A qualitative analysis of third-year medical students' reflection essays regarding the impact of COVID-19 on their education.

BACKGROUND: The COVID-19 pandemic fundamentally changed every aspect of healthcare delivery and training. Few studies have reported on the impact of these changes on the experiences, skill development, and career expectations of medical students. METHOD: Using 59 responses to a short reflection essay prompt, 3rd year medical students in Philadelphia described how the COVID-19 pandemic affected their education in mid-2020. Using conventional content analysis, six main themes were identified across 14 codes. RESULTS: Students reported concerns regarding their decreased clinical skill training and specialty exposure on their career development due to the loss of in-person experience during their family medicine clerkship. A small number felt very let down and exploited by the continued high cost of tuition while missing clinical interactions. However, many students also expressed professional pride and derived meaning from limited patient and mentorship opportunities. Many students developed a new sense of purpose and a call to become stronger public health and patient advocates. CONCLUSIONS: The medical field will need to adapt to support medical students adversely impacted by the COVID-19 pandemic, from an educational and mental health standpoint. However, there are encouraging signs that this may also galvanize many students to engage in leadership roles in their communities, to become more empathetic and thoughtful physicians, and to redesign healthcare in the future to better meet the needs of their most vulnerable patients.

Uterine Fibroids: Diagnosis and Treatment.

Uterine fibroids are common benign neoplasms, with a higher prevalence in older women and in those of African descent. Many are discovered incidentally on clinical examination or imaging in asymptomatic women. Fibroids can cause abnormal uterine bleeding, pelvic pressure, bowel dysfunction, urinary frequency and urgency, urinary retention, low back pain, constipation, and dyspareunia. Ultrasonography is the preferred initial imaging modality. Expectant management is recommended for asymptomatic patients because most fibroids decrease in size during menopause. Management should be tailored to the size and location of fibroids; the patient's age, symptoms, desire to maintain fertility, and access to treatment; and the experience of the physician. Medical therapy to reduce heavy menstrual bleeding includes hormonal contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs. Gonadotropin-releasing hormone agonists or selective progesterone receptor modulators are an option for patients who need symptom relief preoperatively or who are approaching menopause. Surgical treatment includes hysterectomy, myomectomy, uterine artery embolization, and magnetic resonance-guided focused ultrasound surgery.

Diagnosis and management of pancreatic cancer.

Pancreatic cancer remains the fourth leading cause of cancer-related deaths in the United States. Risk factors include family history, smoking, chronic pancreatitis, obesity, diabetes mellitus, heavy alcohol use, and possible dietary factors. Because more than two-thirds of adenocarcinomas occur in the head of the pancreas, abdominal pain, jaundice, pruritus, dark urine, and acholic stools may be presenting symptoms. In symptomatic patients, the serum tumor marker cancer antigen 19-9 can be used to confirm the diagnosis and to predict prognosis and recurrence after resection. Pancreas protocol computed tomography is considered standard for the diagnosis and staging of pancreatic cancer. Although surgical resection is the only potentially curative treatment for pancreatic ductal adenocarcinomas, less than 20% of surgical candidates survive five years. The decision on resectability requires multidisciplinary consultation. Pancreatic resections should be performed at institutions that complete at least 15 of the surgeries annually. Postoperatively, use of gemcitabine or fluorouracil/leucovorin as adjuvant chemotherapy improves overall survival by several months. However, more than 80% of patients present with disease that is not surgically resectable. For patients with locally advanced or metastatic disease, chemoradiotherapy with gemcitabine or irinotecan provides clinical benefit and modest survival improvement. Palliation should address pain control, biliary and gastric outlet obstruction, malnutrition, thromboembolic disease, and depression.

Teaching Population Panel Management: A Patient Outreach Activity in a Family Medicine Clerkship.

BACKGROUND AND OBJECTIVES: The delivery of population health education in medical school can be challenging. We developed a patient outreach activity for third-year students to teach them the role of population panel management in primary care. METHODS: The family medicine undergraduate medical education and population health teams collaborated to develop an educational patient outreach toolkit. After an orientation, family medicine clerkship students were assigned to call patients on their faculty adviser's patient panel to discuss care gaps and identify barriers and potential strategies to improve care. After the experience, students completed reflection questions, which we analyzed. RESULTS: From February to August 2022, 82 third-year medical students participated in the patient outreach activity during their 6-week clerkship. Of the 1,235 total attempted calls, 24% of the patients scheduled their appointments afterward. After analyzing the reflective student feedback, we identified six main takeaways, which focused on the importance of population health, the identification of barriers to care, positive and negative feelings that students experienced when making calls, student self-identified areas of growth, and the fragmentation/inefficiency of the health care system. CONCLUSIONS: An opportunity exists to continue to teach students about how to communicate with patients about their health and how to address and improve social determinants of health. This curricular activity can be a step toward efforts to align population health and clinical practice and a way for medical students to add value by educating patients.

Gender differences in health-related quality of life in patients with bipolar disorder.

Health-related quality of life (HRQOL) is a widely accepted measure of illness state that is related to morbidity and mortality. Findings from various populations show that women report lower HRQOL than men. We analyzed baseline HRQOL data for gender differences from a multisite, randomized controlled study for adults with bipolar disorder. HRQOL was assessed using the 12-item Short Form (SF-12) physical component summary (PCS) and mental component summary (MCS) health scales. Multivariate linear and bivariate regression models examined differences in self-reported data on demographics, depressive symptoms (nine-item Patient Health Questionnaire), bipolar disorder symptoms (Internal State Scale), and medical comorbidities. Out of 384 enrolled (mean age = 42 years), 256 were women (66.7 %). After controlling for sociodemographic characteristics and clinical factors, women had lower SF-12 PCS scores than men [ß = -1.78, standard error (SE) = 0.87, p < 0.05], indicating worse physical health, but there were no gender differences in MCS scores. After controlling for patient factors including medical and behavioral comorbidities, the association between gender and PCS score was no longer significant. Of the medical comorbidities, pain was associated with lower PCS scores (ß = -4.90, SE = 0.86, p < 0.0001). Worse physical HRQOL experienced by women with bipolar disorder may be explained by medical comorbidity, particularly pain, suggesting the importance of gender-tailored interventions addressing physical health conditions.

Impact of the COVID-19 Pandemic on Medical Students' Perceptions of Health Care for Vulnerable Populations.

BACKGROUND AND OBJECTIVES: The COVID-19 pandemic highlighted the shortcomings of our health care delivery system for vulnerable populations and created a need to rethink health disparity education in medical training. We examined how the early COVID-19 pandemic impacted third-year medical students' attitudes, perceptions, and sense of responsibility regarding health care delivery for vulnerable populations. METHODS: Third-year family medicine clerkship students at a large, private medical school in Philadelphia, Pennsylvania responded to a reflection assignment prompt asking how the COVID-19 pandemic impacted their thoughts about health care delivery for vulnerable populations in mid-2020 (N=59). Using conventional content analysis, we identified three main themes across 24 codes. RESULTS: Students recognized homeless individuals and Black, indigenous, and persons of color (BIPOC) as vulnerable populations impacted by the pandemic. Students reported causes of vulnerability that focused heavily on social determinants of health, increased risk for contracting COVID-19 infections, and difficulty adhering to COVID-19 prevention guidelines. Notable action-oriented approaches to addressing these disparities included health care reform and community health intervention. CONCLUSIONS: Our findings describe an educational approach to care for vulnerable populations based on awareness, attitudes, and social action. Medical education must continue to teach students how to identify ways to mitigate disparities in order to achieve health equity.

Demographic Characteristics and Career Plans of First-Generation Medical Students at a Single Medical School in the United States.

Introduction: Recruitment of first-generation medical students is essential to improving diversity and inclusion in US medical colleges. First-generation students offer unique experiential insights that foster empathy and cultural competency in the learning environment and improve health outcomes for patients. However, little is known about their demographic characteristics or career goals. It is important to identify these factors to provide insight on ways to better support first-generation students. Methods: This exploratory pilot study aimed to describe background, demographic characteristics, and goals of students. We administered a secondary analysis of a quality improvement and health disparities survey to third-year medical students at a large, private medical school in Philadelphia, Pennsylvania. Measures included demographic information, interest in loan forgiveness programs, and other career goal items. We conducted χ2 goodness-of-fit tests to examine differences by first-generation status. Results: Thirteen percent of respondents identified as first-generation medical students (n=26). First-generation medical students were more likely to be male, aged 21-26 years, White, and non-Hispanic/Latino. First-generation students were significantly more likely to report wanting to care for underserved populations during their career and enter loan forgiveness programs, with Department of Education's Public Service Loan Forgiveness program most often cited. Conclusion: This study provides an exploratory profile of characteristics of first-generation medical students and their career intentions. Our results suggests that enrollment of first-generation students may increase the number of physicians who are willing to serve underserved populations. However, first-generation students may also need more financial support through loan forgiveness programs which has important implications for medical education.

A Novel Curricular Approach to Teach Quality Improvement and Health Disparities in a Family Medicine Clerkship.

Background and Objectives: Medical schools must integrate educational curricula that teach how to apply quality improvement principles to improve care for vulnerable populations. In this report, we describe the development, implementation, and evaluation of a combined quality improvement (QI) and health disparities curriculum for third-year family medicine clerkship students. Methods: After conducting an educational needs assessment, we developed a health disparities curriculum focused on QI principles for the family medicine clerkship. From November 2019 through August 2021, third-year medical students (N=395) completed the curriculum. The curriculum was delivered in an asynchronous online format, followed by a small group collaboration project to design and present a QI intervention through process mapping. Students also completed an individual reflection assignment that focused on care for vulnerable populations. Pre- and post assessment questions were administered on Qualtrics, after review by the clerkship director, research faculty and staff, and content experts for content and item validity. We analyzed quantitative data using SPSS version 27 software and used paired t tests for pre/post comparisons. Results: In total, 392 students completed the preassessment survey, 395 students completed the postassessment surveys, and 341 had matching study identifiers. Pre-to-post assessment survey evaluations showed statistically significant changes for nine out of nine QI knowledge questions (P<.001), knowledge regarding a community health needs assessment (P<.001), and knowledge about caring for vulnerable populations (homeless, veterans, immigrants/refugees; P<.001). Conclusions: Preliminary evaluation of a combined QI and health disparities curriculum shows improvement in students' self-reported knowledge of use of a community health needs assessment, QI principles, and care for vulnerable populations.

Promotion Preparation Tips for Academic Family Medicine Educators.

BACKGROUND AND OBJECTIVES: Promotion has historically valued the scholarship of discovery over the scholarship of teaching. The clinician-educator promotion pathway is an attractive option for academic family physicians engaged in significant teaching. However, clinician-educators are less often promoted than peers on other tracks. Family medicine educators face unique challenges in promotion due to clinical requirements and often less guidance on how to meet promotion criteria. Promotion recognizes achievements of faculty and is often tied to higher base salary. We aimed to identify promotion preparation tips for academic family medicine educators. METHODS: We surveyed members of the Society of Teachers of Family Medicine (STFM) Medical Student Education Collaborative electronically on promotion preparation lessons learned in (1) curriculum vitae preparation, (2) personal statement preparation, (3) selecting external reviewers, and (4) identifying measurable achievements. This qualitative study used grounded theory and constant comparison. RESULTS: Fourteen individuals from 13 medical institutions responded with tips for success in promotion preparation. The tips identified actionable steps for promotion preparation of academic family medicine educators. Several main themes emerged, including the importance of timely and thorough documentation, detailed planning, and being knowledgeable about institutional-specific criteria early. CONCLUSIONS: The tips provided in this study support family medicine educators in preparing for promotion and can be used as a tool for mentors, chairs and faculty development.

Third-Year Medical Students' Self-perceived Knowledge About Health Disparities and Community Medicine.

INTRODUCTION: Medical providers' attitudes about caring for vulnerable populations have significant implications for persistent health disparities. Therefore, assessing medical students' self-perceived knowledge about community-based medicine and care for underserved populations can provide insights for improving health care delivery to achieve health equity. We evaluated third-year medical students' perceptions of their knowledge and attitudes about community medicine, and addressing health care needs of vulnerable populations. METHODS: From October 2, 2017 to July 12, 2019, third-year medical students at a private, urban medical school were asked to complete an assessment survey during their family medicine clerkship orientation. The anonymous survey assessed students' self-perceived knowledge and attitudes regarding community medicine and care of vulnerable populations. We examined differences in survey responses by student demographics. RESULTS: A total of 401 students participated in the survey; 50.5% of respondents agreed that they had knowledge to assess health literacy of the patient, while only 22.2% of students agreed that they had knowledge about how to identify a community and conduct a community health needs assessment. Additionally, students agreed with being most comfortable providing care to adolescents (73.0%) and the elderly (69.5%), and that they were least comfortable caring for incarcerated individuals (31.7%) and immigrants/refugees (44.1%). CONCLUSION: Assessment of learners' self-perceived knowledge can help highlight areas for educational interventions. Our findings suggest the need for improving medical student knowledge in areas of community health and health care for specific vulnerable populations.

Curricular Recommendations for a National Family Medicine Subinternship: A Qualitative Analysis From Multiple Stakeholders.

BACKGROUND AND OBJECTIVES: The 2011 Alliance for Clinical Education panel recommended the development of a specialty-specific curriculum for all subinternships (sub-Is). A 2019 CERA survey found that 58% of family medicine clerkship directors agreed that a standardized curriculum would be helpful. The goal of this study was to explore attitudes and preferences regarding a national family medicine sub-I curriculum among a broad set of stakeholders. METHODS: Focus groups were conducted with medical students, residents, residency faculty, and undergraduate medical education faculty at the 2020 STFM Conference on Medical Student Education. Focus groups were transcribed, and a qualitative analysis was conducted with participants' responses about the benefits and characteristics of a family medicine sub-I, recommendations for core sub-I skills/objectives, likelihood of using a national curriculum, and preferred student and program evaluation methods. RESULTS: There were four focus groups with a total of 24 participants. The following main themes emerged: the family medicine sub-I has distinctive characteristics from other sub-Is and provides unique benefits for students and residency programs, a standardized curriculum should allow for adaptability and flexibility, and the sub-I evaluation for the students and program should be specific and experience-focused. These themes were classified into specific subthemes. CONCLUSIONS: The stakeholder emphasis on themes of uniqueness, adaptability, and specificity within evaluation will help educators structure a comprehensive framework for national recommendations for the sub-I curriculum. A well-designed family medicine sub-I may provide rigorous educational training for students and may also encourage career commitment to the discipline.

What we learned in the development of a third-year medical student curricular project.

The application of continuous systems improvement in medical education can provide actionable information for curriculum development, improvement, and future planning (as reported by Bowe and Armstrong, Acad Med 92:585-92, 2017). After receiving a medical education grant, we developed a curriculum to teach medical students how to use quality improvement (QI) to address health disparities in vulnerable populations. During the process of developing and implementing this curriculum, we learned several lessons.One of the major surprises was that our proposed project work took much longer to complete than anticipated. This was mainly because we did not have the right team assembled from the beginning. Specifically, we were missing a team member with evaluation expertise, and therefore we did not devise a systematic process for evaluation and assessment. Without periodic checks or timely assessments built into our curriculum design, we received feedback from students after it was too late to implement changes. We realized that our initial research design had some methodological flaws, which we later rectified.We encountered additional technical challenges during the curriculum implementation. We struggled with various online learning platforms. Through this, we learned the importance of being knowledgeable upfront about the features of learning platforms and adaptable to changing educational technologies. We also learned our curriculum could and should evolve to meet the needs of our learners and faculty. Moving forward, we realize the benefit of applying a quality improvement process to our curriculum development and implementation, which will help us to continuously transform medical education for future health care needs.

Moving Toward a Standardized National Family Medicine Subinternship Curriculum: Results From a CERA Clerkship Directors Survey.

BACKGROUND AND OBJECTIVES: Although the subinternship (sub-I) is considered integral in many medical schools' curricula, family medicine does not have standardized course recommendations. Given the variable nature of this clinical experience, this study investigated the potential role of a standardized sub-I curriculum in family medicine. METHODS: Questions about sub-Is were created and data were gathered and analyzed as part of the 2019 Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) survey of family medicine clerkship directors. The survey was distributed via email to 126 US and 16 Canadian recipients between June 19, 2019 and August 2, 2019 through the online program SurveyMonkey. RESULTS: A total of 101 (71.1%) of 142 clerkship directors responded to the survey. Most (84.2%) schools require sub-Is. There was a positive association between students matching into family medicine and having family medicine sub-Is at residency programs (P<.001). There was no relationship between higher family medicine match rates and the presence of family medicine sub-Is at nonresidency sites (P=.48) or having an advanced ambulatory rotation requirement (P=.16). CONCLUSIONS: A sub-I is a way to further expose students to family medicine, and increasing sub-I positions at residency programs may influence the number who pursue the specialty. Creation of a standardized sub-I curriculum presents an opportunity to enhance a critical educational experience in family medicine.

Resident Perceptions of Giving and Receiving Peer-to-Peer Feedback.

BACKGROUND: Peer feedback is increasingly being used by residency programs to provide an added dimension to the assessment process. Studies show that peer feedback is useful, uniquely informative, and reliable compared to other types of assessments. Potential barriers to implementation include insufficient training/preparation, negative consequences for working relationships, and a perceived lack of benefit. OBJECTIVE: We explored the perceptions of residents involved in peer-to-peer feedback, focusing on factors that influence accuracy, usefulness, and application of the information. METHODS: Family medicine residents at the University of Michigan who were piloting an online peer assessment tool completed a brief survey to offer researchers insight into the peer feedback process. Focus groups were conducted to explore residents' perceptions that are most likely to affect giving and receiving peer feedback. RESULTS: Survey responses were provided by 28 of 30 residents (93%). Responses showed that peer feedback provided useful (89%, 25 of 28) and unique (89%, 24 of 27) information, yet only 59% (16 of 27) reported that it benefited their training. Focus group participants included 21 of 29 eligible residents (72%). Approaches to improve residents' ability to give and accept feedback included preparatory training, clearly defined goals, standardization, fewer and more qualitatively oriented encounters, 1-on-1 delivery, immediacy of timing, and cultivation of a feedback culture. CONCLUSIONS: Residents perceived feedback as important and offered actionable suggestions to enhance accuracy, usefulness, and application of the information shared. The findings can be used to inform residency programs that are interested in creating a meaningful peer feedback process.

An update on breast cancer screening and prevention.

The goal of this article is to provide clinical guidance on breast cancer screening and prevention in primary care. The discussion highlights the importance of risk assessment, including screening options and risk-reduction strategies, for women at average and high risk. We review recommendations for breast cancer screening, evaluate current evidence on primary prevention, examine current practice patterns, and consider the impact of recent changes within health care.

Human papillomavirus (HPV) testing for normal cervical cytology in low-risk women aged 30-65 years by family physicians.

PURPOSE: The purpose of this study was to assess ordering of human papillomavirus (HPV) testing for normal cervical cytology among low-risk women aged 30 to 65 years. METHODS: Audits of 833 cytology request forms for low-risk women completing a Papanicolaou smear, from January 2008 to April 2011, from 5 Michigan family medicine clinics determined HPV orders completed by the clinician performing the Papanicolaou smear. Multivariate logistic regression models examined differences in HPV test ordering by patient age at Papanicolaou test, provider status and sex, and clinic across sites. A Poisson regression model analyzed the annual number of HPV test orders over time. RESULTS: Cytology requests were completed by 622 faculty (75%), 169 residents/fellows (20%), and 42 nurse practitioner/physician assistants (NP/PAs) (5%). HPV testing for any cytology result was ordered on 324 request forms (39%) by residents/fellows (48%), faculty (38%), and NP/PAs (10%). Female providers were twice as likely as men to order HPV testing for any cytology result across all clinics and provider statuses (P < .001). There were significant differences in HPV test ordering among clinics. Between 2008 and 2011 annual cytology requests increased 46%, including HPV testing for any cytology result after adjusting for faculty provider sex. CONCLUSION: HPV test ordering when cytology is collected varied by clinic and provider status and sex. HPV co-testing for any cytology result remains modest, but is increasing over time in these clinics.