Developing culturally competent physicians: Empathy, inclusivity, moral distress training and ethical reflections during the Medicine Clerkship.

PURPOSE: We aimed to develop a tool that would allow assessment of ethics competency and moral distress during the Internal Medicine Clerkship and to introduce curricular changes that could empower students to better address ethical dilemmas and challenges encountered during the clerkship. MATERIALS AND METHODS: A structured ethics assignment was introduced where students could reflect on impactful stressful scenarios and address questions related to emotional responses, identified ethical issues, management themes, and professional obligations. A 4-tiered grading rubric and individual narrative feedback was provided for each assignment, and small-group debriefing sessions were introduced for reflective thought and future planning. De-identified assignments were analyzed and classified into subgroups according to 5 main ethical issue subgroups and 10 specific management themes. Assignments were also analyzed for the presence of moral distress. RESULTS: 357 students completed the reflective ethics activities. The most commonly identified ethical issues were related to Shared Medical Decision Making (>40%), Primary of Patient Welfare challenges, (>20%), and Social/Organizational dilemmas. Management themes often pertained to Patient Wishes/Legal Obligations, Professional Behaviors, and Limited Resources. 87% of assignments demonstrated moral distress. CONCLUSION: Medical school is a stressful time and challenges are augmented during clinical years. Our reflective activity demonstrated significant exposures to ethical dilemmas, reviewed earlier principles of ethics training, and provided a safe forum in which to discuss these important aspects of healthcare. We captured powerful images of challenging situations eliciting moral distress, and students greatly appreciated the activity. We encourage future investigations that support student well-being and enable smooth transitions into residency training.

The Calm Before the Storm: A Pheochromocytoma Case Report.

Pheochromocytomas are rare tumors that arise from the sympathetic ganglia or adrenal medulla and secrete catecholamines that are known for the classic triad of headaches, profuse sweating, and paroxysmal hypertension. However, there have been instances of asymptomatic patients found to have a pheochromocytoma. Adrenal incidentalomas are accidentally discovered through radiologic imaging, and subsequent testing can confirm a pheochromocytoma. Here, we present a case of a 67-year-old female found to have an adrenal incidentaloma on kidney ultrasound (US) after presenting to the emergency room (ER) due to nausea. She had minimally elevated creatinine at the ER. At her follow-up with her primary care provider (PCP), a kidney US was ordered and showed a probable right suprarenal mass. Further abdominal computed tomography (CT) and abdominal magnetic resonance imaging (MRI) showed that the mass was indeed adrenal, but its etiology is considered indeterminant. Although asymptomatic, further biochemical tests showed elevated serum and urine metanephrines and normetanephrines. Together, these findings revealed that the adrenal mass was likely a silent pheochromocytoma. She underwent a successful right adrenalectomy with pathology confirming pheochromocytoma. This case adds to the literature on the existence of silent pheochromocytomas and highlights the importance of following up on any abnormal findings with a PCP. This patient, although asymptomatic from her pheochromocytoma, needed surgery to prevent possible pheochromocytoma crises, which could cause cardiovascular complications and even death.

Time Does Matter: Reduced Internal Medicine Clerkship Clinical Experiences Due to COVID-19.

Introduction The coronavirus disease 2019 (COVID-19) pandemic has affected medical education in many ways. The Association of American Medical Colleges (AAMC) temporarily suspended clinical student rotations, calling for a transition to remote learning. Unfortunately, due to the heavy impact of COVID-19 in our South Florida community, medical students were not able to return to in-person activities for a significant time. During this period, students had remote clerkship learning activities, didactic sessions, narrative projects, and small-group learning sessions, which were front-loaded using Zoom technology (Zoom Video Communications, Inc., San Jose, California, United States) and web-based learning tools. Once in-person clinical experiences resumed, the duration of all third-year clerkships for the remainder of the year was reduced to five weeks to allow for timely graduation. The Herbert Wertheim College of Medicine (HWCOM) Internal Medicine (IM) clerkship has traditionally been an eight-week-long rotation. Other clerkships that varied from six to eight weeks were similarly reduced to five weeks. We hypothesized that the shortened duration of the IM clerkship would have negative impacts on National Board of Medical Examiners (NBME) exam performance and clerkship clinical experiences would likely be affected. Methods We compared the NBME subject exam results and end of clerkship evaluations from the Class of 2021 (CO2021) which had the traditional eight weeks of patient care, with the CO2022, which had only five weeks of in-person patient care. A T-test analysis was performed comparing performance on the NBME medicine clinical subject exam between students who completed the usual eight-week rotation versus those who completed a five-week rotation. We also evaluated the IM clerkship course evaluation and analyzed student responses and ratings to assess any areas that were statistically significant when comparing the traditional eight-week IM clerkship to the shortened five-week clerkship. Results There was no statistically significant difference (t=0.68, p<0.4951) in mean NBME subject exam performance between cohorts. Students who completed the shortened five-week IM clerkship indicated there was limited volume and diversity of patients, which consequently affected their ability to complete all the required clinical experiences for the IM clerkship. These results indicated a statistically significant difference between the two cohorts (t =3.33, p<.001). Conclusion Students with shortened IM clerkship clinical care time (five weeks) were found to have no significant statistical differences in NBME subject exam performance compared to the traditional eight-week cohorts. However, students felt there was a decreased volume and diversity of patients, and they reported greater difficulties in completing the required clinical experiences, with diminished clinical confidence. Time does matter, and clinical time is very valuable for a student's undergraduate medical education. If another pandemic were to arise, the duration of different clerkships should be carefully assessed and individualized, and methods to assess and reclaim lost clinical time during the advanced clinical and postgraduate years should be considered.