Assessment of initial serum vancomycin trough concentrations and their association with initial empirical weight-based vancomycin dosing and development of nephrotoxicity in children: a multicenter retrospective study.

STUDY OBJECTIVES: To determine whether a relationship exists between initial serum vancomycin trough concentrations and initial empirical vancomycin dose, patient weight, and patient age, and to determine the risks for vancomycin-associated nephrotoxicity in pediatric patients stratified by hospital setting. DESIGN: Stepwise linear and multinomial logistic regression analysis of retrospectively collected data. SETTING: Two geographically distinct children's tertiary care medical centers. PATIENTS: A total of 316 pediatric patients without preexisting renal dysfunction who were managed outside of the neonatal intensive care unit and were treated with at least 3 doses of vancomycin for gram-positive bacterial infections and had at least one serum vancomycin trough concentration between January 1, 2008, and July 31, 2010. MEASUREMENTS AND MAIN RESULTS: Elevated vancomycin trough concentrations had no statistically significant relationship with initial empirical vancomycin dosing across all hospital settings. Serum vancomycin trough concentrations (lower than 15 mg/L or 15-20 mg/L) were not associated with increased risk of nephrotoxicity. Concomitant nephrotoxic agents, however, including loop diuretics, vasopressors, angiotensin-converting enzyme (ACE) inhibitors, and nonsteroidal antiinflammatory drugs (NSAIDs) were significantly associated with the development of nephrotoxicity in medical-surgical and intensive care patients. Based on this analysis, use of loop diuretics and vasopressors increased the odds of developing nephrotoxicity (odds ratio [OR] 42.8 [p=0.001] and 18.4 [p=0.02], respectively). Use of NSAIDS and ACE inhibitors also increased the odds of developing nephrotoxicity (OR 18.6 [p=0.02] and 4.7 [p=0.03], respectively). CONCLUSION: No significant associations were found between initial empirical weight-based vancomycin dosing or elevated serum trough concentrations and development of nephrotoxicity in children; rather, nephrotoxicity was associated with combination therapy with vancomycin and other potentially nephrotoxic agents.

Assessment of a Brief Handoff Skills Workshop for Incoming Interns: Do past Handoff Experiences Impact Training Outcomes?

BACKGROUND: Patient care handoffs are a core professional activity that incoming interns are expected to perform without direct supervision upon starting residency, yet training in medical schools is inconsistent. OBJECTIVE: To implement a brief handoff communication workshop for incoming interns and determine whether learner-level determinants were associated with differences in training outcomes. METHODS: We conducted a one-hour interactive handoff skills workshop for all incoming interns at a Midwestern academic medical center. We performed paired pre/post-intervention assessments of participants' attitudes and ability to perform representative handoff skills. The results were analyzed in aggregate and based upon participants' prior handoff experiences using Wilcoxon signed-rank test. RESULTS: Ninety-nine of 108 interns (91.7%) completed both pre- and post-surveys. There was significant improvement in all 10 attitude-based questions (P ≤ 0.014 for all) and on the skills assessment (1.07 vs 2.16 on 0-4 point scale, SD 1.25, P ≤ 0.001). Results remained significant regardless of prior training, number of handoffs observed, number of handoffs performed, medical school, or residency discipline. CONCLUSION: A brief interactive workshop for incoming interns can improve participants' confidence and performance of basic handoff skills, regardless of previous training or experience.

Alliance for clinical education perspective paper: recommendations for redesigning the "final year" of medical school.

BACKGROUND: Although medical school typically lasts 4 years, little attention has been devoted to the structure of the educational experience that takes place during the final year of medical school. SUMMARY: In this perspectives paper, we outline goals for the 4th year of medical school to facilitate a transition from undergraduate to graduate medical education. We provide recommendations for capstone courses, subinternship rotations, and specialty-specific schedules, and we conclude with recommendations to medical students and medical schools for how to use the recommendations contained in this document. CONCLUSIONS: We provide an overview of general competencies and specialty specific recommendations to serve as a foundation for medical schools to develop robust 4th-year curricula and for medical students to plan their 4th-year schedules.

Improving child and adolescent psychiatry education for medical students: an inter-organizational collaborative action plan.

OBJECTIVE: A new Child and Adolescent Psychiatry in Medical Education (CAPME) Task Force, sponsored by the Association for Directors of Medical Student Education in Psychiatry (ADMSEP), has created an inter-organizational partnership between child and adolescent psychiatry (CAP) educators and medical student educators in psychiatry. This paper outlines the task force design and strategic plan to address the long-standing dearth of CAP training for medical students. METHOD: The CAPME ADMSEP Task Force, formed in 2010, identified common challenges to teaching CAP among ADMSEP's CAPME Task Force members, utilizing focus-group discussions and a needs-assessment survey. The Task Force was organized into five major sections, with inter-organizational action plans to address identified areas of need, such as portable modules and development of benchmark CAP competencies. RESULTS/CONCLUSION: The authors predict that all new physicians, regardless of specialty, will be better trained in CAP. Increased exposure may also improve recruitment into this underserved area.

Enhancing situational interest in pediatrics.

BACKGROUND: Individual interest, something that persists regardless of the situation, and situational interest, finding personal value in an educational context, have not been studied in medical student education. OBJECTIVE: To determine if individualized case discussions enhance interest in pediatric medicine. METHODS: During the 2008/2009 academic year, 88 clerkship students participated in clinical case discussions. At orientation, students completed an Interest in Pediatrics (IIP) questionnaire, responding 1 = strongly disagree to 5 = strongly agree. Intervention and control groups were randomly assigned. The intervention group personalized cases to students' medical specialty interests. The control group discussed the case presentation. Groups met twice during the 8-week clerkships, completing a post-IIP at the end of the clerkship. RESULTS: Intervention group interest increased from pre-IIP, mean = 3.64, to post-IIP, mean = 4.22 (z = -2.994, p < 0.05, r = -0.44). On post-IIP, application of pediatric medicine increased for both groups; the intervention group was most significant from pre-IIP, mean = 1.09, to post-IIP, mean = 4.33 (z = -6.038, p < 0.05, r = -0.88). DISCUSSION: Enhanced interest in pediatrics from the intervention group indicates that creating a learning environment personally relevant to students' careers facilitates interest to learn.

Clinical experience and examination performance: is there a correlation?

CONTEXT: The Liaison Committee on Medical Education (LCME) requires there to be: '...comparable educational experiences and equivalent methods of evaluation across all alternative instructional sites within a given discipline'. It is an LCME accreditation requirement that students encounter similar numbers of patients with similar diagnoses. However, previous empirical studies have not shown a correlation between the numbers of patients seen by students and performance on multiple-choice examinations. OBJECTIVE: This study examined whether student exposure to patients with specific diagnoses predicts performance on multiple-choice examination questions pertaining to those diagnoses. METHODS: The Department of Pediatrics at the University of Nebraska Medical Center has collected patient logbooks from clerks since 1994. These contain information on patient demographics and students' roles in patient care. During week 7 of an 8-week course, students took an examination intended to help them prepare for their final examination. Logbooks and pre-examination questions were coded using standard ICD-9 codes. Data were analysed using Minitab statistical software to determine dependence between patient encounters and test scores. Subjects comprised a convenience sample of students who completed the clerkship during 1997-2000. RESULTS: Our analysis indicates that performance on a multiple-choice examination is independent of the number of patients seen. CONCLUSIONS: Our data suggest knowledge-based examination performance cannot be predicted by the volume of patients seen. Therefore, too much emphasis on examination performance in clinical courses should be carefully weighed against clinical performance to determine the successful completion of clerkships.

Teaching patient communication skills to medical students: a review of randomized controlled trials.

Tools to examine the effects of teaching interventions across a variety of studies are needed. The authors perform a meta-analysis of 24 randomized controlled trials evaluating the effects of teaching on medical students' patient communication skills. Study quality is rated using a modified Jadad score, and standardized mean difference effect size (d) measures are calculated. Fifteen of 24 studies have sufficient data for analysis. Students' ability to establish rapport improves after teaching. The effects are large when the teaching intervention was small group discussion (n = 5) or giving structured feedback on a student-patient interview (n = 6). A similar effect of teaching is seen on student data gathering skills (n = 5). Teaching medical students patient communication skills using small group discussion or providing feedback on a student-patient interview results in improvement in student performance.

A comparison of clinical pediatric patient encounters in university medical center and community private practice settings.

BACKGROUND: Growing numbers of medical students complete clerkships in community private practice (CPP) settings instead of the more traditional university-based clinics, yet few empirical studies have evaluated how setting type impacts clinical experiences, skill development, and student satisfaction. OBJECTIVE: This study compared the pediatric patient encounters seen by third-year medical students in university medical center (UMC) and CPP settings. METHODS: Third-year medical students were required to keep a log of all patients seen during their 8-week pediatric clerkship. Logbook entries were coded and then analyzed for differences in the number and distribution of the primary diagnostic categories between settings. RESULTS: CPP students reported, on the average, seeing over 3 times more patients than UMC students. The case mix distribution also differed significantly by setting. In general, CPP students reported seeing proportionately more routine illnesses, whereas UMC students reported seeing proportionately more uncommon disorders. Because CPP students saw more patients overall, they averaged more cases in almost all diagnostic categories. CONCLUSION: CPP students received more clinical patient exposure than UMC students, except for patients in a few diagnostic categories.