Feasibility of clinical performance assessment of medical students on a virtual sub-internship in the United States

We aimed to determine whether it was feasible to assess medical students as they completed a virtual sub-internship. Six students (out of 31 who completed an in-person sub-internship) participated in a 2-week virtual sub-internship, caring for patients remotely. Residents and attendings assessed those 6 students in 15 domains using the same assessment measures from the in-person sub-internship. Raters marked “unable to assess” in 75/390 responses (19%) for the virtual sub-internship versus 88/3,405 (2.6%) for the in-person sub-internship (P=0.01), most frequently for the virtual sub-internship in the domains of the physical examination (21, 81%), rapport with patients (18, 69%), and compassion (11, 42%). Students received complete assessments in most areas. Scores were higher for the in-person than the virtual sub-internship (4.67 vs. 4.45, P<0.01) for students who completed both. Students uniformly rated the virtual clerkship positively. Students can be assessed in many domains in the context of a virtual sub-internship.

End-of-Life Care: A Multimodal and Comprehensive Curriculum for Graduating Medical Students Utilizing Experiential Learning Opportunities

INTRODUCTION

End-of-life (EOL) care is an essential skill for most physicians and health care providers, yet there continues to be an educational gap in medical education literature for these skills. The Johns Hopkins School of Medicine developed the Transition to Residency, Internship, and Preparation for Life Events (TRIPLE) curriculum with the primary goal of preparing graduating medical students for life after medical school.

METHODS

The EOL module was one of many within the TRIPLE curriculum and consisted of two half-day sessions that targeted EOL care, death, dying, and communication skills. The first half-day session focused on a standardized patient encounter where learners initiated and completed an EOL care goals conversation around a living will. The second half-day session focused on death and dying. It included didactic sessions on organ donation, autopsy/death certificates, a simulation-based learning session on ending a resuscitation, and a standardized patient encounter where learners disclosed the death of a loved one. End-of-day and end-of-course evaluations were collected via anonymous online surveys.

RESULTS

In 2019, 120 students and 26 instructors participated in TRIPLE. Students rated the EOL module overall as 4.6 of 5 (SD = 0.6) and rated instructors overall as 4.6 of 5 (SD = 0.6).

DISCUSSION

By implementing a thorough and diverse curriculum with a variety of modalities and targeted skills, learners may be better prepared to care for patients dealing with EOL care issues. Further, the generalization of these skills may assist learners in a variety of other aspects of patient and family care.

Effect of a high value care curriculum on standardized patient exam in the Core Clerkship in Internal Medicine

BACKGROUND

With almost 20% unnecessary spending on healthcare, there has been increasing interest in high value care defined as the best care for the patient, with the optimal result for the circumstances, delivered at the right price. The American Association of Medical Colleges recommend that medical students are proficient in concepts of cost-effective clinical practice by graduation, thus leading to curricula on high value care. However little is published on the effectiveness of these curricula on medical students' ability to practice high value care.

METHODS

In addition to the standard curriculum, the intervention group received two classroom sessions and three virtual patients focused on the concepts of high value care. The primary outcome was number of tests and charges for tests on standardized patients.

RESULTS

136 students enrolled in the Core Clerkship in Internal Medicine and 70 completed the high value care curriculum. There were no significant differences in ordering of appropriate tests (3.1 vs. 3.2 tests/students, p = 0.55) and inappropriate tests (1.8 vs. 2.2, p = 0.13) between the intervention and control. Students in the intervention group had significantly lower median Medicare charges ($287.59 vs. $500.86, p = 0.04) and felt their education in high value care was appropriate (81% vs. 56%, p = 0.02).

CONCLUSIONS

This is the first study to describe the impact of a high value care curriculum on medical students' ordering practices. While number of inappropriate tests was not significantly different, students in the intervention group refrained from ordering expensive tests.

Communicating About Stopping Cancer Screening: Comparing Clinicians' and Older Adults' Perspectives

BACKGROUND AND OBJECTIVES

Older adults with limited life expectancy frequently receive cancer screening. We sought to compare the perspectives of clinicians and older adults on how to communicate about stopping cancer screening.

RESEARCH DESIGN AND METHODS

We used data from two studies involving semistructured in-person individual interviews, in which we asked about perspectives on communication about stopping cancer screening, with 28 primary care clinicians and 40 community-dwelling older adults, respectively.

RESULTS

We identified three major themes: (a) Consensus among primary care clinicians and older adults regarding communication around stopping cancer screening. Both groups considered discussing the benefits/risks of cancer screening and involving patients in the decision as important and mentioned framing screening cessation as shift in health priorities. (b) Differences in perceived reactions to stopping cancer screening. Primary care clinicians were concerned about patient reaction to stopping cancer screening, whereas older adults reported no negative reactions in the context of a trusting relationship. (c) Differences in views around whether to discuss life expectancy in the context of stopping cancer screening. Clinicians rarely discussed life expectancy in this context, whereas older adults were divided on whether life expectancy should be discussed.

DISCUSSION AND IMPLICATIONS

Given the heterogeneity in older adults' preferences, it is important to assess whether patients want to discuss life expectancy when discussing stopping cancer screening, though use of the specific term "life expectancy" may not be necessary. Instead, focusing discussion on the benefits/risks of cancer screening and mentioning shift in health priorities are acceptable communication strategies for both clinicians and older adults.

Novel first-year curriculum in high-value care

BACKGROUND

Most medical schools teach a high-value care (HVC) curriculum during the clinical years. Currently, there lacks any research demonstrating the effectiveness of the HVC curriculum taught to students in their first year of medical school.

METHODS

A total of 118 of 466 first-year medical students at Johns Hopkins School of Medicine between 2013 and 2017 enrolled on an HVC course that provided the initial framework necessary to practice cost-conscious clinical medicine. The curriculum was evaluated by comparing the performance of students who completed the course with the performance of students without training, through a standardised patient encounter on musculoskeletal back pain and how to approach a patient's request for imaging. Chi-square testing was used to assess the impact of the course on performance in a standardised patient encounter.

RESULTS

Students enrolled on the HVC course were more likely, compared with their counterparts, to assure patients that back pain was a simple strain (48 versus 31%), and were less likely to ask for preceptor help on how to proceed with management (11 versus 29%) [χ² (4, n = 466) = 14.28, p = 0.007]. There were no differences between students enrolled on the HVC course who had not yet received training compared with students taking another elective [χ² (4, n = 385) = 8.73, p = 0.07].

DISCUSSION

This is the first study to assess the effectiveness of an HVC curriculum for first-year medical students, and it demonstrates promise that they can acquire some skill sets necessary for cost-effective practice in a simulated clinical setting. This is the first study to assess the effectiveness of an HVC curriculum for first-year medical students, and it demonstrates promise that they can acquire some skill sets necessary for cost-effective practice.

Evaluation of a course to prepare international students for the United States Medical Licensing Examination step 2 clinical skills exam

PURPOSE

United States (US) and Canadian citizens attending medical school abroad often desire to return to the US for residency, and therefore must pass US licensing exams. We describe a 2-day United States Medical Licensing Examination (USMLE) step 2 clinical skills (CS) preparation course for students in the Technion American Medical School program (Haifa, Israel) between 2012 and 2016.

METHODS

Students completed pre- and post-course questionnaires. The paired t-test was used to measure students' perceptions of knowledge, preparation, confidence, and competence in CS pre- and post-course. To test for differences by gender or country of birth, analysis of variance was used. We compared USMLE step 2 CS pass rates between the 5 years prior to the course and the 5 years during which the course was offered.

RESULTS

Ninety students took the course between 2012 and 2016. Course evaluations began in 2013. Seventy-three students agreed to participate in the evaluation, and 64 completed the pre- and post-course surveys. Of the 64 students, 58% were US-born and 53% were male. Students reported statistically significant improvements in confidence and competence in all areas. No differences were found by gender or country of origin. The average pass rate for the 5 years prior to the course was 82%, and the average pass rate for the 5 years of the course was 89%.

CONCLUSION

A CS course delivered at an international medical school may help to close the gap between the pass rates of US and international medical graduates on a high-stakes licensing exam. More experience is needed to determine if this model is replicable.

A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training

BACKGROUND

Physicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill.

METHODS

One hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE).

RESULTS

Interns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing 'a' from 'v' waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE.

CONCLUSIONS

A comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.

Medical students' perceptions of low-value care

BACKGROUND

Medical schools are creating high-value care (HVC) curricula in undergraduate medical education; however, there are few studies identifying what are the most pressing low-value care (LVC) practices, as observed by students. This study is a multicentre, targeted needs assessment comparing medical student perceptions of LVC at four institutions, after completion of their internal medicine clerkship, to identify areas of focus for future HVC curriculum development.

METHODS

A total of 307 medical students at four institutions participated in a voluntary survey and identified instances of LVC during the internal medicine clerkship. Responses were organised into seven LVC categories and analysed using chi-square testing to determine response variation by institution.

RESULTS

The four most common themes identified by all institutions were testing for low prevalence disease processes (44%), excessive daily labwork (44%), errors in clinical judgement (26%) and testing that would not change management (21%). Responses did not vary by institution, with the exception that one school identified fewer instances of ordering excessive labwork compared with the other institutions (28 versus 46-54%; p = 0.05). There are few studies identifying what are the most pressing low-value care practices DISCUSSION: This is the first multi-institutional targeted needs assessment to demonstrate similarities in perceptions of LVC by medical students. Despite differences in geographic location and private and public affiliations, the top four categories remained consistent. These findings can provide a framework for educational objectives that address these issues in an HVC curriculum. Response variation, as seen with institution 2, offers opportunities for schools to personalise their HVC curriculum.

Prognosis communication with older patients with multimorbidity: Assessment after an educational intervention

This study aimed to assess how internal medicine residents incorporated prognosis to inform clinical decisions and communicated prognosis in primary care visits with older patients with multimorbidity after an educational intervention, and resident and patient perspectives regarding these visits. Assessment used mixed-methods. The authors assessed the frequency and content of prognosis discussions through residents' self-report and qualitative content analysis of audio-recorded clinic visits. The authors assessed the residents' perceived effect of incorporating prognosis on patient care and patient relationship through a resident survey. The authors assessed the patients' perceived quality of communication and trust in physicians through a patient survey. The study included 21 clinic visits that involved 12 first-year residents and 21 patients. Residents reported incorporating patients' prognoses to inform clinical decisions in 13/21 visits and perceived positive effects on patient care (in 11/13 visits) and patient relationship (in 7/13 visits). Prognosis communication occurred in 9/21 visits by self-report, but only in six of these nine visits by content analysis of audio-recordings. Patient ratings were high regardless of whether or not prognosis was communicated. In summary, after training, residents often incorporated patients' prognoses to inform clinical decisions, but sometimes did so without communicating prognosis to the patients. Residents and patients reported positive perceptions regarding the visits.

Teaching medical students about cost-effectiveness

BACKGROUND

Rising and burdensome health care costs have driven interest in the practice of high-value care (HVC) and have inspired calls for increased HVC training across all levels of medical education, including among undergraduate medical students.

CONTEXT

Classroom-based HVC curricula targeted to medical students have not been previously described in the medical literature.

INNOVATION

We developed and evaluated a workshop comprising a lecture, a small-group exercise and a group discussion to instruct medical students on interpreting cost-effectiveness analyses (CEA), applying CEA to patient care and discussing the cost of care with patients. From January 2014 to September 2015 the workshop was administered to five cohorts, 120 students in total, in the internal medicine clerkships at two US medical schools. Pre- and post-intervention confidence in various domains was assessed with a Likert-type scale ranging from 1 to 4. The overall response rate was 87.9 per cent. The proportion of students reporting high confidence scores (3 or 4) rose significantly (p < 0.01) in each domain: from 16.2 to 76.9 per cent for calculating an incremental cost-effectiveness ratio (ICER); from 16.0 to 79.6 per cent for interpreting quality-adjusted life-years (QALYs); from 8.7 to 71.3 per cent for using CEA in patient management; and from 15.3 to 71.4 per cent for discussing costs with patients. Students rated the overall quality of the course as 3.82 out of 5. Rising and burdensome health care costs have driven interest in the practice of high-value care IMPLICATIONS: Our experience of developing, evaluating and refining an HVC course targeted at medical students taught us that such a course is needed, can be educational and can be well-received. Future research is needed to assess the effects of curricula on clinical practice.

Primary Care Practitioners' Views on Incorporating Long-term Prognosis in the Care of Older Adults

IMPORTANCE

Clinical practice recommendations increasingly advocate that older patients' life expectancy be considered to inform a number of clinical decisions. It is not clear how primary care practitioners approach these recommendations in their clinical practice.

OBJECTIVE

To explore the range of perspectives from primary care practitioners on long-term prognosis, defined as prognosis regarding life expectancy in the range of years, in their care of older adults.

DESIGN, SETTING, AND PARTICIPANTS

A qualitative, semistructured interview study was conducted in a large group practice with multiple sites in rural, urban, and suburban settings. Twenty-eight primary care practitioners were interviewed; 20 of these participants (71%) reported that at least 25% of their patient panel was older adults. The audiorecorded discussions were transcribed and analyzed, using qualitative content analysis to identify major themes and subthemes. The study was conducted between January 30 and May 13, 2015. Data analysis was performed between June 10 and September 1, 2015.

MAIN OUTCOMES AND MEASURES

The constant comparative approach was used to qualitatively analyze the content of the transcripts.

RESULTS

Of the 28 participants, 16 were women and 21 were white; the mean (SD) age was 46.2 (10.3) years. Twenty-six were physicians and 2 were nurse practitioners. Their time since completing clinical training was 16.0 (11.4) years. These primary care practitioners reported considering life expectancy, often in the range of 5 to 10 years, in several clinical scenarios in the care of older adults, but balanced the prognosis consideration against various other factors in decision making. In particular, patient age was found to modulate how prognosis affects the primary care practitioners' decision making, with significant reluctance among them to cease preventive care that has a long lag time to achieve benefit in younger patients despite limited life expectancy. The participants assessed life expectancy based on clinical experience rather than using validated tools and varied widely in their prognostication time frame, from 2 years to 30 years. Participants often considered prognosis without explicitly discussing it with patients and disagreed on whether and when long-term prognosis needs to be specifically discussed. The participants identified numerous barriers to incorporating prognosis in the care of older adults including uncertainty in predicting prognosis, difficulty in discussing prognosis, and concern about patient reactions.

CONCLUSIONS AND RELEVANCE

Despite clinical recommendations to increasingly incorporate patients' long-term prognosis in clinical decisions, primary care practitioners encounter several barriers and ambiguities in the implementation of these recommendations.

Incorporating prognosis in the care of older adults with multimorbidity: description and evaluation of a novel curriculum

BACKGROUND

Prognosis is a critical consideration in caring for older adults with multiple chronic conditions, or "multimorbidity". Clinicians are not adequately trained in this area. We describe an innovative curriculum that teaches internal medicine residents how to incorporate prognosis in the care of older adults with multimorbidity.

METHODS

The curriculum includes three small-group sessions and a clinical exercise; it focuses on the assessment, communication, and application of prognosis to inform clinical decisions. The curriculum was implemented with 20 first-year residents at one university-based residency (intervention group). Fifty-two first-year residents from a separate residency affiliated with the same university served as controls. Evaluation included three components. A survey assessed acceptability. A pre/post survey assessed attitude, knowledge, and self-reported skills (Impact survey). Comparison of baseline and follow-up results used paired t-test and McNemar test; comparison of inter-group differences used t-test and Fisher's exact test. A retrospective, blinded pre/post chart review assessed documentation behavior; abstracted outcomes were analyzed using Fisher's exact test.

RESULTS

The curriculum was highly rated (4.5 on 5-point scale). Eighteen intervention group residents (90 %) and 29 control group residents (56 %) responded to the Impact survey. At baseline, there were no significant inter-group differences in any of the responses. The intervention group improved significantly in prognosis communication skills (5.2 to 6.6 on 9-point scale, p < 0.001), usage of evidence-based prognostic tools (1/18 to 14/18 responses, p < 0.001), and prognostic accuracy (1/18 to 9/18 responses, p = 0.005). These responses were significantly different from the control group at follow-up. Of 71 charts reviewed in each group, prognosis documentation in the intervention group increased from 1/25 charts (4 %) at baseline to 8/46 charts (17 %) at follow-up (p = 0.15). No prognosis documentation was identified in the control group at either time point. Inter-group difference was significant at follow-up (p = 0.006).

CONCLUSION

We developed and implemented a novel prognosis curriculum that had significant short-term impact on the residents' knowledge and communication skills as compared to a control group. This innovative curriculum addresses an important educational gap in incorporating prognosis in the care of older adults with multimorbidity.

Current Practices and Opportunities in a Resident Clinic Regarding the Care of Older Adults with Multimorbidity

OBJECTIVES

Multimorbidity (≥2 chronic conditions) affects more than half of all older adults. The American Geriatrics Society developed and published guiding principles for the care of older adults with multimorbidity in 2012. Improved clinician training in caring for older adults with multimorbidity is needed, but it is not clear what opportunities arise within clinical encounters to apply the guiding principles or how clinicians at all stages of training currently practice in this area. This project aimed to characterize current practice and opportunities for improvement in an internal medicine residency clinic regarding the care of older adults with multimorbidity.

DESIGN

Qualitative content analysis of audio-recorded clinic visits.

SETTING AND PARTICIPANTS

Thirty clinic visits between 21 internal medicine residents and 30 of their primary care patients aged 65 and older with two or more chronic conditions were audio-recorded. Patients' mean age was 73.6, and they had on average 3.7 chronic conditions and took 12.6 medications.

MEASUREMENTS

Transcripts of the audio-recorded visit discussions were analyzed using standard techniques of qualitative content analysis to describe the content and frequency of discussions in the clinic visits related to the five guiding principles: patient preferences, interpreting the evidence, prognosis, clinical feasibility, and optimizing therapies.

RESULTS AND CONCLUSIONS

All visits except one included discussions that were thematically related to at least one guiding principle, suggesting regular opportunities to apply the guiding principles in primary care encounters with internal medicine residents. Discussions related to some guiding principles occurred much more frequently than others. Patients presented a number of opportunities to incorporate the guiding principles that the residents missed, suggesting target areas for future educational interventions.

INTRODUCTION OF SIMULATION BASED MEDICAL EDUCATION AT ADDIS ABABA UNIVERSITY COLLEGE OF HEALTH SCIENCES: EXPERIENCE AND CHALLENGE

BACKGROUND

As one of the countries in Sub-Saharan Africa with a low physician to population ratio, Ethiopia has sought to mitigate the problem by increasing the number of students enrolling in the existing medical schools. This increase in enrolment was not accompanied by expansion of clinical training venues, which has resulted in less patient contact time for each student. As part of the solution to fill the gap simulation-based teaching was introduced.

OBJECTIVE

To describe the process of introducing Simulation based medical education (SBME) at Addis Ababa University College of Health Sciences, school of medicine.

METHODS

Two rounds of intensive training was given by John Hopkins in collaboration with Medical Education partner Initiative (MEPI). to the core clinical educators to introduce them the six-step model of curriculum development for medical education and standardized patient (SP) techniques with the ultimate aim of introducing SPs in the teaching and learning process for medical students. The training included didactic and workshop elements, with group work and created complete educational modules. Each pre and post course assessment of experience and attitude were surveyed. Data was analyzed in aggregate using paired t -test to compare pre and post course means.

RESULTS

There were total of 22 faculty members participated in the first group ,the majority of whom had no prior training in curriculum development or SBME and were skeptical of the value of SBME, as evidenced in their survey responses. (3.42/5 in Likert scale 1 = least 5 = most) at the end of the course the participant were comfortable with the concept of curriculum development the rating increased to 4.45/5 (P < 0.0001) and they embraced more favorable attitudes regarding the feasibility and desirability of simulation with Likert Scale 4.01/5 to 4.51 (P < 0.0001). In the second course, there were 16 participant and the majority had no prior experience with simulation and/or SP encounters. Their Baseline attitudes among participants in the second course were more favourable than in the first course, with a mean precourse Likert score of 4.24/5. Mean post course score was 4.43/5 (p = 0.1003), which did not represent a significant increase. The largest pre/post increases were seen for questions regarding accuracy of SP portrayal of specific clinical conditions (3.93 to 4.43, p = 0.0011), and enjoyability of incorporating SP activities into curricula (4.33 to 4.73, p = 0. 0281). After the course, the faculty remained particularly sceptical of the role of SPs in grading students (3.43/5). Both courses were well received, with 95% reporting they learned what they had hoped to learn.

CONCLUSION

Training courses at CHS were successful for generating enthusiasm about simulation, and improving participant attitudes regarding the usefulness and feasibility of this educational method.

The short-term and long-term impact of a brief aging research training program for medical students

Summer training in aging research for medical students is a strategy for improving the pipeline of medical students into research careers in aging and clinical care of older adults. Johns Hopkins University has been offering medical students a summer experience of mentored research, research training, and clinical shadowing since 1994. Long-term outcomes of this program have not been described. The authors surveyed all 191 participants who had been in the program from 1994-2010 (60% female and 27% underrepresented minorities) and received a 65.8% (N = 125) response rate. The authors also conducted Google and other online searches to supplement study findings. Thirty-seven percent of those who have completed training are now in academic medicine, and program participants have authored or coauthored 582 manuscripts. Among survey respondents, 95.1% reported that participation in the Medical Student Training in Aging Research program increased their sensitivity to the needs of older adults. This program may help to build commitment among medical students to choose careers in aging.

The effect of resident duty-hours restrictions on internal medicine clerkship experiences: surveys of medical students and clerkship directors

PHENOMENON: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students' and clerkship directors' perceptions of the effects of the 2011 DHR on internal medicine clerkship students' experiences with teaching, feedback and evaluation, and patient care.

APPROACH

Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation.

FINDINGS

Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. INSIGHTS: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student-patient relationship and students' clinical skills acquisition.

Complexity in graduate medical education: a collaborative education agenda for internal medicine and geriatric medicine

Internal medicine residents today face significant challenges in caring for an increasingly complex patient population within ever-changing education and health care environments. As a result, medical educators, health care system leaders, payers, and patients are demanding change and accountability in graduate medical education (GME). A 2012 Society of General Internal Medicine (SGIM) retreat identified medical education as an area for collaboration between internal medicine and geriatric medicine. The authors first determined a short-term research agenda for resident education by mapping selected internal medicine reporting milestones to geriatrics competencies, and listing available sample learner assessment tools. Next, the authors proposed a strategy for long-term collaboration in three priority areas in clinical medicine that are challenging for residents today: (1) team-based care, (2) transitions and readmissions, and (3) multi-morbidity. The short-term agenda focuses on learner assessment, while the long-term agenda allows for program evaluation and improvement. This model of collaboration in medical education combines the resources and expertise of internal medicine and geriatric medicine educators with the goal of increasing innovation and improving outcomes in GME targeting the needs of our residents and their patients.

We could have done a better job: a qualitative study of medical student reflections on safe hospital discharge

Because safe transitions of care are critical to patient safety, it is important to prepare physician trainees to assist in patient transitions from the hospital. As part of a discharge skills workshop for medical students, a brief reflective exercise was used to understand student perceptions of discharge problems and encourage application of classroom learning. Written reflections completed before and after the workshop were analyzed qualitatively to identify barriers to discharge observed on clinical clerkships and evaluate how the discharge skills workshop influenced student understanding of safe discharges. Students also completed a quantitative evaluation of the workshop. Seventy-eight of the 96 students (81%) at the Johns Hopkins University School of Medicine who participated in the discharge skills workshop volunteered to submit their written reflections. Eighteen themes were identified within two domains (barriers to safe discharges and solutions to improve discharges). The most commonly cited barrier was the sense that the discharge was rushed or premature. Three of the barrier themes and six of the solution themes were related to the importance of communication and collaboration in safe discharges. Students reported that the reflective exercise personalized the learning experience (mean 3.27 ± 0.86 on a scale of 1 (not at all) to 4 (a lot)). Students observed barriers to safe discharges on their clerkships related to poor communication, insufficient time spent planning discharges, and lack of patient education. Brief reflection encouraged students to apply lessons learned in a didactic session to consider solutions for providing safer patient care.

How medical students learn from residents in the workplace: a qualitative study

PURPOSE

To explore what third-year medical students learn from residents and which teaching strategies are used by excellent resident teachers in their interactions with students in the clinical workplace environment.

METHOD

In this multi-institutional qualitative study between January and March 2012, the authors conducted focus groups with medical students who were midway through their third year. Qualitative analysis was used to identify themes.

RESULTS

Thirty-seven students participated. Students contributed 228 comments related to teaching methods used by residents. The authors categorized these into 20 themes within seven domains: role-modeling, focusing on teaching, creating a safe learning environment, providing experiential learning opportunities, giving feedback, setting expectations, and stimulating learning. Role-modeling, the most frequently classified method of teaching in this study, was not included in three popular "Resident-as-Teacher" (RAT) models. Strategies including offering opportunities for safe practice, involving students in the team, and providing experiential learning opportunities were not emphasized in these models either. Almost 200 comments representing the knowledge and skills students learned from residents were categorized into 33 themes within nine domains: patient care, communication, navigating the system, adaptability, functioning as a student/resident, lifelong learning, general comments, career/professional development, and medical content. Most of these areas are not emphasized in popular RAT models.

CONCLUSIONS

Residents serve as critically important teachers of students in the clinical workplace. Current RAT models are based largely on the teaching behaviors of faculty. The content and teaching strategies identified by students in this study should serve as the foundation for future RAT program development.

"A good career choice for women": female medical students' mentoring experiences: a multi-institutional qualitative study

PURPOSE

The career decisions, practice patterns, and approach to patient care of current female students, who make up close to 50% of medical school classes, will have a profound impact on the profession. This study explores the role gender plays in the mentoring experiences of female medical students.

METHOD

In 2011, the authors conducted focus groups with 48 third- and fourth-year female medical students at four U.S. medical schools. Using a template organizing style, they derived themes in an iterative process to explore female medical students' mentoring relationships and the impact of gender on those relationships.

RESULTS

The authors identified four major themes: (1) Optimal mentoring relationships are highly relational. Students emphasized shared values, trust, and a personal connection in describing ideal mentoring relationships. (2) Relational mentoring is more important than gender concordance. Students identified a desire for access to female mentors but stated that when a mentor and mentee developed a personal connection, the gender of the mentor was less important. (3) Gender-based assumptions and stereotypes affect mentoring relationships. Students described gender-based assumptions and expectations for themselves and their mentors. (4) Gender-based power dynamics influence students' thinking about mentoring. Students stated that they were concerned about how their mentors might perceive their professional decisions because of their gender, which influenced what they disclosed to male mentors and mentors in positions of power.

CONCLUSIONS

Gender appears to play a role in female medical students' expectations and experience with mentoring relationships and may influence their decision making around career planning.

Update in geriatric medicine

INTRODUCTION

With an aging population, internists will provide care to a growing number of older adults, a population at risk of developing multiple chronic medical conditions and geriatric syndromes. For this update in geriatric medicine, we highlight recent key articles focused on preventive strategies and lifestyle changes that reduce the burden of disease and functional decline in older adults.

METHODS

We identified English-language articles published between March 1, 2010 and March 31, 2011 by review of the contents of major geriatrics/general medicine journals and journal watch services including: New England Journal of Medicine, Annals of Internal Medicine, Journal of the American Medical Association, Lancet, Archives of Internal Medicine, British Medical Journal, Journal of the American Geriatrics Society, and the Journals of Gerontology. We also reviewed updates to the Cochrane database of systematic reviews and articles highlighted by the ACP Journal Club and Journal Watch. Inclusion criteria included (1) randomized controlled trials, (2) conditions exclusive or common to older adults, and (3) commonly seen in generalist practices. After abstract review, each author selected five articles, and these were reviewed again by all authors. Through multiple discussions, consensus was reached on the final articles selected for inclusion based on their quality and potential to improve the health of older patients cared for by generalists.

Implementing staff nurse geriatric education in the acute hospital setting

The implementation and evaluation of staff nurse geriatric educational interventions on medical units in an urban teaching hospital are described.

Case study: a midclerkship crisis-lessons learned from advising a medical student with career indecision

Advising medical students is a challenging task. Faculty who serve as advisors for students require specific skills and knowledge to do their jobs effectively. Career choice is one of the many complex issues about which medical students often seek assistance from a faculty advisor. The authors present a case of a third-year medical student with career indecision, with a focus on the various factors that may be influencing her thinking about career choice. Key advising principles are provided as a framework for the discussion of the case and include reflection, self-disclosure, active listening, support and advocacy, confidentiality, and problem solving. These principles were developed as part of the Advising Case Conference series of the Johns Hopkins University School of Medicine Colleges Advisory Program. Emergent themes from the case included a student's evolving professional identity, a student's distress and burnout, lifestyle considerations, and advisor bias and self-awareness. The authors propose reflective questions to enhance meaningful discussions between the advisor and student and assist in problem solving. Many of these questions, together with the key advising principles, are generalizable to a variety of advising scenarios between advisors and learners at all levels of training.

Commentary: using medical student case presentations to help faculty learn to be better advisers

The case presentation is a time-honored tradition in clinical medicine, and medical journals and national conferences have provided a forum for this type of scholarship for more than a century. Case presentations can also be used by educators as a means to understand challenging learner experiences, and by doing so, lead to advances in the practice of medical education. Medical school faculty are asked to serve in student advisor roles, yet best practices for student advising are not known. Unlike clinicians, who often discuss difficult patient cases, medical educators do not typically have opportunities to discuss challenging student cases to learn how best to support trainees. In this commentary, the authors-from the Johns Hopkins University School of Medicine Colleges Advisory Program (CAP), a longitudinal advising program with the goal of promoting personal and professional development of students-describe the novel quarterly Advisory Case Conference, where medical student cases can be confidentially presented and discussed by faculty advisors, along with relevant literature reviews, to enhance faculty advising skills for students. As medical student advising needs often vary, CAP advisors employ adult learning principles and emphasize shared responsibility between advisor and advisee as keys to successful advising. Unlike traditional clinical case conferences, the Advising Case Conference format encourages advisors to share perspectives about the cases by working in small groups to exchange ideas and role-play solutions. This model may be applicable to other schools or training programs wishing to enhance faculty advising skills.

Individualising Therapy for Older Adults with Diabetes Mellitus

The goal when treating patients with diabetes mellitus is to achieve the maximum longevity consistent with an optimal quality of life. To achieve this goal, treatment is typically focused on management of hyperglycaemic symptoms and prevention of microvascular and macrovascular complications. While appropriate for most individuals, including many older adults with robust health, this focus is often too limited for older adults facing diminished life expectancy and co-existing medical illness, frailty and disability. Creating a treatment plan that optimises health and function, and reduces the risk for morbidity and mortality, requires individualised therapy that judiciously manages symptoms and multiple competing health risks while remaining consistent with the patient's or his/her caregiver's healthcare preferences. Physicians caring for older adults with diabetes must be adept at recognising conditions commonly associated with diabetes, including the interplay with co-morbid illness, and be able to assess the patient's health status and use this information to recommend a treatment plan that is consistent with the patient's personal goals for care. The majority of older adults with diabetes will benefit from management of cardiovascular risk, including intensive management of hypertension, lipids, use of aspirin (acetylsalicylic acid) and smoking cessation, and screening for common geriatric syndromes. For a significant minority of older adults with life expectancy of >or=10 years, it is reasonable to consider intensive management of hyperglycaemia (glycosylated haemoglobin [HbA1c] target<or=7%). For frail older adults with life expectancy of <or=5 years, strategies for reducing medical burden, improving function and moderate glucose control (HbA1c approximately 8%) is reasonable and sufficient to control hyperglycaemic symptoms.

Chronic low back pain in older adults: What physicians know, what they think they know, and what they should be taught

Chronic low back pain (CLBP) is a common and debilitating problem in older adults. Little exists in the literature about primary care physicians' (PCPs') knowledge of and confidence in managing this problem. A self-administered survey was mailed to PCPs in western Pennsylvania to measure knowledge of the evaluation and treatment of common contributors to CLBP in older adults, confidence in diagnosing these contributors through physical examination, and the association between confidence levels and knowledge. The survey combined items with an ordinal scale on which PCPs ranked their confidence in detecting various contributors to CLBP (e.g., fibromyalgia) using physical examination and patient vignettes followed by multiple choice questions designed to assess knowledge. One hundred fifty-three of 634 surveys were returned (24.1%). Overall, the majority of PCPs did not feel "very confident" in their ability to diagnose any of the contributors of CLBP listed (most items <40%). PCPs felt most confident in detecting scoliosis and least confident detecting myofascial pain of the piriformis muscle. There was a wide range in the number of respondents answering all questions related to a particular topic correctly (3.9% for sacroiliac joint syndrome to 70.4% for hip osteoarthritis). There was no relationship between knowledge scores and confidence ratings (P > .05 for all comparisons). The results point to a need for more PCP education about CLBP in older adults. It also suggests that accurate needs assessment should not rely on physician confidence ratings alone.