Perception of Medical Student Mistreatment: Does Specialty Matter?

PURPOSE: Medical student mistreatment is pervasive, yet whether all physicians have a shared understanding of the problem is unclear. The authors presented professionally designed trigger videos to physicians from 6 different specialties to determine if they perceive mistreatment and its severity similarly. METHOD: From October 2016 to August 2018, resident and attending physicians from 10 U.S. medical schools viewed 5 trigger videos showing behaviors that could be perceived as mistreatment. They completed a survey exploring their perceptions. The authors compared perceptions of mistreatment across specialties and, for each scenario, evaluated the relationship between specialty and perception of mistreatment. RESULTS: Six-hundred fifty resident and attending physicians participated. There were statistically significant differences in perception of mistreatment across specialties for 3 of the 5 scenarios: aggressive questioning (range, 74.1%-91.2%), negative feedback (range, 25.4%-63.7%), and assignment of inappropriate tasks (range, 5.5%-25.5%) (P ≤ .001, for all). After adjusting for gender, race, professional role, and prior mistreatment, physicians in surgery viewed 3 scenarios (aggressive questioning, negative feedback, and inappropriate tasks) as less likely to represent mistreatment compared with internal medicine physicians. Physicians from obstetrics-gynecology and "other" specialties perceived less mistreatment in 2 scenarios (aggressive questioning and negative feedback), while family physicians perceived more mistreatment in 1 scenario (negative feedback) compared with internal medicine physicians. The mean severity of perceived mistreatment on a 1 to 7 scale (7 most serious) also varied statistically significantly across the specialties for 3 scenarios: aggressive questioning (range, 4.4-5.4; P < .001), ethnic insensitivity (range, 5.1-6.1; P = .001), and sexual harassment (range, 5.5-6.3; P = .004). CONCLUSIONS: Specialty was associated with differences in the perception of mistreatment and rating of its severity. Further investigation is needed to understand why these perceptions of mistreatment vary among specialties and how to address these differences.

Determining Grades in the Internal Medicine Clerkship: Results of a National Survey of Clerkship Directors.

PURPOSE: Trust in and comparability of assessments are essential in clerkships in undergraduate medical education for many reasons, including ensuring competency in clinical skills and application of knowledge important for the transition to residency and throughout students' careers. The authors examined how assessments are used to determine internal medicine (IM) core clerkship grades across U.S. medical schools. METHODS: A multisection web-based survey of core IM clerkship directors at 134 U.S. medical schools with membership in the Clerkship Directors in Internal Medicine was conducted in October through November 2018. The survey included a section on assessment practices to characterize current grading scales used, who determines students' final clerkship grades, the nature/type of summative assessments, and how assessments are weighted. Respondents were asked about perceptions of the influence of the National Board of Medical Examiners (NBME) Medicine Subject Examination (MSE) on students' priorities during the clerkship. RESULTS: The response rate was 82.1% (110/134). There was considerable variability in the summative assessments and their weighting in determining final grades. The NBME MSE (91.8%), clinical performance (90.9%), professionalism (70.9%), and written notes (60.0%) were the most commonly used assessments. Clinical performance assessments and the NBME MSE accounted for the largest percentage of the total grade (on average 52.8% and 23.5%, respectively). Eighty-seven percent of respondents were concerned that students' focus on the NBME MSE performance detracted from patient care learning. CONCLUSIONS: There was considerable variability in what IM clerkships assessed and how those assessments were translated into grades. The NBME MSE was a major contributor to the final grade despite concerns about the impact on patient care learning. These findings underscore the difficulty in comparing learners across institutions and serve to advance discussions for how to improve accuracy and comparability of grading in the clinical environment.

A National Survey of Undergraduate Clinical Education in Internal Medicine.

BACKGROUND: In the present milieu of rapid innovation in undergraduate medical education at US medical schools, the current structure and composition of clinical education in Internal Medicine (IM) is not clear. OBJECTIVE: To describe the current composition of undergraduate clinical education structure in IM. DESIGN: National annual Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey. PARTICIPANTS: One hundred twenty-nine clerkship directors at all Liaison Committee on Medical Education accredited US medical schools with CDIM membership as of September 1, 2017. MAIN MEASURES: IM core clerkship and post-core clerkship structure descriptions, including duration, educational models, inpatient experiences, ambulatory experiences, and requirements. KEY RESULTS: The survey response rate was 83% (107/129). The majority of schools utilized one core IM clerkship model (67%) and continued to use a traditional block model for a majority of their students (84%). Overall 26% employed a Longitudinal Integrated Clerkship model and 14% employed a shared block model for some students. The mean inpatient duration was 7.0 ± 1.7 weeks (range 3-11 weeks) and 94% of clerkships stipulated that students spend some inpatient time on general medicine. IM-specific ambulatory experiences were not required for students in 65% of IM core clerkship models. Overall 75% of schools did not require an advanced IM clinical experience after the core clerkship; however, 66% of schools reported a high percentage of students (> 40%) electing to take an IM sub-internship. About half of schools (48%) did not require overnight call or night float during the clinical IM sub-internship. CONCLUSIONS: Although there are diverse core IM clerkship models, the majority of IM core clerkships are still traditional block models. The mean inpatient duration is 7 weeks and 65% of IM core clerkship models did not require IM-specific ambulatory education.

Clinical Reasoning Education at US Medical Schools: Results from a National Survey of Internal Medicine Clerkship Directors.

BACKGROUND: Recent reports, including the Institute of Medicine's Improving Diagnosis in Health Care, highlight the pervasiveness and underappreciated harm of diagnostic error, and recommend enhancing health care professional education in diagnostic reasoning. However, little is known about clinical reasoning curricula at US medical schools. OBJECTIVE: To describe clinical reasoning curricula at US medical schools and to determine the attitudes of internal medicine clerkship directors toward teaching of clinical reasoning. DESIGN: Cross-sectional multicenter study. PARTICIPANTS: US institutional members of the Clerkship Directors in Internal Medicine (CDIM). MAIN MEASURES: Examined responses to a survey that was emailed in May 2015 to CDIM institutional representatives, who reported on their medical school's clinical reasoning curriculum. KEY RESULTS: The response rate was 74% (91/123). Most respondents reported that a structured curriculum in clinical reasoning should be taught in all phases of medical education, including the preclinical years (64/85; 75%), clinical clerkships (76/87; 87%), and the fourth year (75/88; 85%), and that more curricular time should be devoted to the topic. Respondents indicated that most students enter the clerkship with only poor (25/85; 29%) to fair (47/85; 55%) knowledge of key clinical reasoning concepts. Most institutions (52/91; 57%) surveyed lacked sessions dedicated to these topics. Lack of curricular time (59/67, 88%) and faculty expertise in teaching these concepts (53/76, 69%) were identified as barriers. CONCLUSIONS: Internal medicine clerkship directors believe that clinical reasoning should be taught throughout the 4 years of medical school, with the greatest emphasis in the clinical years. However, only a minority reported having teaching sessions devoted to clinical reasoning, citing a lack of curricular time and faculty expertise as the largest barriers. Our findings suggest that additional institutional and national resources should be dedicated to developing clinical reasoning curricula to improve diagnostic accuracy and reduce diagnostic error.

Development of a Longitudinal Integrated Clerkship at The Warren Alpert Medical School of Brown University.

The Warren Alpert Medical School of Brown University is introducing a longitudinal integrated clerkship for third year students in the Primary Care-Population Medicine Program as an alternative to more traditional clerkship models. In developing the longitudinal integrated clerkship, program faculty incorporated a historical perspective of medical education, modern knowledge about students' development of clinical skills, and educational science as it relates to faculty development and learner evaluation. The longitudinal integrated clerkship is being tailored to the fit the Brown University system; as such, it will be unique in its attention to population medicine, including its exposure of students to several distinct health care systems within a single geographic region, and integration of clinical training with completion of a Master's in Population Medicine.

Antibiotic resistance patterns of bacteria causing urinary tract infections in the elderly living in nursing homes versus the elderly living at home: an observational study.

BACKGROUND: Antibiotic resistance is a problem in nursing homes. Presumed urinary tract infections (UTI) are the most common infection. This study examines urine culture results from elderly patients to see if specific guidelines based on gender or whether the patient resides in a nursing home (NH) are warranted. METHODS: This is a cross sectional observation study comparing urine cultures from NH patients with urine cultures from patients in the same age group living in the community. RESULTS: There were 232 positive urine cultures in the NH group and 3554 in the community group. Escherichia coli was isolated in 145 urines in the NH group (64%) and 2275 (64%) in the community group. There were no clinically significant differences in resistance. Combined, there were 3016 positive urine cultures from females and 770 from males. Escherichia coli was significantly more common in females 2120 (70%) than in males 303 (39%) (p < 0.05). Enterococcus faecalis was significantly less common in females 223 (7%) than males 137 (18%) (p < 0.05). For females, there were lower resistance rates to ciprofloxacin among Escherichia coli (7% vs 12%; p < 0.05) and to mecillinam among Proteus mirabilis (3% vs 12%; p < 0.05). CONCLUSIONS: Differences in resistance rates for patients in the nursing home do not warrant separate recommendations for empiric antibiotic therapy, but recommendations based on gender seem warranted.

Content and timing of feedback and reflection: a multi-center qualitative study of experienced bedside teachers.

BACKGROUND: Competency-based medical education increasingly recognizes the importance of observation, feedback, and reflection for trainee development. Although bedside rounds provide opportunities for authentic workplace-based implementation of feedback and team-based reflection strategies, this relationship has not been well described. The authors sought to understand the content and timing of feedback and team-based reflection provided by bedside teachers in the context of patient-centered bedside rounds. METHODS: The authors conducted a thematic analysis qualitative study using transcripts from audio-recorded, semi-structured telephone interviews with internal medicine attending physicians (n= 34) identified as respected bedside teachers from 10 academic US institutions (2010-2011). RESULTS: Half of the respondents (50%) were associate/full professors, with an average of 14 years of academic experience. In the context of bedside encounters, bedside teachers reported providing feedback on history-taking, physical-examination, and case-presentation skills, patient-centered communication, clinical decision-making, leadership, teaching skills, and professionalism. Positive feedback about physical-exam skills or clinical decision-making occurred during encounters, positive or constructive team-based feedback occurred immediately following encounters, and individualized constructive feedback occurred in one-on-one settings following rounding sessions. Compared to less frequent, emotionally-charged events, bedside teachers initiated team-based reflection on commonplace "teachable moments" related to patient characteristics or emotions, trainee actions and emotions, and attending physician role modeling. CONCLUSIONS: Bedside teachers use bedside rounds as a workplace-based method to provide assessment, feedback, and reflection, which are aligned with the goals of competency-based medical education. Embedded in patient-centered activities, clinical teachers should be encouraged to incorporate these content- and timing-related feedback and reflection strategies into their bedside teaching.

Lifestyle factors and primary care specialty selection: comparing 2012-2013 graduating and matriculating medical students' thoughts on specialty lifestyle.

PURPOSE: To compare how first-year (MS1) and fourth-year students (MS4) ascribe importance to lifestyle domains and specialty characteristics in specialty selection, and compare students' ratings with their primary care (PC) interest. METHOD: In March 2013, MS4s from 11 U.S. MD-granting medical schools were surveyed. Using a five-point Likert-type scale (1 = not important at all; 5 = extremely important), respondents rated the importance of 5 lifestyle domains and 21 specialty selection characteristics. One-way analysis of variance was used to assess differences by PC interest among MS4s. Using logistic regression, ratings from MS4s were compared with prior analyses of ratings by MS1s who matriculated to the same 11 schools in 2012. RESULTS: The response rate was 57% (965/1,701). MS4s, as compared with MS1s, rated as more important to good lifestyle: time off (4.3 versus 4.0), schedule control (4.2 versus 3.9), and financial compensation (3.4 versus 3.2). More MS4s than MS1s selected "time-off" (262/906 [30%] versus 136/969 [14%]) and "control of work schedule" (169/906 [19%] versus 146/969 [15%]) as the most important lifestyle domains. In both classes, PC interest was associated with higher ratings of working with the underserved and lower ratings of prestige and salary. CONCLUSIONS: In the 2012-2013 academic year, matriculating students and graduating students had similar perceptions of lifestyle and specialty characteristics associated with PC interest. Graduating students placed more importance on schedule control and time off than matriculating students. Specialties should consider addressing a perceived lack of schedule control or inadequate time off to attract students.

A simple intervention to reduce inappropriate ciprofloxacin prescribing in the emergency department.

BACKGROUND: According to Norwegian guidelines for antibiotic use in primary care, ciprofloxacin is reserved for complicated urinary tract infections (UTI). Despite these recommendations, ciprofloxacin use has increased in Norway in recent years. We aimed to reduce inappropriate ciprofloxacin prescribing in the emergency department. METHODS: An intervention study was performed by removing ciprofloxacin from the local antibiotic formulary and including a suggestion list for antibiotic use with all point of care urine dipstick testing in an emergency department. An emergency department in the neighbouring county served as the control. Prescriptions for UTI were registered 1 y prior to and 1 y after the intervention. RESULTS: In the targeted emergency department, there was a significant (p < 0.0001) reduction in ciprofloxacin prescribing for cystitis, while the use of mecillinam increased (p = 0.042). In the control department, prescribing of ciprofloxacin doubled (p < 0.0001). CONCLUSIONS: An intervention based on a therapy suggestion list and on limiting the availability of ciprofloxacin in the local formulary, resulted in treatment more in line with national guidelines by reducing ciprofloxacin and increasing mecillinam prescribing.

Identifying and overcoming the barriers to bedside rounds: a multicenter qualitative study.

PURPOSE: The use of bedside rounds in teaching hospitals has declined, despite recommendations from educational leaders to promote this effective teaching strategy. The authors sought to identify reasons for the decrease in bedside rounds, actual barriers to bedside rounds, methods to overcome trainee apprehensions, and proposed strategies to educate faculty. METHOD: A qualitative inductive thematic analysis using transcripts from audio-recorded, semistructured telephone interviews with a purposive sampling of 34 inpatient attending physicians from 10 academic U.S. institutions who met specific inclusion criteria for "bedside rounds" was performed in 2010. Main outcomes were themes pertaining to barriers, methods to overcome trainee apprehensions, and strategies to educate faculty. Quotations highlighting themes are reported. RESULTS: Half of respondents (50%) were associate or full professors, averaging 14 years in academic medicine. Primary reasons for the perceived decline in bedside rounds were physician- and systems related, although actual barriers encountered related to systems, time, and physician-specific issues. To address resident apprehensions, six themes were identified: build partnerships, create safe learning environments, overcome with experience, make bedside rounds educationally worthwhile, respect trainee time, and highlight positive impact on patient care. Potential strategies for educating faculty were identified, most commonly faculty development initiatives, divisional/departmental culture change, and one-on-one shadowing opportunities. CONCLUSIONS: Bedside teachers encountered primarily systems- and time-related barriers and overcame resident apprehensions by creating a learner-oriented environment. Strategies used by experienced bedside teachers can be used for faculty development aimed at promoting bedside rounds.

Tobacco cessation among low-income smokers: motivational enhancement and nicotine patch treatment.

INTRODUCTION: Despite decades of tobacco use decline among the general population in the United States, tobacco use among low-income populations continues to be a major public health concern. Smoking rates are higher among individuals with less than a high school education, those with no health insurance, and among individuals living below the federal poverty level. Despite these disparities, smoking cessation treatments for low-income populations have not been extensively tested. In the current study, the efficacy of 2 adjunctive smoking cessation interventions was evaluated among low-income smokers who were seen in a primary care setting. METHODS: A total of 846 participants were randomly assigned either to motivational enhancement treatment plus brief physician advice and 8 weeks of nicotine replacement therapy (NRT) or to standard care, which consisted of brief physician advice and 8 weeks of NRT. Tobacco smoking abstinence was at 1, 2, 6, and 12 months following baseline. RESULTS: The use of the nicotine patch, telephone counseling, and positive decisional balance were predictive of increased abstinence rates, and elevated stress levels and temptation to smoke in both social/habit and negative affect situations decreased abstinence rates across time. Analyses showed intervention effects on smoking temptations, length of patch use, and number of telephone contacts. Direct intervention effects on abstinence rates were not significant, after adjusting for model predictors and selection bias due to perirandomization attrition. CONCLUSIONS: Integrating therapeutic approaches that promote use of and adherence to medications for quitting smoking and that target stress management and reducing negative affect may enhance smoking cessation among low-income smokers.

The value of bedside rounds: a multicenter qualitative study.

BACKGROUND: Bedside rounds have decreased on teaching services, raising concern about trainees' clinical skills and patient-physician relationships. PURPOSE: We sought to identify recognized bedside teachers' perceived value of bedside rounds to assist in the promotion of bedside rounds on teaching services. METHODS: Authors used a grounded theory, qualitative study design of telephone semistructured interviews with bedside teachers (n = 34) from 10 U.S. institutions (2010-2011). Main outcomes were characteristics of participants, themes pertaining to the perceived value of bedside rounds, and quotations highlighting each respective theme. RESULTS: The mean years in academic medicine was 13.7, and 51% were associate or full professors. Six main themes emerged: (a) skill development for learners (e.g., physical examination, communication, and clinical decision-making skills); (b) observation and feedback; (c) role-modeling; (d) team building among trainees, attending, and patient; (e) improved patient care delivery through combined clinical decision-making and team consensus; and (f) the culture of medicine as patient-centered care, which was embodied in all themes. CONCLUSIONS: Bedside teachers identify potential benefits of bedside rounds, many of which align with national calls to change our approach to medical education. The practice of bedside rounds enables activities essential to high-quality patient care and education.

Primary care, the ROAD less traveled: what first-year medical students want in a specialty.

PURPOSE: Medical students are increasingly choosing non-primary-care specialties. Students consider lifestyle in selecting their specialty, but how entering medical students perceive lifestyle is unknown. This study investigates how first-year students value or rate lifestyle domains and specialty-selection characteristics and whether their ratings vary by interest in primary care (PC). METHOD: During the 2012-2013 academic year, the authors conducted a cross-sectional survey of first-year medical students from 11 MD-granting medical schools. Using a five-point Likert-type scale (1 = not important at all; 5 = extremely important), respondents rated the importance of 5 domains of good lifestyle and 21 characteristics related to specialty selection. The authors classified students into five groups by PC interest and assessed differences by PC interest using one-way analysis of variance. RESULTS: Of 1,704 participants, 1,020 responded (60%). The option "type of work I am doing" was the highest-rated lifestyle domain (mean 4.8, standard deviation [SD] 0.6). "Being satisfied with the job" was the highest-rated specialty-selection characteristic (mean 4.7, SD 0.5). "Availability of practice locations in rural areas" was rated lowest (mean 2.0, SD 1.1). As PC interest decreased, the importance of "opportunities to work with underserved populations" also decreased, but importance of "average salary earned" increased (effect sizes of 0.98 and 0.94, respectively). CONCLUSIONS: First-year students valued enjoying work. The importance of financial compensation was inversely associated with interest in PC. Examining the determinants of enjoyable work may inform interventions to help students attain professional fulfillment in PC.

The art of bedside rounds: a multi-center qualitative study of strategies used by experienced bedside teachers.

BACKGROUND: Medical educators believe bedside rounds are effective for the delivery of patient-centered care, and are necessary in helping trainees acquire competence in clinical care. Although recommendations for bedside rounds have been reported, a recent, systematic assessment of strategies used by current-day bedside teachers was needed to advance knowledge of this teaching method. OBJECTIVE: To identify and understand bedside teachers' 1) preparatory steps, 2) patient selection, and 3) role allocation during the process of bedside rounds. DESIGN: A qualitative inductive thematic analysis using transcripts from audio-recorded, semi-structured telephone interviews. PARTICIPANTS: Internal medicine physicians (n = 34) who perform bedside rounds from ten academic US institutions (2010-2011). APPROACH: A purposive sampling strategy was utilized to identify physicians who were active inpatient attending physicians and met specific inclusion criteria for "bedside rounds." A total of 34 interviews were completed, and each was recorded and transcribed verbatim. A thematic analysis extracted key themes pertaining to the three objectives. KEY RESULTS: Most respondents (51 %) were associate or full professors, with an average of 14 years of academic experience. Attending physicians prepared using trainee-specific, patient-specific and disease-specific information, while also mentally preparing for bedside rounds. They sought trainee buy-in and learning objectives, reviewed expectations and methods to ensure patient comfort, and provided early guidance with bedside encounters. Patients were selected if they required immediate care, were new to the service, or had a high educational value, while patients were deferred if unavailable, unwilling, or unable to communicate. The team members' roles during bedside rounds varied, with trainees being given graduated autonomy with increased experience. CONCLUSIONS: Bedside teachers' methods for preparation, patient selection, and role allocation during bedside rounds enhance trainees' education within the workplace. Strategies used by experienced bedside teachers can be used for faculty development efforts aimed at promoting this activity.

Postinterview communication between military residency applicants and training programs.

PURPOSE: Each year military medical students participate in a separate, military match culminating with the Joint Services Graduate Medical Education Selection Board (JSGMESB). Prior studies have explored postinterview communication that occurs during the National Resident Matching Program (NRMP), but not during the JSGMESB. We examined the frequency and nature of communication during the JSGMESB and compared it with the NRMP. METHODS: Cross-sectional survey study of senior students conducted at Uniformed Services University of the Health Sciences (USU) and seven civilian U.S. medical schools during March to May 2010. Respondents answered questions regarding communication with residency programs during the match. RESULTS: Significantly fewer USU respondents communicated with programs compared with the civilian cohort (54.1% vs. 86.4%, p < 0.01). Specific inquiries regarding rank order were more commonly experienced by USU respondents compared with civilians (17.5% vs. 4.8%, p = 0.02). USU respondents found postinterview communication both helpful (41.3%) and stressful (41.3%). 11.1% of USU respondents indicated that they moved a program higher on their final rank lists because of further communication with these programs. CONCLUSIONS: Postinterview communication during the JSGMESB process is less common and less stressful than that reported in the NRMP. USU respondents are more likely to be asked directly about their rank list and occasionally do change their lists. Uniform guidance mirroring the NRMP's dealing with direct inquiries about rank lists could potentially improve the process.

The prevalence and nature of postinterview communications between residency programs and applicants during the match.

PURPOSE: To examine the frequency and nature of postinterview communications between programs and applicants during the National Resident Matching Program (NRMP) Main Residency Match. METHOD: The authors surveyed senior medical students at seven U.S. medical schools about postinterview communications with residency programs during the 2010 Match and analyzed the data. RESULTS: The response rate was 68.2% (564/827). Among respondents, 86.4% reported communicating with residency programs. Most (59.9%) reported telling more than one program they would rank it highly; 1.1% reported telling more than one they would rank it first. Students reported that programs told them they would be "ranked to match" (34.6%), be "ranked highly" (52.8%), or "fit well" (76.2%). Almost one-fifth (18.6 %) reported feeling assured by a program that they would match there but did not despite ranking that program first; 23.4% reported altering their rank order list based on communications with programs. In multivariate analysis, applicants to more competitive specialties were less likely to report being told they would be "ranked to match" (relative risk [RR] 0.72, 95% confidence interval [CI] 0.52-0.99). Applicants were more likely to report being told that they would be "ranked to match" if they received honors in the specialty clerkship (RR 1.39, 95% CI 1.10-1.77) or were members of Alpha Omega Alpha (RR 1.72, 95% CI 1.37-2.17). CONCLUSIONS: Reports of nonbinding communications with programs were frequent. Students should be advised to interpret any comments made by programs cautiously. Reported violations of the NRMP's Match Participation Agreement were uncommon.

Antibiotic prescribing in nursing homes in an area with low prevalence of antibiotic resistance: compliance with national guidelines.

OBJECTIVE: To examine antibiotic prescribing in nursing homes and determine to what degree the prescribing was in accordance with the national guidelines for antibiotic prescribing. DESIGN: Retrospective examination of patients' records who were prescribed antibiotics in the period 1 March 2007 to 28 February 2008. SETTING AND PATIENTS: Patients residing in the nursing homes of Arendal, Norway. MAIN OUTCOME MEASURES: Choice of antibiotic in respect of the recommendations in the national guidelines for antibiotic prescribing. RESULTS: A total of 714 antibiotic courses were prescribed to 327 patients yielding a prevalence of 6.6%. Compliant prescribing was 77% for urinary tract infections (UTI), 79% for respiratory tract infections (RTI), and 76% for skin and soft tissue infections (SSTI). Ciprofloxacin was responsible for 63% of non-compliant prescribing. On the respite wards there was a higher rate of total prescribing, non-compliant prescribing, and prescribing by physicians employed at the local hospital. CONCLUSION: Guidelines for antibiotic use must be implemented actively and efforts to improve antibiotic prescribing in nursing homes must be aimed at both nursing home and hospital physicians.

Bayes' theorem and the physical examination: probability assessment and diagnostic decision making.

PURPOSE: To determine how examination findings influence the probability assessment and diagnostic decision making of third- and fourth-year medical students, internal medicine residents, and academic general internists. METHOD: In a 2008 cross-sectional, Web-based survey, participants from three medical schools were asked questions about their training and eight examination scenarios representing four conditions. Participants were given literature-derived preexamination probabilities for each condition and were asked to (1) estimate postexamination probabilities (post-EPs) and (2) select a diagnostic choice (report that condition is present, order more tests, or report that condition is absent). Participants' inverse transformed logit (ITL) mean post-EPs were compared with corresponding literature-derived post-EPs. RESULTS: Of 906 individuals invited to participate, 684 (75%) submitted a completed survey. In two of four scenarios with positive findings, the participants' ITL mean post-EPs were significantly less than corresponding literature-derived post-EP point estimates (P<.001 for each). In three of four scenarios with negative findings, ITL mean post-EPs were significantly greater than corresponding literature-derived post-EP point estimates (P<.001 for each). In the four scenarios with positive findings, 17% to 38% of participants ordered more diagnostic tests when the literature indicated a >85% probability that the condition was present. In the four scenarios with largely negative findings, 70% to 85% chose to order diagnostic tests to further reduce diagnostic uncertainty. CONCLUSIONS: All three groups tended to similarly underestimate the impact of examination findings on condition probability assessment, especially negative findings, and often ordered more tests when probabilities indicated that additional testing was unnecessary.

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.

Almost internists: analysis of students who considered internal medicine but chose other fields.

PURPOSE: Medical students' career choices affect health care. To understand how to increase the number of students who choose careers in internal medicine (IM), students who seriously considered IM but chose another field ("Switchers") and those who rejected IM ("Never Considered") were compared with those who chose IM ("Choosers"). METHOD: Fourth-year medical students from 11 U.S. institutions were surveyed about demographics, medical school educational experiences, and aspects of the specialty of IM. Univariate analysis and multivariate logistic regression models examined associations between student characteristics and classification as Switchers, Choosers, and Never Considered. RESULTS: A total of 1,177 students completed the survey (82% response rate). There were 274 (23%) Choosers, 398 (34%) Switchers, and 499 (43%) Never Considered. The authors' models explained over 80% of variance in these three career choice classification groups. For most responses, an increasingly favorable gradient from Never Considered to Choosers was observed. Multivariate analysis revealed six items that were associated with higher probability of choosing IM: types of patients internists see, timing of career decision, interest groups, intellectual challenge, satisfaction among internists, and the core IM clerkship. CONCLUSIONS: Several potentially modifiable educational experiences and aspects of IM distinguished Switchers from the other two groups. The percentage of variance explained by group suggests that these findings identify important underpinnings of career decisions. These items also suggest ways that educational experiences and aspects of the specialty could be redesigned by academicians and policy makers to improve the attractiveness of IM careers.