Evaluating the Impact of an Adolescent Sexuality Education Workshop on Medical Student Communication in an Objective Structured Clinical Examination.

PURPOSE: Gaps still exist in medical education about the sexual health needs of sexual diverse populations, and little is known about how translatable current learning modules are to patient encounters. Efforts at an academic medical institution have been made to address this need, including a two-hour adolescent sexuality workshop during the Core Clerkship in Pediatrics. This workshop's efficacy was evaluated in an objective structured clinical examination (OSCE) given to rising fourth-year medical students, where the standardized patient case focused on an adolescent cisgender male with dysuria and in a new, same-sex relationship. METHODS: Performance of students who completed the workshop prior to the OSCE (n = 48) were compared to those of students who did not participate in the workshop prior to the OSCE (n = 17). The encounters were recorded and transcribed, and the deidentified transcripts were scored on a rubric focusing on five domains: sexual identity disclosure, behavioral assessment, psychosocial history, counseling and anticipatory guidance, and relationship building. RESULTS: Student's t-test comparison of the scores found significantly higher scores for the psychosocial history domain (p = .04), particularly concerning disclosure of a new boyfriend and recent sexual activity (p = .008), for students who had the workshop before the OSCE. DISCUSSION: Students who took the adolescent sexuality workshop performed better in gathering psychosocial information in an OSCE encounter a sexual minority adolescent. These results affirm prior work that active learning on sexual diverse health in medical school curricula may prepare students for effective engagement with adolescents exploring their sexuality.

Problem representation and diagnostic accuracy during an OSCE.

PURPOSE: The National Academy of Medicine has called for "identifying opportunities to improve the diagnostic process". We studied the association between problem representation and diagnostic accuracy during an objective structured clinical exam (OSCE). MATERIALS AND METHODS: We conducted a non-randomized controlled trial during a ten-case OSCE. We measured whether a summary statement prompt increased the likelihood that the student listed the correct diagnosis and whether better summary statements were correlated with diagnostic accuracy. RESULTS: 114 students provided 1135 responses. The non-prompted control group yielded 631 responses, listing the correct diagnosis first 73% of the time and within the top three slots 85% of the time. The intervention group exposed to the prompt yielded 453 responses listing the correct diagnosis first 72% of the time (P = 0.617) and within the top three slots 84% of the time (P = 0.760). Summary statements were scored on a 0, 0.5, or 1 rubric. When grouped according to summary statement score, students listed the correct diagnosis first 74%, 70%, and 72% of the time respectively (P = 0.666). The correct diagnosis was included within the top three slots 88%, 82%, and 83% of the time (P = 0.238). CONCLUSIONS: Prompting students to form a summary statement did not improve diagnostic accuracy. Better summary statements were not correlated with diagnostic accuracy.

Multi-institutional Implementation of the National Clinical Assessment Tool in Emergency Medicine: Data From the First Year of Use.

OBJECTIVES: Uniformly training physicians to provide safe, high-quality care requires reliable assessment tools to ensure learner competency. The consensus-derived National Clinical Assessment Tool in Emergency Medicine (NCAT-EM) has been adopted by clerkships across the country. Analysis of large-scale deidentified data from a consortium of users is reported. METHODS: Thirteen sites entered data into a Web-based platform resulting in over 6,400 discrete NCAT-EM assessments from 748 students and 704 assessors. Reliability, internal consistency analysis, and factorial analysis of variance for hypothesis generation were performed. RESULTS: All categories on the NCAT-EM rating scales and professionalism subdomains were used. Clinical rating scale and global assessment scores were positively skewed, similar to other assessments commonly used in emergency medicine (EM). Professionalism lapses were noted in <1% of assessments. Cronbach's alpha was >0.8 for each site; however, interinstitutional variability was significant. M4 students scored higher than M3 students, and EM-bound students scored higher than non-EM-bound students. There were site-specific differences based on number of prior EM rotations, but no overall association. There were differences in scores based on assessor faculty rank and resident training year, but not by years in practice. There were site-specific differences based on student sex, but overall no difference. CONCLUSIONS: To our knowledge, this is the first large-scale multi-institutional implementation of a single clinical assessment tool. This study demonstrates the feasibility of a unified approach to clinical assessment across multiple diverse sites. Challenges remain in determining appropriate score distributions and improving consistency in scoring between sites.

Improving Medical Students' OSCE Performance in Telehealth: The Effects of a Telephone Medicine Curriculum.

PURPOSE: To report on the implementation of a telephone medicine curriculum as part of the core clerkship in pediatrics for students at Johns Hopkins University School of Medicine and evaluate the curriculum's effect on student performance on a telephone medicine case as part of a required objective structured clinical exam (OSCE). METHOD: Using a prospective cohort design with a convenience sample of third-year medical students during the 2016-2017 and 2017-2018 academic years, the authors compared the OSCE scores of students assigned to the curriculum with both historical and concurrent control groups of students who had not received the curriculum. Additionally, the authors compared the costs of the recommended testing by students in each group using the 2018 Centers for Medicare and Medicaid Services Clinical Laboratory Fee Schedule. RESULTS: Students assigned to the telephone medicine curriculum (students in the intervention group) had a significantly higher mean overall score on the simulated OSCE telephone medicine case compared with the students in the control groups who did not receive the curriculum (the mean score for students in the intervention group was 7.38 vs 6.92 for students in the control groups, P = .02). Additionally, the intervention group had statistically significantly lower costs for their recommended testing compared with the control groups (the median value for tests ordered by students in the intervention group was $27.91 vs $51.23 for students in the control groups, P = .03). CONCLUSIONS: Implementing a dedicated telephone medicine curriculum for medical students improves their overall performance and delivery of high-value care via telephone medicine as part of an OSCE. Medical educators should pursue ongoing research into effective methods for teaching medical students and residents how to navigate digital encounters.

Emergency department management of non-ST-segment elevation myocardial infarction

Chest pain is the second most common complaint in emergency departments, with 6.4 million visits annually in the United States. A quarter of these patients will be diagnosed with acute coronary syndromes, but among those, nearly half will have nondiagnostic electrocardiograms. Non­ST-segment elevation myocardial infarction (NSTEMI) is twice as common as ST-segment elevation myocardial infarction (STEMI), and lack of clarity surrounding the best management of this condition can contribute to adverse outcomes. In this review, current national management guidelines for NSTEMI are summarized as they pertain to the ED, and the evidence base supporting them is considered. Issues surrounding special patient populations are addressed, and new diagnostic and therapeutic modalities are discussed.

A Standardized Needs Assessment Tool to Inform the Curriculum Development Process for Pediatric Resuscitation Simulation-Based Education in Resource-Limited Settings.

INTRODUCTION: Under five mortality rates (UFMR) remain high for children in low- and middle-income countries (LMICs) in the developing world. Education for practitioners in these environments is a key factor to improve outcomes that will address United Nations Sustainable Development Goals 3 and 10 (good health and well being and reduced inequalities). In order to appropriately contextualize a curriculum using simulation, it is necessary to first conduct a needs assessment of the target learner population. The World Health Organization (WHO) has published a tool to assess capacity for emergency and surgical care in LMICs that is adaptable to this goal. MATERIALS AND METHODS: The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was modified to assess pediatric resuscitation capacity in clinical settings in two LMICs: Uganda and Myanmar. Modifications included assessment of self-identified learning needs, current practices, and perceived epidemiology of disease burden in each clinical setting, in addition to assessment of pediatric resuscitation capacity in regard to infrastructure, procedures, equipment, and supplies. The modified tool was administered to 94 respondents from the two settings who were target learners of a proposed simulation-based curriculum in pediatric and neonatal resuscitation. RESULTS: Infectious diseases (respiratory illnesses and diarrheal disease) were cited as the most common causes of pediatric deaths in both countries. Self-identified learning needs included knowledge and skill development in pediatric airway/breathing topics, as well as general resuscitation topics such as CPR and fluid resuscitation in shock. Equipment and supply availability varied substantially between settings, and critical shortages were identified in each setting. Current practices and procedures were often limited by equipment availability or infrastructural considerations. DISCUSSION AND CONCLUSION: Epidemiology of disease burden reported by respondents was relatively consistent with WHO country-specific UFMR statistics in each setting. Results of the needs assessment survey were subsequently used to refine goals and objectives for the simulation curriculum and to ensure delivery of pragmatic educational content with recommendations that were contextualized for local capacity and resource availability. Effective use of the tool in two different settings increases its potential generalizability.

The National Clinical Assessment Tool for Medical Students in the Emergency Department (NCAT-EM).

INTRODUCTION: Clinical assessment of medical students in emergency medicine (EM) clerkships is a highly variable process that presents unique challenges and opportunities. Currently, clerkship directors use institution-specific tools with unproven validity and reliability that may or may not address competencies valued most highly in the EM setting. Standardization of assessment practices and development of a common, valid, specialty-specific tool would benefit EM educators and students. METHODS: A two-day national consensus conference was held in March 2016 in the Clerkship Directors in Emergency Medicine (CDEM) track at the Council of Residency Directors in Emergency Medicine (CORD) Academic Assembly in Nashville, TN. The goal of this conference was to standardize assessment practices and to create a national clinical assessment tool for use in EM clerkships across the country. Conference leaders synthesized the literature, articulated major themes and questions pertinent to clinical assessment of students in EM, clarified the issues, and outlined the consensus-building process prior to consensus-building activities. RESULTS: The first day of the conference was dedicated to developing consensus on these key themes in clinical assessment. The second day of the conference was dedicated to discussing and voting on proposed domains to be included in the national clinical assessment tool. A modified Delphi process was initiated after the conference to reconcile questions and items that did not reach an a priori level of consensus. CONCLUSION: The final tool, the National Clinical Assessment Tool for Medical Students in Emergency Medicine (NCAT-EM) is presented here.

Integration of in-hospital cardiac arrest contextual curriculum into a basic life support course: a randomized, controlled simulation study.

OBJECTIVE: The objective was to compare resuscitation performance on simulated in-hospital cardiac arrests after traditional American Heart Association (AHA) Healthcare Provider Basic Life Support course (TradBLS) versus revised course including in-hospital skills (HospBLS). DESIGN: This study is a prospective, randomized, controlled curriculum evaluation. SETTING: Johns Hopkins Medicine Simulation Center. SUBJECTS: One hundred twenty-two first year medical students were divided into fifty-nine teams. INTERVENTION: HospBLS course of identical length, containing additional content contextual to hospital environments, taught utilizing Rapid Cycle Deliberate Practice (RCDP). MEASUREMENTS: The primary outcome measure during simulated cardiac arrest scenarios was chest compression fraction (CCF) and secondary outcome measures included metrics of high quality resuscitation. MAIN RESULTS: Out-of-hospital cardiac arrest HospBLS teams had larger CCF: [69% (65-74) vs. 58% (53-62), p<0.001] and were faster than TradBLS at initiating compressions: [median (IQR): 9s (7-12) vs. 22s (17.5-30.5), p<0.001]. In-hospital cardiac arrest HospBLS teams had larger CCF: [73% (68-75) vs. 50% (43-54), p<0.001] and were faster to initiate compressions: [10s (6-11) vs. 36s (27-63), p<0.001]. All teams utilized the hospital AED to defibrillate within 180s per AHA guidelines [HospBLS: 122s (103-149) vs. TradBLS: 139s (117-172), p=0.09]. HospBLS teams performed more hospital-specific maneuvers to optimize compressions, i.e. utilized: CPR button to flatten bed: [7/30 (23%) vs. 0/29 (0%), p=0.006], backboard: [21/30 (70%) vs. 5/29 (17%), p<0.001], stepstool: [28/30 (93%) vs. 8/29 (28%), p<0.001], lowered bedrails: [28/30 (93%) vs. 10/29 (34%), p<0.001], connected oxygen appropriately: [26/30 (87%) vs. 1/29 (3%), p<0.001] and used oral airway and/or two-person bagging when traditional bag-mask-ventilation unsuccessful: [30/30 (100%) vs. 0/29 (0%), p<0.001]. CONCLUSION: A hospital focused BLS course utilizing RCDP was associated with improved performance on hospital-specific quality measures compared with the traditional AHA course.

Measuring Assessment Quality With an Assessment Utility Rubric for Medical Education.

INTRODUCTION: Prior research has identified seven elements of a good assessment, but the elements have not been operationalized in the form of a rubric to rate assessment utility. It would be valuable for medical educators to have a systematic way to evaluate the utility of an assessment in order to determine if the assessment used is optimal for the setting. METHODS: We developed and refined an assessment utility rubric using a modified Delphi process. Twenty-nine graduate students pilot-tested the rubric in 2016 with hypothetical data from three examinations, and interrater reliability of rubric scores was measured with interclass correlation coefficients (ICCs). RESULTS: Consensus for all rubric items was reached after three rounds. The resulting assessment utility rubric includes four elements (equivalence, educational effect, catalytic effect, acceptability) with three items each, one element (validity evidence) with five items, and space to provide four feasibility items relating to time and cost. Rater scores had ICC values greater than .75. DISCUSSION: The rubric shows promise in allowing educators to evaluate the utility of an assessment specific to their setting. The medical education field needs to give more consideration to how an assessment drives learning forward, how it motivates trainees, and whether it produces acceptable ranges of scores for all stakeholders.

Pediatric Resuscitation Education in Low-Middle-Income Countries: Effective Strategies for Successful Program Development.

Despite established international guidelines, there is considerable variability in the quality of resuscitative care received by critically ill children in low-middle-income countries. While this problem is certainly multifactorial, education of health care workers is an important determinant of care quality. This article will discuss approaches to health care worker education in pediatric resuscitation in low-middle-income countries, with emphasis on aspects of educational programs that may contribute to positive educational and clinical outcomes.

Optimizing Survival Outcomes For Adult Patients With Nontraumatic Cardiac Arrest.

Patient survival after cardiac arrest can be improved significantly with prompt and effective resuscitative care. This systematic review analyzes the basic life support factors that improve survival outcome, including chest compression technique and rapid defibrillation of shockable rhythms. For patients who are successfully resuscitated, comprehensive postresuscitation care is essential. Targeted temperature management is recommended for all patients who remain comatose, in addition to careful monitoring of oxygenation, hemodynamics, and cardiac rhythm. Management of cardiac arrest in circumstances such as pregnancy, pulmonary embolism, opioid overdose and other toxicologic causes, hypothermia, and coronary ischemia are also reviewed.

Clinical Assessment of Medical Students in Emergency Medicine Clerkships: A Survey of Current Practice.

BACKGROUND: Assessment practices in emergency medicine (EM) clerkships have not been previously described. Clinical assessment frequently relies on global ratings of clinical performance, or "shift cards," although these tools have not been standardized or studied. OBJECTIVE: We sought to characterize assessment practices in EM clerkships, with particular attention to shift cards. METHODS: A survey regarding assessment practices was administered to a national sample of EM clerkship directors (CDs). Descriptive statistics were compiled and regression analyses were performed. RESULTS: One hundred seventy-two CDs were contacted, and 100 (58%) agreed to participate. The most heavily weighted assessment methods in final grades were shift cards (66%) and written examinations (21-26%), but there was considerable variability in grading algorithms. EM faculty (100%) and senior residents (69%) were most commonly responsible for assessment, and assessors were often preassigned (71%). Forty-four percent of CDs reported immediate completion of shift cards, 27% within 1 to 2 days, and 20% within a week. Only 40% reported return rates >75%. Thirty percent of CDs do not permit students to review individual evaluations, and 54% of the remainder deidentify evaluations before student review. Eighty-six percent had never performed psychometric analysis on their assessment tools. Sixty-five percent of CDs were satisfied with their shift cards, but 90% supported the development of a national tool. CONCLUSION: There is substantial variability in assessment practices between EM clerkships, raising concern regarding the comparability of grades between institutions. CDs rely on shift cards in grading despite the lack of evidence of validity and inconsistent process variables. Standardization of assessment practices may improve the assessment of EM students.

Educational Value Units: A Mission-Based Approach to Assigning and Monitoring Faculty Teaching Activities in an Academic Medical Department.

PROBLEM: Increasing emphasis on revenue generation could jeopardize the fundamental notion of what it means to be faculty. Despite being a core mission, education is often marginalized in academic medical departments, and expectations of faculty effort in this area are often vague. A potential solution is mission-based budgeting (MBB), which refers to the allocation of resources based on core-mission-related priorities. APPROACH: From December 2012 to March 2013, the authors developed an educational value unit (EVU) system (using an MBB approach) to assign and monitor teaching activities related to the core departmental educational mission at the Department of Emergency Medicine, Johns Hopkins Medicine. EVUs were based on learner contact time, with one EVU equal to roughly one hour of in-person time with medical students or residents. Core education faculty vetted the proposed system; educational leaders determined the total EVUs needed and assessed the impact of their equitable distribution among faculty; and faculty members selected preferences and were assigned EVU obligations. OUTCOMES: For academic year 2013-2014, 5,896 EVUs were distributed among 54 faculty. At the end of the year, complete EVU data were available for 47 faculty. Of these, only 6 failed to complete their assigned EVU obligations. All core teaching activities were covered, and educational efforts were distributed more equitably across faculty. NEXT STEPS: The system is being refined, with an emphasis on incorporating learner outcome metrics, refining the teaching grid, incorporating failure to meet EVU obligations into yearly faculty evaluations, and disseminating the system to other departments and institutions.

Optimizing survival outcomes for adult patients with nontraumatic cardiac arrest [digest].

Patient survival after cardiac arrest can be improved significantly with prompt and effective resuscitative care. This systematic review analyzes the basic life support factors that improve survival outcome, including chest compression technique and rapid defibrillation of shockable rhythms. For patients who are successfully resuscitated, comprehensive postresuscitation care is essential. Targeted temperature management is recommended for all patients who remain comatose, in addition to careful monitoring of oxygenation, hemodynamics, and cardiac rhythm. Management of cardiac arrest in circumstances such as pregnancy, pulmonary embolism, opioid overdose and other toxicologic causes, hypothermia, and coronary ischemia are also reviewed. [Points & Pearls is a digest of Emergency Medicine Practice].

INTRODUCTION OF SIMULATION BASED MEDICAL EDUCATION AT ADDIS ABABA UNIVERSITY COLLEGE OF HEALTH SCIENCES: EXPERIENCE AND CHALLENGE.

BACKGROUND: As one of the countries in Sub-Saharan Africa with a low physician to population ratio, Ethiopia has sought to mitigate the problem by increasing the number of students enrolling in the existing medical schools. This increase in enrolment was not accompanied by expansion of clinical training venues, which has resulted in less patient contact time for each student. As part of the solution to fill the gap simulation-based teaching was introduced. OBJECTIVE: To describe the process of introducing Simulation based medical education (SBME) at Addis Ababa University College of Health Sciences, school of medicine. METHODS: Two rounds of intensive training was given by John Hopkins in collaboration with Medical Education partner Initiative (MEPI). to the core clinical educators to introduce them the six-step model of curriculum development for medical education and standardized patient (SP) techniques with the ultimate aim of introducing SPs in the teaching and learning process for medical students. The training included didactic and workshop elements, with group work and created complete educational modules. Each pre and post course assessment of experience and attitude were surveyed. Data was analyzed in aggregate using paired t -test to compare pre and post course means. RESULTS: There were total of 22 faculty members participated in the first group ,the majority of whom had no prior training in curriculum development or SBME and were skeptical of the value of SBME, as evidenced in their survey responses. (3.42/5 in Likert scale 1 = least 5 = most) at the end of the course the participant were comfortable with the concept of curriculum development the rating increased to 4.45/5 (P < 0.0001) and they embraced more favorable attitudes regarding the feasibility and desirability of simulation with Likert Scale 4.01/5 to 4.51 (P < 0.0001). In the second course, there were 16 participant and the majority had no prior experience with simulation and/or SP encounters. Their Baseline attitudes among participants in the second course were more favourable than in the first course, with a mean precourse Likert score of 4.24/5. Mean post course score was 4.43/5 (p = 0.1003), which did not represent a significant increase. The largest pre/post increases were seen for questions regarding accuracy of SP portrayal of specific clinical conditions (3.93 to 4.43, p = 0.0011), and enjoyability of incorporating SP activities into curricula (4.33 to 4.73, p = 0. 0281). After the course, the faculty remained particularly sceptical of the role of SPs in grading students (3.43/5). Both courses were well received, with 95% reporting they learned what they had hoped to learn. CONCLUSION: Training courses at CHS were successful for generating enthusiasm about simulation, and improving participant attitudes regarding the usefulness and feasibility of this educational method.

Implementing a third-year emergency medicine medical student curriculum.

BACKGROUND: Emergency medicine (EM) is commonly introduced in the fourth year of medical school because of a perceived need to have more experienced students in the complex and dynamic environment of the emergency department. However, there is no evidence supporting the optimal time or duration for an EM rotation, and a number of institutions offer third-year rotations. OBJECTIVE: A recently published syllabus provides areas of knowledge, skills, and attitudes that third-year EM rotation directors can use to develop curricula. This article expands on that syllabus by providing a comprehensive curricular guide for the third-year medical student rotation with a focus on implementation. DISCUSSION: Included are consensus-derived learning objectives, discussion of educational methods, considerations for implementation, and information on feedback and evaluation as proposed by the Clerkship Directors in Emergency Medicine Third-Year Curriculum Work Group. External validation results, derived from a survey of third-year rotation directors, are provided in the form of a content validity index for each content area. CONCLUSIONS: This consensus-derived curricular guide can be used by faculty who are developing or revising a third-year EM medical student rotation and provide guidance for implementing this curriculum at their institution.