Student Perception of Case-based Teaching by Near-Peers and Faculty during the Internal Medicine Clerkship: A Noninferiority Study.

INTRODUCTION: Third-year medical students traditionally receive their didactic or small group teaching sessions from clinical faculty during clerkship rotations. Near-peer teaching is increasingly recognized as an acceptable method for teaching, however most near-peer teaching takes place during the pre-clinical curriculum. We sought to determine if fourth year medical students were noninferior to faculty in facilitating small group discussions during clerkship rotations. METHODS: Seventy-five third-year medical students participated in a small group session focused on rheumatologic diseases during their internal medicine clerkship rotation. Students were taught by fourth-year medical students who self-selected to participate as near-peer teachers at 1 clinical site (near-peers, N = 36) and by clinical faculty at another site (N = 39). At the end of the session, third-year medical students completed a survey evaluating teacher performance and effectiveness. RESULTS: There was no significant difference between the 2 groups on each of the 17 survey items assessing teacher performance, the total teaching performance score, and the teaching effectiveness rating (all P-values >.05). A mean between-group difference of 2% in favor of the near-peers indicated noninferiority of the near-peer teachers compared with faculty teachers on the total teaching performance score. An absolute difference of 14% in favor of the near-peers indicated noninferiority of the near-peer teachers compared with faculty teachers on the teaching effectiveness score. Near-peer teachers reported several benefits, including improving their own medical knowledge and skills as a future educator. DISCUSSION: Our data supports the noninferiority of the perceived performance and effectiveness of near-peer teachers compared to faculty teachers in the clerkship setting. Adding near-peer teachers to the clerkship setting is feasible and can be beneficial to all stakeholders.

Incoming Interns Perceived Preparedness for Core Entrustable Professional Activities.

INTRODUCTION: The AAMC described 13 core entrustable professional activities (EPAs) for which every graduating medical student should perform proficiently on day 1 of residency. We studied how prepared starting interns felt in the core EPAs. METHODS: Interns from a diverse health system were surveyed on how well medical school prepared them in the 13 core EPAs. Data were collected on type of medical school, participation in an acting/sub-internship (AI/SI), knowledge of EPAs, and participation in an EPA experience. RESULTS: We collected 224 surveys out of 384 (58%) interns. 61.2% attended allopathic, 14.6% attended osteopathic, and 24.2% attended international schools. 67% had not heard of EPAs. 29% had an EPA experience of which 82% were required. 80% or more felt prepared in all EPAs except orders (60.7%) and handovers (73%). Allopathic interns were significantly more likely to have heard of EPAs and participated in an EPA experience than international. Allopathic interns felt more prepared than international in oral presentations and evidence-based medicine. Interns who participated in an EPA experience felt more prepared for oral presentation and evidence-based medicine. There were small but significant differences in feeling prepared in certain EPAs and types of AI/SI taken. CONCLUSION: The majority of interns entering residency have not heard of EPAs with fewer than 1/3 of interns participating in an EPA experience. International graduates were less likely to be aware or have experience with EPAs and report being less prepared in oral presentation and evidence-based medicine compared to allopathic graduates.

Incorporation of an Interprofessional Palliative Care-Ethics Experience Into a Required Critical Care Acting Internship.

Introduction: The literature documents inadequate palliative medicine training in undergraduate and graduate medical education. As the population lives longer, many people will experience multiple chronic illnesses and the associated symptom burden. All physicians involved in clinical care of patients need to be equipped with the knowledge, attitudes, and skills necessary to provide palliative care, yet most physicians do not feel adequately prepared. We designed a curriculum to provide a meaningful palliative care-ethics (PCE) clinical experience to prepare senior medical students for future practice regardless of specialty choice. Methods: The Zucker School of Medicine at Hofstra/Northwell integrated a PCE experience into the required 4-week acting internship in critical care (AICC). Students met weekly with an interprofessional faculty member and presented clinical cases focusing on communication and/or bioethical challenges. Faculty facilitators ensured that the presentations integrated discussion of communication skills. During the final session, students shared written reflections. Students were invited to complete a satisfaction survey postrotation and 1 year after graduation. Results: The curriculum was evaluated positively by the graduating classes of 2015 (n = 28) and 2016 (n = 56) at the end of the course and 1 year postgraduation. Qualitative analysis of the class of 2018 fourth-year students' reflective writing demonstrated themes of role modeling, suffering, family, and goals of care. Discussion: It is feasible to incorporate an interprofessional PCE experience into a required AICC. Students indicated a better understanding of palliative care and, at 1 year postgraduation, reported feeling comfortable caring for patients with serious illness.

Program Director Perceptions of Proficiency in the Core Entrustable Professional Activities.

BACKGROUND: The Association of American Medical Colleges describes 13 core entrustable professional activities (EPAs) that every graduating medical student should be expected to perform proficiently on day 1 of residency, regardless of chosen specialty. Studies have shown wide variability in program director (PD) confidence in interns' abilities to perform these core EPAs. Little is known regarding comparison of United States Medical Licensing Examination (USMLE) scores with proficiency in EPAs. OBJECTIVE: We determined if PDs from a large health system felt confident in their postgraduate year 1 residents' abilities to perform the 13 core EPAs, and compared perceived EPA proficiency with USMLE Step 1 and Step 2 scores. METHODS: The PDs were asked to rate their residents' proficiency in each EPA and to provide residents' USMLE scores. Timing coincided with the reporting period for resident milestones. RESULTS: Surveys were completed on 204 of 328 residents (62%). PDs reported that 69% of residents (140 of 204) were prepared for EPA 4 (orders/prescriptions), 61% (117 of 192) for EPA 7 (form clinical questions), 68% (135 of 198) for EPA 8 (handovers), 63% (116 of 185) for EPA 11 (consent), and 38% (49 of 129) for EPA 13 (patient safety). EPA ratings and USMLE 1 and 2 were negatively correlated (r(101) = -0.23, P = .031). CONCLUSIONS: PDs felt that a significant percentage of residents were not adequately prepared in order writing, forming clinical questions, handoffs, informed consent, and promoting a culture of patient safety. We found no positive association between USMLE scores and EPA ratings.

Hypotension is uncommon in patients presenting to the emergency department with non-traumatic cardiac tamponade.

BACKGROUND: Cardiac tamponade is a life-threatening disease in which hypotension is believed to be a common finding. Prior inpatient studies have described normotensive or hypertensive cases of tamponade; however, because the data were not collected from the Emergency Department (ED), the hemodynamic spectrum may differ from those presenting to the ED. OBJECTIVES: We hypothesized that hypotension is uncommon in patients presenting to the ED with non-traumatic tamponade. METHODS: A retrospective chart review was conducted between January 2002 and December 2007 of patients presenting to our ED who were subsequently diagnosed with cardiac tamponade. RESULTS: A total of 34 patients were identified with a diagnosis of tamponade. The mean blood pressure on ED arrival was 131/79mm Hg. Upon initial presentation to the ED, 35% (n=12) of patients were hypertensive, 50% (n=17) were normotensive, and 15% (n=5) were hypotensive. Of the 5 patients who were hypotensive on ED arrival, only 2 (6% of all patients) remained hypotensive upon admission to the hospital and before a pericardiocentesis. An average of 995mL of fluid was removed from the pericardium. The chief complaint for the majority of patients in tamponade was shortness of breath (70%); 59% were tachycardic in the ED, and 72% had cardiomegaly on chest X-ray study. CONCLUSIONS: Hypotension is uncommon in patients presenting to the ED with non-traumatic cardiac tamponade. The majority of patients are normotensive or even hypertensive. Thus, the emergency physician should not exclude the diagnosis of tamponade even in light of normotension or hypertension.