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.

Medical Student Note Quality on a Pediatrics Core Clerkship Differs by Service.

Introduction Medical students rotate on various clinical disciplines with the same professional goal of learning medical documentation. This study investigated differences between medical student notes on inpatient general and subspecialty pediatric services by comparing note quality, length, and file time. Methods In a single-site, observational cohort study, medical students in the Core Clerkship in Pediatrics (CCP) from July 2020 to June 2021 participated in a note-writing didactic course. We compared notes from medical students completing their inpatient assignment on a general pediatric service to those who completed it on a pediatric subspecialty service. Primary outcomes were note quality measured by Physician Documentation Quality Instrument-9 (PDQI9), note length (measured by line count), and file time (measured by hours to completion since 6 AM on the morning of note initiation). Results We evaluated 84 notes from 84 medical students on the general pediatric services and 50 notes from 49 medical students on the pediatric subspecialty services. Note quality measured by PDQI9 was significantly higher for general pediatric service notes compared to pediatric subspecialty service notes (p = 0.03). General pediatric service notes were significantly shorter (p < 0.001). We found no difference in file time (p = 0.23). Conclusion Medical student notes on pediatric subspecialty services scored significantly lower in quality and were longer compared to general pediatric services, demonstrating the need for a more tailored note-writing curriculum and note template based on service.

Telehealth Curricula in the Pediatric Core Clerkship: Results From a Survey of Clerkship Directors.

OBJECTIVE: Given the increasing prevalence of telehealth, medical students require dedicated instruction in the practice of high-quality telehealth. This study characterizes telehealth practices and curricula in pediatric core clerkships across the United States and Canada. METHODS: We surveyed pediatric core clerkship directors and site directors through the 2020 Council on Medical Student Education in Pediatrics (COMSEP) annual member survey. We analyzed the results using descriptive statistics. RESULTS: Of 104 medical schools represented, 28 responded (26.9%). Directors reported students spent little time on telehealth during their pediatric core clerkships (average 8.2% of clerkship; SD 10.4). Only 10.7% (n=3) of clerkships had dedicated telehealth curricula. The instructional methods, content, and modes of evaluation varied across the clerkships' curricula. Barriers to implementation of telehealth curricula included lack of dedicated time in the existing curriculum (64.0%), lack of faculty time to teach (44.0%), lack of curricular materials (44.0%), students not participating in telehealth activities (40.0%) and lack of faculty expertise (36.0%). CONCLUSIONS: Most pediatric core clerkships do not include dedicated telehealth curricula, and the characteristics of existing curricula vary. Considering the rapid adoption of telemedicine, pediatric core clerkships merit additional support and guidance for the training of medical students in telehealth practice.

Assessing the Impact of a Note-Writing Session and Standardized Note Template on Medical Student Note Length and Quality.

PURPOSE: To determine whether a formal note-writing session and note template for medical students (MS) during the Core Clerkship in Pediatrics (CCP) increase note quality, shortens note length, and decreases time of documentation. METHODS: In this single site, prospective study, MS participating in an 8-week CCP received a didactic session on note-writing in the electronic health record (EHR) and utilized EHR template developed for the study. We assessed note quality (measured by Physician Documentation Quality Instrument-9 [PDQI-9]), note length and note documentation time in this group compared to MS notes on the CCP in the prior academic year. We used descriptive statistics and Kruskal-Wallis tests for analysis. RESULTS: We analyzed 121 notes written by 40 students in the control group and 92 notes writing by 41 students in the intervention group. Notes from the intervention group were more "up to date," "accurate," "organized," and "comprehensible" compared to the control group (P = 0.02, P = 0.04, P = 0.01, and P = 0.02, respectively). Intervention group notes received higher cumulative PDQI-9 scores compared to the control group (median score 38 (IQR 34-42) versus 36 (IQR 32-40) out of 45 total, P = 0.04). Intervention group notes were approximately 35% shorter than the control group notes (median 68.5 lines vs 105 lines, P < 0.0001) and were signed earlier than control group notes (median file time 316 minute vs 352 minute, P = 0.02). CONCLUSIONS: The intervention successfully decreased note length, improved note quality based on standardized metrics, and reduced time to completion of note documentation.

Telemedicine Clinical Skills Needs Assessment in Early Medical Students.

BACKGROUND AND OBJECTIVES: As clinicians increasingly rely on telemedicine, medical students will need to learn how to appropriately use telemedicine in patient care. A formal approach to curriculum development is needed to identify gaps and needs in early medical student performance. METHODS: In October 2020, 120 second-year medical students completed a telemedicine visit with a standardized patient with chronic essential hypertension. Students were assessed across five domains (history-gathering, communication, vitals, physical exam, and assessment/management). An anonymous, voluntary survey was distributed to assess self-efficacy in telemedicine skills. RESULTS: Students perform well in history-gathering and communication (98% of student scored 4 or 5 out of 5 on history, 100% of students received a 7 or 8 out of 8 on communication). Students perform poorly in obtaining vital signs (23% scored 3 or 4 out of 4) and assessment/management (14% scored 3 or 4 out of 4). Students received their lowest scores in physical examination (2% score 4 or 5 out of 5). The number of telemedicine visits completed with patients prior to the standardized patient exercise had no impact on student performance during the exercise. Student response rate on the postexercise survey was 88%. Self-efficacy was lowest in physical examination telemedicine skills compared to other domains. CONCLUSIONS: Findings suggest that early medical students are able to gather history and communicate over telemedicine, but perform poorly on telemedicine physical examination skills. More robust curriculum development addressing telemedicine physical examinations skills is needed early in medical training.

Phone It In: A Medical Student Primer on Telemedicine Consultation in Pediatrics.

Introduction: Telephone triage requires a unique skillset that is not universally taught in medical school. This curriculum was developed to introduce third- and fourth-year medical students participating in their pediatrics core clerkship to the benefits, challenges, and mechanics of telephone triage. Methods: After completing a presession textbook reading and listening to a brief lecture, students participated in two telephone role-play scenarios with parents. The exercise required students to recognize the differences in acuity level of patients and provide appropriate guidance, management, and disposition instructions. Following the session, students completed a telephone note. Students evaluated this curriculum at the completion of the clerkship. Results: The majority of the 74 students who completed the 5-point Likert scale evaluation felt that the curriculum met its stated objectives (a score of 4 or 5 given by 82%), increased their knowledge (73%), engaged them (86%), and was of high quality (82%). Students specifically commented that the experience was useful, interactive, and applicable to their clerkship experience and future career. The most common area of constructive feedback was not understanding the purpose of a telephone note. Discussion: This easily implemented curriculum provided a foundational experience in the nuances of triaging and managing pediatric patients via the telephone. This serves as an important framework to prepare students for more complex telemedicine technology.

Empowering nurses and residents to improve telemetry stewardship in the academic care setting.

AIMS AND OBJECTIVES: Inappropriate use of telemetry frequently occurs in the inpatient, non-intensive care unit setting. Telemetry practice standards have attempted to guide appropriate use and limit the overuse of this important resource with limited success. Clinical-effectiveness studies have thus far not included care settings in which resident-physicians are the primary caregivers. METHODS: We implemented two interventions on general internal medicine units of an academic hospital. The first intervention, or nurse-discontinuation protocol, allowed nurses to trigger the discontinuation of telemetry once the appropriate duration had passed according to practice standards. The second intervention, or physician-discontinuation protocol, instituted a best-practice advisory that notified the resident-physician via the electronic medical record when the appropriate telemetry duration for each patient had elapsed and suggested termination of telemetry. Data collection spanned 8 months following the implementation of the nurse-discontinuation protocol and 12 months following the physician-discontinuation protocol. RESULTS: During the control period, the average time spent on telemetry was 86.29 hours/patient/month. During the nurse-discontinuation protocol, patients spent, on average, 70.86 hours/patient/month on telemetry. During the physician-discontinuation protocol, patients spent, on average, 81.6 hours/patient/month on telemetry. During the nurse-discontinuation protocol, there was no significant change in the likelihood that a patient was placed on telemetry throughout their admission when compared with the control period. During the physician-discontinuation protocol, there was a significant decrease of 56.1% in the likelihood that a patient would be put on telemetry when compared with the control time period. CONCLUSIONS: These findings expand our understanding of telemetry use in the academic care setting in which trainees serve as the primary caregivers. Furthermore, these findings represent an important addition to the telemetry and patient monitoring literature by demonstrating the impact that nurse-managed protocols can have on telemetry use and by highlighting effective strategies to improve telemetry use by physicians in training.

Medical Student Attitudes toward USMLE Step 1 and Health Systems Science - A Multi-Institutional Survey.

Phenomenon: Because of its importance in residency selection, the United States Medical Licensing Examination Step 1 occupies a critical position in medical education, stimulating national debate about appropriate score use, equitable selection criteria, and the goals of undergraduate medical education. Yet, student perspectives on these issues and their implications for engagement with health systems science-related curricular content are relatively underexplored. Approach: We conducted an online survey of medical students at 19 American allopathic medical schools from March-July, 2019. Survey items were designed to elicit student opinions on the Step 1 examination and the impact of the examination on their engagement with new, non-test curricular content related to health systems science. Findings: A total of 2856 students participated in the survey, representing 23.5% of those invited. While 87% of students agreed that doing well on the Step 1 exam was their top priority, 56% disagreed that studying for Step 1 had a positive impact on engagement in the medical school curriculum. Eighty-two percent of students disagreed that Step 1 scores should be the top item residency programs use to offer interviews. When asked whether Step 1 results should be reported pass/fail with no numeric score, 55% of students agreed, while 33% disagreed. The majority of medical students agreed that health systems science topics were important but disagreed that studying for Step 1 helped learn this content. Students reported being more motivated to study a topic if it was on the exam, part of a course grade, prioritized by residency program directors, or if it would make them a better physician in the future. Insights: These results confirm the primacy of the United States Medical Licensing Examination Step 1 exam in preclinical medical education and demonstrate the need to balance the objectives of medical licensure and residency selection with the goals of the broader medical profession. The survey responses suggest several potential solutions to increase student engagement in health systems science curricula which may be especially important after Step 1 examination results are reported as pass/fail.

Effect of a high value care curriculum on standardized patient exam in the Core Clerkship in Internal Medicine.

BACKGROUND: With almost 20% unnecessary spending on healthcare, there has been increasing interest in high value care defined as the best care for the patient, with the optimal result for the circumstances, delivered at the right price. The American Association of Medical Colleges recommend that medical students are proficient in concepts of cost-effective clinical practice by graduation, thus leading to curricula on high value care. However little is published on the effectiveness of these curricula on medical students' ability to practice high value care. METHODS: In addition to the standard curriculum, the intervention group received two classroom sessions and three virtual patients focused on the concepts of high value care. The primary outcome was number of tests and charges for tests on standardized patients. RESULTS: 136 students enrolled in the Core Clerkship in Internal Medicine and 70 completed the high value care curriculum. There were no significant differences in ordering of appropriate tests (3.1 vs. 3.2 tests/students, p = 0.55) and inappropriate tests (1.8 vs. 2.2, p = 0.13) between the intervention and control. Students in the intervention group had significantly lower median Medicare charges ($287.59 vs. $500.86, p = 0.04) and felt their education in high value care was appropriate (81% vs. 56%, p = 0.02). CONCLUSIONS: This is the first study to describe the impact of a high value care curriculum on medical students' ordering practices. While number of inappropriate tests was not significantly different, students in the intervention group refrained from ordering expensive tests.

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.

The Process of Developing an Assessment Checklist for Simulated Infant Respiratory Distress Using a Modified Delphi Method: A Mixed Methods Study.

Introduction Assessing clinical performance, such as managing respiratory distress, in clinical trainees is challenging yet important. Our objective was to describe and evaluate an integrative and iterative approach to developing a checklist measuring simulated clinical performance for infant respiratory distress. Methods We implemented a five-step modified Delphi process with an embedded qualitative component. An implementation period occurred followed by a second qualitative data collection. Validity evidence was collected throughout the process. Results A 19-item assessment checklist was developed for managing infant respiratory distress by medical student learners in a simulation-based setting. The iterative process provided content validity while the qualitative data provided response process validity. Cohen kappa was 0.82 indicating strong rater agreement. The assessment checklist was found to be easy to use and measure what was intended. Conclusion We developed an accurate and reliable assessment checklist for medical student learners in a simulation-based learning setting with high interrater reliability and validity evidence. Given its ease of use, we encourage medical educators and researchers to utilize this method to develop and implement assessment checklists for their interventions.

Decreasing Duplicative Imaging: Inpatient and Emergency Medicine Abdominal Ultrasound Within 72 Hours of Abdominal CT.

PURPOSE: The aim of this project was to reduce abdominal ultrasound examinations in patients who had undergone abdominal CT within 72 hours previously. METHODS: A best practice advisory (BPA) was created in the electronic medical record to advise against the use of abdominal ultrasound in adult inpatients and emergency department patients who had undergone abdominal CT within the preceding 72 hours. Acceptable acknowledgment reasons to proceed with the order were made available if providers chose to override. Frequency of BPA firing and subsequent ordering behavior were evaluated 6 months after integration of the BPA into the electronic medical record. Chart review was conducted for 100 patients whose orders were placed through an override of the alert to determine if the ultrasound study added value and for all patients whose ultrasound studies were canceled to confirm that patient care was not compromised by omitting the ultrasound study. RESULTS: In the first 6 months, a total of 614 inpatient and emergency department abdominal ultrasound orders triggered the BPA. A total of 16% of orders (n = 96) were canceled by the provider after the BPA, reflecting 518 overrides. The majority of retained orders were to evaluate the gallbladder (44% [227 of 518]). Chart review confirmed utility for gallbladder imaging and that the canceled ultrasound examinations would not have contributed value to patients' care. CONCLUSIONS: A recently performed abdominal CT scan may obviate the need for inpatient and emergency department abdominal ultrasound, particularly in the setting of hospital-acquired acute kidney injury. A BPA resulted in only 16% of orders' being canceled, whereas chart review revealed a much larger opportunity to avoid duplicative imaging.

Prescriber Behavior in Clostridioides difficile Testing: A 3-Hospital Diagnostic Stewardship Intervention.

Computerized clinical decision support (CCDS) significantly reduced Clostridioides difficile testing at 3 hospitals; from 12.6 to 9.5, from 10.1 to 6.4, and from 14.0 to 9.6 average weekly tests per 1000 inpatient days. There were no related adverse events. Senior providers were more likely than interns or residents to follow CCDS.

Things We Do For No Reason™: Use of Antipsychotic Medications in Patients with Delirium.

Inspired by the ABIM Foundation's Choosing Wisely® campaign, the "Things We Do for No Reason™" (TWDFNR™) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR™ series do not represent "black and white" conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

Novel first-year curriculum in high-value care.

BACKGROUND: Most medical schools teach a high-value care (HVC) curriculum during the clinical years. Currently, there lacks any research demonstrating the effectiveness of the HVC curriculum taught to students in their first year of medical school. METHODS: A total of 118 of 466 first-year medical students at Johns Hopkins School of Medicine between 2013 and 2017 enrolled on an HVC course that provided the initial framework necessary to practice cost-conscious clinical medicine. The curriculum was evaluated by comparing the performance of students who completed the course with the performance of students without training, through a standardised patient encounter on musculoskeletal back pain and how to approach a patient's request for imaging. Chi-square testing was used to assess the impact of the course on performance in a standardised patient encounter. RESULTS: Students enrolled on the HVC course were more likely, compared with their counterparts, to assure patients that back pain was a simple strain (48 versus 31%), and were less likely to ask for preceptor help on how to proceed with management (11 versus 29%) [χ2 (4, n = 466) = 14.28, p = 0.007]. There were no differences between students enrolled on the HVC course who had not yet received training compared with students taking another elective [χ2 (4, n = 385) = 8.73, p = 0.07]. DISCUSSION: This is the first study to assess the effectiveness of an HVC curriculum for first-year medical students, and it demonstrates promise that they can acquire some skill sets necessary for cost-effective practice in a simulated clinical setting. This is the first study to assess the effectiveness of an HVC curriculum for first-year medical students, and it demonstrates promise that they can acquire some skill sets necessary for cost-effective practice.