If You Build It, Will They Come? Exploring the Impact of Medical Student Engagement on Clerkship Curriculum Outcomes.

Introduction: Inconsistent or superficial access to workplace learning experiences can impede medical students' development. Well-designed clerkship curricula provide comprehensive education by offering developmental opportunities in and out of the workplace, explicitly linked to competency objectives. Questions remain about how students engage with clerkship curriculum offerings and how this affects their achievement. This study investigated student engagement as the source of an apparent clerkship curriculum malfunction: increasing rate of substandard summative clinical competency exam (SCCX) performance over 3 years following curriculum reform. Materials and Methods: We sampled from three cohorts of US medical students (classes of 2018-2020) based on their post-clerkship SCCX performance: substandard (N = 33) vs. exemplary (N = 31). Using a conceptually based, locally developed rubric, a five-person team rated students' engagement in a curriculum offering designed to provide standardized deliberate practice on the clerkship's competency objectives. We examined the association between engagement and SCCX performance, taking prior academic performance into account. Results: Rate of substandard SCCX performance could not be explained by cohort differences in prior academic performance. Student engagement differed across cohorts and was significantly associated with SCCX performance. However, engagement did not meaningfully predict individual students' SCCX performance, particularly in light of prior academic performance. Discussion: Engagement with a particular learning opportunity may not affect clerkship outcomes, but may reflect students' priorities when navigating curricular offerings, personal learning goals, and curriculum policy. Proposing four patterns of engagement in clerkship learning, this study prompts reflection on the complex interaction among factors that affect engagement and outcomes.

Variability in tuition and curriculum among allopathic and osteopathic medical schools in the United States.

BACKGROUND: Medical school tuition has increased dramatically. We aimed to characterize allopathic and osteopathic medical school tuition and its association with geographic region, pre-clerkship and clerkship curriculums, and compare tuition between allopathic and osteopathic schools. METHODS: US allopathic and osteopathic in-state tuition were extracted from the AAMC and AACOM databases and adjusted for cost-of-living. Schools were divided by geographic regions (West, Midwest, South, Northeast). Pre-clerkship and clerkship curricula characteristics were collected from school websites. Pre-clerkship curricula were categorized into one of six categories: 1) discipline-based, 2) organ system-based, 3) combined discipline/organ system based, 4) team-based learning, 5) mixed, and 6) other. Clerkship curricula characteristics collected included; required research block, out-of-state elective option, and global health (international) elective option. This study was reported according to STROCSS guidelines. RESULTS: For allopathic schools, unadjusted and adjusted tuition was significantly higher in the Northeast. After adjusting for cost of living, the West displayed significantly larger in-state tuition than the South. No association was seen between tuition and pre-clerkship curriculum. Of the clerkship characteristics, presence of a required research block or global health electives corresponded to higher tuitions. For osteopathic schools, tuition in the West was significantly higher than the South and Midwest. Schools that offered a discipline-based pre-clerkship curriculum had higher tuitions than other curricula. Clerkship characteristics were not associated with tuition variation. CONCLUSIONS: US medical school tuition is highly variable, demonstrating associations with geographic regions and curriculum characteristics. There is increasing value in team-based learning modalities in improving professional communication skills.

Perspectives on the current state of pre-clerkship clinical reasoning instruction in United States medical schools: a survey of clinical skills course directors.

OBJECTIVES: Clinical reasoning skills are essential for sound medical decision-making. Though many have suggested that clinical reasoning instruction should begin in pre-clerkship curricula, neither pre-clerkship clinical skills director perspectives nor extent of instruction is known. This survey study serves as part of a needs assessment for United States medical school pre-clerkship clinical reasoning curricula. METHODS: United States medical school pre-clerkship clinical skills course directors were surveyed about perceived importance of formal instruction on clinical reasoning concepts, inclusion of these concepts in the curricula, barriers to instruction, and familiarity with clerkship curricula. Results were analyzed using descriptive and analytic statistics. Narrative comments were analyzed qualitatively for themes. RESULTS: Of 148 directors surveyed, 102 (69%) participated and 89 (60%) completed all closed-ended items. Each clinical reasoning concept was identified as somewhat to extremely important to include in pre-clerkship curricula by 90-99% of respondents. Pre-clerkship curricula included variable degrees of formal instruction for concepts, though most respondents rated their inclusion as moderate or extensive. Perceived importance of teaching most concepts moderately correlated with the degree of inclusion in the curriculum (Spearman's rho 0.39-0.44). Curricular time constraints and lack of faculty with skills to teach these concepts were the most frequently cited barriers to instruction. Respondents indicated being somewhat 57% (n=54) to extremely 29% (n=27) familiar with clerkship curricula at their institutions. CONCLUSIONS: This study is the first to examine pre-clerkship clinical skills course director perspectives about clinical reasoning instruction and extent of its inclusion in their curricula.

Skill Session on Writing Patient Assessments for Pediatric Clerkship Students.

Introduction: Formulating written patient assessments requires the student to synthesize subjective and objective information and use clinical reasoning to reach a diagnosis. Medical students lack this skill, and clinical experience is not enough to acquire it. This session provides a structured process for learning how to formulate a patient assessment. Methods: Third-year medical students participated in a large-group interactive skill session at the beginning of their pediatrics clerkship. Instructors following a scripted model walked students through practice examples to ultimately formulate a complete written patient assessment. The session covered data synthesis, use of appropriate medical terminology, and differential diagnosis development. Students used an audience response system to practice these skills. Results: Over 1 academic year, 250 medical students participated in six sessions, with an average of 40-50 attendees per session. Over 90% of students completed pre- and postsession written patient assessments. These assessments were evaluated using portions of the Pediatric History and Physical Exam Evaluation grading rubric. The session had a positive effect on patient assessment formulation skills, with a significant increase in scores after the session. Discussion: The session improved students' skill in generating more complete written patient assessments. Almost all students found the session valuable regardless of prior clinical experience. Nearly 50% of students felt inadequately prepared to formulate a written patient assessment prior to the session, revealing a skills gap for learners and a curricular teaching gap. This skill session provided a structured method and active learning format for teaching this essential clinical skill.

Integrating an Interprofessional Geriatric Active Learning Workshop Into Undergraduate Medical Curriculum.

PURPOSE: The aging population in the United States poses a substantial challenge to our health care system, and particularly affects the training of physicians in geriatric care. To introduce undergraduate medical students to a variety of clinical skills and concepts emphasized in geriatrics, we created an interprofessional geriatric workshop and examined changes in student perceptions of working in interprofessional teams, knowledge regarding geriatric concepts, perceptions of the pre-work material, and suggestions for curricular improvement to enhance the workshop for future students. METHODS: Second-year medical students participated in a 4-hour workshop with tasks that emphasized activities of daily living, geriatric physical assessment, end-of-life discussions, Beers Criteria, and a home health assessment. Pre- and post-surveys were administered including the Students Perceptions of Interprofessional Clinical Education-Revised (SPICE-R) survey and a knowledge assessment. Student perceptions of pre-work and overall program assessment were captured after the workshop. Descriptive statistics and paired t tests assessed for significant differences. Emerging themes were analyzed using the Glaser constant comparative method. RESULTS: Of the 186 medical student participants, 178 students completed the SPICE-R survey, demonstrating significant increases in students' perceptions of the value of interprofessional education (P < .001). In addition, 111 students completed the pre- and post-test for the knowledge assessment, demonstrating significant gains in geriatric concepts (P < .001). Overall, most students perceived the pre-work as useful and felt prepared to evaluate geriatric patients. Open-ended question analysis supported results, in which 34 students indicated that they felt most comfortable performing a home health assessment and emphasized the usage of the home health simulation. CONCLUSIONS: Introducing medical students to a variety of geriatric assessments and concepts in an interprofessional environment early in their career positively influences their perceptions of working as an interprofessional team member to deliver comprehensive care to older adults.

An observational study of an approach to accommodate a fourth-year to third-year neurology clerkship curricular transition.

Background: Curricular transformation can result in bulges in students' clinical placements.Objective: To report on learner outcomes associated with a competency-based opt-out approach for a required 4th-year neurology clerkship.Methods and Study Design: During Oregon Health & Science University's recent undergraduate medical education curricular transformation, a 4-week required neurology clerkship transitioned from the fourth-year to the third-year in academic year 2016-17. Because this would have resulted in the neurology clerkship accommodating double enrollment for an entire academic year, 4th year medical students from the prior curriculum (graduating class of 2017) were offered the option of opting-out of the required neurology clerkship if they demonstrated competency by passing the USA National Board of Medical Examiners (US-NBME) clinical neurology subject examination and completing a neurology faculty-observed history and complete neurological examination.Results: Fifty-seven of 133 fourth-year students (42.9%) chose to complete the required neurology clerkship with 77 (57.9%) choosing to opt-out. All opt-out students passed the neurological exam assessment and scored similarly to the students who took the clerkship (US-NBME Neurology Subject Exam mean raw score in the opt-out group 76.9 vs, 77.6; p = 0.61). Students grades did not differ. Students who opted-out tended to pursue surgical careers (e.g., general surgery -10.8% opted-out vs 0% clerkship, OB/GYN - 6.8% opted-out vs 0% clerkship, orthopedic surgery 5.4% opted-out vs 0% clerkship) where those who took the clerkship tended to choose medical residency training disciplines (family medicine -16.1% clerkship vs 10.8% opting-out; internal medicine - 32.1% clerkship vs 14.9% opting-out; psychiatry 10.7% clerkship vs 2.7% opting-out (p = 0.042)Conclusion: While undertaking the neurology clerkship would have been the desired approach, students appear not to have been harmed by the opt-out approach regarding performance on the US-NBME clinical neurology subject exam. Choices regarding opting-out versus taking the neurology clerkship appear to be associated with career choice.

Clerkship Curriculum Design and USMLE Step 2 Performance: Exploring the Impact of Self-Regulated Exam Preparation.

PURPOSE: This study examined medical students' stress and certification exam preparation practices in a reformed clerkship curriculum that excluded high-stakes knowledge testing from end-of-rotation performance evaluation. METHOD: Stress and exam preparation practices were assessed via a survey comprising locally developed questions, three subscales of the Motivated Strategies for Learning Questionnaire, and two subscales of the Medical Student Stressor Questionnaire. The association between stress, learning self-regulation, and certification exam scores was evaluated retrospectively using non-parametric tests of association (Spearman's rho). RESULTS: Forty students responded to the survey and consented to use of academic performance data (57% participation rate). Mean certification exam scores were indistinguishable from historical controls. Exam preparation practices resembled those of pre-clinical students: exam-related worrying and time devoted to studying were high, increasing as the exam drew near; preferred study resources were directly analogous to exam questions; and study involved relatively few generative strategies (e.g., concept mapping). Sustaining effort and creating time and space to study were associated with better exam performance, as was participation in this study. DISCUSSION: On the surface, the absence of regularly spaced, high-stakes testing from clerkship performance evaluation appears to "do no harm" to students' certification exam scores. Students already performing better academically may excel due in part to effective learning self-regulation strategies. However, a clerkship curriculum that does not scaffold self-regulation via cumulative knowledge assessment could further disadvantage students already earning lower scores. Evaluating the impact of curriculum reforms should continuously examine changes to learners' experience in context.

Bridging the gap between physician and medical student education: using the Train the Trainer model to improve cultural competence training in the clerkship years of medical school.

Cultural competence (CC) training has become a required part of medical education to create future physicians dedicated to decreasing health disparities. However, current training seems to be inadequate as research has demonstrated gaps between CC training and clinical behaviors of students. One aspect that is potentially contributing to this gap is the lack of physician education of CC. Without it being something not only taught in the classroom, but also modeled and taught in the clinical setting, CC will continue to be a theoretical concept instead of a skill set that changes the way that future physicians interact with patients and make decisions about patient care. To change this, we propose the implementation of a Train the Trainer model in which the preclinical professor in charge of CC education trains Clerkship and Residency Directors who then can train and supervise the physicians and residents in their departments on CC to better implement it into the formal and informal curriculum of clerkships.