How we developed and piloted an electronic key features examination for the internal medicine clerkship based on a US national curriculum.

BACKGROUND: Key features examinations (KFEs) have been used to assess clinical decision making in medical education, yet there are no reports of an online KFE-based on a national curriculum for the internal medicine clerkship. What we did: The authors developed and pilot tested an electronic KFE based on the US Clerkship Directors in Internal Medicine core curriculum. Teams, with expert oversight and peer review, developed key features (KFs) and cases. EVALUATION: The exam was pilot tested at eight medical schools with 162 third and fourth year medical students, of whom 96 (59.3%) responded to a survey. While most students reported that the exam was more difficult than a multiple choice question exam, 61 (83.3%) students agreed that it reflected problems seen in clinical practice and 51 (69.9%) students reported that it more accurately assessed the ability to make clinical decisions. CONCLUSIONS: The development of an electronic KFs exam is a time-intensive process. A team approach offers built-in peer review and accountability. Students, although not familiar with this format in the US, recognized it as authentically assessing clinical decision-making for problems commonly seen in the clerkship.

Educational technology in medical education.

This article aims to review the past practices of educational technology and envision future directions for medical education. The discussion starts with a historical review of definitions and perspectives of educational technology, in which the authors propose that educators adopt a broader process-oriented understanding of educational technology. Future directions of e-learning, simulation, and health information technology are discussed based on a systems view of the technological process. As new technologies continue to arise, this process-oriented understanding and outcome-based expectations of educational technology should be embraced. With this view, educational technology should be valued in terms of how well the technological process informs and facilitates learning, and the acquisition and maintenance of clinical expertise.

Chlamydia and gonorrhea screening in United States emergency departments.

BACKGROUND: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the most commonly reported notifiable diseases in the United States, with annual reported cases exceeding 1.2 million and estimated costs exceeding $1.2 billion. Reported Emergency Department (ED) prevalence rates for CT and GC for adolescents and young adults range from 0.9% to 8.1%. OBJECTIVE: Our aim was to evaluate the burden of CT/GC infection in ED patients, assess the extent of associated under- and overtreatment, and investigate mechanisms whereby ED screening can be feasible. METHODS: We performed a systematic review of the time period from 1995 to 2010. DISCUSSION: Positivity rates for ED patients are comparable with other high-risk populations, and sufficient for selected screening to be cost-effective. Unfortunately, ED patient follow-up is notoriously difficult, and clinicians frequently must choose to either delay treatment until laboratory confirmation or presumptively treat based on presenting symptoms and clinical diagnosis. This results in high rates of both undertreatment (i.e., not treating those infected) and overtreatment (i.e., treating those who are infection-free). Incorrect on-the-spot treatment decisions can result in potentially infected future partners and lack of follow-up treatment, or unnecessary treatment and personal stress associated with improper diagnosis. CONCLUSIONS: ED clinician activities are frequently symptom-driven, and screening nonsymptomatic patients presents a major barrier. Educating ED clinicians on the topics of CT/GC epidemiology, sample collection, and analysis will enable them to address the risks in their presenting populations. Collaboration with health department partners for sample analysis, cost-sharing, and patient follow-up can make routine screening feasible and enable EDs to become more important partners in intervention programs.

Using patient-provided information to refine sexually transmitted infection screening criteria among women presenting in the emergency department.

Emergency department patients are at increased risk for infection with chlamydia and gonorrhea, but routine screening of asymptomatic patients is problematic. Limiting screening to patients answering the affirmative to 2 questions would reduce the number of tests administered by 51.9%, increase the tested population prevalence to 15.7%, and still identify 82.8% of those infected.

Evaluating Emergency Medicine Faculty at End-of-Shift.

INTRODUCTION: Faculty often evaluate learners in the emergency department (ED) at the end of each shift. In contrast, learners usually evaluate faculty only at the end of a rotation. In December 2007 Southern Illinois University School of Medicine changed its evaluation process, requiring ED trainees to complete end-of-shift evaluations of faculty. OBJECTIVE: Determine the feasibility and acceptance of end-of-shift evaluations for emergency medicine faculty. METHODS: We conducted this one-year observational study at two hospitals with 120,000 combined annual ED visits. Trainees (residents and students) anonymously completed seven-item shift evaluations and placed them in a locked box. Trainees and faculty completed a survey about the new process. RESULTS: During the study, trainees were assigned 699 shifts, and 633 end-of-shift evaluations were collected for a completion rate of 91%. The median number of ratings per faculty was 31, and the median number of comments was 11 for each faculty. The survey was completed by 16/22 (73%) faculty and 41/69 (59%) trainees. A majority of faculty (86%) and trainees (76%) felt comfortable being evaluated at end-of-shift. No trainees felt it was a time burden. CONCLUSION: Evaluating faculty following an ED shift is feasible. End-of-shift faculty evaluations are accepted by trainees and faculty.

Internal medicine clerkship characteristics associated with enhanced student examination performance.

PURPOSE: To determine which internal medicine (IM) clerkship characteristics are associated with better student examination performance. METHOD: The authors collected data from 17 U.S. medical schools (1,817 students) regarding characteristics of their IM clerkships, including structural characteristics, pedagogical approaches, patient contact, and clinical teacher characteristics. Outcomes of interest were postclerkship National Board of Medical Examiners (NBME) subject examination score, United States Medical Licensing Examination (USMLE) 2 score, and change in score from USMLE 1 to 2. To examine how associations of various clerkship characteristics and examination performance may differ for students of different prior achievement, the authors categorized students into those who scored in the top (1/4) of the cohort on USMLE 1 and the bottom (1/4). The authors conducted analyses at both the school and the individual student levels. RESULTS: In school-level analyses (using a reduced four-variable model), independent variables associated with higher NBME subject examination score were more small-group hours/week and use of community-based preceptors. Greater score increase from USMLE 1 to 2 was associated with students caring for more patients/day. Several variables were associated with enhanced student examination performance at the student level. The most consistent finding was that more patients cared for per day was associated with higher examination performance. More structured learning activities were associated with higher examination scores for students with lower baseline USMLE 1 achievement. CONCLUSION: Certain clerkship characteristics are associated with better student examination performance, the most salient being caring for more patients per day.

Peer assessment of professionalism: a five-year experience in medical clerkship.

INTRODUCTION: Faculty assessment of students' professionalism is often based upon sporadic exposure to students. Peers are in a unique position to provide valid judgments of these behaviors. AIMS: (1) To learn if peer assessments of professional conduct correlate with traditional performance measures; (2) to determine if peer assessments of professionalism influence the designation of honors, and (3) to explore student and faculty opinions regarding peer assessment. SETTING: Internal Medicine Clerkship at Southern Illinois University. PROGRAM DESCRIPTION: Since 2001 anonymous student peer assessments of professionalism have been used in assigning clerkship grades. PROGRAM EVALUATION: Peer assessments of professionalism had weak, though significant, correlations with faculty ratings (r = 0.29), performance on the NBME subject test (r = 0.28), and performance on a cumulative performance assessment (r = 0.30), and did not change the total number of honors awarded. A majority of students (71%) felt comfortable evaluating their peers, and 77% would keep the peer evaluation procedure in place. A majority of faculty (83%) indicated that peer assessments added valuable information. DISCUSSION: Peer assessments of professional conduct have little correlation with other performance measures, are more likely to have a positive influence on final clerkship grades, and have little impact on awarding honors.

Using indirect questions to detect intimate partner violence: the SAFE-T questionnaire.

A screening instrument for detecting intimate partner violence (IPV) was developed using indirect questions. The authors identified 5 of 18 items studied that clearly distinguished victims of IPV from a random group of health conference attendees with a sensitivity of 85% and a specificity of 87%. This 5-item instrument (SAFE-T) was then tested on 435 women presenting to three emergency departments and the results compared to a direct question regarding current abuse. The SAFE-T questions detected only 54% of the women who admitted being abused and correctly classified 81% of the women who said they were not victims. The 1-year prevalence of IPV in this sample of women presenting to an emergency department was 11.6%. The authors conclude that indirect questioning of women appears to be more effective at ruling out IPV in an emergency department population and may be less useful for women "early" in an abusive relationship.