Ensuring the Availability of Clinical Clerkships at U.S. Hospitals: A Tale of 2 States.

U.S. medical schools are facing growing competition for limited clinical training resources, notably slots for the core clerkships that students most often complete in the third year of their undergraduate medical education. In particular, medical schools in the Caribbean (often referred to as offshore medical schools) are buying clerkship slots at U.S. hospitals for their students, most of whom will be U.S. citizen international medical graduates. For hospitals, especially those that are financially stressed, these payments are an attractive source of revenue. Yet, this practice has put pressure on U.S. medical schools to provide similar remuneration for clerkship slots for their students or to find new clinical training sites.In this Perspective, the authors outline the scope of the challenge facing U.S. medical schools and the U.S. medical education system. They outline legislative strategies implemented in 2 states (New York and Texas) to address this issue and propose the passage of similar legislation in other states to ensure that students at U.S. medical schools can access the clerkships they need to obtain the requisite clinical experience before entering residency. Such legislation would preserve the availability of clerkships for U.S. medical students and the educational quality of these clinical training experiences and, therefore, preserve the quantity and quality of the future physician workforce in the United States.

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.

Don't spend, eat less, save more: Responses to the financial stress experienced by nursing students during unpaid clinical placements.

Using an online survey, this study explored the impact of participation in unpaid clinical placements on the financial wellbeing of 160 nursing students attending an Australian university. The research found that the majority of respondents struggle financially during clinical placements, yet are financially adequate or secure outside of semester or during normal periods of study. Increased transport costs and loss of income are the most significant financial stressors during this time, with additional meals, work-appropriate clothing, purchasing additional resources and materials, and childcare costs other causes of financial stress. Most students used savings, budgeting, borrowing, and changed expenditure patterns to cope with the financial impact of unpaid placement. These findings have important implications for the ability of students to successfully complete their nursing degree and draw into question the equity of unpaid clinical placements as a formal degree requirement. However, while participation in unpaid clinical placements can impact financial well-being in the short term, participation does have the potential to increase the financial resilience of students over time, as students learn and grow from these experiences. To achieve this, however, greater attention must be placed on the financial support and personal finance education available for nursing students.

Dundee's Longitudinal Integrated Clerkship: drivers, implementation and early evaluation.

Dundee University School of Medicine established a pilot for a 40 week long comprehensive Longitudinal Integrated Clerkship (LIC) in 2016. Ten places for year 4 students are available which are shared between two regions of Scotland which are largely rural areas by UK definitions. This paper describes the drivers for the pilot, its implementation and early evaluation. For the evaluation, data were collected using focus groups and semi-structured interviews from the first cohort of seven students, four health service employed staff (two with leadership roles and two with regional student facing roles), 21 General Practitioner tutors, and from reflective audio-diaries kept by all students. Analysis was thematic, the themes being identified from the data. Summative assessment data were collated. Students reported positive learning experiences though access to secondary care learning linked to their patients was sometimes problematic. GP tutors were positive and enthusiastic about the programme and could see the potential benefits on recruitment to GP careers. Pre-existing workload pressures were a challenge. Summative assessment results were encouraging. The Dundee LIC is successful in delivering Dundee's year 4 curriculum. Ongoing development has been focused on improving awareness of the programme in secondary care services.

Economic evaluation of simulated and traditional clinical placements in occupational therapy education.

INTRODUCTION: This economic evaluation complements results of the randomised controlled trial that established non-inferiority of the learning outcomes of a one-week simulated clinical placement (SCP) in occupational therapy qualifying degrees in comparison to an equivalent traditional clinical placement (TCP). This companion study presents detailed cost analyses of two placement alternatives and a cost-benefit study to assess the value for money of SCP. An economic evaluation of simulated versus traditional placements has not previously been conducted in Australia. METHODS: Nine SCP/TCP rounds were conducted by six Australian universities. Costs were collected using study-specific instruments. Public health sector costs were sourced from available literature. Willingness-to-pay for SCP/TCP was estimated using both a Discrete Choice Experiment and a Contingent Valuation method. These methods were employed to assess a comparative 'value' of SCP/TCP from the perspective of heads of occupational therapy departments (N = 28), who were asked to put a monetary value on the broader range of benefits associated with SCP/TCP. RESULTS: From the universities' perspective the average cost per student ranged from AUD$460 to AUD$1511 for simulated and AUD$144 to AUD$1112 for traditional placement. From the health care sector perspective, the difference in costs favoured simulated placements for four implementations and traditional placements for five. In the Discrete Choice Experiment respondents preferred traditional rather than simulated placement and would pay additional AUD$533. The estimated monetary value of simulated placements from a contingent valuation ranged from AUD$200 to AUD$1600. CONCLUSIONS: For universities that procure TCPs predominately at public health care facilities and sustain high administrative overheads, the SCP program could be a cost-saving alternative. From a broader value-for-money perspective, respondents favoured TCP over SCP, yet placed importance on placement availability and opportunity to demonstrate competence for students during the placement. Results should be interpreted with caution and further research with larger sample sizes is required.

The Future of Clinical Education: Opportunities and Challenges from Allied Health Deans' Perspective.

ISSUE: There is limited information and consensus on the future of clinical education and the key factors impacting allied health (AH) clinical training. AH deans identified both opportunities and challenges impacting clinical education based on a proposed educational model. METHODS: From July 2013 to March 2014, 61 deans whose institutions were 2013 members of the Association of Schools of Allied Health Professions (ASAHP) participated in a three-round Delphi survey. Agreement on the relative importance of and the ability to impact the key factors was analyzed. Impact was evaluated for three groups: individual, collective, and both individual and collective deans. AH deans' responses were summarized and refined; individual items were accepted or rerated until agreement was achieved or study conclusion. RESULTS: Based on the deans' ratings of importance and impact, 159 key factors within 13 clinical education categories emerged as important for the future of clinical education. Agreement was achieved on 107 opportunities and 52 challenges. CONCLUSIONS: The Delphi technique generated new information where little existed specific to AH deans' perspectives on AH clinical education. This research supports the Key Factors Impacting Allied Health Clinical Education conceptual model proposed earlier and provides a foundation for AH deans to evaluate opportunities and challenges impacting AH clinical education and to design action plans based on this research.

"I got it on Ebay!": cost-effective approach to surgical skills laboratories.

BACKGROUND: Surgical education is witnessing a surge in the use of simulation. However, implementation of simulation is often cost-prohibitive. Online shopping offers a low budget alternative. The aim of this study was to implement cost-effective skills laboratories and analyze online versus manufacturers' prices to evaluate for savings. MATERIALS AND METHODS: Four skills laboratories were designed for the surgery clerkship from July 2014 to June 2015. Skills laboratories were implemented using hand-built simulation and instruments purchased online. Trademarked simulation was priced online and instruments priced from a manufacturer. Costs were compiled, and a descriptive cost analysis of online and manufacturers' prices was performed. Learners rated their level of satisfaction for all educational activities, and levels of satisfaction were compared. RESULTS: A total of 119 third-year medical students participated. Supply lists and costs were compiled for each laboratory. A descriptive cost analysis of online and manufacturers' prices showed online prices were substantially lower than manufacturers, with a per laboratory savings of: $1779.26 (suturing), $1752.52 (chest tube), $2448.52 (anastomosis), and $1891.64 (laparoscopic), resulting in a year 1 savings of $47,285. Mean student satisfaction scores for the skills laboratories were 4.32, with statistical significance compared to live lectures at 2.96 (P < 0.05) and small group activities at 3.67 (P < 0.05). CONCLUSIONS: A cost-effective approach for implementation of skills laboratories showed substantial savings. By using hand-built simulation boxes and online resources to purchase surgical equipment, surgical educators overcome financial obstacles limiting the use of simulation and provide learning opportunities that medical students perceive as beneficial.

Offshore Medical Schools Are Buying Clinical Clerkships in U.S. Hospitals: The Problem and Potential Solutions.

U.S. medical education faces a threat from for-profit Caribbean medical schools which purchase clinical rotation slots for their students at U.S. hospitals. These offshore schools are monetizing a system that was previously characterized as a duty-the duty of the current generation of physicians to educate their successors. Offshore schools purchase clinical rotation slots using funds largely derived from federally subsidized student loans. This leads to pressure on U.S. schools to pay for clinical clerkships and is forcing some of them to find new clinical training sites.For-profit Caribbean schools largely escape the type of scrutiny that U.S. schools face from U.S. national accreditation organizations. They also enroll large classes of students with lower undergraduate GPAs and Medical College Admission Test scores than those of students at U.S. medical schools; their students take and pass Step 1 of the United States Medical Licensing Examination at a substantially lower rate than that of U.S. medical students; and their students match for residencies at a fraction of the rate of U.S. medical school graduates.Among the potential solutions proposed by the authors are passing laws to hold for-profit Caribbean schools to standards for board passage rates, placing restrictions on federal student loans, monitoring attrition rates, and denying offshore schools access to U.S. clinical training sites unless they meet accreditation standards equivalent to those of U.S. medical schools.

Development and assessment of a pediatric emergency medicine simulation and skills rotation: meeting the demands of a large pediatric clerkship.

OBJECTIVE: To implement a curriculum using simulation and skills training to augment a Pediatric Emergency Medicine (PEM) rotation within a pediatric clerkship. BACKGROUND: PEM faculty are often challenged with a high learner to teacher ratio in a chaotic clinical setting. This challenge was heightened when our pediatric clerkship's traditional 1-week PEM rotation (consisting of 4 students completing four 8-hour ED shifts/week) expanded to 8 students every 2 weeks. We sought to meet this challenge by integrating simulation-based education into the rotation. METHODS: Clerkship students from March to June 2012 completed our traditional rotation. Students between July and October 2012 completed the new PEM-SIM curriculum with 19 hours ED shifts/week and 16 hours/week of simulation/skills training. Pre/post-tests evaluated 1) medical management/procedural comfort (five-point Likert scale); and 2) PEM knowledge (15 multiple-choice questions). RESULTS: One hundred and nine students completed the study (48 traditional, 61 PEM-SIM). Improvement in comfort was significantly higher for the PEM-SIM group than the traditional group for 6 of 8 (75%) medical management items (p<0.05) and 3 of 7 (43%) procedures, including fracture splinting, lumbar puncture, and abscess incision/drainage (p<0.05). PEM-SIM students had significantly more improvement in mean knowledge compared to the traditional group (p<0.001). CONCLUSIONS: We have successfully integrated 16 hours/week of faculty-facilitated simulation-based education into a PEM rotation within our clerkship. This curriculum is beneficial in clinical settings with high learner to teacher ratios and when patient care experiences alone are insufficient for all students to meet rotation objectives.

Do we pay our community preceptors? Results from a CERA clerkship directors' survey.

BACKGROUND AND OBJECTIVES: Family medicine clerkships depend heavily on community-based family physician preceptors to teach medical students. These preceptors have traditionally been unpaid, but in recent years some clerkships have started to pay preceptors. This study determines trends in the number and geographic region of programs that pay their community preceptors, identifies reasons programs pay or do not pay, and investigates perceived advantages and disadvantages of payment. METHODS: We conducted a cross-sectional, electronic survey of 134 family medicine clerkship directors at allopathic US medical schools. RESULTS: The response rate was 62% (83/132 clerkship directors). Nineteen of these (23%) currently pay community preceptors, 11 of whom are located in either New England or the South Atlantic region. Sixty-three percent of programs who pay report that their community preceptors are also paid for teaching other learners, compared to 32% of those programs who do not pay. Paying respondents displayed more positive attitudes toward paying community preceptors, though a majority of non-paying respondents indicated they would pay if they had the financial resources. CONCLUSIONS: The majority of clerkships do not pay their community preceptors to teach medical students, but competition from other learners may drive more medical schools to consider payment to help with preceptor recruitment and retention. Medical schools located in regions where there is competition for community preceptors from other medical and non-medical schools may need to consider paying preceptors as part of recruitment and retention efforts.

Physician assistant program directors' attitudes, practices, and plans regarding financial compensation to clinical sites.

PURPOSE: Some physician assistant (PA) program directors believe paying clinicians and administrators for clinical sites is fair and necessary, while others regard such practices as undermining traditional altruistic motivations for precepting. The purpose of this study was to assess PA program directors' attitudes on this topic and describe current practices and future plans regarding compensation to clinical sites. METHODS: A cross-sectional descriptive survey was sent to directors of PA programs with continuing and provisional accreditation status in 2012. RESULTS: Seventy-eight (48%) of the 163 program directors surveyed participated in the study. Although most respondents indicated that paying for clinical sites was not an acceptable practice, almost half believed it would. be acceptable if there were standards and definitions for equitable and fair payments. Despite the finding that most respondents' programs do not pay for clinical sites, nearly half anticipate their programs will be paying for clinical sites in three years, and the cost of such payments will be passed on to students in the form of increased tuition or separate fees. Many indicated a concern that paying for clinical sites may result in monopolies and bidding wars. CONCLUSION: While paying clinical sites may be effective for recruitment and retention of clinical sites, most program directors are concerned about the expanded role economics will have for their program. Agreed-upon standards and definitions for fair and equitable payment practices may alleviate some of these concerns. However, the potential effects on students and programs identified in this study necessitate additional research to fully assess what implications this may have on PA education and the profession.

Assessing learning outcomes and cost effectiveness of an online sleep curriculum for medical students.

OBJECTIVE: Sleep disorders are highly prevalent across all age groups but often remain undiagnosed and untreated, resulting in significant health consequences. To overcome an inadequacy of available curricula and learner and instructor time constraints, this study sought to determine if an online sleep medicine curriculum would achieve equivalent learner outcomes when compared with traditional, classroom-based, face-to-face instruction at equivalent costs. METHOD: Medical students rotating on a required clinical clerkship received instruction in 4 core clinical sleep-medicine competency domains in 1 of 2 delivery formats: a single 2.5-hour face-to-face workshop or 4 asynchronous e-learning modules. Immediate learning outcomes were assessed in a subsequent clerkship using a multiple-choice examination and standardized patient station, with long-term outcomes assessed through analysis of students' patient write-ups for inclusion of sleep complaints and diagnoses before and after the intervention. Instructional costs by delivery format were tracked. Descriptive and inferential statistical analyses compared learning outcomes and costs by instructional delivery method (face-to-face versus e-learning). RESULTS: Face-to-face learners, compared with online learners, were more satisfied with instruction. Learning outcomes (i.e., multiple-choice examination, standardized patient encounter, patient write-up), as measured by short-term and long-term assessments, were roughly equivalent. Design, delivery, and learner-assessment costs by format were equivalent at the end of 1 year, due to higher ongoing teaching costs associated with face-to-face learning offsetting online development and delivery costs. CONCLUSIONS: Because short-term and long-term learner performance outcomes were roughly equivalent, based on delivery method, the cost effectiveness of online learning is an economically and educationally viable instruction platform for clinical clerkships.

Health, sustainability and student travel.

A survey of 246 pre-registration nursing students in a University in the South West of England was carried out to explore the impact of course related travel on the student experience. Results from the survey indicated that students' main mode of transport to practice placements was by car which reflects the rural nature of the South West and the relative paucity of public transport. Long distances that many students travel to their study centre and to placements, and the concurrent financial strain that this creates, impacted negatively on the student experience. Students recognised the need to travel to a place of study and clinical placements and suggestions of minimising the negative impact of travel were offered. These included the increased use of electronic delivery of lectures, attendance at local university premises, the provision of shared transport to placements and placements closer to the student's home. Few students, however, considered the environmental impact of travel. Higher Education Institutions need to address issues of sustainability through promoting student wellbeing and taking steps to reduce greenhouse gas emissions. It is therefore important that student awareness of sustainability related issues is increased as well as focusing on reducing the environmental impact through organisational change.

The use of a lightly preserved cadaver and full thickness pig skin to teach technical skills on the surgery clerkship--a response to the economic pressures facing academic medicine today.

BACKGROUND: In response to declining instruction in technical skills, the authors instituted a novel method to teach basic procedural skills to medical students beginning the surgery clerkship. METHODS: Sixty-three medical students participated in a skills training laboratory. The first part of the laboratory taught basic suturing skills, and the second involved a cadaver with pig skin grafted to different anatomic locations. Clinical scenarios were simulated, and students performed essential procedural skills. RESULTS: Students learned most of their suturing skills in the laboratory skills sessions, compared with the emergency room or the operating room (P = .01). Students reported that the laboratory allowed them greater opportunity to participate in the emergency room and operating room. Students also felt that the suture laboratory contributed greatly to their skills in wound closure. Finally, 90% of students had never received instruction on suturing, and only 12% had performed any procedural skills before beginning the surgery rotation. CONCLUSIONS: The laboratory described is an effective way of insuring that necessary technical skills are imparted during the surgery rotation.

Clerkship directors' characteristics, scholarship, and support: a summary of published surveys from seven medical specialties.

BACKGROUND: Clerkship directors (CDs) ensure that medical students achieve the core clinical skills needed to be effective physicians. Recently guidelines for time and support for U.S. CDs have been published by the Alliance for Clinical Education. PURPOSE: This article reviews 14 published surveys of CDs in seven specialties and assesses CDs' personal characteristics, scholarship, and support for their position. METHODS: Investigators reviewed CD surveys conducted over the last 12 years from seven different specialties. Comparisons were made of CDs demographics, departmental and school support, time allotted to the position, and publication rates. RESULTS: Department support was generally good, but school support was often felt to be lacking. The number of publications was relatively low. Time allotted for the position was lower than the 50% recommended in all specialties. CONCLUSIONS: Many CDs do not feel adequately supported by time or resources. Future studies need to more closely define what support is needed and what impact CD characteristics, scholarship, and resources have on medical student education.

How important is money as a reward for teaching?

PURPOSE: To examine the effect of increases in payment for teaching on retention of primary care faculty, and to compare those faculty members' needs and rewards for teaching with objective data on retention. METHOD: In 2006-2007, the authors compared retention rates of primary care clerkship preceptors at Harvard Medical School (1997-2006) when their stipends were raised from $600 to $900 (in 2003) and to $2,500 (in 2004), and when faculty received payment directly versus indirectly. A survey was sent to all 404 present and past living preceptors, who were asked to rank-order six factors in terms of (1) how much they needed each to continue teaching, and (2) each factor's contribution to their satisfaction with teaching. RESULTS: Retention rates varied from a high of 91% in 2006 to a low of 69% in 2000. Faculty were 2.66 times more likely (P < .0001) to return to teach in the highest pay period than the lowest, and faculty receiving direct payment were more likely to continue teaching than those receiving it indirectly. Only 8% of the 170 responding faculty ranked receiving the stipend as the most important factor in their continuing to teach; no one ranked it first as a source of satisfaction. However, 73% ranked having a good student first as a factor in continuing to teach; 82% ranked it first as a source of satisfaction. CONCLUSION: Raising stipends was associated with increased retention, although faculty ranked stipend low in terms of what motivates them to continue teaching.