An Entrustable Professional Activity (EPA)-Based Framework to Prepare Fourth-Year Medical Students for Internal Medicine Careers.

The purpose of the fourth year of medical school remains controversial. Competing demands during this transitional phase cause confusion for students and educators. In 2014, the Association of American Medical Colleges (AAMC) released 13 Core Entrustable Professional Activities for Entering Residency (CEPAERs). A committee comprising members of the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine applied these principles to preparing students for internal medicine residencies. The authors propose a curricular framework based on five CEPAERs that were felt to be most relevant to residency preparation, informed by prior stakeholder surveys. The critical areas outlined include entering orders, forming and answering clinical questions, conducting patient care handovers, collaborating interprofessionally, and recognizing patients requiring urgent care and initiating that care. For each CEPAER, the authors offer suggestions about instruction and assessment of competency. The fourth year of medical school can be rewarding for students, while adequately preparing them to begin residency, by addressing important elements defined in the core entrustable activities. Thus prepared, new residents can function safely and competently in supervised postgraduate settings.

The effect of resident duty-hours restrictions on internal medicine clerkship experiences: surveys of medical students and clerkship directors.

UNLABELLED: PHENOMENON: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students' and clerkship directors' perceptions of the effects of the 2011 DHR on internal medicine clerkship students' experiences with teaching, feedback and evaluation, and patient care. APPROACH: Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation. FINDINGS: Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. INSIGHTS: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student-patient relationship and students' clinical skills acquisition.

Last chance to observe: assessing residency preparedness following the 4th-year subinternship.

BACKGROUND: The subinternship is an integral part of the 4th year of medical school. There is little description of innovations aimed at assessing the preparedness and confidence of graduating students as they move on the next step in their training. DESCRIPTION: An innovation including an Objective Structured Clinical Examination (OSCE) at the conclusion of the subinternship was designed. We focused on key themes of transitions of care, communication within the health care system, and communication with patients and providers. EVALUATION: A pre- and postsurvey addressed student self-perceived skill, confidence, and overall perception of importance. Improvement (p<.05) was seen across all themes from pre- to postsurvey, with more favorable scores on the postsurvey. CONCLUSIONS: A subinternship innovation including an OSCE was feasible and had a positive effect on student assessment, perception and confidence. As the landscape of medical education evolves, assessing students' preparedness for residency will become increasingly imperative.

The Use of Virtual Standardized Patients for Practice in High Value Care.

INTRODUCTION: This study examined the influence of high value care (HVC)-focused virtual standardized patients (VSPs) on learner attitudes toward cost-conscious care (CCC), performance on subsequent standardized patient (SP) encounters, and the correlation of VSP performance with educational outcomes. METHOD: After didactic sessions on HVC, third-year medical students participated in a randomized crossover design of simulation modalities consisting of 4 VSPs and 3 SPs. Surveys of attitudes toward CCC were administered before didactics and after the first simulation method. Performance markers included automated VSP grading and, for SP cases, faculty-graded observational checklists and patient notes. Performance was compared between modalities using t tests and analysis of variance and then correlated with US Medical Licensing Examination performance. RESULTS: Sixty-six students participated (VSP first: n = 37; SP-first: n = 29). Attitudes toward CCC significantly improved after training (Cohen d = 0.35, P = 0.043), regardless of modality. Simulation order did not impact learner performance for SP encounters. Learners randomized to VSP first performed significantly better within VSP cases for interview (Cohen d = 0.55, P = 0.001) and treatment (Cohen d = 0.50, P = 0.043). The HVC component of learner performance on the SP simulations significantly correlated with US Medical Licensing Examination step 1 ( r = 0.26, P = 0.038) and step 2 clinical knowledge ( r = 0.33, P = 0.031). CONCLUSIONS: High value care didactics combined with either VSPs or SPs positively influenced attitudes toward CCC. The ability to detect an impact of VSPs on learner SP performance was limited by content specificity and sample size.

Evaluating the Association of a Core EPA-Oriented Patient Handover Curriculum on Medical Students' Self-reported Frequency of Observation and Skill Acquisition.

Introduction: "Giving or receiving a patient handover to transition patient care responsibility" is one of the thirteen Core Entrustable Professional Activities (Core EPAs) for Entering Residency. However, implementing a patient handover curriculum in undergraduate medical education (UME) remains challenging. Educational leaders in the multi-institutional Core EPA8 pilot workgroup developed a longitudinal patient handover UME curriculum that was implemented at two pilot institutions. Materials and Methods: We utilized multi-school graduation questionnaire data to assess the association of our patient handover curriculum on self-reported frequency of observation/feedback and skill acquisition by comparing data from the shared curriculum schools to data from other Core EPA pilot schools (three schools with school-specific curriculum; five without a dedicated handover curriculum). Questionnaire data from 1,278 graduating medical students of the class of 2020 from all ten Core EPA pilot schools were analyzed. Results: Graduates from the two medical schools that implemented the shared patient handover curriculum reported significantly greater frequency of handover observation/feedback compared to graduates at the other schools (school-specific curriculum (p < .05) and those without a handover curriculum (p < .05)). Graduates from the two shared approach schools also more strongly agreed that they possessed the skill to perform handovers compared to graduates from the other eight pilot schools that did not implement this curriculum. Conclusion: The findings of this study suggest that the implementation of a multi-institutional Core EPA-based curricular model for teaching and assessing patient handovers was successful and could be implemented at other UME institutions.

Implementing Rubric-Based Peer Review for Video Microlecture Design in Health Professions Education.

Efficient and effective instructional materials designed for asynchronous learning are increasingly important in health professions curricula. Video microlectures are an effective instructional method, but many faculty lack training in applying best-practice multimedia principles to development of their own recorded microlectures. Here we report a rubric designed for use in a peer-review process to evaluate and improve microlectures. The one-page rubric provides a framework for application of multimedia principles and cognitive load theory to microlecture design. Quality improvement of microlectures following redesign according to rubric elements is supported by increased student viewership, which coincided with higher rubric peer review scores.

A National Assessment on Patient Safety Curricula in Undergraduate Medical Education: Results From the 2012 Clerkship Directors in Internal Medicine Survey.

OBJECTIVES: Patient safety is a cornerstone of quality patient care, and educating medical students about patient safety is of growing importance. This investigation was a follow-up to a 2006 study to assess the current status of patient safety curricula within undergraduate medical education in North America with the additional goals of identifying areas for improvement and barriers to implementation. METHODS: Thirteen items regarding patient safety were part of the 2012 Clerkship Directors in Internal Medicine annual survey. Questions addressed curriculum content, delivery, and barriers to implementation. RESULTS: Ninety-nine clerkship directors (82%) responded. Forty-one (45.6%) reported that their medical school had a patient safety curriculum taught during medical school as compared with 25% in a 2006 survey. Fifteen (20%) reported satisfaction with students' level of safety competency at the end of the clerkship. Barriers to implementation included lack of faculty time (n = 57, 78.1%), lack of trained faculty (n = 47, 65.3%), and lack of a mandate from school's dean's office (n = 27, 38.0%). CONCLUSIONS: Our study found that less than half of North American medical schools have a formal patient safety curriculum; although this is higher than in 2006, it still exemplifies a major gap in undergraduate medical education.

Discharge planning curricula in internal medicine residency programs: a national survey.

BACKGROUND: Transition of patient care from an inpatient to outpatient setting is a critical aspect of patient care. The objectives of this study were to describe the content and evaluation of the discharge planning curricula (DPC) in internal medicine (IM) residency programs and identify program directors' perceptions of discharge planning education. METHOD: A 24-item questionnaire was sent to 387 IM program directors during April 2005. The analysis was conducted using SPSS (version 15). RESULTS: A total of 140 program directors (PDs) responded. Formal DPC was offered in 16% (n = 23) of the programs. Hospital resources to coordinate transition of care and communication skills were the main curricular content areas. Seventy-five percent of the PDs agreed that discharge planning should be an important part of the curriculum. More than 50% of the PDs agreed that discharge planning would decrease the re-admission rate, and increase patient satisfaction and referring physician satisfaction. The programs with a DPC had a higher level of agreement that a DPC program would facilitate continuity of care between inpatient and outpatient care (P = 0.027) compared to programs without a DPC. CONCLUSIONS: The majority of the PDs agreed that DPC should be an important curricular component, yet only a few programs offered formal discharge planning education. Residency programs need to address this critical aspect of patient care within the core curricula.

Medical informatics in the internal medicine clerkship: Results of a national survey.

BACKGROUND: Medical Informatics (MI) is increasingly a critical aspect of medical education and patient care. AIMS: This study assessed the status of MI training, perception of needs and barriers for the implementation of MI curricula and utilization of information technology (IT) in patient care and medical education. METHOD: The MI questionnaire was a part of the 2006 Clerkship Directors in Internal Medicine survey of 110 institutional members. Descriptive statistics were calculated using Statistical Package for the Social Sciences (SPSS), version 12 and all p-values are two-tailed. RESULTS: Eighty-three (75%) members responded. Out of this, 52, 32.5 and 12% report that students receive MI training for patient care activities during pre-clinical years, third-year internal medicine clerkship or intersession, respectively. House staff critiques (46.4%), patient billing (44.1%), radiographic imaging (40.8%), accessing clinical data (37.3%), and student evaluations (36.1%) were areas in which 35% of respondents use IT 'all the time.' Fifty-one percent of respondents rate the adequacy of training in MI as average. Cost, time and lack of trained faculty were primary barriers for the implementation. CONCLUSIONS: Significant variations exist in timing of MI curricula. IT is utilized more frequently for non-patient activities. Studies are needed to examine the needs, processes and outcomes of MI curricula.

Patient Safety Morning Report: Innovation in Teaching Core Patient Safety Principles to Third-Year Medical Students.

INTRODUCTION: Patient safety (PS) is one of the most important priorities in modern healthcare systems. Unfortunately, PS education is limited in many medical school curricula. Our objective was to implement an innovative curriculum to introduce third-year medical students on their pediatric clerkship to PS concepts and domains, and to provide a safe environment to discuss lapses in PS that they identified while caring for patients. METHODS: At the start of the pediatric clerkship, students were introduced to the curriculum, instructed to identify a lapse of PS, and to submit a description and analysis of the lapse using the SAFE framework (S = Safety concern, A = Action taken, F = Failure, linked to safety domains, E = Effects on patient outcome). Two sessions, 90-mins each, were conducted every clerkship during which there was a brief didactic presentation, each student presented their case, and the case discussed by students and faculty. RESULTS: Over 19 months, 75 students participated. The most common PS themes identified were Communication (57% of cases), Human factors (39%), and System issues (37%). Anonymous written feedback was obtained; learners reported improved knowledge and ability to identify lapses in PS and to propose potential solutions to prevent similar future events. They expressed a desire for additional PS and quality improvement education. DISCUSSION: Our results show that third-year medical students are able to identify lapses in PS and able to propose solutions. This aligns with the Association of American Medical Colleges (AAMC) goals of entrustable professional activities (EPA) 13. We intend to expand the curriculum to other third-year core clerkships.

Uncomplicated Urinary Tract Infection in Ambulatory Primary Care Pediatrics: Are We Using Antibiotics Appropriately?

OBJECTIVES: Antimicrobial stewardship programs target antimicrobial use within the inpatient care setting. However, most antimicrobials are prescribed at ambulatory sites. We aim to determine the appropriateness of the diagnosis and treatment of uncomplicated urinary tract infection (UTI) in children within the outpatient setting at our institution, and to evaluate the cost of antibiotic treatment in our patient cohort. METHODS: This retrospective study was conducted by reviewing electronic records of patients aged 2 to 18 years diagnosed with uncomplicated UTI and treated with antibiotics in the outpatient setting from January 1, 2016, to April 30, 2016. Appropriate diagnosis was defined as confirmed UTI that included: pyuria (>5 white blood cells per high-power field or positive for leukocyte esterase), a positive urine culture (≥50,000 colony units/mL of a single uropathogen for a catheterized sample or ≥100,000 colony units/mL for a clean catch urine sample), and lower urinary tract symptoms. Treatment was considered appropriate if the patient was prescribed first-line antibiotic for the susceptible isolate (trimethoprim sulfamethoxazole, amoxicillinclavulanate, nitrofurantoin, and cephalexin), and if the appropriate dose was used. RESULTS: We included 178 patients receiving a diagnosis of uncomplicated UTI and treated with antibiotics. Of these, 70% received an inappropriate diagnosis (n = 125). 58% (n= 72) of improperly diagnosed patients had polymicrobial growth in their urine cultures. Antibiotics prescribed mostly in this group were trimethoprim-sulfamethoxazole (53%, n = 66) and cephalexin (22%, n = 27). Only 30% of all included patients received an appropriate diagnosis (n = 53). Of all appropriate diagnosis patients (n = 53), 26% were treated inappropriately (n = 14) with either wide-spectrum antibiotics (n = 8) or with low calculated dose (n = 6). The estimated cost of antibiotic treatment for the inappropriate diagnosis group (n = 125) was $10,755.87. CONCLUSION: Antimicrobial stewardship programs should target the pediatric outpatient setting and antibiograms should be developed. Education of providers about the appropriate diagnosis and treatment of uncomplicated UTI in children is essential for reducing the cost of inappropriate therapy.

Virtual Standardized Patient Simulation: Case Development and Pilot Application to High-Value Care.

INTRODUCTION: High-value care (HVC) suggests that good history taking and physical examination should lead to risk stratification that drives the use or withholding of diagnostic testing. This study describes the development of a series of virtual standardized patient (VSP) cases and provides preliminary evidence that supports their ability to provide experiential learning in HVC. METHODS: This pilot study used VSPs, or natural language processing-based patient avatars, within the USC Standard Patient platform. Faculty consensus was used to develop the cases, including the optimal diagnostic testing strategies, treatment options, and scored content areas. First-year resident physician learners experienced two 90-minute didactic sessions before completing the cases in a computer laboratory, using typed text to interview the avatar for history taking, then completing physical examination, differential diagnosis, diagnostic testing, and treatment modules for each case. Learners chose a primary and 2 alternative "possible" diagnoses from a list of 6 to 7 choices, diagnostic testing options from an extensive list, and treatments from a brief list ranging from 6 to 9 choices. For the history-taking module, both faculty and the platform scored the learners, and faculty assessed the appropriateness of avatar responses. Four randomly selected learner-avatar interview transcripts for each case were double rated by faculty for interrater reliability calculations. Intraclass correlations were calculated for interrater reliability, and Spearman ρ was used to determine the correlation between the platform and faculty ranking of learners' history-taking scores. RESULTS: Eight VSP cases were experienced by 14 learners. Investigators reviewed 112 transcripts (4646 learner query-avatar responses). Interrater reliability means were 0.87 for learner query scoring and 0.83 for avatar response. Mean learner success for history taking was scored by the faculty at 57% and by the platform at 51% (ρ correlation of learner rankings = 0.80, P = 0.02). The mean avatar appropriate response rate was 85.6% for all cases. Learners chose the correct diagnosis within their 3 choices 82% of the time, ordered a median (interquartile range) of 2 (2) unnecessary tests and completed 56% of optimal treatments. CONCLUSIONS: Our avatar appropriate response rate was similar to past work using similar platforms. The simulations give detailed insights into the thoroughness of learner history taking and testing choices and with further refinement should support learning in HVC.

Change in residents' perceptions of teaching: following a one day "Residents as Teachers" (RasT) workshop.

OBJECTIVES: The objective of this study was to assess the perceptions and attitudes of resident physicians toward teaching before and after participation in a mandatory "Residents as Teachers" (RasT) workshop in four domains: (1) setting goals and expectations, (2) use of clinical microskills in teaching, (3) evaluation and feedback, and (4) enthusiasm and preparedness toward teaching. METHODS: Pre- and postintervention questionnaires were utilized. Data were analyzed for all respondents. Subgroup analyses were performed for each academic year and for primary care versus nonprimary care specialties. RESULTS: Over a 5-year period, 15 RasT workshops were presented to 276 residents from 10 different residency programs. Eighty-six percent completed the questionnaire before participation in the workshop, and 88% completed the questionnaire immediately after participation. The difference between the mean post-RasT and pre-RasT ratings on each item was used to measure the change in that item resulting from participation in the workshop. CONCLUSION: Overall, residents' self-assessed ratings of their attitudes toward teaching were positively impacted by participation in a RasT workshop. Further subanalysis showed that residents in primary care specialties showed a significantly greater increase in their ratings than residents in nonprimary care specialties.

The transformation of an EBM curriculum: a 10-year experience.

BACKGROUND: Evidence-based medicine (EBM) is an essential tool for students across the medical education continuum. Incorporation of EBM skills into core competencies by national educational organizations denotes their vital role. AIM: The main purpose is to describe the transformation of an EBM curriculum in an Internal Medicine clerkship and the educational principles that influenced changes over ten years. METHODS: The EBM curriculum over ten years was reviewed. This retrospective review was divided into four phases, based on the educational interventions used. Associated outcomes of the curriculum, student skills, and satisfaction with the course and faculty involvement were assessed. RESULTS: A majority of the 493 students felt they received adequate and appropriate exposure to EBM. The curriculum evolved from a teacher-centered approach using computer-based case scenarios to a learner-centered, and patient centric approach. Student skills in EBM improved, as was evidenced by the pre- and post-tests and the evaluations of critically appraised topic assignments. CONCLUSIONS: EBM is an essential tool to develop life-long learners. A learner-centered, patient centric approach is well received by students. Long-term studies are needed to assess the impact of these teaching interventions on patient outcomes.

Cryptococcemia in an HIV-negative patient with decompensated liver cirrhosis.

BACKGROUND: Cryptococcal infections have been mostly associated with immunocompromised individuals, 80-90% of whom have been HIV-positive patients. Increasingly, cryptococcal infections are being reported in cirrhotic patients who are HIV-negative. The underlying immunologic defects in cirrhotic patients seem to play an important role in predisposing them to cryptococcosis and affecting their morbidity and mortality. CASE PRESENTATION: We present a case of disseminated cryptococcosis in an HIV-negative patient with underlying cirrhosis, who had rapid worsening of his hyponatremia with renal failure and was unable to recover, despite aggressive measures. CONCLUSION: Cryptococcus is a more common culprit of infections seen in cirrhotic patients than what it was previously known, and a high index of suspicion is required to diagnose these patients. Identification of poor prognostic factors, early diagnosis and intervention is crucial in the management of these patients.

What Are We Telling Our Students? A National Survey of Clerkship Directors' Advice for Students Applying to Internal Medicine Residency.

BACKGROUND: Little is known about the advice fourth-year medical students receive from their advisors as they prepare to apply for residency training. OBJECTIVE: We collected information on recommendations given to medical students preparing to apply to internal medicine residencies regarding fourth-year schedules and application strategies. METHODS: Clerkship Directors in Internal Medicine conducted its annual member survey in June 2013. We analyzed responses on student advising using descriptive and comparative statistics, and free-text responses using content analysis. RESULTS: Of 124 members, 94 (76%) responded, and 83 (88%) advised fourth-year medical students. Nearly half (45%) advised an average of more than 20 students a year. Advisors encouraged students to take a medicine subinternship (Likert scale mean 4.84 [1, strongly discourage, to 5, strongly encourage], SD = 0.61); a critical care rotation (4.38, SD = 0.79); and a medicine specialty clinical rotation (4.01, SD = 0.80). Advisors reported they thought fourth-year students should spend a mean of 6.5 months doing clinical rotations (range 1-10, SD = 1.91). They recommended highest academic quartile students apply to a median of 10 programs (range 1-30) and lowest quartile students apply to 15 programs (range 3-100). Top recommendations involved maximizing student competitiveness, valuing program fit over reputation, and recognizing key decision points in the application process. CONCLUSIONS: Undergraduate medical advisors recommended specific strategies to enhance students' competitiveness in the Match and to prepare them for residency. The results can inform program directors and encourage dialogue between undergraduate medical education and graduate medical education on how to best utilize the fourth year.

Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship.

The fourth year of medical school remains controversial, despite efforts to reform it. A committee from the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine examined transitions from medical school to internship with the goal of better academic advising for students. In 2013 and 2014, the committee examined published literature and the Web sites of 136 Liaison Committee on Medical Education-accredited schools for information on current course offerings for the fourth year of medical school. The authors summarized temporal trends and outcomes when available.Subinternships were required by 122 (90%) of the 136 schools and allow students to experience the intern's role. Capstone courses are increasingly used to fill curricular gaps. Revisiting basic sciences in fourth-year rotations helps to reinforce concepts from earlier years. Many schools require rotations in specific settings, like emergency departments, intensive care units, or ambulatory clinics. A growing number of schools require participation in research, including during the fourth year. Students traditionally take fourth-year clinical electives to improve skills, both within their chosen specialties and in other disciplines. Some students work with underserved populations or seek experiences that will be henceforth unavailable, whereas others use electives to "audition" at desired residency sites. Fourth-year requirements vary considerably among medical schools, reflecting different missions and varied student needs. Few objective outcomes data exist to guide students' choices. Nevertheless, both medical students and educators value the fourth year of medical school and feel it can fill diverse functions in preparing for residency.

What skills should new internal medicine interns have in july? A national survey of internal medicine residency program directors.

PROBLEM: The transition from medical student to intern may cause stress and burnout in new interns and the delivery of suboptimal patient care. Despite a formal set of subinternship curriculum guidelines, program directors have expressed concern regarding the skill set of new interns and the lack of standardization in that skill set among interns from different medical schools. To address these issues, the Accreditation Council for Graduate Medical Education's Next Accreditation System focuses on the development of a competency-based education continuum spanning undergraduate, graduate, and continuing medical education. APPROACH: In 2010, the Clerkship Directors in Internal Medicine subinternship task force, in collaboration with the Association of Program Directors in Internal Medicine survey committee, surveyed internal medicine residency program directors to determine which competencies or skills they expected from new medical school graduates. The authors summarized the results using categories of interest. OUTCOMES: In both an item rank list and free-text responses, program directors were nearly uniform in ranking the skills they deemed most important for new interns-organization and time management and prioritization skills; effective communication skills; basic clinical skills; and knowing when to ask for assistance. NEXT STEPS: Stakeholders should use the results of this survey as they develop a milestone-based curriculum for the fourth year of medical school and for the internal medicine subinternship. By doing so, they should develop a standardized set of skills that meet program directors' expectations, reduce the stress of transitions across the educational continuum, and improve the quality of patient care.

The subinternship curriculum in internal medicine: a national survey of clerkship directors.

BACKGROUND: The 4th-year internal medicine subinternship (subI), with its strong emphasis on experience-based learning and increased patient responsibilities, is an important component of undergraduate medical education. Discussions have begun amongst educational leaders on the importance of standardizing curriculum and evaluation tools utilized during the subinternship. PURPOSE: The objective of this survey was to describe the current state of educational practices regarding the subI curriculum, use of Clerkship Directors in Internal Medicine (CDIM) curricular guidelines, evaluation methodologies, and subintern call frequency and duty hours. METHODS: The survey was a part of the CDIM annual survey sent to 109 institutional members in 2005. The subinternship survey included 17 questions that addressed the prevalence of formal curricula in the subinternship, use of CDIM curricular guidelines and resources, and the evaluation tools utilized for assessment of the subinternship. Two questions examined the call frequency and duty hours of the subinterns. RESULTS: Eighty-eight members responded (81%). Of the respondents, 37% have a formal curriculum and 35% used CDIM curricular guidelines for the subinternship. More than half of the respondents agreed that the curricular guide helped organize their subI rotations (53%), and 48% agreed that it enhanced the quality of subI education. A global rating summative evaluation form (56%) was the most commonly used evaluation tool in the subinternship. Objective Structured Clinical Examinations (1%) and Mini-Clinical Evaluation Exercise (mini-CEX)(2%) were much less utilized during the subinternship. The respondents expressed an interest in the development of a standardized exam (47%) and clinical assessment tools such as the mini-CEX (59%). The vast majority of IM subinterns participate in 3 to 9 calls per rotation and spend less than 80 hr in the hospital per week. CONCLUSIONS: A formal curriculum is offered in slightly more than one third of subIs. Clerkship directors expressed interest in developing standardized evaluation tools to assess subintern competencies. The majority of IM subinterns spend less than 80 hr in the hospital per week. Further studies are needed to assess barriers to incorporating a formal curriculum and develop standardized tools to assess subintern competencies.

Retention of EBM competencies.

This longitudinal follow-up study surveyed the attitudes toward, and skills in, evidence-based medicine (EBM) of medical school graduates who had participated in a formal EBM curriculum during their third-year Internal Medicine (IM) clerkship. The objective was to measure whether competencies were retained over time and to identify the long- term impact on the graduates' attitudes toward, and proficiency in, EBM after graduation. Questionnaire results showed that a group of medical school graduates retained EBM skills and a positive attitude about the importance of applying EBM principles in patient care one to three years after completing an EBM course.