Closing the Gap Between Preclinical and Clinical Training: Impact of a Transition-to-Clerkship Course on Medical Students' Clerkship Performance.

PROBLEM: Medical students typically perform worse on clinical clerkships that take place early in their training compared with those that occur later. Some institutions have developed transition-to-clerkship courses (TTCCs) to improve students' preparedness for the clinical phase of the curriculum. Yet, the impact of TTCCs on students' performance has not been evaluated. APPROACH: The authors developed and implemented a TTCC at Virginia Commonwealth University School of Medicine and measured its impact on students' clerkship performance. During the 2014-2015 academic year, they introduced a 2-week intersession TTCC. The goal was to improve students' readiness for clerkships by fostering the knowledge, skills, and attitudes required to care for patients throughout a hospitalization. The TTCC included panel discussions, skills development sessions, case-based workshops, and a 4-station standardized patient simulation. The authors assessed the feasibility of designing and implementing the TTCC and students' reactions and clerkship performance. OUTCOMES: The total direct costs were $3,500. Students reacted favorably and reported improved comfort on entering clerkships. Summative performance evaluations across clerkships were higher for those students who received the TTCC with simulation compared with those students who received the standard clerkship orientation (P < .001-.04, Cohen's d range = 0.23-0.62). This finding was particularly apparent in those clerkships that occurred earlier in the academic year. NEXT STEPS: Future plans include evaluating the impact of the TTCC on student well-being and incorporating elements of the TTCC into the preclinical curriculum.

An Internal Medicine Simulated Practical Examination for Assessment of Clinical Competency in Third-Year Medical Students.

INTRODUCTION: Achieving standardized assessment of medical student competency in patient care is a challenge. Simulation may provide unique contributions to overall assessment. We developed an Internal Medicine Standardized Simulation-Based Examination (SSBE) for the third-year clerkship to assess students' medical knowledge, diagnostic skills, and clinical management skills. We assessed convergent and test criterion validity by comparing the relationship of SSBE scores with United States Medical Licensing Examination step 2 clinical knowledge, shelf examination, eQuiz, objective structured clinical examination, ward evaluation scores, and overall clerkship grades. We hypothesize that the use of the SSBE will allow for a more reliable assessment of these competencies and add value to existing assessments. METHODS: A prospective study design was used. The SSBE consisted of a computer-based photo quiz and cases on high-fidelity simulators. Performance on the SSBE was compared with standardized examinations, clinical evaluations, and overall clerkship grades. Students completed an evaluation of the experience. RESULTS: Two hundred seven students completed the SSBE, with a mean (SD) score of 76.69 (7.78). The SSBE performance was positively related to other assessments of medical knowledge eQuiz scores (r203 = 0.33, P < 0.01), shelf examination scores (r158 = 0.53, P < 0.01), and clinical performance (ward scores) (r163 = 0.31, P < 0.01) but not to objective structured clinical examination scores. There was a positive relationship to final class grades (r163 = 0.45, P < 0.01), shelf examination (r158 = 0.52, P < 0.01) and step 2 clinical knowledge scores (r76 = 0.54, P < 0.01). Most students (93%) agreed that it was a fair examination. CONCLUSIONS: Our results provide validity evidence for the SSBE as an additional assessment tool that uses a novel approach for evaluating competency in patient care at the clerkship level.

Hysterectomy in obese patients: special considerations.

A literature search was performed to find evidence-based practices that aid in the preoperative evaluation, intraoperative techniques, and postoperative management of the obese patient requiring hysterectomy. Complications are more frequent than in normal weight patients and are more difficult to manage. Few studies provide direct evidence with which to help guide surgical decision-making and postoperative management. However, there is sufficient evidence to support that when feasible, the vaginal route is preferable in obese patients. Techniques validated for normal weight patients like antibiotic and thromboembolism prophylaxis seem effective in obese patients, and are likely even more important.

Alcohol use, injuries, and prenatal visits during three successive pregnancies among American Indian women on the Northern Plains who have children with fetal alcohol syndrome or incomplete fetal alcohol syndrome.

INTRODUCTION: The purpose of the study was to compare three sequential pregnancies of American Indian women who have children with FAS or children with incomplete FAS with women who did not have children with FAS. METHODS: Two retrospective case-control studies were conducted of Northern Plains American Indian children with fetal alcohol syndrome (FAS) (Study 1) or incomplete FAS (Study 2) in 1981-1993. Three successive pregnancies ending in live births of 43 case mothers who had children with FAS, and 35 case mothers who had children with incomplete FAS were compared to the pregnancies of 86 and 70 control mothers who did not have children with FAS, respectively, in the two studies. Prenatal records were abstracted for the index child (child with FAS or incomplete FAS) and siblings born just before and just after the index child, and comparable prenatal records for the controls. RESULTS: Compared to the controls, significantly more case mothers used alcohol before and after all three pregnancies and during pregnancy with the before sibling and the index child. Mothers who had children with FAS reduced their alcohol use during the pregnancy following the birth of the index child. All Study 1 case mothers (100%) and 60% of Study 2 case mothers used alcohol during the pregnancy with the index child compared to 20 and 9% of respective control mothers. More study 1 case mothers experienced unintentional injuries (OR 9.50) and intentional injuries during the index pregnancy (OR 9.33) than the control mothers. Most case mothers began prenatal care in the second trimester. CONCLUSIONS: Alcohol use was documented before, during and after each of the three pregnancies. Women of child-bearing age should be screened for alcohol use whenever they present for medical services. Mothers who had a child with FAS decreased their alcohol consumption with the next pregnancy, a finding that supports the importance of prenatal screening throughout pregnancy. Women who receive medical care for injuries should be screened for alcohol use and referred for appropriate treatment. Protective custody, case management and treatment services need to be readily available for women who use alcohol.

Induction of labor using a foley balloon, with and without extra-amniotic saline infusion.

OBJECTIVE: To compare transcervical Foley bulb with and without extra-amniotic saline infusion for induction of labor in patients with an unfavorable cervix. METHODS: Women who presented for induction of labor with Bishop score less than 5 were randomly assigned to receive Foley alone or Foley with extra-amniotic saline infusion for induction of labor. Primary outcome was time from start of induction to vaginal delivery. Secondary outcomes were cesarean delivery rates, incidence of chorioamnionitis, Apgar scores at 1 and 5 minutes, and adverse events. RESULTS: One hundred forty women completed the study. Time from induction to vaginal delivery was 16.58 (+/- 7.55) hours in the extra-amniotic saline infusion group compared with 21.47 (+/- 9.95) hours in the Foley group (P < .01). Chorioamnionitis occurred in 4 of 66 (6.1%) women in the extra-amniotic saline infusion group compared with 12 of 74 (16.2%) women in the Foley group (P = .067). Cesarean delivery rate was 21.2% versus 20.1% in the extra-amniotic saline infusion and Foley groups, respectively (P = 1.0). Median 1-minute and 5-minute Apgar scores were 9 in both groups. Adverse events were rare and unrelated to method of induction. CONCLUSION: Induction of labor by using Foley with extra-amniotic saline infusion results in shorter induction-to-vaginal-delivery time than Foley alone, without affecting cesarean delivery rates. LEVEL OF EVIDENCE: II-I

Characteristics of children who have full or incomplete fetal alcohol syndrome.

OBJECTIVE: To describe the clinical features and hospitalization rates of American Indian children with full or incomplete fetal alcohol syndrome (FAS). STUDY DESIGN: Two retrospective case-control studies were conducted of Northern Plains American Indian children with presumed FAS identified from 1981 to 1993 by using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), code 760.71. Children who had full or incomplete FAS were compared with each other and with children who did not have FAS. RESULTS: Compared with the control children, the 43 children with FAS and the 35 children with incomplete FAS had more facial dysmorphology, growth deficiency, central nervous system dysfunction, and muscular problems and were hospitalized more frequently with otitis media, pneumonia, FAS, dehydration, and anemia. Case children were hospitalized more days than were control children. Case children were removed from their homes and placed in foster care more often than were control children. CONCLUSIONS: Children with full or incomplete FAS had many health, learning, and social needs. Health care providers and community programs should identify the needs of these children and offer optimal services to meet those needs.

Predicting failed trial of labor after primary cesarean delivery.

OBJECTIVE: To apply published scoring systems retrospectively to patients who had undergone a trial of labor after cesarean delivery to estimate whether there was a score at which a trial of labor should be discouraged. METHODS: Patients with 1 previous cesarean delivery who then delivered between January 1, 1998, and December 31, 1998, were studied. An investigator blinded to outcome assigned scores using 3 different scoring systems. Student t test, chi(2), analysis of variance, and receiver operating curve analysis were performed. P <.05 was significant. RESULTS: Seventy-six percent (117/153) of trial of labor patients had a vaginal birth after cesarean delivery. Successful vaginal birth after cesarean delivery patients had significantly different mean scores using all 3 scoring systems, but none of the systems accurately predicted failed trial of labor resulting in cesarean delivery. Unfavorable scores were associated with high rates of major complications. CONCLUSIONS: An unfavorable score predicting a high rate of complications and more failed trials of labor may help in counseling patients considering trial of labor. A better system to predict the success or failure of trial of labor is needed. LEVEL OF EVIDENCE: III

Characteristics of mothers who have children with fetal alcohol syndrome or some characteristics of fetal alcohol syndrome.

BACKGROUND: Health care providers can more effectively prevent fetal alcohol syndrome and prenatal alcohol exposure if they know more about mothers who have children with fetal alcohol syndrome (FAS) or some characteristics of FAS. METHODS: We conducted two retrospective case-control studies of Northern Plains Indian children with FAS and some characteristics of FAS diagnosed from 1981 to 1993 by using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), code 760.71. We compared mothers who had children with FAS or some characteristics of FAS with mothers who had children that did not have FAS. RESULTS: Compared with control mothers, 43 mothers who had children with FAS and 35 mothers who had children with some characteristics of FAS were older, had fewer prenatal visits, more pregnancies, more mental health problems, and more injuries (both total and alcohol-related). Although the prevalence of drinking was high in both case and control mothers, case mothers had more alcohol-related medical problems, drank heavily, in binges, and daily more often than control mothers. CONCLUSIONS: Women with injuries and mental health problems should be screened for substance use. Mothers of children with FAS or of some characteristics of FAS have numerous needs that must be addressed to prevent future prenatal alcohol exposure.