Innovation and Missed Opportunities in Internal Medicine Undergraduate Education During COVID-19: Results from a National Survey.

BACKGROUND: COVID-19 disrupted undergraduate clinical education when medical schools removed students from clinical rotations following AAMC recommendations. Clerkship directors (CDs) had to adapt rapidly and modify clerkship curricula. However, the scope and effects of these modifications are unknown. OBJECTIVE: To examine the effects of the initial phase of COVID-19 on the internal medicine (IM) undergraduate clinical education. DESIGN: A nationally representative web survey. PARTICIPANTS: IM CDs from 137 LCME-accredited US medical schools in 2020. MAIN MEASURES: Items (80) assessed clerkship structure and curriculum, assessment in clerkships, post-clerkship IM clinical experiences, and CD roles and support. The framework of Understanding Crisis Response (Royal Society for Encouragement of Arts, Manufactures, and Commerce) was used to determine whether curricular modifications were "amplified," "restarted," "let go," or "ended." KEY RESULTS: Response rate was 74%. In response to COVID-19, 32% (32/101) of clerkships suspended all clinical activities and 66% (67/101) only in-person. Prior to clinical disruption, students spent a median of 8.0 weeks (IQR: 2) on inpatient and 2.0 weeks (IQR: 4) on ambulatory rotations; during clinical re-entry, students were spending 5.0 (IQR: 3) and 1.0 (IQR: 2) weeks, respectively. Bedside teaching and physical exam instruction were "let go" during the early phase. Students were removed from direct patient care for a median of 85.5 days. The sub-internship curriculum remained largely unaffected. Before the pandemic, 11% of schools were using a pass/fail grading system; at clinical re-entry 47% and during the survey period 23% were using it. Due to the pandemic, 78.2% of CDs assumed new roles or had expanded responsibilities; 51% reported decreased scholarly productivity. CONCLUSIONS: Curricular adaptations occurred in IM clerkships across US medical schools as a result of COVID-19. More research is needed to explore the long-term implications of these changes on medical student education and clinical learning environments.

Expectations of and for Clerkship Directors 2.0: A Collaborative Statement from the Alliance for Clinical Education.

This article presents an update of the collaborative statement on clerkship directors (CDs), first published in 2003, from the national undergraduate medical education organizations that comprise the Alliance for Clinical Education (ACE). The clerkship director remains an essential leader in the education of medical students on core clinical rotations, and the role of the CD has and continues to evolve. The selection of a CD should be an explicit contract between the CD, their department, and the medical school, with each party fulfilling their obligations to ensure the success of the students, the clerkship and of the CD. Educational innovations and accreditation requirements have evolved in the last two decades and therefore this article updates the 2003 standards for what is expected of a CD and provides guidelines for the resources and support to be provided.In their roles as CDs, medical student educators engage in several critical activities: administration, education/teaching, coaching, advising, and mentoring, faculty development, compliance with accreditation standards, and scholarly activity. This article describes (a) the work products that are the primary responsibility of the CD; (b) the qualifications for the CD; (c) the support structure, resources, and personnel that are necessary for the CD to accomplish their responsibilities; (d) incentives and career development for the CD; and (e) the dedicated time that should be provided for the clerkship and the CD to succeed. Given all that should rightfully be expected of a CD, a minimum of 50% of a full-time equivalent is recognized as appropriate. The complexity and needs of the clerkship now require that at least one full-time clerkship administrator (CA) be a part of the CD's team.To better reflect the current circumstances, ACE has updated its recommendations for institutions and departments to have clear standards for what is expected of the director of a clinical clerkship and have correspondingly clear guidelines as to what should be expected for CDs in the support they are provided. This work has been endorsed by each of the eight ACE member organizations.

A National Survey of Undergraduate Clinical Education in Internal Medicine.

BACKGROUND: In the present milieu of rapid innovation in undergraduate medical education at US medical schools, the current structure and composition of clinical education in Internal Medicine (IM) is not clear. OBJECTIVE: To describe the current composition of undergraduate clinical education structure in IM. DESIGN: National annual Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey. PARTICIPANTS: One hundred twenty-nine clerkship directors at all Liaison Committee on Medical Education accredited US medical schools with CDIM membership as of September 1, 2017. MAIN MEASURES: IM core clerkship and post-core clerkship structure descriptions, including duration, educational models, inpatient experiences, ambulatory experiences, and requirements. KEY RESULTS: The survey response rate was 83% (107/129). The majority of schools utilized one core IM clerkship model (67%) and continued to use a traditional block model for a majority of their students (84%). Overall 26% employed a Longitudinal Integrated Clerkship model and 14% employed a shared block model for some students. The mean inpatient duration was 7.0 ± 1.7 weeks (range 3-11 weeks) and 94% of clerkships stipulated that students spend some inpatient time on general medicine. IM-specific ambulatory experiences were not required for students in 65% of IM core clerkship models. Overall 75% of schools did not require an advanced IM clinical experience after the core clerkship; however, 66% of schools reported a high percentage of students (> 40%) electing to take an IM sub-internship. About half of schools (48%) did not require overnight call or night float during the clinical IM sub-internship. CONCLUSIONS: Although there are diverse core IM clerkship models, the majority of IM core clerkships are still traditional block models. The mean inpatient duration is 7 weeks and 65% of IM core clerkship models did not require IM-specific ambulatory education.

Use of Standard Guidelines for Department of Medicine Summary Letters.

Phenomenon: Fourth-year medical students obtain Department of Medicine (DOM) letters ("Chair" letters) to support their residency applications. Writing and interpreting DOM letters are challenging. There is heterogeneity in the letters that makes it difficult to both write and read these letters. APPROACH: The purpose of this study is to determine the value of new guidelines developed by a task force of clerkship directors and program directors in internal medicine and assess the implementation of these guidelines. The Clerkship Directors in Internal Medicine performed a cross-sectional survey of internal medicine clerkship directors at U.S. and Canadian medical schools in 2014. In addition, the primary author's institution reviewed 1,347 DOM letters between 2012 and 2014 to assess the implementation of these guidelines. FINDINGS: The survey response rate was 78%. DOM letter writers reported the guidelines were better, easier to implement, and more compatible with the purpose of DOM letters than previously. Most letter readers reported that letters using the guidelines were more credible. Writers of DOM letters in lower academic ranks rated the letters with guidelines higher in several domains than those in higher academic ranks. Readers of DOM letters in higher academic ranks rated the letters with guidelines higher in several domains than those in lower academic ranks. In the DOM letters examined, the odds of meeting each guideline increased with each additional year. However, for 3 guidelines there was an initial decline in adherence from 2012 to 2013 before increasing again in 2014-the recommended length, clerkship description, and detailed narrative guidelines. Letters solely written by a chair were less likely to incorporate the guidelines. Insights: Clerkship directors often write the DOM letters and identify with the purpose of the guidelines. As writers, lower ranking academic faculty value the guidelines more than higher ranking academic faculty. As readers of DOM letters, higher academic ranking faculty value letters that incorporate the guidelines more than lower academic ranking faculty. DOM letters implemented more guideline criteria since the guidelines were released. If implementing the guidelines, chairs should solicit the help of their clerkship director or educational representative when writing DOM letters. Although many clerkship directors read letters for their residency programs, additional program directors' opinions are needed.

Abstracts From the Proceedings of the 2015 Annual Meeting of the Clerkship Directors of Internal Medicine (CDIM).

Since its inception in 1989, Clerkship Directors in Internal Medicine (CDIM) has promoted excellence in medical student education. CDIM members move medical education forward by sharing innovations in curriculum and assessment and discoveries related to educating our students and administering our programs. The Alliance for Academic Internal Medicine, of which CDIM is a founding member, broadens the umbrella beyond student education to include five academically focused specialty organizations representing departments of medicine, teaching hospitals, and medical schools working together to advance learning, discovery, and caring. CDIM held its 2015 annual meeting at Academic Internal Medicine Week in Atlanta, Georgia. This year 36 innovation and research submissions were selected for either oral abstract or poster presentation. The quality of the presentations was outstanding this year and included many of the most important issues in medical education. The CDIM research committee selected the following seven abstracts as being of the highest quality, the most generalizable, and relevant to the readership of Teaching and Learning in Medicine. Two abstracts include information from the CDIM annual survey, which remains a rich source for answering questions about student education on a national level. Looking at trends in medical education, three of the seven selected abstracts mention entrustable professional activities. Three of the abstracts address how we assess student skill and provide them with appropriate feedback. These include two schools' approach to bringing milestones into the medical student realm, use of objective structured clinical exam for assessing clinical skill in clerkship, and what students want in terms of feedback. Four articles deal with curricular innovation. These include interprofessional education, high-value care, transitions of care, and internship preparation. We are pleased to share these abstracts, which represent the breadth and quality of thought of our CDIM members.

Medical students' dietary habits: Motivations and barriers to reaching health goals.

Introduction: It has been well reported that medical students do not follow healthy diets overall. Effectively guiding patients to change their health behavior is a crucial skill for primary care providers and family physicians. Our objective was to investigate medical students' dietary decision-making, including the motivations and barriers that influence their dietary choices. Methods: A self-administered online questionnaire was conducted among preclinical students at one allopathic medical school in the United States. The survey was comprised of questions about students' dietary goals, habits, and the barriers they face in reaching their nutritional ideals. Trends in the percentage of students who selected each survey answer choice were interpreted. Results: Of the 363 preclinical students provided with the optional survey, 71 (19.6%) chose to participate. The participants' dietary decisions were predominately driven by convenience. Most students wanted to eat nutritiously to support their well-being but had been eating less healthily since starting medical school due to financial limitations and limited time. Approximately half (46.5%, 33/71) of the participants stated that they would buy the in-house food provided at the medical school campus more often if it better matched their dietary goals, but 36.6% (26/71) would only do so if the new foods were affordable compared to competitor's prices. Conclusion: There is an opportunity to help medical students meet their dietary goals, which are negatively impacted by personal and structural academic barriers. Further research is needed on the obstacles that institutions face in offering healthy, affordable options to medical students.

Development of a Novel Evidence-Based Practice-Specific Competency for Doctor of Physical Therapy Students in Clinical Education: A Modified Delphi Approach.

INTRODUCTION: Evidence-based practice (EBP) results in high-quality care and decreases unwarranted variation in practice. REVIEW OF THE LITERATURE: Few performance criteria related to EBP are included in physical therapy clinical education (CE) performance measures, despite EBP requirements in Doctor of Physical Therapy education. The purpose of this study was to develop EBP-specific competencies that may be used for Doctor of Physical Therapy students for use throughout CE. SUBJECTS: Thirteen subject matter experts (SME) participated in this study. METHODS: Subject matter experts were asked to rank each core EBP competency, from a previously described framework, using a 3-point Likert scale, which included "Not Essential," "Essential," and "Not Sure." A consensus of 70% or greater for the "Essential" rating advanced the competency to the final Delphi round, whereas a consensus of 70% or greater for the "Not Essential" rating was required for competency elimination. Subject matter experts voted to either "Accept" or "Modify" the competencies that had reached the inclusion consensus threshold. All competencies that reached consensus for inclusion after all 3 rounds were included in the final EBP Domain of Competence. RESULTS: Consensus was achieved in round one for 38% (n = 26) of items. In round 2, a consensus was achieved for 20% (n = 8) of items. Of the items remaining after rounds 1 and 2, 6 overarching competencies were identified, and all remaining items served as descriptions and specifications in the final EBP Domain of Competence. DISCUSSION AND CONCLUSIONS: The 6 competencies developed from this study constitute the EBP Domain of Competence and may be used throughout CE to assess students' EBP competency in clinical practice.

Specialty-Specific Entrustable Professional Activities: A Bridge to Internship.

Background Undergraduate medical education aims to prepare learners to become capable residents. New interns are expected to perform clinical tasks with distant supervision reliant on having acquired a medical degree. However, there is limited data to discuss what entrustment residency programs grant versus what the medical schools believe they have trained their graduates to perform. At our institution, we sought to foster an alliance between undergraduate medical education (UME) and graduate medical education (GME) toward specialty-specific entrustable professional activities (SSEPAs). These SSEPAs create a bridge to residency and help students structure the final year of medical school while striving for entrustability for day one of residency. This paper describes the SSEPA curriculum development process and student self-assessment of competence. Methodology We piloted an SSEPA program with the departments of Family Medicine, Internal Medicine, Neurology, and Obstetrics & Gynecology. Utilizing Kern's curriculum development framework, each specialty designed a longitudinal curriculum with a post-match capstone course. Students participated in pre-course and post-course self-assessments utilizing the Chen scale for each entrustable professional activity (EPA). Results A total of 42 students successfully completed the SSEPA curriculum in these four specialties. Students' self-assessed competence levels rose from 2.61 to 3.65 in Internal Medicine; 3.23 to 4.12 in Obstetrics and Gynecology; 3.62 to 4.13 in Neurology; and 3.65 to 3.79 in Family Medicine. Students across all specialties noted an increase in confidence from 3.45 to 4.38 in Internal Medicine; 3.3 to 4.6 in Obstetrics and Gynecology; 3.25 to 4.25 in Neurology; and 4.33 to 4.67 in Family Medicine. Conclusions A specialty-specific curriculum utilizing a competency-based framework for learners traversing the UME to GME journey in the final year of medical school improves learner confidence in their clinical abilities and may lead to an improved educational handoff between UME and GME.