Teaching Medical Students to Help Patients Manage Their Weight: Outcomes of an Eight-School Randomized Controlled Trial.

BACKGROUND: Given the rising rates of obesity there is a pressing need for medical schools to better prepare students for intervening with patients who have overweight or obesity and for prevention efforts. OBJECTIVE: To assess the effect of a multi-modal weight management curriculum on counseling skills for health behavior change. DESIGN: A pair-matched, group-randomized controlled trial (2015-2020) included students enrolled in eight U.S. medical schools randomized to receive either multi-modal weight management education (MME) or traditional weight management education (TE). SETTING/PARTICIPANTS: Students from the class of 2020 (N=1305) were asked to participate in an objective structured clinical examination (OSCE) focused on weight management counseling and complete pre and post surveys. A total of 70.1% of eligible students (N=915) completed the OSCE and 69.3% (N=904) completed both surveys. INTERVENTIONS: The MME implemented over three years included a web-based course, a role-play classroom exercise, a web-patient encounter with feedback, and an enhanced clerkship experience with preceptors trained in weight management counseling (WMC). Counseling focused on the 5As (Ask, Advise, Assess, Assist, Arrange) and patient-centeredness. MEASUREMENTS: The outcome was student 5As WMC skills assessed using an objective measure, an OSCE, scored using a behavior checklist, and a subjective measure, student self-reported skills for performing the 5As. RESULTS: Among MME students who completed two of three WMC components compared to those who completed none, exposure was significantly associated with higher OSCE scores and self-reported 5A skills. LIMITATIONS: Variability in medical schools requiring participation in the WMC curriculum. CONCLUSIONS: This trial revealed that medical students struggle with delivering weight management counseling to their patients who have overweight or obesity. Medical schools, though restrained in adding curricula, should incorporate should incorporate multiple WMC curricula components early in medical student education to provide knowledge and build confidence for supporting patients in developing individualized plans for weight management. NIH TRIAL REGISTRY NUMBER: R01-194787.

The Community Preceptor Crisis: Recruiting and Retaining Community-Based Faculty to Teach Medical Students-A Shared Perspective From the Alliance for Clinical Education.

ISSUE: Community-based instruction is invaluable to medical students, as it provides "real-world" opportunities for observing and following patients over time while refining history taking, physical examination, differential diagnosis, and patient management skills. Community-based ambulatory settings can be more conducive to practicing these skills than highly specialized, academically based practice sites. The Association of American Medical Colleges and other national medical education organizations have expressed concern about recruitment and retention of preceptors to provide high-quality educational experiences in community-based practice sites. These concerns stem from constraints imposed by documentation in electronic health records; perceptions that student mentoring is burdensome resulting in decreased clinical productivity; and competition between allopathic, osteopathic, and international medical schools for finite resources for medical student experiences. EVIDENCE: In this Alliance for Clinical Education position statement, we provide a consensus summary of representatives from national medical education organizations in 8 specialties that offer clinical clerkships. We describe the current challenges in providing medical students with adequate community-based instruction and propose potential solutions. IMPLICATIONS: Our recommendations are designed to assist clerkship directors and medical school leaders overcome current challenges and ensure high-quality, community-based clinical learning opportunities for all students. They include suggesting ways to orient community clinic sites for students, explaining how students can add value to the preceptor's practice, focusing on educator skills development, recognizing preceptors who excel in their role as educators, and suggesting forms of compensation.

Geriatric palliative care: do medical students' narrative reflections after a hospice clinical experience link to geriatric competencies?

Since the Association of American Medical Colleges geriatric competencies were released, educators are striving to incorporate them into medical student curricula. The purpose of this study is to examine medical students' reflections after an interdisciplinary, hospice staff-precepted clinical experience, and whether these reflections relate to the geriatric competencies which focus on palliative care. From July 2010 to June 2011, 155 2nd- and 3rd-year medical students participated in a required, half-day hospice experience, with 120 (77%) submitting narrative reflections for analysis. The narratives were analyzed using the constant comparative method associated with grounded theory, followed by consensus-building in an iterative process, to identify themes. Six themes were identified from the analysis of student narratives: demonstrating a new or expanded knowledge of hospice care (79%, 95/120), developing new insights about self and others (74%, 89/120), changing attitudes toward hospice care (63%, 76/120), linking patient needs with appropriate team members (43%, 52/120), understanding patient goals of care (43%, 51/120), and discussing palliative care as a treatment option (27%, 32/120). The authors conclude that a brief, interdisciplinary, hospice staff-precepted clinical experience is an effective model to inspire medical students to reflect on geriatric palliative care. Students clearly reflected on the geriatric palliative care competencies of symptom assessment and management, and gained insight into the role of the hospice team members and how hospice care can be a positive treatment option. Future educators should think about building on this type of high impact learning experience, and developing items to measure application of knowledge gained.

Opportunities and challenges in integrating electronic health records into undergraduate medical education: a national survey of clerkship directors.

BACKGROUND: Few studies have reported on the utilization and the effect of electronic health records on the education of medical students. PURPOSE: The purpose of this study was to describe the current use of electronic health records by medical students in the United States and explore the opportunities and challenges of integrating electronic health records into daily teaching of medical students. METHODS: A survey with 24 questions regarding the use of electronic health records by medical students was developed by the Alliance for Clinical Educators and sent to clerkship directors across the United States. Both quantitative and qualitative responses were collected and analyzed to determine current access to and use of electronic health records by medical students. RESULTS: This study found that an estimated 64% of programs currently allow student use of electronic health records, of which only two thirds allowed students to write notes within the electronic record. Overall, clerkship directors' opinions on the effects of electronic health records on medical student education were neutral, and despite acknowledging many advantages to electronic health records, there were many concerns raised regarding their use in education. CONCLUSIONS: Medical students are using electronic health records at higher rates than physicians in practice. Although this is overall reassuring, educators have to be cautious about the limitations being placed on student's documentation in electronic health records as this can potentially have consequences on their training, and they need to explore ways to maximize the benefits of electronic health records in medical education.

Medical student documentation in electronic health records: a collaborative statement from the Alliance for Clinical Education.

PURPOSE: The electronic health record (EHR) is an important advancement in health care. It facilitates improvement of health care delivery and coordination of care, but it creates special challenges for student education. This article represents a collaborative effort of the Alliance for Clinical Education (ACE), a multidisciplinary group formed in 1992. ACE recognizes the importance of medical student participation in patient care including the ability of documentation. This article proposes guidelines that can be used by educators to establish expectations on medical student documentation in EHRs. SUMMARY: To provide the best education for medical students in the electronic era, ACE proposes to use the following as practice guidelines for medical student documentation in the EHR: (a) Students must document in the patient's chart and their notes should be reviewed for content and format, (b) students must have the opportunity to practice order entry in an EHR--in actual or simulated patient cases--prior to graduation, (c) students should be exposed to the utilization of the decision aids that typically accompany EHRs, and (d) schools must develop a set of medical student competencies related to charting in the EHR and state how they would evaluate it. This should include specific competencies to be documented at each stage, and by time of graduation. In addition, ACE recommends that accreditation bodies such as the Liaison Committee for Medical Education utilize stronger language in their educational directives standards to ensure compliance with educational principles. This will guarantee that the necessary training and resources are available to ensure that medical students have the fundamental skills for lifelong clinical practice. CONCLUSIONS: ACE recommends that medical schools develop a clear set of competencies related to student in the EHR which medical students must achieve prior to graduation in order to ensure they are ready for clinical practice.

Enhancing Examination Success: the Cumulative Benefits of Self-Assessment Questions and Virtual Patient Cases.

Purpose: Research on the learning benefits of the feedback-rich formative assessment environment of virtual patient cases (VPCs) has largely been limited to single institutions and focused on discrete clinical skills or topical knowledge. To augment current understanding, we designed a multi-institutional study to explore the distinct and cumulative effects of VPC formative assessments and optional self-assessment questions (SAQs) on exam performance. Method: In this correlational study, we examined the records of 1,692 students on their family medicine (FM) clerkship at 20 medical schools during the 2014-2015 academic year. Schools utilized an established online curriculum, which included family medicine VPCs, embedded formative assessments, context-rich SAQs corresponding with each VPC, and an associated comprehensive family medicine exam. We used mixed-effects modeling to relate the student VPC composite formative assessment score, SAQ completion, and SAQ performance to students' scores on the FM final examination. Results: Students scored higher on the final exam when they performed better on the VPC formative assessments, completed associated SAQs, and scored higher on those SAQs. Students' SAQ completion enhanced examination performance above that explained by engagement with the VPC formative assessments alone. Conclusions: This large-scale, multi-institutional study furthers the body of research on the effect of formative assessments associated with VPCs on exam performance and demonstrates the added benefit of optional associated SAQs. Findings highlight opportunities for future work on the broader impact of formative assessments for learning, exploring the benefits of integrating VPCs and SAQs, and documenting effects on clinical performance and summative exam scores.

Student attitudes: potential barriers to implementing a community medicine field activity.

OBJECTIVE: Clerkship-year medical students may have complex attitudes regarding communities in which they train. Our objective was to assess medical students' attitudes following implementation of a community medicine experience in their clerkship year. METHODS: We analyzed transcripts of audiotaped medical student group discussions following a community field activity. A multidisciplinary team coded the transcripts using content analysis techniques to identify key features of student narratives regarding students' attitudes and attributions regarding their community medicine experiences. RESULTS: Students expressed several important perceptions regarding the community in which they conducted their field experience. These included strong insider/outsider themes, resentment that historical legacy shape the doctor-patient relationship, and concerns over personal safety and educational relevance of the activity. Some students noted improvement in understanding of patients within their communities. CONCLUSIONS: Negative attitudes and attributions expressed by students can act as obstacles in the development of community medicine initiatives, hinder professional development if unaddressed, and have the potential to contribute to health disparities. Further work on how to incorporate community medicine training is needed.

Clerkship directors' characteristics, scholarship, and support: a summary of published surveys from seven medical specialties.

BACKGROUND: Clerkship directors (CDs) ensure that medical students achieve the core clinical skills needed to be effective physicians. Recently guidelines for time and support for U.S. CDs have been published by the Alliance for Clinical Education. PURPOSE: This article reviews 14 published surveys of CDs in seven specialties and assesses CDs' personal characteristics, scholarship, and support for their position. METHODS: Investigators reviewed CD surveys conducted over the last 12 years from seven different specialties. Comparisons were made of CDs demographics, departmental and school support, time allotted to the position, and publication rates. RESULTS: Department support was generally good, but school support was often felt to be lacking. The number of publications was relatively low. Time allotted for the position was lower than the 50% recommended in all specialties. CONCLUSIONS: Many CDs do not feel adequately supported by time or resources. Future studies need to more closely define what support is needed and what impact CD characteristics, scholarship, and resources have on medical student education.

Selected Abstracts From the Proceedings of the 2015 Society of Teachers of Family Medicine (STFM) Conference on Medical Student Education.

The Society of Teachers of Family Medicine (STFM; http://www.stfm.org) is a community of professionals devoted to teaching family medicine through undergraduate, graduate, and continuing medical education. This multidisciplinary group of physicians, educators, behavioral scientists, and researchers works to further STFM's mission of improving the health of all people through education, research, patient care, and advocacy. The STFM held its 41st Conference on Medical Student Education in Atlanta, Georgia from February 5-8, 2015. The conference this year was met with record attendance and student scholarship winners. The STFM Education Committee selected 10 abstracts, of which five are presented below.

Selected Abstracts From the Proceedings of the 2017 Society of Teachers of Family Medicine Conference on Medical Student Education.

The Society of Teachers of Family Medicine (STFM) is an organization made up of educators devoted to teaching family medicine to learners of all levels. This multidisciplinary group of physicians, behavioral scientists, researchers, and educators from other health professions works to further STFM's mission of improving the health of all people through education, research, patient care, and advocacy. STFM held its 43rd Conference on Medical Student Education in Anaheim, California from February 9 to 12, 2017. Abstracts for conference sessions can be viewed online.1 The conference was held concurrently with the 2017 Society of Student-Run Free Clinics Annual Conference. This partnership empowered many passionate medical students to participate in STFM sessions and present their posters. A wide variety of topics were explored by STFM conference presenters and attendees. The plenary speakers addressed physician wellness (Dike Drummond, MD), family medicine as a career (Wanda Filer, MD), and the future of family medicine (Aaron Michelfelder, MD, and Michelle Byrne, MD). The STFM Education Committee reviewed and selected eight exemplary abstracts from 22 presented educational research papers. Criteria for selection included strength of contribution to medical student education, topic of interest within and beyond family medicine, and quality of study, including well-described rationale, appropriate methods, clear results, and thoughtful conclusions. The areas covered are related to new educational methods and tools, faculty development, and interprofessional learning and assessment.

Design and rationale of the medical students learning weight management counseling skills (MSWeight) group randomized controlled trial.

Physicians have an important role addressing the obesity epidemic. Lack of adequate teaching to provide weight management counseling (WMC) is cited as a reason for limited treatment. National guidelines have not been translated into an evidence-supported, competency-based curriculum in medical schools. Weight Management Counseling in Medical Schools: A Randomized Controlled Trial (MSWeight) is designed to determine if a multi-modal theoretically-guided WMC educational intervention improves observed counseling skills and secondarily improve perceived skills and self-efficacy among medical students compared to traditional education (TE). Eight U.S. medical schools were pair-matched and randomized in a group randomized controlled trial to evaluate whether a multi-modal education (MME) intervention compared to traditional education (TE) improves observed WMC skills. The MME intervention includes innovative components in years 1-3: a structured web-course; a role play exercise, WebPatientEncounter, and an enhanced outpatient internal medicine or family medicine clerkship. This evidence-supported curriculum uses the 5As framework to guide treatment and incorporates patient-centered counseling to engage the patient. The primary outcome is a comparison of scores on an Objective Structured Clinical Examination (OSCE) WMC case among third year medical students. The secondary outcome compares changes in scores of medical students from their first to third year on an assessment of perceived WMC skills and self-efficacy. MSWeight is the first RCT in medical schools to evaluate whether interventions integrated into the curriculum improve medical students' WMC skills. If this educational approach for teaching WMC is effective, feasible and acceptable it can affect how medical schools integrate WMC teaching into their curriculum.

Predoctoral directors: who are they and what do they do in these trying times?

BACKGROUND AND OBJECTIVES: Family medicine faces declining student interest and funding. Predoctoral directors will help lead efforts to overcome these challenges. Academic success will be important for predoctoral directors to be effective leaders in academic health centers. We therefore sought to describe predoctoral directors and factors associated with their academic success. METHODS: We carried out a cross-sectional survey of all family medicine predoctoral directors at US allopathic medical schools using a Web-based questionnaire. The response rate was 82%. We measured academic success using a variable combining rank and tenure status. We used bivariate analysis and multiple linear regression analysis to identify factors associated with academic success. RESULTS: The mean age of predoctoral directors is 47, and 45% are women. Forty-two percent are assistant professors, 36% associate professors, 20% full professors, and 33% are on a tenure track. Sixty-four percent of predoctoral programs receive Title VII funding, and 63% of predoctoral directors believe that loss of Title VII funding will adversely affect student education. Factors associated with academic success include years since residency, total publications, years as predoctoral director, male gender, state funding for predoctoral family medicine programs, and participation in an academic fellowship. Involvement in educational research was associated with number of publications. CONCLUSIONS: Providing predoctoral directors with the skills and support needed to study their educational undertakings and publish their findings may help them achieve academic success. Medical educators must assess the effects of loss of Title VII funding on predoctoral education while seeking new sources of funding.

A gain in cultural competence through an international acupuncture elective.

OBJECTIVE: This study describes an international acupuncture elective and its impact on medical students' development of cultural competence. METHODS: Collaborating with Chinese colleagues, we created a 4-week elective that teaches medical students about acupuncture in its native cultural environment. Three focus groups were conducted to elicit students' experiences. RESULTS: Students' reflections indicated that studying an alternative medical system in its own cultural setting helped them become open to other medical beliefs and realize the importance of culture in health care delivery. Further, being linguistically isolated allowed students to personally experience what it is like for those patients with limited language proficiency. CONCLUSION: Studying an alternative medical system while immersed in another culture maybe an effective way to enhance cultural competence.

Scope of Practice and Family Medicine Match Rates: Results From a CERA Clerkship Directors' Survey.

BACKGROUND AND OBJECTIVES: Family medicine clerkship directors depend on community preceptors to teach and attract medical students to family medicine. Many community preceptors do not provide the full range of family medicine services, and some are not family physicians. This study aimed to determine the types of practices in which family medicine clerkship students train and whether scope of practice is associated with family medicine Match rates. METHODS: Data were collected as part of the 2014 Council of Academic Family Medicine Educational Research Alliance (CERA) Family Medicine Clerkship Director Survey. Clerkship directors estimated the percentage of their preceptor sites providing each of nine clinical services and the percentage of students placed with internal medicine physicians for their family medicine rotations. We devised a Scope of Practice Index (SPI) to assess scope of practice and measured the association between a clerkship's SPI and family medicine Match rate. RESULTS: Limited scopes of practice were common. SPI was lowest in the Northeast and highest in the West. In bivariate and multivariable analyses, a lower SPI was associated with lower family medicine Match rates. Preventive gynecological care was the service most highly associated with family medicine Match rates. Family medicine Match rates were lower when programs used internal medicine sites for their family medicine rotations. CONCLUSIONS: Many clerkship students are exposed to practices with limited scopes of family medicine practice, and this is associated with lower family medicine Match rates. These findings have implications for the specialty as preceptor scope of practice declines.

Evaluation and management of hip pain: an algorithmic approach.

Start by determining whether pain is located in the anterior, lateral, or posterior hip. As the site varies, so does the etiology. Besides location, consider sudden vs insidious onset, motions and positions that reproduce pain, predisposing activities, and effect of ambulation or weight bearing. Physical examination tests that elucidate range of motion, muscle strength, and pain replication will narrow the diagnostic search. Magnetic resonance imaging is usually diagnostic if plain x-rays and conservative therapy are ineffective. Conservative measures and selective use of injection therapy are usually effective.