION

In MR mammography of premenopausal breast parenchyma, focal contrast enhancing lesions-even with enhancement beyond the malignancy threshold-may occur without any underlying pathology.

A nontransportable substrate for lactose permease

A substrate for lactose permease of Escherichia coli was synthesized that binds to the protein with a relatively high affinity, but is not transported to any detectable extent. This substrate, 6'-[(N-phenylalanylphenylalanyl)amino]hexyl 1-thio-beta-D-galactoside, is a peptide galactoside composed of a bulky aromatic dipeptide that is linked to galactose via an aminohexyl spacer. Binding of the peptide galactoside to lactose permease in cytoplasmic membranes was determined in a competition assay yielding a dissociation constant of 150 microM. Transport was measured by a counterflow assay using lipid vesicles with reconstituted lactose permease. An upper limit for the rate constant of transport was obtained as 0.02 s-1, 3 orders of magnitude smaller than the value for lactose.

The impact of the Trial Coordinator in the Diabetes Control and Complications Trial (DCCT). The DCCT Research Group

The Diabetes Control and Complications Trial (DCCT) is a multicenter, randomized clinical trial studying the effects of two different diabetes regimens on the development and progression of early vascular complications in persons with insulin-dependent diabetes mellitus (IDDM). All of the centers have a Trial Coordinator. We administered a self-report questionnaire to each center to document the different activities for which the Trial Coordinator assumed responsibility in successfully orchestrating the trial. All Trial Coordinators were responsible primarily for recruitment, screening, medical management, education and training, and adherence and administration. Although documentation indicated that the Trial Coordinator was responsible for all of the above activities, the original applications reflected that very few of the Principal Investigators anticipated such a wide variety of duties. A Trial Coordinator was named in only 13 of the 21 applications and of these, only 6 actually assumed the position. This study points out the need to develop a means to define characteristics, background, and training appropriate for candidates for a Trial Coordinator position in future studies.

Comparison of lymphangiography and computed tomography scanning in evaluating abdominal disease in stages III and IV Hodgkin's disease. A Southwest Oncology Group study

The authors reviewed the records of 139 patients who had laparotomy plus computed tomography (CT) and/or lymphangiograms (LAG) as part of a their staging workup for Hodgkin's disease, in accordance with Southwest Oncology Group (SWOG) protocol 7808. They evaluated the relative ability of CT and LAG to detect disease in the abdomen. Two regions of the abdomen were designated, the upper and the lower, to further examine the capabilities of CT and LAG in the lower abdomen and CT in the upper abdomen. A LAG was more sensitive (P less than 0.05) than CT in detecting positive lower abdominal nodes. In the upper abdomen, CT scan had low sensitivity for detecting positive nodes, liver, or spleen. This study suggests that LAG of the lower abdomen provided more information than CT, and therefore should not be abandoned as a valid method for detecting nodal disease.

Development of tolerance in brain mitochondria for calcium uptake following chronic ethanol ingestion

Brain mitochondria isolated from rats following 10 weeks of chronic exposure to ethanol were not deficient in respiratory function or in rates of calcium uptake under control conditions. Ethanol (80 mM) in the incubation medium caused significant depression in the respiratory and ATP-dependent rates of calcium uptake in control mitochondria, but did not affect mitochondria from ethanol-tolerant rats. Chronic exposure to ethanol causes mitochondria to take calcium up at a normal rate when challenged acutely by ethanol.

A cross-sectional prevalence study of lumbar disc degeneration in a working population

The prevalence of lumbar degenerative discs (LDD) was determined in 38 ambulating and 21 sedentary employees of a Rocky Mountain company. Lumbar degenerative discs were identified by magnetic resonance imaging (MRI) performed with a sagittal T2 image of the lumbar spine using a .5 Tesla unit. The L5-S1 level was the most common disc with degenerative changes. Analysis of the two groups showed a significant association at the L5-S1 level between occupation and LDD, as evidenced by the ambulating females having no degenerative lumbar discs and sedentary females having a large number of degenerative discs. The males in the study did not demonstrate a significant difference in prevalence of LDD. Lumbar degenerative discs may be increased in less active females at the L5-S1 level.

Correlation of neuropsychological and MRI findings in chronic/progressive multiple sclerosis

Sixty patients with chronic/progressive MS received a newly assembled neuropsychological screening battery (NSB) and a brain MRI. A neuroradiologist blinded to NSB findings quantified cerebral lesions on MRI. We developed weighted brain area lesion scores according to number and size of cerebral lesions. Patients who were impaired on NSB testing had a significantly higher mean bihemispheric lesion score (X = 26.1) than those who were unimpaired (X = 17.4); this MRI lesion rating score correlated significantly with the cognitive summary score of the NSB (r = 0.35, p less than 0.01). However, we did not find a significant correlation between the Kurtzke Expanded Disability Status Scale and any MRI or NSB summary measures. Compared with the Mini-Mental State Exam (MMSE), the NSB cognitive summary score yielded a prevalence estimate for cognitive impairment that is more consistent with previous findings in chronic/progressive MS. The NSB is a useful screening test for cognitive dysfunction in chronic/progressive MS because of its relationship to cerebral lesions on MRI and its greater sensitivity than the frequently used MMSE.

Radiographic classification of the vestibular and cochlear aqueducts: the paired correlation between normal and abnormal vestibular aqueduct and cochlear aqueduct anatomy

Multidirectional tomography (MDT) can be useful in determining the caliber, shape, and course of the vestibular aqueduct (VA) and cochlear aqueduct (CA). Clinical decisions have been based on the findings from MDT. Unfortunately, the clinical utility of these observations has been confusing and controversial because similar MDT techniques were not used. This study will address some of the difficult questions and clinical controversies derived from MDT observations. This new perspective has evolved with the use of high resolution computed tomography (HRCT). An analysis of 750 petrous bones for the occurrence of the various types of VAs and CAs using Gado's classification, further vestibular aqueduct and a variation of Gado's classification for the cochlear classification is reported. The distribution of the possible paired types of VA and CA are evaluated. MDT results indicate that the paired analysis in patients with inner ear dysfunction is not useful, cost effective, diagnostic, or of prognostic value. MDT can provide clinically valid observations of periaqueductal and perilabyrinthine pneumatization which is helpful in anticipating the size and position of the endolymphatic sac at the time of surgery for those few patients who may benefit from endolymphatic system surgery. However, when a comparison is made between MDT and CT of 60 ears in those same patients, the clinical limitations of MDT for inner ear diagnosis and prognosis became apparent. The future for HRCT scanning with reformatting holds potential for clinically meaningful visualization of inner and middle ear structures previously expected from MDT imaging.

Model approach to immunological rejuvenation of the aged

Reconstitution of a damaged or exhausted immune system by injection of genetically compatible immunocompetent cells (immunologic rejuvenation) is a promising approach for restoration of immune activity. By using this model, spleen cells from young-adult mice, previously immunized with Salmonella typhimurium, were transferred to either young-adult or old, syngeneic recipients before or after storage at -196 C. The susceptibility of recipient mice was then determined by challenging them at increasing time intervals after reconstitution with lethal doses of the virulent organisms. The findings, although preliminary in nature, demonstrate that (i) immunological rejuvenation of mice is possible with immunocompetent cells from specifically immunized donors; (ii) prolonged "takes" of these cells can occur even in nonirradiated recipient mice, and (iii) storage at -196 C does not impair their protective capacity.