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.

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.

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.

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.

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.

Brief Alcohol Intervention Among At-Risk Drinkers with Diabetes.

Twenty-eight patients with diabetes who screened positive for at-risk drinking were assigned to brief alcohol intervention (BAI) (n = 14) or standard care (SC) (n = 14) treatment conditions. All participants completed a baseline interview and one-, three, and six-month follow-up interviews. Across the six-month follow-up period, there was a significantly greater reduction in quantity of alcohol consumed in the BAI group. At the six-month follow-up, the BAI group had a greater reduction in quantity of alcohol consumed, percentage of heavy drinking days, and frequency of drinking. Reductions in alcohol use were associated with improved adherence in certain components of diabetes self-care behavior. The results of this study suggest that brief alcohol interventions are efficacious in reducing alcohol use among at-risk drinkers with diabetes and that reductions in alcohol use may result in some improvements in adherence to diabetes self-care behavior.

Internal medicine clerkship characteristics associated with enhanced student examination performance.

PURPOSE: To determine which internal medicine (IM) clerkship characteristics are associated with better student examination performance. METHOD: The authors collected data from 17 U.S. medical schools (1,817 students) regarding characteristics of their IM clerkships, including structural characteristics, pedagogical approaches, patient contact, and clinical teacher characteristics. Outcomes of interest were postclerkship National Board of Medical Examiners (NBME) subject examination score, United States Medical Licensing Examination (USMLE) 2 score, and change in score from USMLE 1 to 2. To examine how associations of various clerkship characteristics and examination performance may differ for students of different prior achievement, the authors categorized students into those who scored in the top (1/4) of the cohort on USMLE 1 and the bottom (1/4). The authors conducted analyses at both the school and the individual student levels. RESULTS: In school-level analyses (using a reduced four-variable model), independent variables associated with higher NBME subject examination score were more small-group hours/week and use of community-based preceptors. Greater score increase from USMLE 1 to 2 was associated with students caring for more patients/day. Several variables were associated with enhanced student examination performance at the student level. The most consistent finding was that more patients cared for per day was associated with higher examination performance. More structured learning activities were associated with higher examination scores for students with lower baseline USMLE 1 achievement. CONCLUSION: Certain clerkship characteristics are associated with better student examination performance, the most salient being caring for more patients per day.

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.

Procedural and interpretive skills of medical students: experiences and attitudes of fourth-year students.

BACKGROUND: Recent data do not exist regarding fourth-year medical students' performance of and attitudes toward procedural and interpretive skills, and how these differ from third-year students'. METHOD: Cross-sectional survey conducted in February 2006 of 122 fourth-year students from seven U.S. medical schools, compared with their responses in summer 2005. Students estimated their cumulative performance of 22 skills and reported self-confidence and perceived importance using a five-point Likert-type scale. RESULTS: The response rate was 79% (96/122). A majority reported never having performed cardioversion, thoracentesis, cardiopulmonary resuscitation, blood culture, purified protein derivative placement, or paracentesis. One fifth of students had never performed peripheral intravenous catheter insertion, phlebotomy, or arterial blood sampling. Students reported increased cumulative performance of 17 skills, increased self-confidence in five skills, and decreased perceived importance in three skills (two-sided P < .05). CONCLUSIONS: A majority of fourth-year medical students still have never performed important procedures, and a substantial minority have not performed basic procedures.

Factors associated with medical students' career choices regarding internal medicine.

CONTEXT: Shortfalls in the US physician workforce are anticipated as the population ages and medical students' interest in careers in internal medicine (IM) has declined (particularly general IM, the primary specialty serving older adults). The factors influencing current students' career choices regarding IM are unclear. OBJECTIVES: To describe medical students' career decision making regarding IM and to identify modifiable factors related to this decision making. DESIGN, SETTING, AND PARTICIPANTS: Web-based cross-sectional survey of 1177 fourth-year medical students (82% response rate) at 11 US medical schools in spring 2007. MAIN OUTCOME MEASURES: Demographics, debt, educational experiences, and number who chose or considered IM careers were measured. Factor analysis was performed to assess influences on career chosen. Logistic regression analysis was conducted to assess independent association of variables with IM career choice. RESULTS: Of 1177 respondents, 274 (23.2%) planned careers in IM, including 24 (2.0%) in general IM. Only 228 (19.4%) responded that their core IM clerkship made a career in general IM seem more attractive, whereas 574 (48.8%) responded that it made a career in subspecialty IM more attractive. Three factors influenced career choice regarding IM: educational experiences in IM, the nature of patient care in IM, and lifestyle. Students were more likely to pursue careers in IM if they were male (odds ratio [OR] 1.75; 95% confidence interval [CI], 1.20-2.56), were attending a private school (OR, 1.88; 95% CI, 1.26-2.83), were favorably impressed with their educational experience in IM (OR, 4.57; 95% CI, 3.01-6.93), reported favorable feelings about caring for IM patients (OR, 8.72; 95% CI, 6.03-12.62), or reported a favorable impression of internists' lifestyle (OR, 2.00; 95% CI, 1.39-2.87). CONCLUSIONS: Medical students valued the teaching during IM clerkships but expressed serious reservations about IM as a career. Students who reported more favorable impressions of the patients cared for by internists, the IM practice environment, and internists' lifestyle were more likely to pursue a career in IM.

Internal medicine clerkship directors' perceptions about student interest in internal medicine careers.

BACKGROUND: Experienced medical student educators may have insight into the reasons for declining interest in internal medicine (IM) careers, particularly general IM. OBJECTIVE: To identify factors that, according to IM clerkship directors, influence students' decisions for specialty training in IM. DESIGN: Cross-sectional national survey. PARTICIPANTS: One hundred ten institutional members of Clerkship Directors in IM. MEASUREMENTS: Frequency counts and percentages were reported for descriptive features of clerkships, residency match results, and clerkship directors' perceptions of factors influencing IM career choice at participating schools. Perceptions were rated on a five-point scale (1 = very much pushes students away from IM careers; 5 = very much attracts students toward IM careers). RESULTS: Survey response rate was 83/110 (76%); 80 answered IM career-choice questions. Clerkship directors identified three educational items attracting students to IM careers: quality of IM faculty (mean score 4.3, SD = 0.56) and IM rotation (4.1, SD = 0.67), and experiences with IM residents (3.9, SD = 0.94). Items felt most strongly to push students away from IM careers were current practice environment for internists (mean score 2.1, SD = 0.94), income (2.1, SD = 1.08), medical school debt (2.3, SD = 0.89), and work hours in IM (2.4, SD = 1.05). Factor analysis indicated three factors explaining students' career choices: value/prestige of IM, clerkship experience, and exposure to internists. CONCLUSIONS: IM clerkship directors believe that IM clerkship experiences attract students toward IM, whereas the income and lifestyle for practicing internists dissuade them. These results suggest that interventions to enhance the practice environment for IM could increase student interest in the field.