Entice With Procedures, Inspire With Primary Care: A Preclerkship Pipeline Course.

BACKGROUND AND OBJECTIVES: The growing demand for primary care clinicians in the United States continues to outstrip their dwindling supply. Many allopathic medical schools, including Stanford University School of Medicine, are not adequately meeting this shortage. We sought to develop a preclerkship elective to increase the visibility and desirability of primary care at our institution. METHODS: A novel 9-week preclerkship elective titled "Primary Care Defined: Perspectives and Procedures," was designed as a series of procedural workshops followed by interactive sessions with local primary care clinicians. A total of 36 medical and physician assistant students were enrolled. We administered a questionnaire pre- and postcourse to evaluate the impact of the elective on learner interest and attitudes toward primary care. RESULTS: Twenty-four enrolled and 10 nonenrolled learners completed the questionnaire both pre- and postcourse. A one-way analysis of covariance controlling for gender, program (medical doctor versus physician assistant), and precourse responses demonstrated that enrollees had a significantly increased interest in primary care compared to nonenrollees after the course (F 1,32=9.22, P=.005). Enrollees also more positively rated their attitudes toward compensation, scope of practice, and job fulfillment than nonenrollees. Both groups had high levels of agreement on statements concerning patient-physician interactions and the importance of primary care to the health care system. CONCLUSION: The design and content of this elective offers a framework for other institutions looking to promote the value of primary care specialties, particularly family medicine. Creating opportunities for experiential learning and early student-faculty engagement may encourage preclerkship learners to consider a career in primary care.

Hands Off Yet All In: A Virtual Clerkship Pilot in the Ambulatory Setting During the COVID-19 Pandemic.

PROBLEM: There is a paucity of guidance regarding implementation of telemedicine curricula at the clerkship level, particularly with students actively engaged in video and telephone encounters. The COVID-19 pandemic caused rapid shifts in the delivery of medical education to clerkship-level students. This article describes the successful pilot of a direct patient care, virtual health curriculum at the clerkship level and discusses lessons learned. APPROACH: All 18 preceptors and 5 students at Stanford University School of Medicine, California, enrolled in the required 4-week family medicine clerkship in April 2020 were connected as virtual partners via a commercial video platform. The combined use of both this video program and Epic electronic health record (EHR) software as modes for teaching and patient care led to technical challenges and logistical hurdles. As part of an iterative process, clerkship leadership identified problems via preceptor and student interviews and integrated that feedback to create a model for delivering high-quality, clerkship-level clinical instruction during the COVID-19 shelter in place order. OUTCOMES: Of those who completed an evaluation, the majority of preceptors (n = 16; 89%) and students (n = 4; 100%, 1 student did not respond) expressed satisfaction with the virtual, remote teaching model conducted over 37 clinic visits. A detailed 14-step process list resulted from identifying and addressing both audio and video technical challenges and is provided for use by other institutions that wish to implement this workflow. NEXT STEPS: Future directions include assessing patient perspectives on the involvement of students in virtual visits, soliciting patient input for a more robust patient-physician-student virtual experience, and integrating a multiparty platform, when available, via the EHR to afford greater student autonomy.

Balancing Forces: Medical Students' Reflections on Professionalism Challenges and Professional Identity Formation.

BACKGROUND AND OBJECTIVES: Professionalism is essential in medical education, yet how it is embodied through medical students' lived experiences remains elusive. Little research exists on how students perceive professionalism and the barriers they encounter. This study examines attitudes toward professionalism through students' written reflections. METHODS: Family medicine clerkship students at Stanford University School of Medicine answered the following prompt: "Log a patient encounter in which you experienced a professionalism challenge or improvement opportunity." We collected and analyzed free-text responses for content and themes using a grounded theory approach. RESULTS: One hundred responses from 106 students generated a total of 168 codes; 13 themes emerged across four domains: challenging patients, interpersonal interactions, self-awareness, and health care team dynamics. The three most frequently occurring themes were interacting with emotional patients, managing expectations in the encounter, and navigating the trainee role. CONCLUSIONS: Medical students view professionalism as a balance of forces. While many students conceived of professionalism in relation to patient encounters, they also described how professionalism manifests in inner qualities as well as in health systems. Interpersonal challenges related to communication and agenda-setting are predominant. Systems challenges include not being seen as the "real doctor" and being shaped by team behaviors through the hidden curriculum. Our findings highlight salient professionalism challenges and identity conflicts for medical students and suggest potential educational strategies such as intentional coaching and role-modeling by faculty. Overall, students' reflections broaden our understanding of professional identity formation in medical training.

Granule neurons generated during development extend divergent axon collaterals to hippocampal area CA3.

Most excitatory intrahippocampal pathways are characterized by significant, highly ordered projections into the long, or septotemporal, hippocampal axis. However, the mossy fiber system, the excitatory projection by which the dentate gyrus projects to hippocampal area CA3, is considered an exception, being organized to innervate exclusively transversely oriented cortical layers of the hippocampus. In the present study, the anatomy of the rat mossy fiber system was investigated using axonal tracing techniques, with an emphasis on determining its projection pattern into the long hippocampal axis. To this end, we used dual ipsilateral retrograde tracer injections to determine whether individual granule cells extend divergent axon collaterals to septotemporally distinct levels of hippocampal area CA3. We combined this technique with the fluorescent immunohistochemical detection of 5-bromo-2'-deoxyuridine (BrdU), a marker of granule cell precursors and their progeny, to address whether the divergence of mossy fiber collaterals within area CA3 might by related to ontogenic gradients in granule cell genesis. We observed single granule neurons that had retrogradely transported both tracers, indicating that they had axon collaterals passing through or terminating within the distinct levels of area CA3 into which tracer had been injected. By using BrdU labeling, we identified divergent granule neurons that were produced during embryonic and postnatal development. We observed no adult-generated granule neurons with significantly diverging mossy fiber collaterals. However, many fewer cells were labeled with BrdU in adult-exposed animals. Because of this smaller sample, we cannot rule out the possibility that small numbers of divergent adult-generated granule cells exist. We conclude that a proportion of the hippocampal mossy fiber projection extends septotemporally divergent axon collaterals to hippocampal area CA3.