ABSTRACT
BACKGROUND: The acting internship (AI) in internal medicine plays a key role in the transition from medical school to residency. While there have been recent changes in medical education including a pass/fail USMLE Step 1 and increasing use of competency-based assessment, there has not been a large survey of the state of the AI in many years. OBJECTIVE: To assess the current landscape of the internal medicine AI and identify areas in need of standardization. DESIGN: This was a voluntary online survey of medical schools in the United States (U.S.). PARTICIPANTS: Course directors of the AI rotation at U.S. medical schools. MAIN MEASURES: Number of AI rotations required for graduation, length of AI rotation, types of services allowed for AI, clinical responsibilities of students, curricular components. KEY RESULTS: Response rate was 50.7% (71/140 LCME accredited schools). All responding institutions require at least one AI for graduation, with nearly all schools integrating students into resident teaching teams, and almost half also allowing AI students to work on hospitalist services. Students carry 3-4 patients per day on average with a maximum of 5-6 in most institutions. Students are responsible for most aspects of patient care including notes, orders, interprofessional communication, and transitions of care. Night call or night float responsibilities are infrequently required. The structured curriculum published by AAIM is used by only 41% of schools. CONCLUSIONS: The internal medicine AI continues to be a staple in the medical school experience, but there is variation in the structure, curriculum, and expectations on the rotation. Opportunities exist to improve standardization of the AI experience and expectations to better prepare medical students for the transition from medical school to residency.
Subject(s)
Internal Medicine , Internal Medicine/education , Humans , Surveys and Questionnaires , Internship and Residency , United States , Male , FemaleABSTRACT
BACKGROUND: At some US Academic Health Centers (AHCs), patients with predominantly Medicaid insurance are seen in one clinic and patients with other insurance are seen in another. The extent of this practice and implications are unknown. OBJECTIVE: To estimate the proportion of AHCs that have at least two primary care internal medicine clinics that differ substantially in proportion of patients with Medicaid and to compare patient demographic, staffing, and operational features. PARTICIPANTS: General internal medicine chiefs and clinic directors at 40 randomly selected US AHCs plus the top 10 AHCs in terms of NIH funding. MAIN MEASURE: An AHC was classified as maintaining clinics that differed substantially in the proportion of patients with Medicaid if any two differed by ≥ 40% (absolute). Other criteria were used for pre-specified secondary analyses (e.g., ≥ 30%). KEY RESULTS: Thirty-nine of 50 AHCs (78%) participated. Four of 39 (10%; 95% CI, 3 to 24%) had two clinics differing by ≥ 40% in the proportion of patients with Medicaid, eight (21%; 95% CI, 9 to 36%) had clinics differing by ≥ 30%, and 15 (38%; 95% CI, 23 to 55%) had clinics differing by ≥ 20%. Clinics with more patients with Medicaid by any of the three criteria were more likely to employ resident physicians as providers of longitudinal care (with faculty supervision) and more likely to have patients who were Black or Hispanic. CONCLUSIONS: Some US AHCs maintain separate clinics defined by the proportion of patients with Medicaid. Clinics with a higher proportion of patients insured by Medicaid are more likely to employ residents (with faculty oversight), feature residents as providers of longitudinal care, and serve patients who are Black and Hispanic. Further research is needed to understand why some AHCs have primary care clinics distinguishable by insurance mix with the goal of ensuring that racism and discrimination are not root causes.
Subject(s)
Insurance, Health , Medicaid , United States , Humans , Cross-Sectional Studies , Ambulatory Care Facilities , Primary Health CareABSTRACT
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.
Subject(s)
Clinical Clerkship , Education, Medical, Undergraduate , Clinical Competence , Educational Measurement , Humans , Licensure, Medical , United StatesABSTRACT
BACKGROUND: Medical students matriculating from their preclinical curriculum into clinical clerkships face a significant learning curve when using an electronic medical record (EMR) system for clinical documentation. With the trend toward reduction in preclinical medical education, students now have fewer opportunities to optimize their note-writing and overall clinical skills before transitioning to patient-care settings. METHODS: This study sought to investigate how a structured medical scribing program in an outpatient clinic helps bridge the gap between traditional preclinical and clinical curricula in medical education. A small cohort of medical students were trained in medical scribing within our institutions' existing preclinical preceptorship program. We surveyed students, preceptors, and patients during the project to better understand confidence around documentation, the EMR, and the impact of the scribing program on workflow efficiency and patient satisfaction. RESULTS: There was no significant difference between the scribe and non- scribe students in their confidence documenting a patient encounter or navigating EMR (all p > .05). Our study demonstrated that preceptors for scribe students reported a significant decrease in documentation time compared to non-scribes (Mdiff = - 5.75, p = .02), with no negative impact on patient satisfaction. CONCLUSIONS: Medical scribing can be a tool to further develop medical trainees in clinical documentation and help prepare them for the responsibilities during clinical years. When summing the per encounter time savings over the course of a half or full clinic day, scribing can return a significant amount of time back to preceptors. The time saved by the preceptor needs to be further investigated to determine if the time can lend itself towards better patient care, student-specific feedback, focused teaching, or even mentoring.
Subject(s)
Schools, Medical , Students, Medical , Curriculum , Electronic Health Records , Humans , Pilot ProjectsABSTRACT
BACKGROUND: Over 41 million people in the United States speak Spanish as their primary language, of which 16 million have limited English proficiency (LEP). It is well-established that language barriers contribute to health disparities and that the use of ad-hoc interpretation by untrained family members results in substandard care. We developed a novel interpreter training program for medical students to serve as in-person interpreters at a charitable, resident continuity clinic so as to overcome the language barrier in the delivery of healthcare to LEP patients. METHODS: The Medical Student Interpreter Training Program (MSITP) consists of three steps. First, fluent Spanish-speaking students shadowed a licensed interpreter. Second, students took a standardized phone exam to demonstrate language proficiency. Finally, students completed a three-hour training on the methodology and ethics of interpreting conducted by the Department of Interpreter Services. RESULTS: Pre- and post-tests were administered to assess students' familiarity with the Interpreter Code of Ethics and interpreter skills. Familiarity with the Interpreter Code of Ethics increased significantly with all students reporting feeling comfortable (47%) or very comfortable (53%) after training. The pre- and post-tests included free response questions, which were administered to assess competence in the methodology and ethics of interpreting. The cohort's aggregate score increased by 35% after the training (Wilcoxon signed rank z-score = 2.53; p = .01). CONCLUSIONS: Implementing the MSITP resulted in an increased number of trained, Spanish-speaking interpreters available to provide their services to LEP patients at an affiliated charitable clinic and throughout the university hospital. Unlike other program models which are time and resource-intensive, this program is replicable and easily managed by volunteers. The MSITP is an effective model for training students as medical interpreters to ensure the delivery of quality healthcare for LEP patients.
Subject(s)
Students, Medical , Communication Barriers , Curriculum , Humans , Physician-Patient Relations , Translating , United States , VolunteersABSTRACT
PURPOSE: To identify which internal medicine clerkship characteristics may relate to NBME Medicine Subject Examination scores, given the growing trend toward earlier clerkship start dates. METHOD: The authors used linear mixed effects models (univariable and multivariable) to determine associations between medicine exam performance and clerkship characteristics (longitudinal status, clerkship length, academic start month, ambulatory clinical experience, presence of a study day, involvement in a combined clerkship, preclinical curriculum type, medicine exam timing). Additional covariates included number of NBME clinical subject exams used, number of didactic hours, use of a criterion score for passing the medicine exam, whether medicine exam performance was used to designate clerkship honors, and United States Medical Licensing Examination Step 1 performance. The sample included 24,542 examinees from 62 medical schools spanning 3 academic years (2011-2014). RESULTS: The multivariable analysis found no significant association between clerkship length and medicine exam performance (all pairwise P > .05). However, a small number of examinees beginning their academic term in January scored marginally lower than those starting in July (P < .001). Conversely, examinees scored higher on the medicine exam later in the academic year (all pairwise P < .001). Examinees from schools that used a criterion score for passing the medicine exam also scored higher than those at schools that did not (P < .05). Step 1 performance remained positively associated with medicine exam performance even after controlling for all other variables in the model (P < .001). CONCLUSIONS: In this sample, the authors found no association between many clerkship variables and medicine exam performance. Instead, Step 1 performance was the most powerful predictor of medicine exam performance. These findings suggest that medicine exam performance reflects the overall medical knowledge students accrue during their education rather than any specific internal medicine clerkship characteristics.
Subject(s)
Clinical Clerkship , Educational Measurement/methods , Internal Medicine/education , Licensure, Medical , Specialty Boards , Clinical Competence , Humans , Linear Models , Multivariate Analysis , Time Factors , United StatesABSTRACT
Phenomenon: Fourth-year medical students obtain Department of Medicine (DOM) letters ("Chair" letters) to support their residency applications. Writing and interpreting DOM letters are challenging. There is heterogeneity in the letters that makes it difficult to both write and read these letters. APPROACH: The purpose of this study is to determine the value of new guidelines developed by a task force of clerkship directors and program directors in internal medicine and assess the implementation of these guidelines. The Clerkship Directors in Internal Medicine performed a cross-sectional survey of internal medicine clerkship directors at U.S. and Canadian medical schools in 2014. In addition, the primary author's institution reviewed 1,347 DOM letters between 2012 and 2014 to assess the implementation of these guidelines. FINDINGS: The survey response rate was 78%. DOM letter writers reported the guidelines were better, easier to implement, and more compatible with the purpose of DOM letters than previously. Most letter readers reported that letters using the guidelines were more credible. Writers of DOM letters in lower academic ranks rated the letters with guidelines higher in several domains than those in higher academic ranks. Readers of DOM letters in higher academic ranks rated the letters with guidelines higher in several domains than those in lower academic ranks. In the DOM letters examined, the odds of meeting each guideline increased with each additional year. However, for 3 guidelines there was an initial decline in adherence from 2012 to 2013 before increasing again in 2014-the recommended length, clerkship description, and detailed narrative guidelines. Letters solely written by a chair were less likely to incorporate the guidelines. Insights: Clerkship directors often write the DOM letters and identify with the purpose of the guidelines. As writers, lower ranking academic faculty value the guidelines more than higher ranking academic faculty. As readers of DOM letters, higher academic ranking faculty value letters that incorporate the guidelines more than lower academic ranking faculty. DOM letters implemented more guideline criteria since the guidelines were released. If implementing the guidelines, chairs should solicit the help of their clerkship director or educational representative when writing DOM letters. Although many clerkship directors read letters for their residency programs, additional program directors' opinions are needed.
Subject(s)
Correspondence as Topic , Guidelines as Topic , Internship and Residency , Canada , Cross-Sectional Studies , Education, Medical, Undergraduate , Internal Medicine/education , Job Application , United StatesABSTRACT
Glycogenic hepatopathy (GH) is an underdiagnosed complication of uncontrolled type 1 diabetes mellitus (T1DM). It appears as an acute relapsing hepatitis with reversible transaminase elevations secondary to excessive hepatic glycogen accumulation. Patients are often asymptomatic but can present with abdominal pain, nausea and vomiting. Physical examination shows hepatomegaly without splenomegaly. GH is diagnosed by biopsy as it is clinically indistinguishable from non-alcoholic fatty liver disease (NAFLD), a more common cause of hepatic dysfunction in diabetics. Here we describe a case of GH in a patient with uncontrolled type 1 diabetes whose clinical course was complicated by drug-induced liver injury. The patient initially presented with diabetic ketoacidosis and had a mild transaminitis, thought to be due to NAFLD. She developed profound transaminase elevations while receiving treatment with newer antipsychotic medications for her bipolar disorder. Liver biopsy showed evidence of resolving glycogenic hepatopathy with signs of drug-induced liver injury. This case report reviews the pathology and pathogenesis of GH and reminds the clinician to keep GH within the differential diagnosis for severe transaminitis in a patient with type 1 diabetes mellitus.
Subject(s)
Antipsychotic Agents/adverse effects , Bipolar Disorder/drug therapy , Chemical and Drug Induced Liver Injury/diagnosis , Heterocyclic Compounds, 4 or More Rings/adverse effects , Abdominal Pain/etiology , Biopsy , Bipolar Disorder/complications , Diabetes Mellitus, Type 1/complications , Diabetic Ketoacidosis/complications , Diagnosis, Differential , Dibenzocycloheptenes , Female , Glycogen/metabolism , Hepatomegaly/diagnostic imaging , Humans , Liver/pathology , Magnetic Resonance Imaging , Young AdultABSTRACT
BACKGROUND: Authorities suggest academic medical centers eliminate conflicts of interest. The authors evaluated medical students' opinions and knowledge of the pharmaceutical industry. METHOD: An anonymous 20-item questionnaire was administered to medical students from four different medical schools; 15 items addressed opinions, and five items were free-response knowledge questions. Results were analyzed by Fisher exact test. RESULTS: Authors received 667 responses from the schools. Sixty-five percent of clinical students believed accepting gifts was appropriate; 28% of preclinical students believed it was appropriate (P < .001). Knowledge was the same for clinical and preclinical students. CONCLUSIONS: Clinical students were more favorable toward receiving gifts than were preclinical students, yet there was no difference in their knowledge of the industry. Increased formal and informal education about the pharmaceutical industry is necessary during the clinical years.