The oral case presentation: what internal medicine clinician-teachers expect from clinical clerks.

BACKGROUND: The oral case presentation (OCP) is a fundamental communication skill that frequently is taught as part of internal medicine clerkships. However, little is known about the optimal content for an OCP. PURPOSE: We hypothesized that internal medicine clinician-teachers have common expectations regarding OCPs by 3rd-year medical students. METHODS: We administered a 42-item survey to 136 internal medicine faculty members at 5 U.S. medical schools who spent at least 8 weeks as "ward attending" in the 2005-6 academic year, or spent at least 4 weeks as a "ward attending" and had an administrative role in medical education. We asked about the relative importance of 14 potential attributes in a 3rd-year medical student OCP using a 6-point Likert scale. We also asked about their expectations for the length of a new patient presentation. Mean responses from the 5 schools were compared using chi-squared, analysis of variance (ANOVA), and t testing, as appropriate. RESULTS: We received 106 responses (78% response rate). Of our respondents, 45% were hospitalists and 80% self-identified as "clinician-educators." Some aspects of the OCP were rated as more important than others (p<.001) Six items, including aspects of the history of present illness, organization, and structuring the presentation to "make a case" were rated as important or very important by more than 70% of respondents. Fewer than 10% of respondents believed that inclusion of a complete review of systems or detailed family history were important. Few differences were seen between institutions. Faculty expected that OCPs should take 9.9±5.4 min, with faculty at one institution having significantly different expectations than all others (15.9±6.4 min vs. 7.8±2.8, p<.001). CONCLUSIONS: Internal medicine clinician teachers from 5 U.S. medical schools share common expectations for OCPs.

Expectations for oral case presentations for clinical clerks: opinions of internal medicine clerkship directors.

BACKGROUND: Little is known about the expectations of undergraduate internal medicine educators for oral case presentations (OCPs). OBJECTIVE: We surveyed undergraduate internal medicine educational leaders to determine the degree to which they share the same expectations for oral case presentations. SUBJECTS: Participants were institutional members of the Clerkship Directors of Internal Medicine (CDIM). DESIGN: We included 20 questions relating to the OCP within the CDIM annual survey of its institutional members. We asked about the relative importance of specific attributes in a third-year medical student OCP of a new patient as well as its expected length. Percentage of respondents rating attributes as "very important" were compared using chi-squared analysis. RESULTS: Survey response rate was 82/110 (75%). Some attributes were more often considered very important than others (p < .001). Eight items, including aspects of the history of present illness, organization, a directed physical exam, and a prioritized assessment and plan focused on the most important problems, were rated as very important by >50% of respondents. Respondents expected the OCP to last a median of 7 minutes. CONCLUSIONS: Undergraduate internal medicine education leaders from a geographically diverse group of North American medical schools share common expectations for OCPs which can guide instruction and evaluation of this skill.

A cross-sectional measurement of medical student empathy.

BACKGROUND: Empathy is important in the physician-patient relationship. Prior studies have suggested that physician empathy may decline with clinical training. OBJECTIVE: To measure and examine student empathy across medical school years. DESIGN AND PARTICIPANTS: A cross-sectional study of students at Boston University School of Medicine in 2006. Incoming students plus each class near the end of the academic year were surveyed. MEASUREMENTS: The Jefferson Scale of Physician Empathy-Student Version (JSPE-S), a validated 20-item self-administered questionnaire with a total score ranging from 20 to 140. JSPE-S scores were controlled for potential confounders such as gender, age, anticipated financial debt upon graduation, and future career interest. RESULTS: 658 students participated in the study (81.4% of the school population). The first-year medical student class had the highest empathy scores (118.5), whereas the fourth-year class had the lowest empathy scores (106.6). Measured empathy differed between second- and third-year classes (118.2 vs 112.7, P < .001), corresponding to the first year of clinical training. Empathy appears to increase from the incoming to the first-year class (115.5 vs 118.5, P = .02). Students preferring people-oriented specialties had higher empathy scores than students preferring technology-oriented specialties (114.6 vs 111.4, P = .002). Female students were more likely than male students to choose people-oriented specialties (51.5 vs 26.9%, P < .001). Females had higher JSPE-S scores than males (116.5 vs 112.1, P < .001). Age and debt did not affect empathy scores. CONCLUSIONS: Empathy scores of students in the preclinical years were higher than in the clinical years. Efforts are needed to determine whether differences in empathy scores among the classes are cohort effects or represent changes occurring in the course of medical education. Future research is needed to confirm whether clinical training impacts empathy negatively, and, if so, whether interventions can be designed to mitigate this impact.

Disagreement between students and preceptors regarding the value of teaching behaviors for ambulatory care settings.

BACKGROUND: Medical students and preceptors commonly disagree on methods of clinical instruction in ambulatory care, although the extent of the problem is not documented. PURPOSE: The purpose is to identify disagreement and concordance between students and preceptors for teaching behaviors in ambulatory care. METHODS: We surveyed students and preceptors at 4 U.S. schools. Respondents rated 58 behaviors on two scales. Disagreement was recognized when the percentage of students and preceptors who recommended a behavior and rated it important differed by over 15% (p < .01). RESULTS: Disagreement was identified for 8 behaviors (14%). Six were valued less by students, including "watch the student perform critical tasks in history taking and other communication" (59% compared with 82%). Two behaviors were valued more by students, including "delegate responsibility to the student for the wrap up discussion with the patient" (82% compared with 61%). CONCLUSIONS: Students and preceptors disagree regarding the value of a minority of teaching behaviors. Because some are potentially important, however, early negotiation regarding their use may enhance teaching effectiveness and mutual satisfaction with learning.

Developing and implementing universal guidelines for oral patient presentation skills.

BACKGROUND: Oral case presentations are important for patient care and clinical education. Previously published attempts to improve oral presentation skills have been labor intensive and have focused primarily on medical students. DESCRIPTION: We created a multifaceted intervention to improve oral case presentations of medical students and internal medicine residents. Our intervention included a written handout with detailed instructions, pocket cards, model presentations, and multiple teaching sessions. The intervention was developed by consensus, supported by the department of medicine and endorsed by key faculty within the department. In addition to soliciting feedback from students and residents, we evaluated our intervention with prospectively acquired ratings of student oral case presentation skills recorded on a standardized evaluation for the internal medicine clerkship. EVALUATION: Students, residents, and faculty gave positive feedback, although they noted some practical obstacles to effective oral case presentations. After dissemination of the guidelines, 44% of students (42/96) were rated as "excellent" in oral presentation skills on standardized evaluations of the internal medicine clerkship, compared to 30% in the previous academic year (33/111; odds ratio [OR]=1.8, 95% confidence interval=1.04-3.3; p=.036). CONCLUSION: A multifaceted intervention improved medical student oral case presentation skills. Although participants noted barriers that need further attention, we demonstrated modest improvement in student performance.

The Value of the Subinternship: A Survey of Fourth Year Medical Students.

BACKGROUND: Although the subinternship is often regarded as an important part of many fourth year curricula it is rarely studied. PURPOSE: We aimed to understand the how well the subinternship prepared medical students to perform core clinical skills. METHODS: Senior medical students at Boston University School of Medicine rated their perception of the effectiveness of the subinternship and "medical school overall" in preparing them to perform core clinical skills using a written survey. RESULTS: Overall, 69% (101) of students responded. Students believe that the subinternship prepares them to perform most key skills involved in day-to-day medical care. However, students feel less prepared by either their subinternship or overall medical school experience to carry out some complex patient communication skills including delivering "bad news" and discussing endof- life wishes. CONCLUSIONS: The subinternship appears to be effective in preparing students for many of the challenges they will face as an intern and beyond. However, students identified several complex communication skills that could be addressed in part by the subinternship for which they felt unprepared. Student learning would likely be enhanced by creating a longitudinal program to teach these higher-level communication skills during medical school and by integrating practice and feedback of these skills into the subinternship.