The Impact of Internal Medicine Clerkship Characteristics and NBME Subject Exams on USMLE Step 2 Clinical Knowledge Exam Performance.

BACKGROUND: Residency program directors will likely emphasize the United States Medical Licensing Exam (USMLE) Step 2 clinical knowledge (CK) exam more during residency application given the recent USMLE Step 1 transition to pass/fail scoring. We examined how internal medicine clerkship characteristics and NBME subject exam scores affect USMLE Step 2 CK performance. DESIGN: The authors used univariable and multivariable generalized estimating equations to determine associations between Step 2 CK performance and internal medicine clerkship characteristics and NBME subject exams. The sample had 21,280 examinees' first Step 2 CK scores for analysis. RESULTS: On multivariable analysis, Step 1 performance (standardized ß = 0.45, p < .001) and NBME medicine subject exam performance (standardized ß = 0.40, p < .001) accounted for approximately 60% of the variance in Step 2 CK performance. Students who completed the internal medicine clerkship last in the academic year scored lower on Step 2 CK (Mdiff = -3.17 p < .001). Students who had a criterion score for passing the NBME medicine subject exam scored higher on Step 2 CK (Mdiff = 1.10, p = .03). There was no association between Step 2 CK performance and other internal medicine clerkship characteristics (all p > 0.05) nor with the total NBME subject exams completed (ß=0.05, p = .78). CONCLUSION: Despite similarities between NBME subject exams and Step 2 CK, the authors did not identify improved Step 2 CK performance for students who had more NBME subject exams. The lack of association of Step 2 CK performance with many internal medicine clerkship characteristics and more NBME subject exams has implications for future clerkship structure and summative assessment. The improved Step 2 CK performance in students that completed their internal medicine clerkship earlier warrants further study given the anticipated increase in emphasis on Step 2 CK.

"Tell Me More": Students Can Practice and Self-Evaluate Primary Palliative Care Skills in a Large, Multistate Internal Medicine Clerkship.

Background: Experts recommend integrating palliative care throughout the four-year medical school curriculum, including in required clerkships such as internal medicine (IM). Objective: The aim of this study was to determine whether third-year medical students could gain meaningful experience in primary palliative care during their IM clerkship with observation and feedback from internists and/or IM residents or fellows. Design: We implemented two clinical exercises: (1) perform advance care planning with a patient and (2) participate in the delivery of important news. Students self-reported aspects of their experience in a confidential online survey. Setting/Subjects: Third-year medical students enrolled in a required IM clerkship. Measurements: Students reported the setting in which they completed the exercises, their level of independence, and their level of comfort with advance care planning after completing the exercise. We performed a qualitative analysis of open-ended comments to determine domains, themes, and subthemes and a separate analysis to determine the extent to which the comments suggested learning relevant to the stated learning objectives for each exercise. Results: The majority of students completed both exercises without palliative care specialists present, 76% (196/258) for the advance care planning exercise and 75% (195/259) for important news. Fifty-one percent (132/258) of students completed advance care planning with a significant level of independence, and 70% (182/258) reported being comfortable or very comfortable with advance care planning after completing the exercise. Qualitative analyses of student comments found that the majority of students described learning something related to the stated learning objectives for each exercise and suggested that they gained an appreciation of the complexity of patient-provider interactions around serious illness and palliative care. Conclusion: We found it feasible to integrate clinical exercises in advance care planning and delivering important news into an IM clerkship.

Pilot study of a 'RIME'-based tool for giving feedback in a multi-specialty longitudinal clerkship.

CONTEXT: The Reporter-Interpreter-Manager-Educator (RIME) evaluation framework is intuitive and reliable. Our preceptors' frustration with using summative tools for formative feedback and the hypothesis that the RIME vocabulary might improve students' and preceptors' experiences with feedback prompted us to develop and pilot a RIME-based feedback tool. METHODS: The tool was based on the RIME vocabulary, which has previously been used for evaluation. As interpersonal skills and professionalism are difficult areas in which to give feedback, we added these as explicit categories. We piloted the tool in a longitudinal, 5-month, multi-specialty clerkship. Preceptors completed pre- and post-introductory workshop surveys. Students completed post-workshop and post-clerkship surveys. RESULTS: Preceptors (n = 14) and students (n = 8) preferred RIME-based feedback to 'usual feedback' (previously given using end-of-clerkship evaluation forms). After the initial workshop, preceptors expected that giving feedback, including critical feedback, would be easier. After the 5-month clerkship, students reported receiving more feedback than in previous clerkships and rated feedback given using this tool more highly (P = 0.002; effect size 1.2). Students also felt it helped them understand specifically how to improve their performance (P = 0.003; effect size 1.2). DISCUSSION: In this pilot study, preceptors and students preferred feedback with a specific RIME-based tool. Students felt such feedback was more useful and helped them identify specifically how to improve. Whether this method can improve student performance through improved feedback remains an area for further research.

Common Drug Side Effects and Drug-Drug Interactions in Elderly Adults in Primary Care.

Prescribing medications, recognizing and managing medication side effects and drug interactions, and avoiding polypharmacy are all essential skills in the care of older adults in primary care. Important side effects of medications commonly prescribed in older adults (statins, proton pump inhibitors, trimethoprim-sulfamethoxazole and fluoroquinolone antibiotics, zolpidem, nonsteroidal antiinflammatory drugs, selective serotonin reuptake inhibitors, dipeptidyl peptidase 4 inhibitors) were reviewed. Important drug interactions with four agents or classes (statins, warfarin, factor Xa inhibitors, and calcium channel blockers) are discussed.

Placebo HAART regimen as a method for teaching medication adherence issues to students.

Placebo medication regimens may help educate students about adherence issues. In this randomized trial, 23 third-year medical students took a 2-week placebo regimen mimicking highly active antiretroviral therapy (HAART) during their medicine clerkship; 15 students served as controls. Although no effect was demonstrated from this intervention on an evaluation instrument examining attitudes and beliefs about medication nonadherence, all 23 student-subjects agreed in postintervention interviews that the experience was useful and had learning value. Representative comments from the 19 subjects who expanded their interview responses portray this intervention as an eye-opening and unique method for teaching students about medication adherence issues.

Appropriate prescribing and important drug interactions in older adults.

Polypharmacy, specifically the overuse and misuse of medications, is associated with adverse health events, increased disability, hospitalizations, and mortality. Mechanisms through which polypharmacy may increase adverse health outcomes include decreased adherence, increased drug side effects, higher use of potentially inappropriate medications, and more frequent drug-drug interactions. This article reviews clinical problems associated with polypharmacy and presents a framework to optimize prescribing for older adults.

The Management of Sarcoidosis: A Primary Care Approach.

Sarcoidosis is an idiopathic inflammatory disorder characterized by noncaseating granulomas, which can affect any organ system. The lungs are most commonly affected but extrapulmonary sites may cause the initial and/or sole symptoms. In this review, the disease manifestations and treatment are described, with particular emphasis on the management of each affected organ system. Diagnosis and management can be difficult and greatly affect quality of life, but despite these challenges, it is possible to successfully manage patients with sarcoidosis in the primary care setting.

Examination room presentations in general internal medicine clinic: patients' and students' perceptions.

PURPOSE: To determine if patients are more satisfied with their health care when medical students present in the exam room to both the attending physician and patient than they are when medical students present outside the exam room to only the attending. To determine medical students' preference for location of presentation and the reasons for their preference. To determine if exam-room presentations promote the education of medical students to a greater degree than presentations outside of the exam room. METHOD: In 2001, 108 patients and 142 fourth-year medical students at internal medicine (IM) clinics affiliated with the University of Washington School of Medicine were asked to complete an 11-point ordinal scale questionnaire on their attitudes toward medical student presentations. RESULTS: One hundred patients (93%) and 68 medical students (48%) responded. Patients with in-room presentations enjoyed working with the medical student more than did patients with out-of-room presentations. Both groups expressed a preference for in-room presentations on future visits and a high level of comfort with student and physician discussing their health. Medical students reported a slight preference for presenting out of the room. When presenting in the room, students reported learning more about physical diagnosis and bedside manner and less about mechanism of disease than when presenting out-of-room. CONCLUSIONS: Patients preferred in-room case presentations and were comfortable with medical students and physicians discussing their health in their presence. In-room presentations also foster instruction on bedside manner and physical diagnosis. These data suggest that both patients and students would benefit from participating in more in-room presentations.

Medical myths involving diabetes.

Medical myths occur for many different reasons. Myths surrounding diabetes are common and are usually attributable to practices that have not been evaluated rigorously (sliding-scale insulin use), concerns related to pathophysiology (beta-blocker use), or extrapolation from small studies or case series (niacin use in patients with diabetes). Myths often are passed on from generation of house staff to students by word of mouth. It is often difficult to determine the origins of some myths, as is the case with sliding-scale insulin use. Other myths may have grown from the inclusion of information from a small case series in an authoritative text [1]. Understanding the myths and misconceptions about the care of patients with diabetes is important in providing excellent care to the patient with diabetes.

Evaluation and treatment of chronic cough.

Chronic cough is a frustrating and common problem, resulting in significant psychological and physical sequelae as well as enormous financial costs in terms of health care expense and time lost from work. Decreased QoL and depression are common. However, using a systematic approach, including assessing whether the patient uses ACE-I and cigarettes, excluding the presence of red flags and risk factors for life-threatening diseases, and obtaining and normal chest radiograph, more than 90% of cases of chronic cough are diagnosed as being caused by UACS, asthma, or GERD. It is recommended to address these conditions sequentially, starting with UACS. Nonasthmatic eosinophilic bronchitis and pertussis infections are unrecognized by primary care providers and should be considered after UACS, asthma, and GERD have been addressed. Finally, cough hypersensitivity syndrome is a new area of research and has been hypothesized to be the underlying factor in many cases of chronic cough, regardless of the inciting factor. More clinical research is needed to further elucidate the cough reflex pathway and the factors involved in modulating its sensitivity, which may eventually lead to new antitussive therapeutics.

Diagnosis and treatment of headache in the ambulatory care setting: a review of classic presentations and new considerations in diagnosis and management.

Headaches represent the most common constellation of neurologic disorders and are a very common cause of morbidity, lost work time, and decreased quality of life among sufferers. In this article, the diagnostic features, workup, and treatment of common, nuanced, and difficult-to-diagnose headache conditions were addressed. The future will hold a number of changes, with respect to both the diagnosis and treatment of headache disorders. As the aging population continues to grow, primary care providers will need to become increasingly familiar with differentiating between benign primary and more serious secondary headache disorders and will need to be able to treat the headache disorders unique to the elderly. With respect to therapeutic options, the future for treatment of the various headache disorders is promising. With the rise in popularity of complementary medical practices, there is likely to be more research on the roles of acupuncture, herbal and alternative remedies, massage therapy, and mind-body techniques. Further, new research is suggesting that neurostimulation may be useful in certain chronic, intractable headache conditions. Finally, the pathophysiology of headache disorders is still poorly understood and there is great hope that better understanding of the underlying mechanics of headache might contribute to improved treatment modalities and better quality of life for patients.

Medically unexplained symptoms.

In summary, caring for patients with MUS is challenging for health care providers. Even defining somatization syndromes is complex and controversial, reflecting the medical community's limited understanding of the pathophysiology for this group of disorders. Although risk factors for MUS have been described and are well understood, little is known about how MUS can be prevented. Uncertainty in medicine, as in any human enterprise, is a given, but the difficulties in identification and treatment of patients with MUS highlight the limitations in understanding the intersection between physical and mental health. Patients come to their physician looking for clarity, understanding, and relief of debilitating symptoms. The understanding of MUS will evolve, and perhaps an organic cause not yet understood or described may emerge to lend clarity and therapeutic opportunities to some patients with somatic disorders. In the meantime, the most powerful tools available are the ability to communicate the limits of current understanding, acknowledge the difficulties faced by patients with this disorder, and reinforce the willingness and desire of clinicians to partner with patients as the focus shifts from diagnosis to symptom management. Thus, the physician-patient relationship, still in its rightful place at the heart of the practice of medicine, lies at the center of effective treatment of patients with MUS.

Lifestyle factors and primary care specialty selection: comparing 2012-2013 graduating and matriculating medical students' thoughts on specialty lifestyle.

PURPOSE: To compare how first-year (MS1) and fourth-year students (MS4) ascribe importance to lifestyle domains and specialty characteristics in specialty selection, and compare students' ratings with their primary care (PC) interest. METHOD: In March 2013, MS4s from 11 U.S. MD-granting medical schools were surveyed. Using a five-point Likert-type scale (1 = not important at all; 5 = extremely important), respondents rated the importance of 5 lifestyle domains and 21 specialty selection characteristics. One-way analysis of variance was used to assess differences by PC interest among MS4s. Using logistic regression, ratings from MS4s were compared with prior analyses of ratings by MS1s who matriculated to the same 11 schools in 2012. RESULTS: The response rate was 57% (965/1,701). MS4s, as compared with MS1s, rated as more important to good lifestyle: time off (4.3 versus 4.0), schedule control (4.2 versus 3.9), and financial compensation (3.4 versus 3.2). More MS4s than MS1s selected "time-off" (262/906 [30%] versus 136/969 [14%]) and "control of work schedule" (169/906 [19%] versus 146/969 [15%]) as the most important lifestyle domains. In both classes, PC interest was associated with higher ratings of working with the underserved and lower ratings of prestige and salary. CONCLUSIONS: In the 2012-2013 academic year, matriculating students and graduating students had similar perceptions of lifestyle and specialty characteristics associated with PC interest. Graduating students placed more importance on schedule control and time off than matriculating students. Specialties should consider addressing a perceived lack of schedule control or inadequate time off to attract students.

Complications of antibiotic therapy.

Antibiotics have greatly changed the practice of medicine for the better. Many infections commonly treated in the outpatient setting with antibiotics (eg, urinary tract infections, streptococcal pharyngitis), which previously caused significant morbidity and mortality, are now typically benign. However, with antibiotic therapy come side effects, ranging in severity from mild nausea to life-threatening cytopenias. This article highlights important complications of antibiotic therapy that may be encountered by outpatient providers. Side effects by system are discussed, and a few important drug-specific complications and important drug-drug interactions highlighted.

Herpes zoster.

Herpes zoster is a common condition that significantly affects health-related quality of life. Most cases occur in immunocompetent individuals older than 60 years; however, immunosuppressed patients are at particularly high risk. Post-herpetic neuralgia is the most common serious complication of herpes zoster, and is much more common in the very elderly. Vaccination with the zoster vaccine is recommended for most people older than 60, and reduces the incidence of herpes zoster and the occurrence of post-herpetic neuralgia.

Primary care, the ROAD less traveled: what first-year medical students want in a specialty.

PURPOSE: Medical students are increasingly choosing non-primary-care specialties. Students consider lifestyle in selecting their specialty, but how entering medical students perceive lifestyle is unknown. This study investigates how first-year students value or rate lifestyle domains and specialty-selection characteristics and whether their ratings vary by interest in primary care (PC). METHOD: During the 2012-2013 academic year, the authors conducted a cross-sectional survey of first-year medical students from 11 MD-granting medical schools. Using a five-point Likert-type scale (1 = not important at all; 5 = extremely important), respondents rated the importance of 5 domains of good lifestyle and 21 characteristics related to specialty selection. The authors classified students into five groups by PC interest and assessed differences by PC interest using one-way analysis of variance. RESULTS: Of 1,704 participants, 1,020 responded (60%). The option "type of work I am doing" was the highest-rated lifestyle domain (mean 4.8, standard deviation [SD] 0.6). "Being satisfied with the job" was the highest-rated specialty-selection characteristic (mean 4.7, SD 0.5). "Availability of practice locations in rural areas" was rated lowest (mean 2.0, SD 1.1). As PC interest decreased, the importance of "opportunities to work with underserved populations" also decreased, but importance of "average salary earned" increased (effect sizes of 0.98 and 0.94, respectively). CONCLUSIONS: First-year students valued enjoying work. The importance of financial compensation was inversely associated with interest in PC. Examining the determinants of enjoyable work may inform interventions to help students attain professional fulfillment in PC.

Perspective: the education community must develop best practices informed by evidence-based research to remediate lapses of professionalism.

In July 2011, the Alpha Omega Alpha Honor Medical Society sponsored a think tank of experts in the field of medical professionalism to focus on interventions and remediation strategies for those-medical students, residents, faculty, and practicing physicians-who demonstrate lapses in professional performance, particularly if the lapses are repeated. Several participants have produced scholarly work on the assessment of professionalism. However, assessment has a limited purpose unless it leads to improvements at both the organizational and individual levels. The field of professionalism has matured enough to recognize that one of the contemporary issues within the self-regulation framework is the task of remediation. Yet there is a paucity of evidence to inform best practices to help those who have lapses. Ultimately, the most effective response to an individual's lapse in professionalism may not be simply to gather knowledge about remedial practices but also to understand organizational responses to the information about such practices already possessed by the institution.The authors report the think tank participants' recommendations on (1) how to use existing data on professionalism remediation and (2) what new evidence is needed to advance approaches to remediation of professional performance. Participants also recommended that the education community can focus on interventions and remediation by (1) performing studies about improving medical professionalism when lapses occur, (2) identifying best evidence-based remediation practices, (3) widely disseminating those practices, and (4) moving over time from a best-practices approach to remediation (which does not yet exist) to a best-evidence model.