Medical Students' Assessment of Eduard Pernkopf's Atlas: Topographical Anatomy of Man.

INTRODUCTION: To date, there has been no study examining the perceptions of first-year medical students regarding Eduard Pernkopf's atlas, particularly during their study of gross anatomy and prior to coursework in medical ethics. We present a discussion of Pernkopf's Atlas: Topographical Anatomy of Man from the perspective of U.S. medical students, and sought to determine whether medical students view Pernkopf's Topographical Anatomy of Man as a resource of greater accuracy, detail, and potential educational utility as compared to Netter's Atlas of Human Anatomy. METHODS: The entire first-year class at Drexel University College of Medicine (265 students) was surveyed at approximately the midpoint of their gross anatomy course and 192 responses were collected (72% response rate). RESULTS: Of these, 176 (95%) were unaware of the existence of Pernkopf's atlas. Another 71% of students found the Pernkopf atlas more likely complete and accurate, whereas 76% thought the Netter atlas more useful for learning (p<.001). When presented with a hypothetical scenario in which the subjects used in creating Pernkopf's atlas were donated, or unclaimed, but with knowledge that Pernkopf was an active member of the Nazi party, 133 students (72%) retained their original position (p=.001). About 94% desired discussion of Pernkopf within a medical school bioethics course. The relationship between level of self-reported knowledge and whether or not students would advocate removal of the atlas was statistically significant (p=.013). CONCLUSION: Discussing ethical violations in medical history, especially the Pernkopf atlas, must attain a secure place in medical school curricula, and more specifically, within a bioethics course.

Performance in physical examination on the USMLE Step 2 Clinical Skills examination.

PURPOSE: To provide descriptive information about history-taking (HX) and physical examination (PE) performance for U.S. medical students as documented by standardized patients (SPs) during the Step 2 Clinical Skills (CS) component of the United States Medical Licensing Examination. The authors examined two hypotheses: (1) Students perform worse in PE compared with HX, and (2) for PE, students perform worse in the musculoskeletal system and neurology compared with other clinical domains. METHOD: The sample included 121,767 student-SP encounters based on 29,442 examinees from U.S. medical schools who took Step 2 CS for the first time in 2011. The encounters comprised 107 clinical presentations, each categorized into one of five clinical domains: cardiovascular, gastrointestinal, musculoskeletal, neurological, and respiratory. The authors compared mean percent-correct scores for HX and PE via a one-tailed paired-samples t test and examined mean score differences by clinical domain using analysis of variance techniques. RESULTS: Average PE scores (59.6%) were significantly lower than average HX scores (78.1%). The range of scores for PE (51.4%-72.7%) was larger than for HX (74.4%-81.0%), and the standard deviation for PE scores (28.3) was twice as large as the HX standard deviation (14.7). PE performance was significantly weaker for musculoskeletal and neurological encounters compared with other encounters. CONCLUSIONS: U.S. medical students perform worse on PE than HX; PE performance was weakest in musculoskeletal and neurology clinical domains. Findings may reflect imbalances in U.S. medical education, but more research is needed to fully understand the relationships among PE instruction, assessment, and proficiency.

Within-session score gains for repeat examinees on a standardized patient examination.

PURPOSE: Previous studies on standardized patient (SP) exams reported score gains both across attempts when examinees failed and retook the exam and over multiple SP encounters within a single exam session. The authors analyzed the within-session score gains of examinees who repeated the United States Medical Licensing Examination Step 2 Clinical Skills to answer two questions: How much do scores increase within a session? Can the pattern of increasing first-attempt scores account for across-session score gains? METHOD: Data included encounter-level scores for 2,165 U.S. and Canadian medical students and graduates who took Step 2 Clinical Skills twice between April 1, 2005 and December 31, 2010. The authors modeled examinees' score patterns using smoothing and regression techniques and applied statistical tests to determine whether the patterns were the same or different across attempts. In addition, they tested whether any across-session score gains could be explained by the first-attempt within-session score trajectory. RESULTS: For the first and second attempts, the authors attributed examinees' within-session score gains to a pattern of score increases over the first three to six SP encounters followed by a leveling off. Model predictions revealed that the authors could not attribute the across-session score gains to the first-attempt within-session score gains. CONCLUSIONS: The within-session score gains over the first three to six SP encounters of both attempts indicate that there is a temporary "warm-up" effect on performance that "resets" between attempts. Across-session gains are not due to this warm-up effect and likely reflect true improvement in performance.

The flame photometer as engine of nephrology: a biography.

In the 1940s, the flame photometer made possible for the first time relatively simple and quick measurements of sodium and potassium in serum and urine. During World War II, it unexpectedly fell into the hands of John P. Peters of Yale University, who sought to understand water and electrolyte physiology and apply such knowledge to patient problems. Pupils and young associates of Peters would seed the early nephrology divisions and training programs in the United States; the flame photometer was essential to their work and that of their trainees, both Americans and international visitors. Hyponatremia and the syndrome of inappropriate antidiuretic hormone secretion became the "attribute" disorders of nephrologists. Invention of a microflame photometer fostered the revival of micropuncture and transport studies. In the 1960s, the flame photometer was linked to Leonard Skeggs' sequential automated analysis system, leading to enormous numbers of routine measurements of electrolytes. The growing number of nephrologists, then based mostly at teaching hospitals, thus found plentiful instances of sodium and potassium abnormalities to address. The autoanalyzer also catalyzed use of the anion gap, another emblem of nephrology in its early decades. Not only ideas and theories, but also the usually invisible machinery, enable the growth of a knowledge base and formation of a scientific discipline or medical specialty. Of course, the flame photometer did not itself shape the agenda of nephrology, but it allowed the most influential group of progenitors and their progeny to explore normal function and bring a strongly physiologic imperative to their daily work with patients.

The Fielding H. Garrison lecture: "I am their physician": Dr. Owen J. Wister of Germantown and his too many patients.

Owen J. Wister, M.D. (1825-1896) acquired one of the busiest "outdoor" practices in nineteenth-century Philadelphia, conducted throughout the city's large northwest district. Through letters, he described events in his daily rounds to his wife, the writer Sarah Butler Wister, when she was traveling to restore her own health. Wister's practice was filled with the mundane details of any general doctor's existence but also with confrontations with sudden and overpowering disease, and sometimes the grisly deaths of friends and family. Often he worked from early morning until late evening, seeing as many as thirty or forty patients scattered over a thirty-mile range. He endured as well frequent calls at night for real or imagined emergencies and maternity cases. In 1869 he collapsed from overwork and was able to resume his career only after a three-year respite. This lecture describes Wister's practice and his emotional responses to it, as inscribed in the letters. In addition, I explore what attributes he had as a physician and as a man that accounted for his popularity and why the social environment of his practice made it virtually impossible for him to control its demands, even at the cost of his own well-being.

Checklist content on a standardized patient assessment: an ex post facto review.

While checklists are often used to score standardized patient based clinical assessments, little research has focused on issues related to their development or the level of agreement with respect to the importance of specific items. Five physicians independently reviewed checklists from 11 simulation scenarios that were part of the former Educational Commission for Foreign Medical Graduate's Clinical Skills Assessment and classified the clinical appropriateness of each of the checklist items. Approximately 78% of the original checklist items were judged to be needed, or indicated, given the presenting complaint and the purpose of the assessment. Rater agreement was relatively poor with pairwise associations (Kappa coefficient) ranging from 0.09 to 0.29. However, when only consensus indicated items were included, there was little change in examinee scores, including their reliability over encounters. Although most checklist items in this sample were judged to be appropriate, some could potentially be eliminated, thereby minimizing the scoring burden placed on the standardized patients. Periodic review of checklist items, concentrating on their clinical importance, is warranted.

Scoring standardized patient examinations: lessons learned from the development and administration of the ECFMG Clinical Skills Assessment (CSA).

Throughout the 40 year history of standardized patient assessments and OSCEs, there have been numerous advancements, including many that involve scoring the simulated clinical encounters. While there is no clear agreement on how examinees' performance should be documented or scored in an encounter, there is a consensus that several well-chosen SP encounters are required to produce reliable examinee scores. There also continues to be some debate as to who should do the scoring on an SP-based assessment. While logistics and cost will certainly play a role, it is probably best to use the person who is most familiar with the domain being assessed. In some instances this will be the SP; in others, an outside observer or content expert. Finally, with the growing use of OSCEs for summative purposes (e.g. certification, licensure), special attention must be paid to fairness issues. Since the same test form cannot be used day after day, examinee scores must be 'equated', taking into account the psychometric properties of scores from individual cases and individual SPs. To date, the CSA has been one of the highest-volume, high-stakes, standardized patient assessments to be developed and successfully administered. In 2003 alone, over 11 500 IMGs were tested. The early conceptual framework for this assessment was synthesized from the research endeavours of several notable individuals, including, amongst many others, Harden et al. 1975, Swanson & Stillman, 1990, Newble & Swanson, 1988, Vu et al. 1992 and Colliver, 1995. The early prototype administrations of the CSA, including many operational research studies, were supported and guided by Dr Friedman Ben-David, Friedman et al. 1991, 1993, Stillman et al. 1992, and Sutnick et al. 1993, 1995.

Why support a women's medical college? Philadelphia's early male medical pro-feminists.

The male founders and early faculty of Philadelphia's Woman's Medical College were mostly abolitionist physicians, zealous moralists for whom medical feminism formed only one of the cherished causes they could "manfully" and righteously defend. Male faculty of the late nineteenth century comprised "self-made" men, mostly new specialists, for whom strict sexism probably seemed inconsistent with progressive medicine. For some of these physicians-obviously a small minority-defending medical women and breaking the barriers of fraternity could be consistent with "manly" responsibility. The outcome of the collaboration of women and the dissident men physicians in nineteenth-century Philadelphia amounted to another seeming paradox: the majority of the male medical profession, both locally and nationally, tyrannically hindered women's entry into the profession, yet medicine opened its doors in advance of law and the clergy; and where this first occurred, such as in the community centered on Woman's Medical College, a novel gender rearrangement arose based on collaboration and friendship.

A pilot test of WebOSCE: a system for assessing trainees' clinical skills via teleconference.

WebOSCE is a computer-based system that allows a student at an affiliate site to participate in a 10-station standardized patient-based exam using a videoconference interface, while nine other students take the exam on-site. We pilot-tested this system during a required year-end objective structured clinical exam. We compared performance data between the 26 distance students taking the exam via WebOSCE with 221 on-site students. We also compared both student groups' responses on a post-exam questionnaire, and conducted a post-exam structured interview to elicit the Pittsburgh students' perspectives on the WebOSCE experience. Students taking the exam via WebOSCE scored significantly lower in most categories except for physical exam and information-giving skills, on which the groups did not differ. There were no differences between groups in students' overall evaluation of the exam experiences. In general, Pittsburgh students rated WebOSCE highly and offered many helpful comments to improve the technology and the experience.