Feasibility of clinical performance assessment of medical students on a virtual sub-internship in the United States.

We aimed to determine whether it was feasible to assess medical students as they completed a virtual sub-internship. Six students (out of 31 who completed an in-person sub-internship) participated in a 2-week virtual sub-internship, caring for patients remotely. Residents and attendings assessed those 6 students in 15 domains using the same assessment measures from the in-person sub-internship. Raters marked "unable to assess" in 75/390 responses (19%) for the virtual sub-internship versus 88/3,405 (2.6%) for the in-person sub-internship (P=0.01), most frequently for the virtual sub-internship in the domains of the physical examination (21, 81%), rapport with patients (18, 69%), and compassion (11, 42%). Students received complete assessments in most areas. Scores were higher for the in-person than the virtual sub-internship (4.67 vs. 4.45, P<0.01) for students who completed both. Students uniformly rated the virtual clerkship positively. Students can be assessed in many domains in the context of a virtual sub-internship.

End-of-Life Care: A Multimodal and Comprehensive Curriculum for Graduating Medical Students Utilizing Experiential Learning Opportunities.

Introduction: End-of-life (EOL) care is an essential skill for most physicians and health care providers, yet there continues to be an educational gap in medical education literature for these skills. The Johns Hopkins School of Medicine developed the Transition to Residency, Internship, and Preparation for Life Events (TRIPLE) curriculum with the primary goal of preparing graduating medical students for life after medical school. Methods: The EOL module was one of many within the TRIPLE curriculum and consisted of two half-day sessions that targeted EOL care, death, dying, and communication skills. The first half-day session focused on a standardized patient encounter where learners initiated and completed an EOL care goals conversation around a living will. The second half-day session focused on death and dying. It included didactic sessions on organ donation, autopsy/death certificates, a simulation-based learning session on ending a resuscitation, and a standardized patient encounter where learners disclosed the death of a loved one. End-of-day and end-of-course evaluations were collected via anonymous online surveys. Results: In 2019, 120 students and 26 instructors participated in TRIPLE. Students rated the EOL module overall as 4.6 of 5 (SD = 0.6) and rated instructors overall as 4.6 of 5 (SD = 0.6). Discussion: By implementing a thorough and diverse curriculum with a variety of modalities and targeted skills, learners may be better prepared to care for patients dealing with EOL care issues. Further, the generalization of these skills may assist learners in a variety of other aspects of patient and family care.

Effect of a high value care curriculum on standardized patient exam in the Core Clerkship in Internal Medicine.

BACKGROUND: With almost 20% unnecessary spending on healthcare, there has been increasing interest in high value care defined as the best care for the patient, with the optimal result for the circumstances, delivered at the right price. The American Association of Medical Colleges recommend that medical students are proficient in concepts of cost-effective clinical practice by graduation, thus leading to curricula on high value care. However little is published on the effectiveness of these curricula on medical students' ability to practice high value care. METHODS: In addition to the standard curriculum, the intervention group received two classroom sessions and three virtual patients focused on the concepts of high value care. The primary outcome was number of tests and charges for tests on standardized patients. RESULTS: 136 students enrolled in the Core Clerkship in Internal Medicine and 70 completed the high value care curriculum. There were no significant differences in ordering of appropriate tests (3.1 vs. 3.2 tests/students, p = 0.55) and inappropriate tests (1.8 vs. 2.2, p = 0.13) between the intervention and control. Students in the intervention group had significantly lower median Medicare charges ($287.59 vs. $500.86, p = 0.04) and felt their education in high value care was appropriate (81% vs. 56%, p = 0.02). CONCLUSIONS: This is the first study to describe the impact of a high value care curriculum on medical students' ordering practices. While number of inappropriate tests was not significantly different, students in the intervention group refrained from ordering expensive tests.

Communicating About Stopping Cancer Screening: Comparing Clinicians' and Older Adults' Perspectives.

BACKGROUND AND OBJECTIVES: Older adults with limited life expectancy frequently receive cancer screening. We sought to compare the perspectives of clinicians and older adults on how to communicate about stopping cancer screening. RESEARCH DESIGN AND METHODS: We used data from two studies involving semistructured in-person individual interviews, in which we asked about perspectives on communication about stopping cancer screening, with 28 primary care clinicians and 40 community-dwelling older adults, respectively. RESULTS: We identified three major themes: (a) Consensus among primary care clinicians and older adults regarding communication around stopping cancer screening. Both groups considered discussing the benefits/risks of cancer screening and involving patients in the decision as important and mentioned framing screening cessation as shift in health priorities. (b) Differences in perceived reactions to stopping cancer screening. Primary care clinicians were concerned about patient reaction to stopping cancer screening, whereas older adults reported no negative reactions in the context of a trusting relationship. (c) Differences in views around whether to discuss life expectancy in the context of stopping cancer screening. Clinicians rarely discussed life expectancy in this context, whereas older adults were divided on whether life expectancy should be discussed. DISCUSSION AND IMPLICATIONS: Given the heterogeneity in older adults' preferences, it is important to assess whether patients want to discuss life expectancy when discussing stopping cancer screening, though use of the specific term "life expectancy" may not be necessary. Instead, focusing discussion on the benefits/risks of cancer screening and mentioning shift in health priorities are acceptable communication strategies for both clinicians and older adults.

Novel first-year curriculum in high-value care.

BACKGROUND: Most medical schools teach a high-value care (HVC) curriculum during the clinical years. Currently, there lacks any research demonstrating the effectiveness of the HVC curriculum taught to students in their first year of medical school. METHODS: A total of 118 of 466 first-year medical students at Johns Hopkins School of Medicine between 2013 and 2017 enrolled on an HVC course that provided the initial framework necessary to practice cost-conscious clinical medicine. The curriculum was evaluated by comparing the performance of students who completed the course with the performance of students without training, through a standardised patient encounter on musculoskeletal back pain and how to approach a patient's request for imaging. Chi-square testing was used to assess the impact of the course on performance in a standardised patient encounter. RESULTS: Students enrolled on the HVC course were more likely, compared with their counterparts, to assure patients that back pain was a simple strain (48 versus 31%), and were less likely to ask for preceptor help on how to proceed with management (11 versus 29%) [χ2 (4, n = 466) = 14.28, p = 0.007]. There were no differences between students enrolled on the HVC course who had not yet received training compared with students taking another elective [χ2 (4, n = 385) = 8.73, p = 0.07]. DISCUSSION: This is the first study to assess the effectiveness of an HVC curriculum for first-year medical students, and it demonstrates promise that they can acquire some skill sets necessary for cost-effective practice in a simulated clinical setting. This is the first study to assess the effectiveness of an HVC curriculum for first-year medical students, and it demonstrates promise that they can acquire some skill sets necessary for cost-effective practice.

Current and Optimal Training in High-Value Care in the Internal Medicine Clerkship: A National Curricular Needs Assessment.

PURPOSE: The clinical skills needed to practice high-value care (HVC) are core to all medical disciplines. Medical students form practice habits early, and HVC instruction is essential to this formation. The purpose of this study was to describe the state of HVC instruction and assessment in internal medicine clerkships and identify needs for additional curricula. METHOD: In 2014, the Clerkship Directors in Internal Medicine conducted its annual survey of 121 U.S. and Canadian medical schools. The authors evaluated a subset of questions from that survey asking clerkship directors about the perceived importance of HVC instruction, type and amount of formal instruction and assessment, achievement of student competence, prioritization of topics, and barriers to curriculum implementation. Descriptive statistics were used to summarize responses, and chi-square tests were used to examine associations between response categories. RESULTS: The overall response rate was 77.7% (94/121). The majority (85; 91.4%) agreed that medical schools have a responsibility to teach about HVC across all phases of the curriculum. Of respondents, 31 (32.9%) reported their curricula as having some formal instruction on HVC, and 66 (70.2%) felt the amount was inadequate. Highest-priority topics for inclusion included overuse of diagnostic tests and treatments, defining value and its application to clinical reasoning, and balancing benefit and harm. Only 11 (17.8%) assessed students' competence in HVC. CONCLUSIONS: Internal medicine clerkship directors reported that HVC is insufficiently taught and assessed in medical school, despite relevance to practice. Developing generalizable curricular materials, faculty development, and dedicated curricular time may enhance HVC education.

Medical students' perceptions of low-value care.

BACKGROUND: Medical schools are creating high-value care (HVC) curricula in undergraduate medical education; however, there are few studies identifying what are the most pressing low-value care (LVC) practices, as observed by students. This study is a multicentre, targeted needs assessment comparing medical student perceptions of LVC at four institutions, after completion of their internal medicine clerkship, to identify areas of focus for future HVC curriculum development. METHODS: A total of 307 medical students at four institutions participated in a voluntary survey and identified instances of LVC during the internal medicine clerkship. Responses were organised into seven LVC categories and analysed using chi-square testing to determine response variation by institution. RESULTS: The four most common themes identified by all institutions were testing for low prevalence disease processes (44%), excessive daily labwork (44%), errors in clinical judgement (26%) and testing that would not change management (21%). Responses did not vary by institution, with the exception that one school identified fewer instances of ordering excessive labwork compared with the other institutions (28 versus 46-54%; p = 0.05). There are few studies identifying what are the most pressing low-value care practices DISCUSSION: This is the first multi-institutional targeted needs assessment to demonstrate similarities in perceptions of LVC by medical students. Despite differences in geographic location and private and public affiliations, the top four categories remained consistent. These findings can provide a framework for educational objectives that address these issues in an HVC curriculum. Response variation, as seen with institution 2, offers opportunities for schools to personalise their HVC curriculum.

Teaching medical students about cost-effectiveness.

BACKGROUND: Rising and burdensome health care costs have driven interest in the practice of high-value care (HVC) and have inspired calls for increased HVC training across all levels of medical education, including among undergraduate medical students. CONTEXT: Classroom-based HVC curricula targeted to medical students have not been previously described in the medical literature. INNOVATION: We developed and evaluated a workshop comprising a lecture, a small-group exercise and a group discussion to instruct medical students on interpreting cost-effectiveness analyses (CEA), applying CEA to patient care and discussing the cost of care with patients. From January 2014 to September 2015 the workshop was administered to five cohorts, 120 students in total, in the internal medicine clerkships at two US medical schools. Pre- and post-intervention confidence in various domains was assessed with a Likert-type scale ranging from 1 to 4. The overall response rate was 87.9 per cent. The proportion of students reporting high confidence scores (3 or 4) rose significantly (p < 0.01) in each domain: from 16.2 to 76.9 per cent for calculating an incremental cost-effectiveness ratio (ICER); from 16.0 to 79.6 per cent for interpreting quality-adjusted life-years (QALYs); from 8.7 to 71.3 per cent for using CEA in patient management; and from 15.3 to 71.4 per cent for discussing costs with patients. Students rated the overall quality of the course as 3.82 out of 5. Rising and burdensome health care costs have driven interest in the practice of high-value care IMPLICATIONS: Our experience of developing, evaluating and refining an HVC course targeted at medical students taught us that such a course is needed, can be educational and can be well-received. Future research is needed to assess the effects of curricula on clinical practice.

Evaluation of a course to prepare international students for the United States Medical Licensing Examination step 2 clinical skills exam.

PURPOSE: United States (US) and Canadian citizens attending medical school abroad often desire to return to the US for residency, and therefore must pass US licensing exams. We describe a 2-day United States Medical Licensing Examination (USMLE) step 2 clinical skills (CS) preparation course for students in the Technion American Medical School program (Haifa, Israel) between 2012 and 2016. METHODS: Students completed pre- and post-course questionnaires. The paired t-test was used to measure students' perceptions of knowledge, preparation, confidence, and competence in CS pre- and post-course. To test for differences by gender or country of birth, analysis of variance was used. We compared USMLE step 2 CS pass rates between the 5 years prior to the course and the 5 years during which the course was offered. RESULTS: Ninety students took the course between 2012 and 2016. Course evaluations began in 2013. Seventy-three students agreed to participate in the evaluation, and 64 completed the pre- and post-course surveys. Of the 64 students, 58% were US-born and 53% were male. Students reported statistically significant improvements in confidence and competence in all areas. No differences were found by gender or country of origin. The average pass rate for the 5 years prior to the course was 82%, and the average pass rate for the 5 years of the course was 89%. CONCLUSION: A CS course delivered at an international medical school may help to close the gap between the pass rates of US and international medical graduates on a high-stakes licensing exam. More experience is needed to determine if this model is replicable.

A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training.

BACKGROUND: Physicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill. METHODS: One hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE). RESULTS: Interns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing 'a' from 'v' waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE. CONCLUSIONS: A comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.

Prognosis communication with older patients with multimorbidity: Assessment after an educational intervention.

This study aimed to assess how internal medicine residents incorporated prognosis to inform clinical decisions and communicated prognosis in primary care visits with older patients with multimorbidity after an educational intervention, and resident and patient perspectives regarding these visits. Assessment used mixed-methods. The authors assessed the frequency and content of prognosis discussions through residents' self-report and qualitative content analysis of audio-recorded clinic visits. The authors assessed the residents' perceived effect of incorporating prognosis on patient care and patient relationship through a resident survey. The authors assessed the patients' perceived quality of communication and trust in physicians through a patient survey. The study included 21 clinic visits that involved 12 first-year residents and 21 patients. Residents reported incorporating patients' prognoses to inform clinical decisions in 13/21 visits and perceived positive effects on patient care (in 11/13 visits) and patient relationship (in 7/13 visits). Prognosis communication occurred in 9/21 visits by self-report, but only in six of these nine visits by content analysis of audio-recordings. Patient ratings were high regardless of whether or not prognosis was communicated. In summary, after training, residents often incorporated patients' prognoses to inform clinical decisions, but sometimes did so without communicating prognosis to the patients. Residents and patients reported positive perceptions regarding the visits.

Primary Care Practitioners' Views on Incorporating Long-term Prognosis in the Care of Older Adults.

IMPORTANCE: Clinical practice recommendations increasingly advocate that older patients' life expectancy be considered to inform a number of clinical decisions. It is not clear how primary care practitioners approach these recommendations in their clinical practice. OBJECTIVE: To explore the range of perspectives from primary care practitioners on long-term prognosis, defined as prognosis regarding life expectancy in the range of years, in their care of older adults. DESIGN, SETTING, AND PARTICIPANTS: A qualitative, semistructured interview study was conducted in a large group practice with multiple sites in rural, urban, and suburban settings. Twenty-eight primary care practitioners were interviewed; 20 of these participants (71%) reported that at least 25% of their patient panel was older adults. The audiorecorded discussions were transcribed and analyzed, using qualitative content analysis to identify major themes and subthemes. The study was conducted between January 30 and May 13, 2015. Data analysis was performed between June 10 and September 1, 2015. MAIN OUTCOMES AND MEASURES: The constant comparative approach was used to qualitatively analyze the content of the transcripts. RESULTS: Of the 28 participants, 16 were women and 21 were white; the mean (SD) age was 46.2 (10.3) years. Twenty-six were physicians and 2 were nurse practitioners. Their time since completing clinical training was 16.0 (11.4) years. These primary care practitioners reported considering life expectancy, often in the range of 5 to 10 years, in several clinical scenarios in the care of older adults, but balanced the prognosis consideration against various other factors in decision making. In particular, patient age was found to modulate how prognosis affects the primary care practitioners' decision making, with significant reluctance among them to cease preventive care that has a long lag time to achieve benefit in younger patients despite limited life expectancy. The participants assessed life expectancy based on clinical experience rather than using validated tools and varied widely in their prognostication time frame, from 2 years to 30 years. Participants often considered prognosis without explicitly discussing it with patients and disagreed on whether and when long-term prognosis needs to be specifically discussed. The participants identified numerous barriers to incorporating prognosis in the care of older adults including uncertainty in predicting prognosis, difficulty in discussing prognosis, and concern about patient reactions. CONCLUSIONS AND RELEVANCE: Despite clinical recommendations to increasingly incorporate patients' long-term prognosis in clinical decisions, primary care practitioners encounter several barriers and ambiguities in the implementation of these recommendations.

Incorporating prognosis in the care of older adults with multimorbidity: description and evaluation of a novel curriculum.

BACKGROUND: Prognosis is a critical consideration in caring for older adults with multiple chronic conditions, or "multimorbidity". Clinicians are not adequately trained in this area. We describe an innovative curriculum that teaches internal medicine residents how to incorporate prognosis in the care of older adults with multimorbidity. METHODS: The curriculum includes three small-group sessions and a clinical exercise; it focuses on the assessment, communication, and application of prognosis to inform clinical decisions. The curriculum was implemented with 20 first-year residents at one university-based residency (intervention group). Fifty-two first-year residents from a separate residency affiliated with the same university served as controls. Evaluation included three components. A survey assessed acceptability. A pre/post survey assessed attitude, knowledge, and self-reported skills (Impact survey). Comparison of baseline and follow-up results used paired t-test and McNemar test; comparison of inter-group differences used t-test and Fisher's exact test. A retrospective, blinded pre/post chart review assessed documentation behavior; abstracted outcomes were analyzed using Fisher's exact test. RESULTS: The curriculum was highly rated (4.5 on 5-point scale). Eighteen intervention group residents (90 %) and 29 control group residents (56 %) responded to the Impact survey. At baseline, there were no significant inter-group differences in any of the responses. The intervention group improved significantly in prognosis communication skills (5.2 to 6.6 on 9-point scale, p < 0.001), usage of evidence-based prognostic tools (1/18 to 14/18 responses, p < 0.001), and prognostic accuracy (1/18 to 9/18 responses, p = 0.005). These responses were significantly different from the control group at follow-up. Of 71 charts reviewed in each group, prognosis documentation in the intervention group increased from 1/25 charts (4 %) at baseline to 8/46 charts (17 %) at follow-up (p = 0.15). No prognosis documentation was identified in the control group at either time point. Inter-group difference was significant at follow-up (p = 0.006). CONCLUSION: We developed and implemented a novel prognosis curriculum that had significant short-term impact on the residents' knowledge and communication skills as compared to a control group. This innovative curriculum addresses an important educational gap in incorporating prognosis in the care of older adults with multimorbidity.

INTRODUCTION OF SIMULATION BASED MEDICAL EDUCATION AT ADDIS ABABA UNIVERSITY COLLEGE OF HEALTH SCIENCES: EXPERIENCE AND CHALLENGE.

BACKGROUND: As one of the countries in Sub-Saharan Africa with a low physician to population ratio, Ethiopia has sought to mitigate the problem by increasing the number of students enrolling in the existing medical schools. This increase in enrolment was not accompanied by expansion of clinical training venues, which has resulted in less patient contact time for each student. As part of the solution to fill the gap simulation-based teaching was introduced. OBJECTIVE: To describe the process of introducing Simulation based medical education (SBME) at Addis Ababa University College of Health Sciences, school of medicine. METHODS: Two rounds of intensive training was given by John Hopkins in collaboration with Medical Education partner Initiative (MEPI). to the core clinical educators to introduce them the six-step model of curriculum development for medical education and standardized patient (SP) techniques with the ultimate aim of introducing SPs in the teaching and learning process for medical students. The training included didactic and workshop elements, with group work and created complete educational modules. Each pre and post course assessment of experience and attitude were surveyed. Data was analyzed in aggregate using paired t -test to compare pre and post course means. RESULTS: There were total of 22 faculty members participated in the first group ,the majority of whom had no prior training in curriculum development or SBME and were skeptical of the value of SBME, as evidenced in their survey responses. (3.42/5 in Likert scale 1 = least 5 = most) at the end of the course the participant were comfortable with the concept of curriculum development the rating increased to 4.45/5 (P < 0.0001) and they embraced more favorable attitudes regarding the feasibility and desirability of simulation with Likert Scale 4.01/5 to 4.51 (P < 0.0001). In the second course, there were 16 participant and the majority had no prior experience with simulation and/or SP encounters. Their Baseline attitudes among participants in the second course were more favourable than in the first course, with a mean precourse Likert score of 4.24/5. Mean post course score was 4.43/5 (p = 0.1003), which did not represent a significant increase. The largest pre/post increases were seen for questions regarding accuracy of SP portrayal of specific clinical conditions (3.93 to 4.43, p = 0.0011), and enjoyability of incorporating SP activities into curricula (4.33 to 4.73, p = 0. 0281). After the course, the faculty remained particularly sceptical of the role of SPs in grading students (3.43/5). Both courses were well received, with 95% reporting they learned what they had hoped to learn. CONCLUSION: Training courses at CHS were successful for generating enthusiasm about simulation, and improving participant attitudes regarding the usefulness and feasibility of this educational method.