An E-learning Module on Chronic Low Back Pain in Older Adults: Effect on Medical Resident Attitudes, Confidence, Knowledge, and Clinical Skills.

Objective: To determine 1) the feasibility of implementing an e-learning module on chronic low back pain (CLBP) in an older adult into an existing internal medicine residency curriculum and 2) the impact of this module on resident attitudes, confidence, knowledge, and clinical skills relating to CLBP. Methods: Participants were assigned to complete either the online module (N = 73) or the Yale Office-based curriculum on CLBP (N = 70). Attitudes, confidence, and knowledge were evaluated pre- and postintervention via survey. A retrospective blinded chart review of resident clinic encounters was conducted, wherein diagnosis codes and physical exam documentation were rated as basic or advanced. Results: There was no improvement in overall knowledge scores in either group (60% average on both metrics). There were tendencies for greater improvements in the intervention group compared with controls for confidence in managing fibromyalgia (2.4 to 2.9 vs 2.5 to 2.5, P = 0.06) and leg length discrepancy (1.8 to 2.5 vs 1.5 to 1.9, P = 0.05). Those exposed to the online module also showed an increase in the percentage of physical exam documentation rated as advanced following the intervention (13% to 32%, P = 0.006), whereas the control group showed no change (14% to 12%, P = 0.68). Conclusions: An online module on CLBP in the older adult was a feasible addition to an existing curriculum for internal medicine residents. The module positively and substantively impacted resident clinical behaviors, as evidenced by enhanced sophistication in physical exam documentation; it also was associated with improved confidence in certain aspects of chronic pain management.

An Entrustable Professional Activity (EPA)-Based Framework to Prepare Fourth-Year Medical Students for Internal Medicine Careers.

The purpose of the fourth year of medical school remains controversial. Competing demands during this transitional phase cause confusion for students and educators. In 2014, the Association of American Medical Colleges (AAMC) released 13 Core Entrustable Professional Activities for Entering Residency (CEPAERs). A committee comprising members of the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine applied these principles to preparing students for internal medicine residencies. The authors propose a curricular framework based on five CEPAERs that were felt to be most relevant to residency preparation, informed by prior stakeholder surveys. The critical areas outlined include entering orders, forming and answering clinical questions, conducting patient care handovers, collaborating interprofessionally, and recognizing patients requiring urgent care and initiating that care. For each CEPAER, the authors offer suggestions about instruction and assessment of competency. The fourth year of medical school can be rewarding for students, while adequately preparing them to begin residency, by addressing important elements defined in the core entrustable activities. Thus prepared, new residents can function safely and competently in supervised postgraduate settings.

The Selling of Primary Care 2015.

The role of undergraduate medical education in creating, perpetuating, and potentially solving the physician shortage in adult primary care has been debated for years, but often the discussions revolve around overly simplistic notions of supply and demand. The supply is curtailed, it is said, because the work is hard and the pay is low relative to other career options. Missing is a recognition that medical schools make choices in developing primary care learning environments that profoundly affect student perceptions of this career. Emerging developments in healthcare, including the transformation of academic health centers into integrated health systems that enter into risk-based contracts, may provide an opportunity to re-direct discussions about primary care. More schools may begin to recognize that they can control the quality of primary care teaching environments, and that doing so will help them achieve excellence in education and compete in the new marketplace. The selling of primary care to medical schools may be the first step in primary care selling itself to medical students.

Hold-over admissions: are they educational for residents?

PURPOSE: Since implementation of resident duty-hour restrictions, many academic medical centers utilize night-float teams to admit patients during off hours. Patients are transferred to other resident physicians the subsequent morning as "hold-over admissions." Despite the increase of hold-over admissions, there are limited data on resident perceptions of their educational value. This study investigated resident perceptions of hold-over admissions, and whether they approach hold-over admissions differently than new admissions. METHOD: Survey of internal medicine residents at an academic medical center. RESULTS: A total of 111 residents responded with a response rate of 71 %. Residents reported spending 56.2 min (standard deviation [SD] 18.9) compared to 80.0 min (SD 25.8) admitting new patients (p < 0.01). Residents reported spending significantly (p < 0.01) less time reviewing the medical record, performing histories, examining patients, devising care plans and writing orders in hold-over admissions compared to new admissions. Residents had neutral views on the educational value of hold-over admissions. Features that significantly (p < 0.01) increased the educational value of admissions included severe illness, patient complexity, and being able to write the initial patient care orders. Residents estimated 42.5 % (SD 14) of their admissions were hold-over patients. CONCLUSIONS: Residents spend less time in all aspects of admitting hold-over patients. Despite less time spent admitting hold-over patients, residents had neutral views on the educational value of such admissions.

The art of bedside rounds: a multi-center qualitative study of strategies used by experienced bedside teachers.

BACKGROUND: Medical educators believe bedside rounds are effective for the delivery of patient-centered care, and are necessary in helping trainees acquire competence in clinical care. Although recommendations for bedside rounds have been reported, a recent, systematic assessment of strategies used by current-day bedside teachers was needed to advance knowledge of this teaching method. OBJECTIVE: To identify and understand bedside teachers' 1) preparatory steps, 2) patient selection, and 3) role allocation during the process of bedside rounds. DESIGN: A qualitative inductive thematic analysis using transcripts from audio-recorded, semi-structured telephone interviews. PARTICIPANTS: Internal medicine physicians (n = 34) who perform bedside rounds from ten academic US institutions (2010-2011). APPROACH: A purposive sampling strategy was utilized to identify physicians who were active inpatient attending physicians and met specific inclusion criteria for "bedside rounds." A total of 34 interviews were completed, and each was recorded and transcribed verbatim. A thematic analysis extracted key themes pertaining to the three objectives. KEY RESULTS: Most respondents (51 %) were associate or full professors, with an average of 14 years of academic experience. Attending physicians prepared using trainee-specific, patient-specific and disease-specific information, while also mentally preparing for bedside rounds. They sought trainee buy-in and learning objectives, reviewed expectations and methods to ensure patient comfort, and provided early guidance with bedside encounters. Patients were selected if they required immediate care, were new to the service, or had a high educational value, while patients were deferred if unavailable, unwilling, or unable to communicate. The team members' roles during bedside rounds varied, with trainees being given graduated autonomy with increased experience. CONCLUSIONS: Bedside teachers' methods for preparation, patient selection, and role allocation during bedside rounds enhance trainees' education within the workplace. Strategies used by experienced bedside teachers can be used for faculty development efforts aimed at promoting this activity.

Integrating medical students' goals, self-assessment and preceptor feedback in an ambulatory clerkship.

BACKGROUND: Self-assessment and feedback are important elements for improving performance. However, coordinating their content remains elusive. PURPOSE: The purpose is to determine whether student self-assessment and preceptor feedback correlate with course outcomes and whether preceptor feedback informs student self-assessment. METHODS: Our students generate initial and midterm goals and preceptors provide midterm feedback. We coded goals and feedback as clinical subsets, knowledge, career oriented, and attitudinal. We assessed associations with exams and evaluations using correlations, chi-square, and comparisons of means. RESULTS: Students usually listed clinical goals (72%), whereas preceptors noted attitudes (50%). Students' self-assessments had little association with exams, evaluations, or preceptor feedback. Students cited by preceptors for clinical strengths scored higher on exams (77.2 vs. 72.7, p < .01). Those cited for knowledge received more honors and high pass (78 vs. 60%, p = .05) evaluations. CONCLUSIONS: Students and preceptors emphasize different aspects of performance. Student self-assessments were not associated with outcomes, but preceptor feedback was. Student self-assessment seemed resistant to feedback.

The value of bedside rounds: a multicenter qualitative study.

BACKGROUND: Bedside rounds have decreased on teaching services, raising concern about trainees' clinical skills and patient-physician relationships. PURPOSE: We sought to identify recognized bedside teachers' perceived value of bedside rounds to assist in the promotion of bedside rounds on teaching services. METHODS: Authors used a grounded theory, qualitative study design of telephone semistructured interviews with bedside teachers (n = 34) from 10 U.S. institutions (2010-2011). Main outcomes were characteristics of participants, themes pertaining to the perceived value of bedside rounds, and quotations highlighting each respective theme. RESULTS: The mean years in academic medicine was 13.7, and 51% were associate or full professors. Six main themes emerged: (a) skill development for learners (e.g., physical examination, communication, and clinical decision-making skills); (b) observation and feedback; (c) role-modeling; (d) team building among trainees, attending, and patient; (e) improved patient care delivery through combined clinical decision-making and team consensus; and (f) the culture of medicine as patient-centered care, which was embodied in all themes. CONCLUSIONS: Bedside teachers identify potential benefits of bedside rounds, many of which align with national calls to change our approach to medical education. The practice of bedside rounds enables activities essential to high-quality patient care and education.

Associations between medical student log data and clerkship learning outcomes.

BACKGROUND: Largely due to regulatory requirements, medical students increasingly document patient encounters in logs. Prior studies demonstrated value in achieving course objectives but not regarding objective learning outcomes. PURPOSE: The purpose of this article is to assess the associations between students' log data and clerkship outcomes. METHODS: We assessed ambulatory, internal medicine-pediatrics clerkship logs. Students recorded patients' diagnoses, preceptor's teaching content and performing histories and physicals (H&P). We examined associations between log data and National Board of Medical Examiners Subject Exams (NBME), Objective Structured Clinical Exams (OSCE), and clinical evaluations. RESULTS: All 272 students completed logs (M diagnoses = 146.5, SD = 24.9). In univariate analysis number of diagnoses, preceptors' teaching patient management and performing H&P independently correlated with OSCE scores (r = .13-.24, p < .05). NBME scores correlated with diagnoses, performing H&P independently (r = .13-.18, p < .05). Teaching patient management, diagnoses, performing H&P independently were associated with clinical evaluations (all ps < .05). Regressions demonstrated that performing physicals independently was associated with NBME and OSCE scores (p < .05, R (2) = .03 and .05, respectively). Teaching disease management and pediatric diagnoses were associated with clinical evaluations (p < .05) in medicine and pediatrics, respectively. CONCLUSIONS: Aspects of teaching, increased clinical involvement, and student autonomy were associated with clerkship performance.

Medical education in the United States of America.

This article was written to provide a brief history of the medical educational system in the USA, the current educational structure, and the current topics and challenges facing USA medical educators today. The USA is fortunate to have a robust educational system, with over 150 medical schools, thousands of graduate medical education programs, well-accepted standardized examinations throughout training, and many educational research programs. All levels of medical education, from curriculum reform in medical schools and the integration of competencies in graduate medical education, to the maintenance of certification in continuing medical education, have undergone rapid changes since the turn of the millennium. The intent of the changes has been to involve the patient sooner in the educational process, use better educational strategies, link educational processes more closely with educational outcomes, and focus on other skills besides knowledge. However, with the litany of changes have come increased regulation without (as of yet) clear evidence as to which of the changes will result in better physicians. In addition, the USA governmental debt crisis threatens the current educational structure. The next wave of changes in the USA medical system needs to focus on what particular educational strategies result in the best physicians and how to fund the system over the long term.

Implementing faculty evaluation of written sign-out.

PURPOSE: Recently the Accreditation Council for Graduate Medical Education mandated decreased shift duration for intern physicians to no more than 16 hours. Such work-hour restrictions are likely to increase patient care hand-offs. It is well accepted that sign-out (i.e., hand-off) processes are error prone and lack standardization. Moreover, many residency programs do not evaluate sign-out. We designed and tested whether a sign-out evaluation process could be implemented to improve written sign-out. METHOD: Based on observed sign-out deficiencies at our institution we adapted a simple curriculum incorporating the SIGNOUT mnemonic, which we paired with weekly faculty member evaluation and feedback on sign-out using a structured sign-out evaluation tool. Later in the week, written sign-out was independently scored by 2-blinded senior resident reviewers who compared the inclusion of sign-out content, organization, and readability. RESULTS: Compared to baseline data in 128 written sign-outs, the pairing of a 1-page curriculum with weekly faculty member evaluation of written sign-out improved the inclusion of advanced directives from 38% to 69% (p < .001) and anticipatory guidance from a mean score of 1.8 (SD = 1.2) to 2.3 (SD = 1.5) on a 5-point scale (p = .01) in 177 written sign-outs. Readability and organization were unchanged. CONCLUSIONS: A simple curriculum paired with structured faculty evaluation and feedback can improve some parameters of sign-out. Structured evaluative sign-out tools may be useful to improve and teach sign-out skills.

Postinterview communication between military residency applicants and training programs.

PURPOSE: Each year military medical students participate in a separate, military match culminating with the Joint Services Graduate Medical Education Selection Board (JSGMESB). Prior studies have explored postinterview communication that occurs during the National Resident Matching Program (NRMP), but not during the JSGMESB. We examined the frequency and nature of communication during the JSGMESB and compared it with the NRMP. METHODS: Cross-sectional survey study of senior students conducted at Uniformed Services University of the Health Sciences (USU) and seven civilian U.S. medical schools during March to May 2010. Respondents answered questions regarding communication with residency programs during the match. RESULTS: Significantly fewer USU respondents communicated with programs compared with the civilian cohort (54.1% vs. 86.4%, p < 0.01). Specific inquiries regarding rank order were more commonly experienced by USU respondents compared with civilians (17.5% vs. 4.8%, p = 0.02). USU respondents found postinterview communication both helpful (41.3%) and stressful (41.3%). 11.1% of USU respondents indicated that they moved a program higher on their final rank lists because of further communication with these programs. CONCLUSIONS: Postinterview communication during the JSGMESB process is less common and less stressful than that reported in the NRMP. USU respondents are more likely to be asked directly about their rank list and occasionally do change their lists. Uniform guidance mirroring the NRMP's dealing with direct inquiries about rank lists could potentially improve the process.

Effects of varying inpatient attending physician rotation length on medical students' and attending physicians' perceptions of teaching quality.

BACKGROUND: Patient care needs and work hour restrictions have altered inpatient internal medicine educational experiences. PURPOSE: The goal is to compare different attending physician rotation lengths on medical students' and attending physicians' experiences. METHODS: We studied clerkship students' evaluations (N= 86) and internal medicine attending surveys (N=21). We divided attending experiences into 2-week and 4-week rotations. We assessed exam scores and evaluations with 5-point Likert questions (5=strongly agree). Means were compared with t tests, Wilcoxon Ranked Sums, and logistic regression. RESULTS: More than 90% of students and attending physicians responded. Students and attending physicians generally evaluated their 2- and 4-week experiences similarly. Attending physicians favored 4 weeks for evaluating students' performance (3.30 vs. 4.36, p<.01). Exam scores were similar in the 2- and 4-week student groups (M=78.2, SD=5.0 vs. 76.5, SD=8.5, p=.43). CONCLUSIONS: Shorter rotations do not negatively impact students' experiences. Obtaining quality evaluations may be difficult for shorter rotations.

Resident sign-out and patient hand-offs: opportunities for improvement.

BACKGROUND: Inpatient care is characterized by multiple transitions of patient care responsibilities. In most residency programs trainees manage transitions via verbal, written, or combined methods of communication termed "sign-out." Often sign-out occurs without standardization or supervision. PURPOSE: The purpose was to assess daily sign-out with a goal of identifying aspects of this process most in need of improvement. METHODS: This was a prospective, observational cohort study of interns' sign-out conducted by industrial engineering students. Daily sign-out was analyzed for inclusion of multiple criteria and scored on organization (on a scale of 0-4) based on how effectively written information was conveyed. RESULTS: We observed 124 unique verbal and written sign-outs. We found that 99% of sign-outs included a general hospital course. Sign-outs were well organized with a mean of 3.1, though substantial variation was noted (SD = 0.8). Directions for anticipated patient events were included in only 42% of sign-outs. Do Not Resuscitate (DNR) or advanced directive discussions were reported in only 11% of sign-outs. Only 50% of successive daily sign-outs were updated. CONCLUSIONS: We found variability in the content and organization of interns' sign-out, possibly reflecting a lack of instruction and supervision. Standardization of sign-out content, and education on good sign-out skills are increasingly important as patient hand-offs become more frequent.

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.

Comparing PDA- and paper-based evaluation of the clinical skills of third-year students.

BACKGROUND: The mini-Clinical Evaluation Exercise (mini-CEX) is used to assess medical students' clinical skills during medicine clerkships. PURPOSE: To evaluate reliability, feasibility, and user satisfaction of a paper vs PDA-based mini-CEX in a third-year medicine clerkship. METHODS: The mini-CEX was reformatted as a PDA-based rating form for a medicine clerkship over 1 year. Faculty and residents were instructed to use either paper-based or the PDA form to assess clinical skills of students. A 9-point Likert scale was used to assess clinical skills and user satisfaction. Independent t-tests were used to assess differences between delivery formats. FINDINGS: Nearly all (98%) students completed 2 Mini-CEXs, with 275 PDA- and 101 paper-based records performed. Form reliability (Cronbach alpha) exceeded 0.9 for both. Overall resident satisfaction scores with the PDA form (7.2 +/- 1.8) were higher (P = 0.01) than the paper-based form (6.6/1.7). However, faculty satisfaction scores with the PDA form (6.9 +/- 1.6) were significantly lower (P = 0.01) than the paper form (7.6 +/- 1.5). Mean scores for all 7 clinical competencies of PDA format (7.9 +/- 0.9) were higher than the paper-based (7.6 +/- 1.1) version (P = .01). Mean observation (26 min; +/- 16) and feedback time (11 min +/- 8) were longer (both P < .05) with PDA-based form compared to the paper version (22 min +/- 14);(8.7 +/- 6.3). Student and evaluator satisfaction ratings were not significantly different by form. CONCLUSIONS: Both PDA- and paper-based mini-CEX delivery was acceptable to evaluators and students with both formats demonstrating high reliability. However, because evaluators' satisfaction, observation, and feedback time differed by form, further studies are needed to determine factors influencing rating variability.

Riding the rapids: COVID-19, the three rivers curriculum, and the experiences of the University of Pittsburgh School of Medicine.

When faced with the COVID-19 pandemic this past spring, the University of Pittsburgh's School of Medicine (UPSOM) took rapid steps to ensure the safety of students, staff, and the faculty as well as to maintain the educational process. Curriculum reform efforts, already underway, proved to be an advantage in the transformation. We quickly converted to a remote and then a hybrid curriculum. Research labs were reopened with appropriate safety measures. Clinical experiences for students restarted via a phased process that emphasized safety and graduation requirements. A variety of assessment mechanisms were restarted with appropriate modifications. New teaching models, such as flipped classrooms, have become the norm, and it seems hard to imagine our returning to our old pedagogy. The curriculum committee met continually to guide the process of change and reopening. The curricular adaptation process remains ongoing, and challenges remain. Nonetheless, we have learned from our experiences and hope to use this knowledge gained as we move forward.