Analysis of a Near Peer Tutoring Program to Improve Medical Students' Note Writing Skills.

Problem: The ability to document a patient encounter is integral for any physician. Previous studies indicate that medical students' note writing skills are poor due to a lack of formal clinical documentation instruction. Barriers to formally teaching students how to write patient notes include the significant time burden and variability in faculty feedback. Implementing a near-peer teaching program to teach students how to write a patient note can overcome these barriers and fill this curricular gap. Intervention: Fourth year medical students who completed a Teaching in Medicine elective course were trained to provide individual feedback to 1st and 2nd year students on note writing as a part of their Introduction to Clinical Medicine course. In order to determine the effect of this two year, near-peer feedback program on note writing skills, we analyzed students' scores on the note writing portion of two Objective Structured Clinical Exams that took place at the end of the 2nd and 3rd years of medical school. Context: The near-peer feedback sessions were implemented in the Fall of 2013 during the preclinical years of the medical school curriculum. Data from students who received near-peer feedback (N = 112) were compared to a historical control group who did not receive near-peer feedback on their note writing (N = 110). Objective Structured Clinical Exam scores that were specific to note writing skills, including the history, physical exam, and differential diagnosis subscales were examined. Impact: The near-peer feedback had a positive impact on the quality of patient notes. On the end of the 2nd year Objective Structured Clinical Exam, the near-peer feedback intervention group outperformed the no feedback group on the history and physical exam subscale scores but not on the differential diagnosis subscale score. One year later, the near-peer feedback intervention group continued to outperform the no feedback group on the physical exam subscale score, but not the history or the differential diagnosis subscale scores. Lessons Learned: Near-peer teaching improves student documentation of the history and physical exam, however only the effects on the physical exam portion persist into the clinical years of training. Writing up a differential diagnosis is a skill that develops through the clerkship experience regardless of exposure to feedback in the preclinical years. Implementing near-peer teaching in the medical school setting is feasible and can provide students with valuable learning experiences without relying on clinical faculty.

Reforming the 4th-Year Curriculum as a Springboard to Graduate Medical Training: One School's Experiences and Lessons Learned.

PROBLEM: Concerns regarding the quality of training in the 4th year of medical school and preparation of graduates to enter residency education persist and are borne out in the literature. INTERVENTION: We reviewed the published literature regarding Year 4 concerns as well as institutional efforts to improve the 4th-year curriculum from several schools. Based on input from key stakeholders, we established 4 goals for our Year 4 curriculum reform: (a) standardize the curricular structure, (b) allow flexibility and individualization, (c) improve the preparation for residency, and (d) improve student satisfaction. After the reform, we evaluated the outcomes using results from the Association of American Medical Colleges Questionnaire, student focus groups, and program director surveys. CONTEXT: This article describes the context, process, and outcomes of the reform of the Year 4 curriculum at Stony Brook University School of Medicine. OUTCOME: We were able to achieve all four stated goals for the reform. The significant components of the change included a flexible adaptable curriculum based on individual needs and preferences, standardized learning objectives across the year, standardized competency-based evaluations regardless of discipline, reinforcement of clinical skills, and training for the transition to the workplace as an intern. The reform resulted in increased student satisfaction, increased elective time, and increased preparedness for residency training as perceived by the graduates. The Program Director survey showed significant changes in ability to perform a medical history and exam, management of common medical conditions and emergencies, clinical reasoning and problem-solving skills, working and communication with the healthcare team, and overall professionalism in meeting obligations inherent in the practice of medicine. LESSONS LEARNED: Lessons learned from our 4th-year reform process are discussed. Listening to the needs of the stakeholders was an important step in ensuring buy-in, having an institutional champion with an organizational perspective on the overall institutional mission was helpful in building the guiding coalition for change, building highly interactive collaborative interdisciplinary teams to work together addressed departmental silos and tunnel vision early on, and planning a curriculum is exciting but planning the details of the implementation can be quite tedious.

MRSA rates and antibiotic susceptibilities from skin and soft tissue cultures in a suburban ED.

BACKGROUND: Prior studies suggest that more than half of all skin and soft tissue infections (SSTIs) are caused by methicillin-resistant Staphylococcus aureus (MRSA). These data mainly represent inner-city urban centers. OBJECTIVE: We determined the bacteriologic etiologies and antibiotic susceptibilities from wound cultures in the emergency department (ED). We hypothesized that in a suburban ED, MRSA would not represent the major pathogen. METHODS: The study design was a retrospective, electronic medical record review in a suburban tertiary care ED with 80,000 annual visits. Subjects included ED patients of all ages who had skin or soft tissue cultures obtained in 2005-2008. Demographics and clinical data, including type of SSTI (MRSA or methicillin-sensitive S. aureus [MSSA]), culture results, and antibiotic susceptibility, were analyzed using descriptive statistics. RESULTS: From the 1246 cultures obtained during the study period, 252 (20.2%) were MSSA and 270 (21.6%) were MRSA. The rates of MRSA infections over time increased from 13.5% to 25.7% during 2005-2008. The rates of MRSA in males and females were comparable at 23.3% and 19.6%, respectively. In 2008, MRSA was 97-100% susceptible to vancomycin, linezolid, rifampin, nitrofurantoin, chloramphenicol, gentamycin, tetracycline, and trimethoprim-sulfamethoxazole (TMP-SMZ). To a lesser extent it was susceptible to clindamycin (75%), erythromycin (62%), and levofloxacin (50%). CONCLUSIONS: There has been a significant increase in the rates of MRSA SSTIs in a suburban ED, yet only 1 in 4 SSTIs are caused by MRSA. Both MRSA and MSSA are completely susceptible to vancomycin, linezolid, rifampin, nitrofurantoin, and chloramphenicol. Gentamicin, tetracycline, and TMP-SMZ cover > 97% of both isolates.

Comparison of sitting face-to-face intubation (two-person technique) with standard oral-tracheal intubation in novices: a mannequin study.

BACKGROUND: Few studies have evaluated the impact of the upright position on the success of oral-tracheal intubation. Yet, for patients with airway difficulties (i.e, active intraoral bleeding or morbidly obese), the upright position may both benefit the patient and facilitate intubation. OBJECTIVES: We compared the success rates of subjects performing standard intubation to a modified version of the sitting face-to-face oral-tracheal intubation technique on a simulation model. We also reviewed the possible advantages and limitations of the sitting face-to-face intubation technique. METHODS: Volunteer medical and paramedical students were given instruction, then tested, performing in random order both standard oral-tracheal and two-person sitting face-to-face oral-tracheal intubation on full-bodied mannequins. Observers reviewed video recordings, noting the number of successful intubations and the time to completion of each procedure at 15, 20, and 30 s. RESULTS: All of the sitting face-to-face intubations were successful, 53/53 (100%, 95% confidence interval [CI] 93-100%); whereas of the 53 subjects who performed standard intubation, 48 were successful (91%, 95% CI 80-96%). The difference between successful intubations using the standard vs. sitting face-to-face technique was 9% (95% CI 1.3-9.4%, p=0.025). At times 15 and 20 s, medical student subjects who successfully performed both techniques were less successful at completing the procedure when performing the standard technique as compared to the sitting face-to-face technique (p=0.016). A post-procedural survey found that the majority of subjects preferred the sitting technique. CONCLUSION: Subjects were significantly more successful at performing and preferred the sitting face-to-face intubation when compared to standard intubation.

Surgical boot camp for fourth-year medical students: Impact on objective skills and subjective confidence.

BACKGROUND: Within surgical education, there has been a recent emphasis on preparing medical students for the rigors of residency in an effort to improve confidence and technical preparedness throughout postgraduate training. The aim of this study is to test the impact of a boot camp course using the American College of Surgeons-based curriculum and objective, observer-based rating tools on both subjective confidence and objective skills of fourth-year medical students. MATERIALS AND METHODS: Informed consent was obtained on the first day of the boot camp. Before any teaching, students performed 5 tasks (patient handoff, suturing, knot tying, central line placement, and chest tube placement), which were scored using objective rating tools provided by the American College of Surgeons. Students also completed 2 confidence measures. After 2 weeks of dedicated teaching and review, students were scored on the 5 same tasks and repeated the confidence measures. RESULTS: Fourth-year medical students (N = 12) who had matched into surgical subspecialties were invited to participate in a 2-week surgical boot camp. All students beginning the study completed the study. The average age was 26.7 years; 25% of students were female. Subspecialties represented included general surgery (n = 5), orthopedics (n = 3), integrated plastics (n = 2), urology (n = 1), and neurosurgery (n = 1). Scores on objective skills improved significantly in all 5 tasks measured. Confidence improved significantly on individual task items, while overall self-efficacy remained unchanged. CONCLUSIONS: Implementation of a 2-week, multimodal surgical boot camp improved student performance on objectively rated surgical skills and increased student confidence.

Bullard laryngoscopy by naïve operators in the cervical spine immobilized patient.

To determine ease of Bullard laryngoscopy by naïve operators during cervical spine immobilization, 21 residents, naïve to the Bullard laryngoscope, were assigned to perform Bullard laryngoscopy and standard direct laryngoscopy on the Laerdal SimMan Universal Patient Simulator while the rigid cervical spine function was engaged. Sequences were repeated. Success of laryngeal intubation, time to intubation, ease of intubation, and grade of laryngoscopic view were recorded and compared. Pairwise comparisons of consecutive times between standard and Bullard devices showed significant difference in mean times at first attempt, 28.8 (95% confidence interval [CI] 18.1-39.5) seconds in favor of Macintosh laryngoscopy, but no statistical differences between devices at second and third attempts, with differences in mean times of 4.5 (95% CI 2.5-6.5) and 3.8 (95% CI, 0.1-7.7) seconds, respectively. Similarly, ease of use was statistically unchanged over time for Macintosh laryngoscopy, but there was statistically significant improvement in ease of use for the Bullard. The Bullard laryngoscope is an easily mastered airway management device for intubation of the cervical spine immobilized patient.

Comparison of valdecoxib and an oxycodone-acetaminophen combination for acute musculoskeletal pain in the emergency department: a randomized controlled trial.

UNLABELLED: Oral opioids are potent analgesics that are used to treat acute pain in the emergency department (ED). However, they are associated with adverse events such as sedation that may delay safe patient discharge. OBJECTIVE: To compare the safety and efficacy of a new cyclooxygenase-2 inhibitor, valdecoxib, with those of an oxycodone-acetaminophen combination in patients with acute musculoskeletal pain. METHODS: This was a double-blind, randomized controlled trial at an immediate care section of a suburban university-based ED with an annual census of 75,000. Adults with acute musculoskeletal pain without contraindications to the study medications were included. After recording their initial pain scores, patients were randomized to either oral valdecoxib 40 mg or oxycodone 10 mg with acetaminophen 650 mg. Pain scores were recorded at 30 and 60 minutes, and patients who requested additional pain relief were given an oral analgesic at the physician's discretion. Twenty-four-hour telephone follow-up was performed. The pain severity was recorded at 0, 30, and 60 minutes using a validated 100-mm visual analog scale marked "most" at the high end. The need for rescue medications and the occurrence of adverse events were determined. Study outcomes were compared with Student's t-test, repeated-measures analysis of variance (ANOVA), and chi(2) tests as appropriate. RESULTS: Fifty-one patients were randomized to valdecoxib (26) or oxycodone (25). Mean (+/- SD) age was 36 (+/- 14.7) years; 49% were women. Pain locations included extremities (49%), neck (29%), and back (22%). Baseline patient characteristics and pain severities were similar. There was no between-group difference in pain scores at 30 and 60 minutes. The changes in pain scores over time were also similar in the two study groups (repeated-measures ANOVA, p = 0.32). Patients treated with valdecoxib were less likely to experience sedation/dizziness (15% vs. 44%, p = 0.03) and to require rescue medications within the next 24 hours (44% vs. 74%, p = 0.04). CONCLUSIONS: Valdecoxib is as effective as an oxycodone-acetaminophen combination in treating ED patients with acute musculoskeletal pain at 30 minutes and less likely to cause sedation or the need for rescue analgesia over the next day.

Developing checklists to prevent diagnostic error in Emergency Room settings.

BACKGROUND: Checklists have been shown to improve performance of complex, error-prone processes. To develop a checklist with potential to reduce the likelihood of diagnostic error for patients presenting to the Emergency Room (ER) with undiagnosed conditions. METHODS: Participants included 15 staff ER physicians working in two large academic centers. A rapid cycle design and evaluation process was used to develop a general checklist for high-risk situations vulnerable to diagnostic error. Physicians used the general checklists and a set of symptom-specific checklists for a period of 2 months. We conducted a mixed methods evaluation that included interviews regarding user perceptions and quantitative assessment of resource utilization before and after checklist use. RESULTS: A general checklist was developed iteratively by obtaining feedback from users and subject matter experts, and was trialed along with a set of specific checklists in the ER. Both the general and the symptom-specific checklists were judged to be helpful, with a slight preference for using symptom-specific lists. Checklist use commonly prompted consideration of additional diagnostic possibilities, changed the working diagnosis in approximately 10% of cases, and anecdotally was thought to be helpful in avoiding diagnostic errors. Checklist use was prompted by a variety of different factors, not just diagnostic uncertainty. None of the physicians used the checklists in collaboration with the patient, despite being encouraged to do so. Checklist use did not prompt large changes in test ordering or consultation. CONCLUSIONS: In the ER setting, checklists for diagnosis are helpful in considering additional diagnostic possibilities, thus having potential to prevent diagnostic errors. Inconsistent usage and using the checklists privately, instead of with the patient, are factors that may detract from obtaining maximum benefit. Further research is needed to optimize checklists for use in the ER, determine how to increase usage, to evaluate the impact of checklist utilization on error rates and patient outcomes, to determine how checklist usage affects test ordering and consultation, and to compare checklists generally with other approaches to reduce diagnostic error.

Feasibility and reliability of a multisource feedback tool for emergency medicine residents.

BACKGROUND: While the Accreditation Council for Graduate Medical Education recommends multisource feedback (MSF) of resident performance, there is no uniformly accepted MSF tool for emergency medicine (EM) trainees, and the process of obtaining MSF in EM residencies is untested. OBJECTIVE: To determine the feasibility of an MSF program and evaluate the intraclass and interclass correlation of a previously reported resident professionalism evaluation, the Humanism Scale (HS). METHODS: To assess 10 third-year EM residents, we distributed an anonymous 9-item modified HS (EM-HS) to emergency department nursing staff, faculty physicians, and patients. The evaluators rated resident performance on a 1 to 9 scale (needs improvement to outstanding). Residents were asked to complete a self-evaluation of performance, using the same scale. ANALYSIS: Generalizability coefficients (Eρ(2)) were used to assess the reliability within evaluator classes. The mean score for each of the 9 questions provided by each evaluator class was calculated for each resident. Correlation coefficients were used to evaluate correlation between rater classes for each question on the EM-HS. Eρ(2) and correlation values greater than 0.70 were deemed acceptable. RESULTS: EM-HSs were obtained from 44 nurses and 12 faculty physicians. The residents had an average of 13 evaluations by emergency department patients. Reliability within faculty and nurses was acceptable, with Eρ(2) of 0.79 and 0.83, respectively. Interclass reliability was good between faculty and nurses. CONCLUSIONS: An MSF program for EM residents is feasible. Intraclass reliability was acceptable for faculty and nurses. However, reliable feedback from patients requires a larger number of patient evaluations.