Determining Grades in the Internal Medicine Clerkship: Results of a National Survey of Clerkship Directors.

PURPOSE: Trust in and comparability of assessments are essential in clerkships in undergraduate medical education for many reasons, including ensuring competency in clinical skills and application of knowledge important for the transition to residency and throughout students' careers. The authors examined how assessments are used to determine internal medicine (IM) core clerkship grades across U.S. medical schools. METHODS: A multisection web-based survey of core IM clerkship directors at 134 U.S. medical schools with membership in the Clerkship Directors in Internal Medicine was conducted in October through November 2018. The survey included a section on assessment practices to characterize current grading scales used, who determines students' final clerkship grades, the nature/type of summative assessments, and how assessments are weighted. Respondents were asked about perceptions of the influence of the National Board of Medical Examiners (NBME) Medicine Subject Examination (MSE) on students' priorities during the clerkship. RESULTS: The response rate was 82.1% (110/134). There was considerable variability in the summative assessments and their weighting in determining final grades. The NBME MSE (91.8%), clinical performance (90.9%), professionalism (70.9%), and written notes (60.0%) were the most commonly used assessments. Clinical performance assessments and the NBME MSE accounted for the largest percentage of the total grade (on average 52.8% and 23.5%, respectively). Eighty-seven percent of respondents were concerned that students' focus on the NBME MSE performance detracted from patient care learning. CONCLUSIONS: There was considerable variability in what IM clerkships assessed and how those assessments were translated into grades. The NBME MSE was a major contributor to the final grade despite concerns about the impact on patient care learning. These findings underscore the difficulty in comparing learners across institutions and serve to advance discussions for how to improve accuracy and comparability of grading in the clinical environment.

The Clinical Reasoning Mapping Exercise (CResME): a new tool for exploring clinical reasoning.

INTRODUCTION: National organizations have identified a need for the creation of novel approaches to teach clinical reasoning throughout medical education. The aim of this project was to develop, implement and evaluate a novel clinical reasoning mapping exercise (CResME). METHODS: Participants included a convenience sample of first and second year medical students at two US medical schools: University of Central Florida (UCF) and Uniformed Services University of Health Sciences (USUHS). The authors describe the creation and implementation of the CResME. The CResME uses clinical information for multiple disease entities as nodes in different domains (history, physical exam, imaging, laboratory results, etc.), requiring learners to connect these nodes of information in an accurate and meaningful way to develop diagnostic and/or management plans in the process. RESULTS: The majority of medical students at both institutions felt that the CResME promoted their understanding of the differential diagnosis and was a valuable tool to compare and contrast elements of a differential diagnosis. Students at both institutions recommended using the CResME for future sessions. DISCUSSION: The CResME is a promising tool to foster students' clinical reasoning early in medical school. Research is needed on the implementation of the CResME as an instructional and assessment strategy for clinical reasoning throughout medical school training.

Interprofessional Education in the Internal Medicine Clerkship Post-LCME Standard Issuance: Results of a National Survey.

BACKGROUND: Several decades of work have detailed the value and goals of interprofessional education (IPE) within the health professions, defining IPE competencies and best practices. In 2013, the Liaison Committee for Medical Education (LCME) elevated IPE to a U.S. medical school accreditation standard. OBJECTIVE: To examine the status of IPE within internal medicine (IM) clerkships including perspectives, curricular content, barriers, and assessment a year after the LCME standard issuance. DESIGN: Anonymous online survey. PARTICIPANTS: IM clerkship directors from each of the Clerkship Directors in Internal Medicine's 121 U.S. and Canadian member medical schools in 2014. METHODS: In 2014, a section on IPE (18 items) was included in the Clerkship Directors in Internal Medicine annual survey of its 121 U.S. and Canadian member medical schools. MAIN MEASURES: Items (18) assessed clerkship director (CD) perspectives, status of IPE curricula in IM clerkships, and barriers to IPE implementation. Data were analyzed using descriptive statistics and qualitative analysis of free-text responses to one of the survey questions. KEY RESULTS: The overall survey response rate was 78% (94/121). The majority (88%) agreed that IPE is important to the practice of IM, and 71% believed IPE should be part of the IM clerkship. Most (76%) CDs agreed there is need for faculty development programs in IPE; 27% had such a program at their institution. Lack of curricular time, scheduling conflicts, and lack of faculty trained in IPE were the most frequently cited barriers. Twenty-nine percent had formal IPE activities within their IM clerkships, and 38% were planning to make changes. Of those with formal IPE activities, over a third (37%) did not involve student assessment. CONCLUSIONS: Since LCME standard issuance, only a minority of IM clerkships have included formal IPE activities, with lectures as the predominant method. Opportunities exist for enhancing educational methods as well as IPE faculty development.

Perioperative management of a patient with recently placed drug-eluting stents requiring urgent spinal surgery.

Patients receiving drug-eluting coronary stents (DES) require antiplatelet therapy for at least 12 months to prevent stent thrombosis (ST), a potentially calamitous event. Since interruption of antiplatelet therapy is the greatest risk factor for ST, it is imperative that the decision to discontinue these agents be based on an accurate assessment of the patient's risk for bleeding complications. Individuals who are regarded as being at a high risk are those undergoing intracranial, spinal or intraocular surgeries. These patients require alternative agents during the perioperative period to minimize both their risk of perioperative thrombosis and intraoperative hemorrhage. We report the case of a woman who required spinal surgery 3 months after she underwent placement of two drug-eluting stents. The patient's clopidogrel was stopped 5 days prior to surgery and an infusion of eptifibatide was used to "bridge" antiplatelet therapy during the perioperative period. Postoperatively, anticoagulation therapy was reinstituted using aspirin with clopidogrel. This case serves as a successful example of bridging therapy using a short acting and gycoprotein (GP) IIb/IIIa inhibitor as a means of maintaining antiplatelet therapy during the perioperative period to minimize the risk of stent thrombosis and the risk of intraoperative bleeding.

Enfermedad de Kawasaki. Aspectos a considerar / Kawasaki disease. Aspects to take into consideration

La enfermedad de Kawasaki ha sido objeto de interés por epidemiólogos, clínicos e investigadores, desde su primera descripción en 1967. Su causa no se ha podido identificar, aunque las principales hipótesis apuntan a una etiología infecciosa. Desde el punto de vista patogénico, la incapacidad de recuperar un agente infeccioso en forma consistente y las evidencias anatomopatológicas y de laboratorio de una activación de la inmunidad celular y humoral, tienden a situar la enfermedad de Kawasaki en la categoría de una enfermedad autoinmune. Uno de los principales problemas actuales es la demora en el diagnóstico, que se correlaciona con un peor pronóstico en cuanto a las principales secuelas de la enfermedad, entre las que destaca el compromiso de los vasos coronarios. En este trabajo se realiza una revisión de la enfermedad y se muestra la importancia del diagnóstico y tratamiento precoz, así como se señalan apuntes del comportamiento de esta afección en el Hospital Provincial Pediátrico Docente Eliseo Noel Caamaño, de Matanzas, en el período de 2001 al 2010.

Kawasaki disease has been studied by epidemiologists, clinicians and researchers, since it was described firstly in 1967. Its cause has not been identified, though the main hypothesis point out to an infectious etiology. From the pathogenic point of view, the incapacity of recovering an infectious agent in a consistent way and the anatomopathological and laboratory evidences of a cellular and humoral immunity activation tend to place Kawasaki disease in the category of an autoimmune disease. One of the main current problems is the diagnosis delay, correlated with a worst prognostic of the main consequences of the disease, the compromise of the coronary vases among them. In this work we make a review of the disease and show the importance of the precocious diagnostic and treatment, and also present notes of the behavior of this disease at the Teaching Provincial Pediatric Hospital Eliseo Noel Caamaño, of Matanzas, in the period from 2001 to 2010.

Validation of a provider self-report inventory for measuring patient-centered cultural sensitivity in health care using a sample of medical students.

The paper describes the construction and initial evaluation of the new Tucker-Culturally Sensitive Health Care Inventory (T-CSHCI) Provider Form, which was developed to address the shortcomings of existing similar measures. Two hundred seventeen (217) 3rd and 4th year medical students completed the T-CSHCI-Provider Form. Factor analysis was used to identify non-overlapping items. The final solution produced five factors: patient-centeredness, interpersonal skills, disrespect/disempowerment, competence, and cultural knowledge/responsiveness. The five T-CSHCI-Provider Form factors/subscales proved to be reliable and were associated with related constructs as hypothesized. This study provides initial evidence that the T-CSHCI-Provider Form measures independent dimensions of patient-centered culturally sensitive health care as perceived by medical students. Recommendations for ways in which the T-CSHCI Provider Form can be used to guide culturally sensitive health care training are provided.