The effect of resident duty-hours restrictions on internal medicine clerkship experiences: surveys of medical students and clerkship directors.

UNLABELLED: PHENOMENON: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students' and clerkship directors' perceptions of the effects of the 2011 DHR on internal medicine clerkship students' experiences with teaching, feedback and evaluation, and patient care. APPROACH: Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation. FINDINGS: Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. INSIGHTS: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student-patient relationship and students' clinical skills acquisition.

Reducing the Risk of Mortality in Chronic Obstructive Pulmonary Disease With Pharmacotherapy: A Narrative Review.

In 2020, chronic obstructive pulmonary disease (COPD) was the fifth leading cause of death in the United States excluding COVID-19, and its mortality burden has been rising since the 1980s. Smoking cessation, long-term oxygen therapy, noninvasive ventilation, and lung volume reduction surgery have had a beneficial effect on mortality; however, until recently, the effects of pharmacologic therapies on all-cause mortality have been unclear. Inhaled pharmacologic treatments for patients with COPD include combinations of long-acting muscarinic receptor antagonists (LAMAs), long-acting-ß2-agonists (LABAs), and inhaled corticosteroids (ICS). The recent IMPACT and ETHOS clinical trials reported mortality benefits with ICS/LAMA/LABA triple therapy compared with LAMA/LABA dual therapy. In IMPACT, fluticasone furoate/umeclidinium/vilanterol therapy significantly reduced the risk of on-/off-treatment all-cause mortality vs umeclidinium/vilanterol (hazard ratio, 0.72; 95% CI, 0.53 to 0.99; P=.042). The ETHOS trial found a reduction in the risk of on-/off-treatment all-cause mortality in patients treated with budesonide/glycopyrrolate/formoterol vs glycopyrrolate/formoterol (hazard ratio, 0.51 [0.33 to 0.80]; nominal P=.0035). Both trials included populations of patients with symptomatic COPD at high risk of future exacerbations, and a post hoc analysis of the final retrieved vital status data suggested that the observed mortality benefits are conferred by the ICS component. In conclusion, triple therapy reduces the risk of mortality in patients with symptomatic COPD characterized by moderate or severe airflow obstruction and a recent history of moderate or severe exacerbations. This benefit is likely to be driven by reductions in exacerbations. Future research efforts should focus on improving the long-term prognosis of patients living with COPD.

Developing a national collaborative of medical educators who lead clinical skills courses.

BACKGROUND: The majority of US medical schools now have pre-clerkship clinical skills (PCCS) courses. Course directors for these often logistically complicated courses may be in different medical specialties and, historically, have had few formal opportunities for communication and collaboration with their counterparts at other institutions. As such, we hypothesized that leaders of PCCS courses would benefit from a national network. SUMMARY: In this paper, we outline the methodology used to form a national collaborative from grass roots interest. Over three years, a self-identified eleven-person task force with national representation has created an organization for PCCS course directors from US medical schools called Directors Of Clinical Skills courses (DOCS) that meets annually. CONCLUSIONS: Through iterative presentations at regional and national medical education meetings, we have produced an inventory of educational issues for those developing, administering, and evaluating PCCS courses. Further development of this nascent organization is ongoing. Our process is generalizable.

Analysis and publication rates of Clerkship Directors in Internal Medicine (CDIM) annual meeting abstracts 1995-2005.

BACKGROUND: Abstracts presented at meetings may be a reflection of the meeting's quality. SUMMARY: The goal is to determine purpose, content areas, research design, and subsequent publication rates of abstracts presented at Clerkship Directors in Internal Medicine's annual meetings. Abstracts presented in 1995-2005 were analyzed. A total of 201 abstracts were analyzed and coded. The purpose of the majority of the studies was description (155, 77%), 44 (22%) were justification studies, and 2 (1%) were clarification studies. In all, 109 (54%) assessed the relationship between teaching and student performance. Seven (4%) were studies about how students learn, study, solve problems, obtain medical knowledge, and think critically. Nineteen (10%) were studies about students' noncognitive skills, professionalism, interpersonal skills, and well-being studies. In all, 29 (14%) were measurement studies assessing reliability or validity of assessments. Twenty (10%) focused on career or faculty development pertaining to either faculty or residents. Research design of most studies was descriptive or pre-experimental (175, 87%), some were quasi-experimental (13, 7%), and two thirds (135, 66%) were not published as full articles in peer-reviewed journals. and there was an upward trend in publication rates. CONCLUSIONS: These findings may serve as an indicator of the quality of the educational meeting. It may further stimulate efforts to develop programs to help program attendees achieve scholarly publications for work presented and serve as a benchmark against which future meetings may be judged.

GOLD in Practice: Chronic Obstructive Pulmonary Disease Treatment and Management in the Primary Care Setting.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Early detection and appropriate treatment and management of COPD can lower morbidity and perhaps mortality. Clinicians in the primary care setting provide the majority of COPD care and are pivotal in the diagnosis and management of COPD. In this review, we provide an overview of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 report, with a focus on the management of COPD in the primary care setting. We discuss the pathophysiology of COPD; describe COPD risk factors, signs, and symptoms that may facilitate earlier diagnosis of COPD; and reinforce the importance of spirometry use in establishing the diagnosis of COPD. Disease monitoring, as well as a review of the 2020 GOLD treatment recommendations, is also discussed. Patients and families are important partners in COPD management; therefore, we outline simple steps that may assist them in caring for those affected by COPD. Finally, we discuss nonpharmacological treatment options for COPD, COPD monitoring tools that may aid in the evaluation of disease progression and response to therapy, and the importance of developing a COPD action plan on an individualized basis.

Patients' and primary care physicians' beliefs about asthma control and risk.

Patients' and physicians' knowledge of asthma control and risks can affect long-term outcomes. The Asthma General Awareness and Perceptions II (Asthma GAP II) survey sought to assess the beliefs and behaviors of asthma patients and their physicians. In the United States, a telephone survey was conducted among 1885 adults with asthma (representative population sample [n = 1001] plus additional black [n = 436] and Hispanic samples [n = 448]) who took asthma medication in the previous year. An online survey included 300 primary care physicians. Most patients (66, 84, and 78% of national, black, and Hispanic samples, respectively) and physicians (80%) considered asthma a very or extremely serious condition. In contrast to current guidelines, most patients (69, 72, and 70%) believed that quick-relief medications could be taken daily. Many patients (42, 52, and 60%) and some physicians (22%) stated controller medications could be taken less regularly when symptoms decrease, although most patients (92, 92, and 89%) and physicians (95%) indicated that controller medications are most effective when taken daily. Of patients who discontinued controller medications (21%), 71% discontinued when symptoms abated. Most physicians (87%) believed that patients discontinued controller medications without their advice. After controller medication cessation, more black (22%) and Hispanic patients (22%) than patients in the national sample (15%) experienced serious health consequences after an asthma attack. Gaps exist between patients' understanding of asthma control and their use of controller and quick-relief medications. Many patients and physicians fail to recognize that, even with symptom abatement, serious asthma risks remain.

Letters of recommendation: rating, writing, and reading by clerkship directors of internal medicine.

BACKGROUND: Letters of Recommendations (LORs) are used for applications to medical school and graduate medical education, but how they are used by current internal medicine educators is unknown. DESCRIPTION: In 2006, the Clerkship Directors of Internal Medicine conducted its annual, voluntary survey, and one section pertained to LORs. Survey items were categorized into questions regarding rating, writing, and reading LORs with answers on 3- to 5-point scales. EVALUATION: The response rate for the 110 institution members was 75%. When rating LORs, the most important factor was depth of understanding of the trainee (98% essential or important), followed by a numerical comparison to other students (94%), grade distribution (92%), and summary statement (91%). Although most (78%) agreed that reading LORs in general were important for trainee selection, few agreed that this was because of the ability to discern marginal performance (31%) or predict future performance (25%). CONCLUSIONS: LORs remain an important part of the application process for medical school and internal medicine residency. Letter writers should convey a great depth of understanding of the applicant, provide a numerical comparison with other students (including a denominator), and give a specific summary statement.

Medical informatics in the internal medicine clerkship: Results of a national survey.

BACKGROUND: Medical Informatics (MI) is increasingly a critical aspect of medical education and patient care. AIMS: This study assessed the status of MI training, perception of needs and barriers for the implementation of MI curricula and utilization of information technology (IT) in patient care and medical education. METHOD: The MI questionnaire was a part of the 2006 Clerkship Directors in Internal Medicine survey of 110 institutional members. Descriptive statistics were calculated using Statistical Package for the Social Sciences (SPSS), version 12 and all p-values are two-tailed. RESULTS: Eighty-three (75%) members responded. Out of this, 52, 32.5 and 12% report that students receive MI training for patient care activities during pre-clinical years, third-year internal medicine clerkship or intersession, respectively. House staff critiques (46.4%), patient billing (44.1%), radiographic imaging (40.8%), accessing clinical data (37.3%), and student evaluations (36.1%) were areas in which 35% of respondents use IT 'all the time.' Fifty-one percent of respondents rate the adequacy of training in MI as average. Cost, time and lack of trained faculty were primary barriers for the implementation. CONCLUSIONS: Significant variations exist in timing of MI curricula. IT is utilized more frequently for non-patient activities. Studies are needed to examine the needs, processes and outcomes of MI curricula.

Relationships between drug company representatives and medical students: medical school policies and attitudes of student affairs deans and third-year medical students.

OBJECTIVES: The authors sought to ascertain the details of medical school policies about relationships between drug companies and medical students as well as student affairs deans' attitudes about these interactions. METHODS: In 2005, the authors surveyed deans and student affairs deans at all U.S. medical schools and asked whether their schools had a policy about relationships between drug companies and medical students. They asked deans at schools with policies to summarize them, queried student affairs deans regarding their attitudes about gifts, and compared their attitudes with those of students who were studied previously. RESULTS: Independently of each other, 114 out of 126 deans (90.5%) and 114 out of 126 student affairs deans (90.5%) responded (identical numbers are not misprints). Ten schools had a policy regarding relationships between medical students and drug company representatives. Student affairs deans were much more likely than students to perceive that gifts were inappropriate. CONCLUSION: These 2005 policies show trends meriting review by current medical schools in considering how to comply with the 2008 Association of American Medical Colleges recommendations about relationships between drug companies and medical students or physicians.

Internal medicine clerkship directors' perceptions about student interest in internal medicine careers.

BACKGROUND: Experienced medical student educators may have insight into the reasons for declining interest in internal medicine (IM) careers, particularly general IM. OBJECTIVE: To identify factors that, according to IM clerkship directors, influence students' decisions for specialty training in IM. DESIGN: Cross-sectional national survey. PARTICIPANTS: One hundred ten institutional members of Clerkship Directors in IM. MEASUREMENTS: Frequency counts and percentages were reported for descriptive features of clerkships, residency match results, and clerkship directors' perceptions of factors influencing IM career choice at participating schools. Perceptions were rated on a five-point scale (1 = very much pushes students away from IM careers; 5 = very much attracts students toward IM careers). RESULTS: Survey response rate was 83/110 (76%); 80 answered IM career-choice questions. Clerkship directors identified three educational items attracting students to IM careers: quality of IM faculty (mean score 4.3, SD = 0.56) and IM rotation (4.1, SD = 0.67), and experiences with IM residents (3.9, SD = 0.94). Items felt most strongly to push students away from IM careers were current practice environment for internists (mean score 2.1, SD = 0.94), income (2.1, SD = 1.08), medical school debt (2.3, SD = 0.89), and work hours in IM (2.4, SD = 1.05). Factor analysis indicated three factors explaining students' career choices: value/prestige of IM, clerkship experience, and exposure to internists. CONCLUSIONS: IM clerkship directors believe that IM clerkship experiences attract students toward IM, whereas the income and lifestyle for practicing internists dissuade them. These results suggest that interventions to enhance the practice environment for IM could increase student interest in the field.

Factors associated with medical students' career choices regarding internal medicine.

CONTEXT: Shortfalls in the US physician workforce are anticipated as the population ages and medical students' interest in careers in internal medicine (IM) has declined (particularly general IM, the primary specialty serving older adults). The factors influencing current students' career choices regarding IM are unclear. OBJECTIVES: To describe medical students' career decision making regarding IM and to identify modifiable factors related to this decision making. DESIGN, SETTING, AND PARTICIPANTS: Web-based cross-sectional survey of 1177 fourth-year medical students (82% response rate) at 11 US medical schools in spring 2007. MAIN OUTCOME MEASURES: Demographics, debt, educational experiences, and number who chose or considered IM careers were measured. Factor analysis was performed to assess influences on career chosen. Logistic regression analysis was conducted to assess independent association of variables with IM career choice. RESULTS: Of 1177 respondents, 274 (23.2%) planned careers in IM, including 24 (2.0%) in general IM. Only 228 (19.4%) responded that their core IM clerkship made a career in general IM seem more attractive, whereas 574 (48.8%) responded that it made a career in subspecialty IM more attractive. Three factors influenced career choice regarding IM: educational experiences in IM, the nature of patient care in IM, and lifestyle. Students were more likely to pursue careers in IM if they were male (odds ratio [OR] 1.75; 95% confidence interval [CI], 1.20-2.56), were attending a private school (OR, 1.88; 95% CI, 1.26-2.83), were favorably impressed with their educational experience in IM (OR, 4.57; 95% CI, 3.01-6.93), reported favorable feelings about caring for IM patients (OR, 8.72; 95% CI, 6.03-12.62), or reported a favorable impression of internists' lifestyle (OR, 2.00; 95% CI, 1.39-2.87). CONCLUSIONS: Medical students valued the teaching during IM clerkships but expressed serious reservations about IM as a career. Students who reported more favorable impressions of the patients cared for by internists, the IM practice environment, and internists' lifestyle were more likely to pursue a career in IM.

Acting on reflection: the effect of reflection on students' clinical performance on a standardized patient examination.

BACKGROUND: Little evidence exists to support the value of reflection in the clinical setting. OBJECTIVE: To determine whether reflecting and revisiting the "patient" during a standardized patient (SP) examination improves junior medical students' performance and to analyze students' perceptions of its value. DESIGN: Students completed a six-encounter clinical skills examination, writing a guided assessment after each encounter to trigger reflection. SPs evaluated the students with Medical Skills and Patient Satisfaction checklists. During the last three encounters, students could opt to revisit the SP and be reevaluated with identical checklists. PARTICIPANTS: One hundred and forty-nine third year medical students. MEASUREMENTS: Changes in scores in the Medical Skills and Patient Satisfaction checklists between first visit and revisit were tested separately per case as well as across cases. RESULTS: On the medical skills and patient satisfaction checklists, mean revisit scores across cases were significantly higher than mean first visit scores [12.6 vs 12.2 (pooled SD = 2.4), P = .0001; 31.2 vs 31.0 (pooled SD = 3.5), P = .0001)]. Sixty-five percent of the time, students rated "reflect-revisit" positively, 34% neutrally, and 0.4% negatively. Five themes were identified in the positive comments: enhancement of (1) medical decision making, (2) patient education/counseling, (3) student satisfaction/confidence, (4) patient satisfaction/confidence, and (5) clinical realism. CONCLUSIONS: Offering third year medical students the option to reflect and revisit an SP during a clinical skills examination produced a small but nontrivial increase in clinical performance. Students perceived the reflect-revisit experience as enhancing patient-centered practices (counseling, education) as well as their own medical decision making and clinical confidence.

Survey of handheld computing among medical students.

The purpose of this study was to identify trends in the utilization and acceptance of handheld computers (personal digital assistants) among medical students during preclinical and clinical training. We surveyed 366 medical students and collected information on computer expertise, current handheld computer use, predicted future use, and user acceptance. Handheld computers were primarily used for personal applications by students during their preclinical training and as drug references and clinical calculators during their clinical training. In the future, all participants predicted they would use handheld computers at significantly higher rates and on a broader range of medical applications. The adoption of handheld computing was independent of user satisfaction. Those with more clinical experience were less satisfied with handheld computers, suggesting that the expectations of the more experienced users were not met. The lack of institutional support was seen as a key limitation.

Role of the Kidney in Type 2 Diabetes and Mechanism of Action of Sodium Glucose Cotransporter-2 Inhibitors.

The aim of this supplement is to discuss the important role of the kidney in glucose homeostasis. It produces glucose via gluconeogenesis, it filters glucose from the blood, and reabsorbs the filtered glucose in the proximal tubule, mainly via the sodium-glucose cotransporter-2 (SGLT-2). SGLT-2 is paradoxically upregulated in individuals with type 2 diabetes (T2D), which results in increased glucose reabsorption and hyperglycemia. This core defect in the pathophysiology of T2D provides the rationale for the use of SGLT-2 inhibitors to increase urinary glucose excretion and reduce hyperglycemia in an insulin-independent manner. Benefits of SGLT-2 inhibitor use in patients with T2D, in addition to improved glycemic control, include modest weight loss, decreased systolic blood pressure, reduced serum uric acid, and reduced risk of cardiovascular events. Common adverse events are urinary tract infection and genital mycotic infections. The risk of hypoglycemia is low with SGLT-2 inhibitors, particularly when they are given as monotherapy.

Do attending physicians, nurses, residents, and medical students agree on what constitutes medical student abuse?

BACKGROUND: Whether attending physicians, residents, nurses, and medical students agree on what constitutes medical student abuse, its severity, or influencing factors is unknown. METHOD: We surveyed 237 internal medicine attending physicians, residents, medical students, and nurses at 13 medical schools after viewing five vignettes depicting potentially abusive behaviors. RESULTS: The majority of each group felt the belittlement, ethnic insensitivity, and sexual harassment scenarios represented abuse but that excluding a student from participating in a procedure did not. Only a majority of attending physicians considered the negative feedback scenario as abuse. Medical students rated abuse severity significantly lower than other groups in the belittlement scenario (p<.05). Respondents who felt abused as students were more likely to rate behaviors as abusive (p<.05). CONCLUSIONS: The groups generally agree on what constitutes abuse, but attending physicians and those abused as students may perceive more behaviors as abusive.

Medical students' exposure to and attitudes about drug company interactions: a national survey.

CONTEXT: While exposure to and attitudes about drug company interactions among residents have been studied extensively, relatively little is known about relationships between drug companies and medical students. OBJECTIVE: To measure third-year medical students' exposure to and attitudes about drug company interactions. DESIGN, SETTING, AND PARTICIPANTS: In 2003, we distributed a 64-item anonymous survey to 1143 third-year students at 8 US medical schools, exploring their exposure and response to drug company interactions. The schools' characteristics included a wide spectrum of ownership types, National Institutes of Health funding, and geographic locations. In 2005, we conducted a national survey of student affairs deans to measure the prevalence of school-wide policies on drug company-medical student interactions. MAIN OUTCOME MEASURES: Monthly frequency of students' exposure to various activities and gifts during clerkships, and attitudes about receiving gifts. RESULTS: Overall response rate was 826/1143 (72.3%), with range among schools of 30.9%-90.7%. Mean exposure for each student was 1 gift or sponsored activity per week. Of respondents, 762/818 (93.2%) were asked or required by a physician to attend at least 1 sponsored lunch. Regarding attitudes, 556/808 (68.8%) believed gifts would not influence their practices and 464/804 (57.7%) believed gifts would not affect colleagues' practices. Of the students, 553/604 (80.3%) believed that they were entitled to gifts. Of 183 students who thought a gift valued at less than $50 was inappropriate, 158 (86.3%) had accepted one. The number of students who simultaneously believed that sponsored grand rounds are educationally helpful and are likely to be biased was 452/758 (59.6%). Students at 1 school who had attended a seminar about drug company-physician relationships were no more likely than the nonattending classmates to show skepticism. Of the respondents, 704/822 (85.6%) did not know if their school had a policy on these relationships. In a national survey of student affairs deans, among the 99 who knew their policy status, only 10 (10.1%) reported having school-wide policies about these interactions. CONCLUSIONS: Student experiences and attitudes suggest that as a group they are at risk for unrecognized influence by marketing efforts. Research should focus on evaluating methods to limit these experiences and affect the development of students' attitudes to ensure that physicians' decisions are based solely on helping each patient achieve the greatest possible benefit.

Changes in medical students' exposure to and attitudes about drug company interactions from 2003 to 2012: a multi-institutional follow-up survey.

PURPOSE: To ascertain whether changes occurred in medical student exposure to and attitudes about drug company interactions from 2003-2012, which factors influence exposure and attitudes, and whether exposure and attitudes influence future plans to interact with drug companies. METHOD: In 2012, the authors surveyed 1,269 third-year students at eight U.S. medical schools. Items explored student exposure to, attitudes toward, and future plans regarding drug company interactions. The authors compared 2012 survey data with their 2003 survey data from third-year students at the same schools. RESULTS: The 2012 response rate was 68.2% (866/1,269). Compared with 2003, in 2012, students were significantly less frequently exposed to interactions (1.6/month versus 4.1/month, P < .001), less likely to feel entitled to gifts (41.8% versus 80.3%, P < .001), and more apt to feel gifts could influence them (44.3% versus 31.2%, P < .001). In 2012, 545/839 students (65.0%) reported private outpatient offices were the main location of exposure to pharmaceutical representatives, despite spending only 18.4% of their clerkship-rotation time there. In 2012, 310/703 students (44.1%) were unaware their schools had rules restricting interactions, and 467/837 (55.8%) planned to interact with pharmaceutical representatives during residency. CONCLUSIONS: Students in 2012 had less exposure to drug company interactions and were more likely to have skeptical attitudes than students in 2003. These changes are consistent with national organizations' recommendations to limit and teach about these interactions. Continued efforts to study and influence students' and physician role models' exposures to and attitudes about drug companies are warranted.