Evaluating Clinical Reasoning in Undergraduate Medical Education: The Value of a Virtual Oral Assessment.

BACKGROUND: Oral assessments are essential components of board certification in numerous fields, as they provide insight into problem-solving capacity and clinical reasoning. The development of clinical reasoning often begins in undergraduate medical education and remains a challenge to assess. OBJECTIVE: We developed a pilot oral assessment to evaluate medical student oral presentations and systematically assess clinical reasoning. This was incorporated into a previously existing cumulative assessment at the conclusion of the third year of medical school, with the intent to demonstrate feasibility and future reliability of this exam format. METHODS: This pilot oral assessment was developed using content taught during third year clerkships. A modified Assessment of Reasoning Tool (ART) was used as the evaluation metric. It was conducted virtually to include faculty members from multiple disciplines and accommodate schedules and space limitations. RESULTS: A total of 152 third year medical students completed the exam, with a total of 15 faculty examiners. 89% of medical students scored as complete in hypothesis directed history, 93% in problem representation, 86% in prioritized differential diagnoses, and 67% in effectively directing management. Most examiners felt an oral assessment is effective to determine a medical student's clinical reasoning ability. CONCLUSIONS: Virtual oral assessments of clinical reasoning can be incorporated in undergraduate medical education to identify students struggling with components of clinical reasoning, while also allowing maximum flexibility for the clinician educator workforce as examiners. Longitudinal use of these exams would be valuable to track the development of clinical reasoning across the medical school curriculum.

Critical Care Teamwork in the Future: The Role of TeamSTEPPS® in the COVID-19 Pandemic and Implications for the Future.

At our institution, we observed inconsistency in the application of structural facilitators for interprofessional teamwork such as handoffs and communication of contingency planning, complete formation and engagement of teams on interprofessional rounds, regular situation monitoring, interprofessional huddles, use of "check back" during code situations, and standard debriefings after codes and procedures (TeamSTEPPS®). To enhance team performance, we piloted TeamSTEPPS® training and reinforcement for all healthcare team members in the medical intensive care unit (MICU), inclusive of trainees, advanced practice providers (APPs), nurses, and respiratory therapists rotating through the unit. Seven months after the training launch, the initial COVID-19 surge interrupted the reinforcement stage of the pilot providing an opportunity to study the retention of TeamSTEPPS® principles and its potential role in response to a crisis. We conducted interprofessional focus groups after a year of crisis management during the pandemic. Themes revealed how TeamSTEPPS® training impacted teamwork and communication, as well as factors that influenced the use of TeamSTEPPS®. This work points to the value of team training in unexpected scenarios. Additional studies at multiple sites are needed to determine scalability for all MICU teams or for onboarding new team members.

A Pre-Clerkship Medical Education Elective as Catalyst for Student Learning, Faculty Teaching, and Curricular Improvement.

Recent reviews of student-as-teacher programs call for early, longitudinal, and timely training in both learning principles and applied teaching skills. We describe a longitudinal elective for pre-clerkship students that includes interactive meetings addressing a range of theoretical and practical teaching topics and the tools needed to conduct medical education research.

Twelve tips for embedding assessment for and as learning practices in a programmatic assessment system.

Programmatic assessment supports the evolution from assessment of learning to fostering assessment for learning and as learning practices. A well-designed programmatic assessment system aligns educational objectives, learning opportunities, and assessments with the goals of supporting student learning, making decisions about student competence and promotion decisions, and supporting curriculum evaluation. We present evidence-based guidance for implementing assessment for and as learning practices in the pre-clinical knowledge assessment system to help students learn, synthesize, master and retain content for the long-term so that they can apply knowledge to patient care. Practical tips are in the domains of culture and motivation of assessment, including how an honour code and competency-based grading system can support an assessment system to develop student self-regulated learning and professional identity, curricular assessment structure, such as how and when to utilize low-stakes and cumulative assessment to drive learning, exam and question structure, including what authentic question and exam types can best facilitate learning, and assessment follow-up and review considerations, such exam retake processes to support learning, and academic success structures. A culture change is likely necessary for administrators, faculty members, and students to embrace assessment as most importantly a learning tool for students and programs.

Nutrition Education on the Wards: A Self-Study Module for Improving Medical Student Knowledge of Nutrition Assessment and Interventions.

Introduction: Nutrition plays a key role in the prevention and treatment of disease. Hospitalized patients are often malnourished, which is a major contributor to medical complications, decreased quality of life, lengthened medical stay, increased health care costs, and mortality. However, medical students continue to have inadequate education in nutrition and report feeling poorly trained in nutrition. We proposed an online module that could be used by medical students as a self-study activity to learn about key signs for the diagnosis of malnutrition and the nutrition interventions available in the hospital setting. Methods: Third- and fourth-year medical students at Rutgers Robert Wood Johnson Medical School in medicine, surgery, and critical care clerkships were given access to an online nutrition education module discussing the signs of malnutrition in hospitalized patients and the interventions available in the inpatient setting. A premodule and postmodule survey was given via email at the beginning and at the end of the clerkship. A one-sample t test was used to assess the relationship between the mean scores of the pre- and postmodule surveys. Results: One hundred nine out of 255 students responded to the premodule survey. Thirty-two students completed the module and postmodule survey. There was a significant difference in mean scores between students who completed the module and postmodule survey compared to the overall student population prior to having access to the module. Discussion: Medical students have limited training in nutrition education, and our findings show that a self-study online module can improve students' knowledge.

Three Decades Later: A Scoping Review of the Literature Related to the United States Medical Licensing Examination.

PURPOSE: To conduct a scoping review of the timing, scope, and purpose of literature related to the United States Medical Licensing Examination (USMLE) given the recent impetus to revise USMLE scoring. METHOD: The authors searched PubMed, PsycInfo, and ERIC for relevant articles published from 1990 to 2019. Articles selected for review were labeled as research or commentaries and coded by USMLE Step level, sample characteristics (e.g., year(s), single/multiple institutions), how scores were used (e.g., predictor/outcome/descriptor), and purpose (e.g., clarification/justification/description). RESULTS: Of the 741 articles meeting inclusion criteria, 636 were research and 105 were commentaries. Publication totals in the past 5 years exceeded those of the first 20 years.Step 1 was the sole focus of 38%, and included in 84%, of all publications. Approximately half of all research articles used scores as a predictor or outcome measure related to other curricular/assessment efforts, with a marked increase in the use of scores as predictors in the past 10 years. The overwhelming majority of studies were classified as descriptive in purpose. CONCLUSIONS: Nearly 30 years after the inception of the USMLE, aspirations for its predictive utility are rising faster than evidence supporting the manner in which the scores are used. A closer look is warranted to systematically review and analyze the contexts and purposes for which USMLE scores can productively be used. Future research should explore cognitive and noncognitive factors that can be used in conjunction with constrained use of USMLE results to inform evaluation of medical students and schools and to support the residency selection process.

How curricular changes influence medical students' perceptions of basic science: A pilot study.

THEORY: The perceived value of study material may have implications on learning and long-term retention. This study compares the perceived value of basic science of medical students from schools with a traditional "2+2" curriculum and the USMLE Step 1 placed before core clerkships to those from medical schools that have undergone curricular revisions, resulting in shortened pre-clerkship curricula and administration of the USMLE Step 1 after core clerkships. HYPOTHESIS: We hypothesize that differences in curricula, particularly duration of pre-clerkship curriculum and timing of the USMLE Step 1, affect medical students' perceived value of basic science. METHODS: A twenty item anonymous questionnaire using a 5-point Likert scale was developed to assess medical students' perceptions of basic science. The questionnaire was distributed to third-year medical students across four medical schools. Generalized linear models and p-values were calculated comparing the perceived value and use of basic science between medical schools with the USMLE Step 1 before clerkships and 2-years of basic science (BC) and medical schools with the USMLE Step 1 after core clerkships and 1.5-years of basic science (AC). RESULTS: The questionnaire was distributed to 695 eligible students and completed by 287 students. Students at BC schools tended to view basic science as more essential for clinical practice than students at AC schools across both outcomes (rating independence of basic science and clinical practice, AC school mean = 2.97, BC school mean = 2.73, p = 0.0017; rating importance of basic science to clinical practice, AC school mean = 3.30, BC schools mean = 3.50, p = 0.0135). CONCLUSIONS: Our study suggests that students who have a longer basic science curriculum tend to value basic science greater than students with a shorter basic science curriculum. The timing of the USMLE Step 1 may also influence this relationship. Curricular decisions, such as reductions in pre-clerkship curricula and administration of the USMLE Step 1 after clerkships, may impact medical students' perceptions of the value of basic science to clinical practice. This can have implications on their future engagement with basic science and should be considered when modifying curriculum.

Development and Validation of a Shared Secure Biochemistry Test Bank for Medical, Dental, and Pharmacy Schools.

A shared secure biochemistry test bank (abeQbank) was developed by 61 members of the Association of Biochemistry Educators (ABE) who are from medical, pharmacy, and dental schools. The initial abeQbank contained 305 questions, which were almost all clinical vignettes, and were classified into 9 biochemistry megaThemes with subthemes as determined by ABE workshops 2009-2011. Three medical schools selected 163 board-style abeQbank questions approved by ABE and administered a proctored formative exam using ExamSoft to 97 second-year medical students prior to their USMLE or COMLEX 1 board exam followed by a review session in which students examined their answers and read the rationale for each question. The goals of this project were to (1) provide a resource to biochemistry educators; (2) evaluate the quality of these questions; and (3) ascertain students' relative knowledge in different biochemical concepts. Individual questions and 9 megaTheme groups performed similarly across schools, with the lowest and highest megaThemes ranging from 40 to 70% correct. Five questions were dropped due to miscoding, poor metrics, or questionable distractors requiring a rewrite. The results showed that the examination was strongly reliable with the average KR20 = 0.85, discrimination index and point-biserial > 0.2, and students scoring the examination 8 out of 10 in usefulness. This test bank represents the first attempt by an international biochemistry organization to create a standardized set of questions, with future expansion planned to help standardize the content of biochemistry topics in the curricula.

Shaping Perceptions of Basic Science Education by Utilizing Real Patient Encounters.

BACKGROUND: Integrating basic science into clinical teaching has been a struggle for medical schools. However, early exposure to clinical experience has been associated with an increased understanding of the importance of basic science, positive attitudes, and developing clinical skills faster. Furthermore, early clinical exposure can help students reconnect with what drove them into medicine in the first place, especially when they are starting to feel burned out by the volume of lecture material. As a result, increasing patient experience during the first year has become a goal of many medical schools. METHODS: At Rutgers Robert Wood Johnson Medical School, interprofessional case discussions (ICDs) begin with a lecture that explicitly integrates basic science with a disease, followed by a discussion with a patient, their family, the healthcare team, and first-year students. Our objective is to explore whether ICDs enhanced the learning experience of basic science. CONTEXT: ICD satisfaction was assessed using evaluations from two different courses (2013-2016). Responses were analyzed quantitatively using descriptive statistics and qualitatively using a grounded-theory-content analysis. Study 2: A follow-up measure with current third- and fourth-year students on long-term retention of basic science was analyzed using a Wilcoxon signed rank test. Relative rankings of three different case-based teaching modalities were assessed using chi-square. RESULTS: Students reported significantly higher satisfaction with ICDs (93%) for reinforcing concepts and integrating materials compared to Flipped Classrooms (66%) and Jigsaws (65%), x 2 = 120.9, p < .001. Student comments fit into five categories: enjoyment, learning/retention, the clinical usefulness of basic science, affirming passion to be in medicine, and others. The follow-up measure indicated significantly greater retention of the biochemical basis of diseases covered during ICDs. CONCLUSIONS: While other teaching modalities integrate basic science into a clinical context, ICDs go further by displaying interprofessional care and the manifestation of the disease on the patient and the lives of their family. As a result, ICDs lead to a positive learning environment in which students feel comfortable, have a sense of rapport with the patients and health care providers, and feel motivated to learn basic science.

Wanting more: A look at preclinical students' desires for increased clinical experiences and interest in mentoring young adults with chronic illness.

A growing population of children with chronic illness must transition from pediatric to adult healthcare. Medical students receive little formal training about the needs of these young patients. Strategies for educating students about how to address medical and psychosocial consequences of these conditions are needed. Interventions pairing medical students as mentors for young adults with chronic illness may provide dual benefit for both patient and student. To establish the feasibility of developing this type of program, we surveyed 165 medical students about their extra-curricular and clinical experiences as well their interest in and expectations for a patient mentoring experience.

Exploring the Role of Peer Advice in Self-Regulated Learning: Metacognitive, Social, and Environmental Factors.

This Conversation Starters article presents a selected research abstract from the 2016 Association of American Medical Colleges Northeast Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the pilot study. These thoughts explore the metacognitive, social, and environmental mechanisms whereby advice plays a role in self-regulated learning.

Visual identity and uncertainty in repetition blindness.

Repetition blindness (RB) was investigated in 6 experiments. In the first 3 experiments participants detected vowel targets in 11-letter sequences. When all letters were uppercase, detection was poorer for same (e.g., AA) than for different (e.g., AO) targets. However, when one target was uppercase and the other lowercase, RB was found only for targets visually identical except for size (e.g., Oo), not for visually different pairs (e.g., Aa). Experiment 4 found RB for visually identical versus different consonant-vowel-consonant words. Experiments 5 and 6 replicated Kanwisher's (1987) experiment in which RB was insensitive to word case but revealed these effects to be artifacts of poor recognition of 5-letter words coupled with a biased guessing strategy. Overall, these experiments found RB only at a low level of visual information processing.