Roles and Responsibilities of Medicine Subinternship Directors : Medicine Subinternship Director Roles.

BACKGROUND: The internal medicine (IM) subinternship (also referred to as acting internship) plays a crucial part in preparing medical students for residency. The roles, responsibilities, and support provided to subinternship directors have not been described. OBJECTIVE: We sought to describe the current role of IM subinternship directors with respect to their responsibilities, salary support, and reporting structure. DESIGN: Nationally representative, annually recurring thematic survey of IM core clerkship directors with membership in an academic professional association as of September 2017. PARTICIPANTS: A total of 129 core clinical medicine clerkship directors at Liaison Committee on Medical Education fully accredited U.S./U.S.-territory-based medical schools. MAIN MEASURES: Responsibilities, salary support, and reporting structure of subinternship directors. KEY RESULTS: The survey response rate was 83.0% (107/129 medical schools). Fifty-one percent (54/107) of respondents reported overseeing both core clerkship inpatient experiences and/or one or more subinternships. For oversight, 49.1% (28/53) of subinternship directors also reported that they were the clerkship director, 26.4% (14/53) that another faculty member directed all medicine subinternships, and 18.9% (10/53) that each subinternship had its own director. The most frequently reported responsibilities for the subinternship directors were administration, including scheduling, and logistics of student schedules (83.0%, 44/53), course evaluation (81.1%, 43/53), and setting grades 79.2% (42/53). The modal response for estimated FTE per course was 10-20% FTE, with 33.3% (16/48) reporting this level of support and 29.2% (14/54) reporting no FTE support. CONCLUSIONS: The role of the IM subinternship director has become increasingly complex. Since the IM subinternship is critical to preparing students for residency, IM subinternship directors require standard expectations and adequate support. Future studies are needed to determine the appropriate level of support for subinternship directors and to define essential roles and responsibilities.

Clerkship Roles and Responsibilities in a Rapidly Changing Landscape: a National Survey of Internal Medicine Clerkship Directors.

BACKGROUND: In the rapidly changing landscape of undergraduate medical education (UME), the roles and responsibilities of clerkship directors (CDs) are not clear. OBJECTIVE: To describe the current roles and responsibilities of Internal Medicine CDs. 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: Responsibilities of core CDs, including oversight of other faculty, and resources available to CDs including financial support and dedicated time. KEY RESULT: The survey response rate was 83% (107/129). Ninety-four percent of the respondents oversaw the core clerkship inpatient experience, while 47.7% (n = 51) and 5.6% (n = 6) oversaw the outpatient and longitudinal integrated clerkships respectively. In addition to oversight, CDs were responsible for curriculum development, evaluation and grades, remediation, scheduling, student mentoring, and faculty development. Less than one-third of CDs (n = 33) received the recommended 0.5 full-time equivalent (FTE) support for their roles, and 15% (n = 16) had less than 20% FTE support. An average 0.41 FTE (SD .2) was spent in clinical work and 0.20 FTE (SD .21) in administrative duties. Eighty-three percent worked with other faculty who assisted in the oversight of departmental UME experiences, with FTE support varying by role and institution. Thirty-five percent of CDs (n = 38) had a dedicated budget for managing their clerkship. CONCLUSIONS: The responsibilities of CDs have increased in both number and complexity since the dissemination of previous guidelines for expectations of and for CDs in 2003. However, resources available to them have not substantially changed.

Untying the Gordian knot: remediation problems in medical schools that need remediation.

This position paper discusses on-going academic remediation challenges within the field of medical education. More specifically, we identify three common contemporary problems and propose four recommendations to strengthen remediation efforts. Selecting or determining what type of remediation is needed for a particular student is akin to analyzing a Gordian knot with individual, institutional and systemic contributors. More emphasis, including multi-institutional projects and research funding is needed. Recommendations regarding language use and marketing of such programs are given.

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.

Validity evidence for medical school OSCEs: associations with USMLE® step assessments.

BACKGROUND: Recently, there has been a surge in the use of objective structured clinical examinations (OSCEs) at medical schools around the world, and with this growth has come the concomitant need to validate such assessments. PURPOSES: The current study examined the associations between student performance on several school-level clinical skills and knowledge assessments, including two OSCEs, the National Board of Medical Examiners® (NBME) Subject Examinations, and the United States Medical Licensing Examination® (USMLE) Step 2 Clinical Skills (CS) and Step 3 assessments. METHODS: The sample consisted of 806 medical students from the Uniformed Services University of the Health Sciences. We conducted Pearson correlation analysis as well as stepwise multiple linear regression modeling to examine the strength of associations between students' performance on 2nd- and 3rd-year OSCEs and their two Step 2 CS component scores and Step 3 scores. RESULTS: Positive associations were found between the OSCE variables and the USMLE scores; in particular, student performance on both the 2nd- and 3rd-year OSCEs was more strongly associated with the two Step 2 CS component scores than with Step 3 scores. CONCLUSIONS: These findings, although preliminary, provide some predictive validity evidence for the use of OSCEs in determining readiness of medical students for clinical practice and licensure.

Using Self-Regulated Learning Microanalysis to Examine Regulatory Processes in Clerkship Students Engaged in Practice Questions.

Introduction: Self-regulated learning is a cyclical process of forethought, performance, and self-reflection that has been used as an assessment tool in medical education. No prior studies have evaluated SRL processes for answering multiple-choice questions (MCQs) and most evaluated one or two iterations of a non-MCQ task. SRL assessment during MCQs may elucidate reasons why learners are successful or not on these questions that are encountered repeatedly during medical education. Methods: Internal medicine clerkship students at three institutions participated in a SRL microanalytic protocol that targeted strategic planning, metacognitive monitoring, causal attributions, and adaptive inferences across seven MCQs. Responses were transcribed and coded according to previously published methods for microanalytic protocols. Results: Forty-four students participated. In the forethought phase, students commonly endorsed prioritizing relevant features as their diagnostic strategy (n = 20, 45%) but few mentioned higher-order diagnostic reasoning processes such as integrating clinical information (n = 5, 11%) or comparing/contrasting diagnoses (n = 0, 0%). However, in the performance phase, students' metacognitive processes included high frequencies of integration (n = 38, 86%) and comparing/contrasting (n = 24, 55%). In the self-reflection phase, 93% (n = 41) of students faulted their management reasoning and 84% (n = 37) made negative references to their abilities. Less than 10% (n = 4) of students indicated that they would adapt their diagnostic reasoning process for these questions. Discussion: This study describes in detail student self-regulatory processes during MCQs. We found that students engaged in higher-order diagnostic reasoning processes but were not explicit about it and seldom reflected critically on these processes after selecting an incorrect answer. Self-reflections focused almost exclusively on management reasoning and negative references to abilities which may decrease self-efficacy. Encouraging students to identify and evaluate diagnostic reasoning processes and make attributions to controllable factors may improve performance.

Does the authenticity of preclinical teaching format affect subsequent clinical clerkship outcomes? A prospective randomized crossover trial.

BACKGROUND: Educational theories predict conflicting results for the effect of increasing the authenticity of the teaching format of complex information on educational outcomes. We sought to determine the effect of increasingly authentic small-group, preclerkship teaching format on clerkship outcomes to further enlighten this debate. SUMMARY: Students enrolled in a prospective randomized crossover trial that involved three content areas. For each content area, three teaching formats were tested. Participants were randomized to teaching format by content area. Clerkship outcomes were performance on an objective structured clinical exam, a DVD exam, internal medicine clerkship grades, and performance on the subject examination. The data were analyzed using a multivariate analysis of covariance. One hundred and thirty-three (78%) students participated. Teaching format did not have a statistically significant effect on any of the specified clerkship outcomes. However, number of patients seen was significantly associated with higher scores in respective outcomes by topic. CONCLUSIONS: Second-year teaching format did not directly influence subsequent clerkship performance. Our study adds to the literature by demonstrating that the authenticity of preclinical teaching format does not appear to matter for clerkship performance; however, the number of actual patients seen does appear to influence related clerkship outcomes.

Determining Grades in the Internal Medicine Clerkship: Results of a National Survey of Clerkship Directors.

PURPOSE: Trust in and comparability of assessments are essential in clerkships in undergraduate medical education for many reasons, including ensuring competency in clinical skills and application of knowledge important for the transition to residency and throughout students' careers. The authors examined how assessments are used to determine internal medicine (IM) core clerkship grades across U.S. medical schools. METHODS: A multisection web-based survey of core IM clerkship directors at 134 U.S. medical schools with membership in the Clerkship Directors in Internal Medicine was conducted in October through November 2018. The survey included a section on assessment practices to characterize current grading scales used, who determines students' final clerkship grades, the nature/type of summative assessments, and how assessments are weighted. Respondents were asked about perceptions of the influence of the National Board of Medical Examiners (NBME) Medicine Subject Examination (MSE) on students' priorities during the clerkship. RESULTS: The response rate was 82.1% (110/134). There was considerable variability in the summative assessments and their weighting in determining final grades. The NBME MSE (91.8%), clinical performance (90.9%), professionalism (70.9%), and written notes (60.0%) were the most commonly used assessments. Clinical performance assessments and the NBME MSE accounted for the largest percentage of the total grade (on average 52.8% and 23.5%, respectively). Eighty-seven percent of respondents were concerned that students' focus on the NBME MSE performance detracted from patient care learning. CONCLUSIONS: There was considerable variability in what IM clerkships assessed and how those assessments were translated into grades. The NBME MSE was a major contributor to the final grade despite concerns about the impact on patient care learning. These findings underscore the difficulty in comparing learners across institutions and serve to advance discussions for how to improve accuracy and comparability of grading in the clinical environment.

Contemporary management of renal tumors with venous tumor thrombus.

PURPOSE: Renal cell carcinoma with intravenous tumor thrombus remains one of the most intriguing and challenging topics in urological oncology. With better understanding of the biology of intravascular tumor invasion and improvements in overall survival, the surgical and medical treatment of these patients is being completely redefined. MATERIALS AND METHODS: We performed a MEDLINE(R) search for relevant articles on renal cell carcinoma with intravenous tumor thrombus. RESULTS: We describe the staging systems, prognostic factors and surgical techniques involved in the management of renal cell carcinoma with intravenous tumor thrombus. We also review long-term survival of local, advanced and metastatic renal cell carcinoma with tumor thrombus invasion. Finally, we propose a clinical algorithm for the treatment of patients with renal cell carcinoma invading the venous system. CONCLUSIONS: Management of a kidney cancer tumor invading the venous system should now consider the primary biology and natural behavior of a given tumor in that specific patient rather than only focusing on the level and extent of venous invasion. Treatment must be individualized for every patient based on performance status, tumor biology and risk of surgery.

Cytogenetic and molecular tumor profiling for type 1 and type 2 papillary renal cell carcinoma.

PURPOSE: The goal of this study was to evaluate immunohistochemical and cytogenetic features and their prognostic value in papillary renal cell carcinoma (PRCC) subtypes. EXPERIMENTAL DESIGN: One hundred fifty-eight cases of PRCC were identified and reclassified by subtype. Tumoral expression of 29 molecular markers was determined by immunohistochemistry. Cytogenetic analyses were done on a prospective series of 65 patients. Associations with clinicopathologic information and disease-specific survival were assessed. RESULTS: Fifty-one patients (32%) had type 1 and 107 (68%) type 2 PRCC. Type 2 patients had worse Eastern Cooperative Oncology Group performance status, higher T stages, nodal and distant metastases, higher grades, and a higher frequency of necrosis, collecting system invasion and sarcomatoid features. Type 2 showed greater expression of vascular endothelial growth factor (VEGF)-R2 in the tumor epithelium, and of VEGF-R3 in both tumor epithelium and endothelium. Loss of chromosome 1p, loss of 3p, and gain of 5q were exclusively observed in type 2, whereas type 1 more frequently had trisomy 17. Type 2 PRCC was associated with worse survival than type 1, but type was not retained as an independent prognostic factor. Lower PTEN, lower EpCAM, lower gelsolin, higher CAIX, and higher VEGF-R2 and VEGF-R3 expression, loss of 1p, 3p, or 9p, and absence trisomy 17 were all associated with poorer prognosis. CONCLUSIONS: Type 2 PRCC is associated with more aggressive clinicopathologic features and worse outcome. Molecular and chromosomal alterations can distinguish between PRCC subtypes and influence their prognosis. The effect of 3p loss on survival in PRCC is opposite to the relationship seen in clear cell RCC.

SimLEARN Musculoskeletal Training for VHA Primary Care Providers and Health Professions Educators.

A simulation-based training curricula applied to the primary care evaluation and management of shoulder and knee pain resulted in improved access to care for veterans and cost savings for the health care system.

Molecular signatures of localized clear cell renal cell carcinoma to predict disease-free survival after nephrectomy.

PURPOSE: To identify the molecular signature of localized (N0M0) clear cell renal cell carcinoma (RCC) and assess its ability to predict outcome. METHODS: Clinical characteristics and pathologic records of 170 patients with localized clear cell RCC who underwent nephrectomy were reviewed. Immunohistochemical analysis was done on a tissue microarray of all primary tumors using a kidney cancer-related panel of protein markers, which included CAIX, CAXII, CXCR3, gelsolin, Ki-67, vimentin, EpCAM, p21, p27, p53, pS6, PTEN, HIF-1alpha, pAkt, VEGF-A, VEGF-C, VEGF-D, VEGFR-1, VEGFR-2, and VEGFR-3. Associations with disease-free survival (DFS) were evaluated with Cox models, and a concordance index assessed prognostic accuracy. RESULTS: Median follow-up was 7.1 years. The final multivariate Cox model determined T classification, Eastern Cooperative Oncology Group performance status, and five molecular markers (Ki-67, p53, endothelial VEGFR-1, epithelial VEGFR-1, and epithelial VEGF-D) to be independent prognostic indicators of DFS. The molecular signature based on these markers predicted DFS with an accuracy of 0.838, an improvement over T classification of 0.746, and the University of California-Los Angeles Integrated Staging System of 0.780. A constructed nomogram combined the molecular, clinical, and pathologic factors and approached a concordance index of 0.904. CONCLUSIONS: A molecular signature consisting of five molecular markers (Ki-67, p53, endothelial VEGFR-1, epithelial VEGFR-1, and epithelial VEGF-D) can predict DFS for localized clear cell RCC. The prognostic ability of the signature and nomogram may be superior to clinical and pathologic factors alone and may identify a subset of localized patients with aggressive clinical behavior. Independent, external validation of the nomogram is required.

Intraoperative thrombus embolization during nephrectomy and tumor thrombectomy: critical analysis of the University of California-Los Angeles experience.

PURPOSE: Vascular invasion commonly occurs in renal cell carcinoma and intraoperative thrombus embolization is a known complication of tumor thrombectomy. We reviewed our experience with this complication to determine frequency, mortality, common factors and management strategies. MATERIALS AND METHODS: We retrospectively reviewed a prospective database of cases of open nephrectomy/tumor thrombectomy performed from 1989 to 2008. All cases were reviewed to identify clinicopathological variables, the thrombus extent and intraoperative complications. All cases with events were reviewed to identify preoperative pulmonary embolism, preoperative imaging, thrombus extent, presentation, management and outcome. RESULTS: A total of 282 cases of venous tumor thrombus were identified. Tumor thrombus level was 0 in 133 cases (47.2%), I to II in 85 (30.1%), III in 27 (9.6%) and IV in 29 (10.3%). Thrombus embolization was identified in 5 patients (1.8%). The incidence in level 0 vs I to IV was 0 of 133 cases (0%) vs 5 of 149 (3.4%), which was statistically significant (p = 0.04). Three patients (60%) died of the event. A review of recent series demonstrated a 1.49% incidence with 75% mortality. CONCLUSIONS: Intraoperative thrombus embolization is rare but when it occurs, mortality is extremely high. Strict attention to surgical principles is necessary to decrease risk. Extension into the vena cava, preoperative pulmonary embolism and a bland thrombus component may indicate increased risk. Adjunct procedures, such as preoperative filters and endoluminal occlusive balloons, may be justified in patients at high risk. Even with prompt recognition and embolectomy survival is rare.

Presence of tumor necrosis is not a significant predictor of survival in clear cell renal cell carcinoma: higher prognostic accuracy of extent based rather than presence/absence classification.

PURPOSE: The presence of necrosis has been proposed as an adverse prognostic factor in clear cell renal cell carcinoma. However, classification based on a presence/absence basis ignores its heterogeneity, which may be associated with other important pathological factors and prognosis. We performed the first prospective study of necrosis in clear cell renal cell carcinoma to our knowledge and tested the traditional presence/absence classification vs an alternative extent based classification. MATERIALS AND METHODS: We studied the presence and extent of tumor necrosis, pathological features and cancer specific survival of 343 consecutive patients. RESULTS: Tumor necrosis was present in 227 tumors (66%) and was associated with more advanced tumors. However, the predictive accuracy for cancer specific survival was low (64.6%) and the presence of necrosis was not retained as an independent prognostic factor on multivariate analysis (p = 0.299). There was significant heterogeneity among tumors with necrosis. Increasing extent of necrosis was associated with poorer performance status, higher T, N, M stages and grades, vascular invasion and sarcomatoid features. Extent based classification predicted cancer specific survival better than presence alone (74.5% vs 64.6%) and was retained as an independent prognostic factor on multivariate analysis (p = 0.029). For clinical use a cutoff of 20% was identified for further prognostic subclassification of tumors with necrosis (c-index 71.7%). CONCLUSIONS: Tumor necrosis is an adverse prognostic factor in clear cell renal cell carcinoma but prospective evaluation of necrosis on a presence/absence basis shows that it does not provide independent prognostic information. The predictive accuracy of an extent based classification is superior and is retained as an independent prognostic factor. We recommend the scoring of necrosis according to its extent with further subclassification based on a 20% cutoff.

CA9 gene: single nucleotide polymorphism predicts metastatic renal cell carcinoma prognosis.

PURPOSE: We assessed CA9 single nucleotide polymorphisms and mutations, and their association with CAIX protein expression, overall survival and response to interleukin-2 in white patients with metastatic clear cell renal cell carcinoma. MATERIALS METHODS: Genomic DNA was extracted from frozen tumor samples of 54 metastatic clear cell renal cell carcinomas. The CA9 gene exons and flanking regions were amplified by polymerase chain reaction and sequenced. The monoclonal antibody M75 was used to evaluate CAIX protein expression in the primary tumor by immunohistochemistry. RESULTS: CA9 reference single nucleotide polymorphisms rs2071676, rs12553173, rs3829078 and rs1048638 were found in 59%, 15%, 11% and 33% of patients, respectively. The deletion c.376del393 was observed in 2 patients. CAIX expression was greater than 85% in 65% of patients. No single nucleotide polymorphisms were significantly associated with CAIX expression. Patients with the C allele variant of rs12553173 had improved median survival (27.3 vs 13.6 months, p = 0.0431) and a greater likelihood of an interleukin-2 response (57% vs 22%, p = 0.081) Likewise high CAIX expression was associated with longer median survival (25.5 vs 8.5 months, p <0.0001) and a greater interleukin-2 response rate (37% vs 8%, p = 0.070). In a multivariate Cox model the C allele variant of CA9 single nucleotide polymorphism rs12553173 and CAIX expression were retained as independent prognostic factors. CONCLUSIONS: CA9 single nucleotide polymorphisms are common in patients with metastatic clear cell renal cell carcinoma. The synonymous C allele variant of rs12553173 may be associated with improved overall survival and a greater likelihood of a response to interleukin-2. CA9 rs12553173 and CAIX are independent prognostic factors of overall survival and complementary for predicting the prognosis of metastatic clear cell renal cell carcinoma.

Readdressing the need for consensus in preclinical education.

PURPOSE: Clinical skills are often taught in preclinical courses such as "Introduction to Clinical Medicine" (ICM). We sought to define current national course objectives, roles of standardized and real patients, and methods of assessment in ICM courses, and to readdress the need and desire for establishing consensus. METHODS: In April 2005, the Clerkship Directors in Internal Medicine (CDIM) organization conducted its annual, voluntary, and confidential survey. The survey contained a section (24 questions) on preclinical education teaching methods and evaluations. RESULTS: Wide variations exist in the teaching and assessment methods used by ICM courses in 4-year medical schools. Respondents indicated a desire for a consensus statement concerning ICM course objectives in addition to guidance on case development, use of standardized patients, and student assessments. CONCLUSION: Our findings suggest that consensus remains elusive for preclinical education teaching objectives, but would be embraced by ICM course directors.