Cost of failure in the context of social mission.

In the study by Foo et al. ( 2017 ) authors calculated the economic cost (referred to as cost) due to physiotherapy student failure in a pre-clinical course based on a number of supported assumptions. In this study, the calculated cost per student is 60% lower for students who pass all pre-clinical units compared to the cohort that does not. The cost is 15% higher per student when spread across the cohort. A sensitivity analysis demonstrates that as the failure rate and attrition rate rises, the cost increases. I applaud the authors for addressing this important topic and providing an approach and model that can be replicated in other contexts. If institutions repeated this analysis in different areas of the world and across different health professions, the estimated cost would change, but the conclusion would not. The economic cost of a student failing in a professional education program is high.

The adaptive medical curriculum: A model for continuous improvement.

This paper describes the medical curriculum designed to foster adaptive expertise. Engaging in the formal and informal curriculum, students learn to achieve desired outcomes in novel situations, perform comfortably with uncertainty, and are often recognized for creative problem-solving. Students learn by asking and answering their own and others' questions. They readily operate at the metacognitive level, anticipating events, self-monitoring, and checking decisions and emotions. A key function of the reflective process is to identify gaps or shortcomings in the thinking process. The adaptive learner shifts into reflective thinking when confronted with complex contextual and situational demands. We are only beginning to understand how to create educational pathways to foster adaptive learning. An essential focus is the adaptive teacher who frames learning and assessment around predictive analytics, reflective spaced practice, and authentic learning material. To be effective, the teacher must engage the learner outside the formal classroom in the parallel curriculum. A major premise is that learning occurs individually and together with peers, teachers, and team members in multiple contexts. During the learning process, the learner readily operates at the metacognitive level, anticipating behavior, self-monitoring and assessing, and checking theirs and others decisions and emotions. The adaptive medical curriculum provides the pathway for such learning.

Patient-centered interviewing and student performance in a comprehensive clinical skills examination: is there an association?

OBJECTIVE: Communication skills, including patient-centered interviewing (PCI), have become a major priority for educational and licensing organizations in the United States. While patient-centered interviewing is associated with positive patient outcomes and improved diagnostic accuracy, it is unknown if an association exists between patient-centered interviewing and student performance in high-stakes clinical skills assessment (CSA) examinations. The purpose of this study was to determine if generic communication skills and patient-centered interviewing skills were associated with students' overall student performance on a multi-station clinical skills assessment (CSA) examination. METHODS: This was a cross-sectional study to assess student performance with standardized patients (SPs). We conducted a retrospective review of 30 videotaped SP encounters of Third year medical students (class of 2006) at the University of Kansas School of Medicine. We measured correlations between observed PCI scores, overall CSA scores and CSA interpersonal and communication (ICS) skills scores of student-SP encounters. RESULTS: PCI scores, as measured with the Four Habits Coding Scheme, a measurement tool of patient-centered communication, were not correlated with either overall CSA scores or ICS scores. Students' PCI scores were lower than the ICS scores (57% vs. 85% of correct items). The students performed poorly (30% mean score of correct items) in eliciting patient perspectives, compared to three other domains (Invest in the beginning, Demonstrate empathy, and Invest in end) of patient-centered interviewing. CONCLUSIONS: Our study failed to demonstrate any association between student performance and patient-centered interviewing skills (PCI) in the setting of a comprehensive in-house CSA examination. Third-year medical students in our study did not practice some elements of patient-centered interviewing. PRACTICE IMPLICATIONS: Given the increasing importance of patient-centered communication, the high-stakes in-house clinical skills examinations may consider assessing patient-centered interviewing using a more comprehensive and valid checklist.

Information-gathering patterns associated with higher rates of diagnostic error.

Diagnostic errors are an important source of medical errors. Problematic information-gathering is a common cause of diagnostic errors among physicians and medical students. The objectives of this study were to (1) determine if medical students' information-gathering patterns formed clusters of similar strategies, and if so (2) to calculate the percentage of incorrect diagnoses in each cluster. A total of 141 2nd year medical students completed a computer case simulation. Each student's information-gathering pattern included the sequence of history, physical examination, and ancillary testing items chosen from a predefined list. We analyzed the patterns using an artificial neural network and compared percentages of incorrect diagnoses among clusters of information-gathering patterns. We input patterns into a 35 x 35 self organizing map. The network trained for 10,000 epochs. The number of students at each neuron formed a surface that was statistically smoothed into clusters. Each student was assigned to one cluster, the cluster that contributed the largest value to the smoothed function at the student's location in the grid. Seven clusters were identified. Percentage of incorrect diagnoses differed significantly among clusters (Range 0-42%, Chi (2) = 13.62, P = .034). Distance of each cluster from the worst performing cluster was used to rank clusters. This rank was compared to rank determined by percentage incorrect. We found a high positive correlation (Spearman Correlation = .893, P = .007). Clusters closest to the worst performing cluster had the highest percentages of incorrect diagnoses. Patterns of information-gathering were distinct and had different rates of diagnostic error.

Visual prompt poster for promoting patient-physician conversations on weight loss.

PURPOSE: This study investigated the effect of a simple visual prompt in the form of a poster on the occurrence of patient-physician weight loss conversations during routine office encounters in a primary care outpatient clinic. METHODS: We conducted a 2-phase study in a family medicine residency program outpatient clinic in August and September 2006. During the first phase, lasting 5 days, we surveyed all nonpregnant adult patients (preintervention group) about weight loss. We then implemented a visual prompt in the form of a colorful poster (11 x 17 inches) in both English and Spanish. The poster read "Do you want to lose weight? Ask your doctor today!" and included a picture of a bathroom scale. During the second phase, also lasting 5 days, we again surveyed all nonpregnant adult patients (postintervention group). RESULTS: Analyses were based on 283 patients in the preintervention group and 386 patients in the postintervention group. The mean body mass index, obtained from medical records, did not differ significantly between groups (31 vs 32 kg/m2, respectively). Fully 60% of patients in the postintervention group recalled seeing the poster during their visit; however, the percentage of patients who reported discussing weight loss with their physician did not differ between the preintervention and postintervention groups overall (29% vs 27%), among the two-thirds of patients who wanted to lose weight (26% vs 23%), or when only postintervention patients who saw the poster were included in the comparison (29% vs 29%). The large majority of patients in both groups who had such discussions--82% and 77%--indicated that they found them useful; the difference between groups was not significant. CONCLUSION: A simple visual prompt in the form of a poster directed at patients did not increase the occurrence of conversations between patients and their physicians about weight loss.

Electronic health records in outpatient clinics: perspectives of third year medical students.

BACKGROUND: United States academic medical centers are increasingly incorporating electronic health records (EHR) into teaching settings. We report third year medical students' attitudes towards clinical learning using the electronic health record in ambulatory primary care clinics. METHODS: In academic year 2005-06, 60 third year students were invited to complete a questionnaire after finishing the required Ambulatory Medicine/Family Medicine clerkship. The authors elicited themes for the questionnaire by asking a focus group of third year students how using the EHR had impacted their learning. Five themes emerged: organization of information, access to online resources, prompts from the EHR, personal performance (charting and presenting), and communication with patients and preceptors. The authors added a sixth theme: impact on student and patient follow-up. The authors created a 21-item questionnaire, based on these themes that used a 5-point Likert scale from "Strongly Agree" to "Strongly Disagree". The authors emailed an electronic survey link to each consenting student immediately following their clerkship experience in Ambulatory Medicine/Family Medicine. RESULTS: 33 of 53 consenting students (62%) returned completed questionnaires. Most students liked the EHR's ability to organize information, with 70% of students responding that essential information was easier to find electronically. Only 36% and 33% of students reported accessing online patient information or clinical guidelines more often when using the EHR than when using paper charts. Most students (72%) reported asking more history questions due to EHR prompts, and 39% ordered more clinical preventive services. Most students (69%) reported that the EHR improved their documentation. 39% of students responded that they received more feedback on their EHR notes compared to paper chart notes. Only 64% of students were satisfied with the doctor-patient communication with the EHR, and 48% stated they spent less time looking at the patient. CONCLUSION: Third year medical students reported generally positive attitudes towards using the EHR in the ambulatory setting. They reported receiving more feedback on their electronic charts than on paper charts. However, students reported significant concerns about the potential impact of the EHR on their ability to conduct the doctor-patient encounter.

Teaching medical students to prioritize preventive services.

BACKGROUND: Clinicians cannot provide all recommended preventive services in a single office visit and must learn to prioritize. This skill is not overtly addressed in medical school. METHODS: We designed a workshop to teach third-year medical students to prioritize preventive services during an office visit. In a prospective controlled trial, we compared performance on a standardized patient case. RESULTS: Students performed well, but there was no significant difference between intervention and control groups' mean scores on the standardized patient encounter. CONCLUSIONS: Our brief intervention failed to increase students' scores on a standardized patient case requiring preventive services prioritization.

Nursing faculty teaching basic skills to medical students.

Medical education often uses a 'see one, do one, teach one' approach to teaching basic skills, whereas nursing education uses a more intense, competency based approach. Many nursing faculty become experts in teaching skills; however, there is little literature evaluating medical student skills training led by nursing faculty. The purpose of this paper is to describe and report initial evaluation data on an innovative teaching strategy using nursing faculty to teach specific skills to medical students. Nursing faculty designed a hands-on four hour clinical skills training laboratory for medical students. All (176) medical students completed and evaluated this skills laboratory and their own preparation for these skills. Medical students felt the laboratory was outstanding or good (94%), the content was at an appropriate level (94%) and the relevance was high or medium (96%). Medical students felt more prepared to perform the skills after completing the skills laboratory than before, and when compared to previous medical students without the skills laboratory. Many medical students commented positively about the nursing faculty. Nursing faculty teaching specific skills to medical students is acceptable and effective and provides medical students with positive exposure to nurses as experts.

Case-based exercises fail to improve medical students' information management skills: a controlled trial.

BACKGROUND: Tomorrow's physicians must learn to access, retrieve, integrate and apply current information into ambulatory patient encounters, yet few medical schools teach 'real time' information management. METHODS: We compared two groups of clerkship students' information management skills using a standardized patient case. The intervention group participated in case-based discussions including exercises that required them to manage new information. The control group completed the same case discussions without information management exercises. RESULTS: After five weeks, there was no significant difference between the control and intervention groups' scores on the standardized patient case. However, third rotation students significantly outperformed first rotation students. CONCLUSION: Case-based exercises to teach information management failed to improve students' performance on a standardized patient case. Increased number of clinical rotations was associated with improved performance.

A short transitional course can help medical students prepare for clinical learning.

BACKGROUND AND OBJECTIVES: Despite the move toward integrated 4-year medical school curricula, many medical schools still offer a "2+2" curriculum divided into preclinical and clinical phases. These phases represent distinct learning environments that require different learning skills. To prepare students for learning in the clinical environment of the second 2 years, many medical schools offer transitional experiences before the third-year clerkships. Few of these transitional courses have published evaluations, and there is no consensus on the ideal content. In this paper, we provide evaluation and content validity data on a 2-week intensive clinical transition course for beginning third-year medical students. METHODS: A multidisciplinary team designed, implemented, and evaluated a 2-week transition course. Students indicated through surveys how prepared they felt for 18 clinical skills. We analyzed pre- and post-survey data using a Wilcoxen rank sum test and compared current to prior students using a chi-square analysis. RESULTS: Students felt more prepared for 16 of 18 skills after the transitional course and for 14 of 18 skills compared to historical controls. CONCLUSIONS: A transitional course based on common skills is relevant to students' clerkship experiences and can increase students' self-reported preparedness for the clinical years of medical school.

Eliciting the patient's perspective: does experience or type of case make a difference?

OBJECTIVE: Patient-centered interviewing is an increasingly important aspect of medical education. One way to quantify this skill is the Four Habits Model, which helps to organize medical interviewing. The Four Habits are: invest in the beginning, elicit the patient's perspective, demonstrate empathy and invest in the end. In a previous study at our institution, students were competent in all of the habits but "eliciting the patient's perspective" during a standardized patient case. Based on this study, we hypothesized that the students' poor performance could be related to the type of case or to clinical experience. METHODS: We placed three "eliciting the patient's perspective" items on the checklist for two standardized patients, one with and one without a clear diagnosis. We planned to compare group performance between cases and semesters of the third year. We hypothesized that students would be more patient-centered earlier in the year and with an ambiguous diagnosis. RESULTS: Students were more patient-centered with the ambiguous diagnosis and later in their third year. Patient-centeredness was measured by an eliciting the patient's perspective (EPP) score based on the checklist items. CONCLUSION: Our results provide information that may help guide curriculum development and future study to advance patient-centered interviewing skills.

Mid-clerkship feedback is effective in changing students' recorded patient encounters.

BACKGROUND AND OBJECTIVES: Family medicine clerkship directors review students' patient encounter logs. Encounter data can be used to alter students' learning experiences. Our purpose was to determine if students record different types of patient encounters before and after reviewing log data with clerkship directors. METHODS: Clerkship directors met with each student at clerkship midpoint, reviewed encounter data, and encouraged the student to seek out less frequently seen diseases. RESULTS: A total of 56/105 students (53%) saw different types of patients after the review. CONCLUSIONS: More than half of the students recorded different types of patient encounters after an intervention encouraging them to do so.