Determining Grades in the Internal Medicine Clerkship: Results of a National Survey of Clerkship Directors.

PURPOSE: Trust in and comparability of assessments are essential in clerkships in undergraduate medical education for many reasons, including ensuring competency in clinical skills and application of knowledge important for the transition to residency and throughout students' careers. The authors examined how assessments are used to determine internal medicine (IM) core clerkship grades across U.S. medical schools. METHODS: A multisection web-based survey of core IM clerkship directors at 134 U.S. medical schools with membership in the Clerkship Directors in Internal Medicine was conducted in October through November 2018. The survey included a section on assessment practices to characterize current grading scales used, who determines students' final clerkship grades, the nature/type of summative assessments, and how assessments are weighted. Respondents were asked about perceptions of the influence of the National Board of Medical Examiners (NBME) Medicine Subject Examination (MSE) on students' priorities during the clerkship. RESULTS: The response rate was 82.1% (110/134). There was considerable variability in the summative assessments and their weighting in determining final grades. The NBME MSE (91.8%), clinical performance (90.9%), professionalism (70.9%), and written notes (60.0%) were the most commonly used assessments. Clinical performance assessments and the NBME MSE accounted for the largest percentage of the total grade (on average 52.8% and 23.5%, respectively). Eighty-seven percent of respondents were concerned that students' focus on the NBME MSE performance detracted from patient care learning. CONCLUSIONS: There was considerable variability in what IM clerkships assessed and how those assessments were translated into grades. The NBME MSE was a major contributor to the final grade despite concerns about the impact on patient care learning. These findings underscore the difficulty in comparing learners across institutions and serve to advance discussions for how to improve accuracy and comparability of grading in the clinical environment.

AAIM Recommendations for the 2020-2021 Internal Medicine Residency Application Cycle in Response to the COVID-19 Pandemic.

This statement was released in June 2020 by the Alliance for Academic Internal Medicine to provide guidance for the 2020-2021 residency application cycle in light of the COVID-19 pandemic. While many of the recommendations are specific to this cycle, others, such as the Department Summary Letter of Evaluation, are meant to be an enduring change to the internal medicine residency application process. AAIM realizes that some schools may not yet have the tools or resources to implement the template fully this cycle and look toward collaboration within the internal medicine education community to facilitate adoption in the cycles to come.

Early experience with a combined surgical and obstetrics/gynecology clerkship: We do get along.

BACKGROUND: In 2012, the Ohio State University College of Medicine (OSUCOM) implemented a new undergraduate medical curriculum. We compare outcomes of a third year traditional clerkship format to a combined Surgery and Obstetrics/Gynecology 'ring'. METHODS: Performance outcomes of 4 consecutive classes were compared between pre- (2014, 2015) and post-curricular revision (2016, 2017). RESULTS: Three hundred ninety-one students consented use of their educational data for research. We examined medical knowledge (NBME scores, USMLE Step 1 and Step 2 CK scores) and student satisfaction between pre- and post-curricular revision. Results demonstrated no statistically significant difference in the Obstetrics/Gynecology NBME shelf examination. Surgery NBME and USMLE Step 2 scores were increased and statistically significant but satisfaction of both disciplines was higher pre-curricular revision. CONCLUSION: Medical knowledge outcomes in this combined 'ring' were similar to or higher than performance in previous years'. Future analyses are needed to assess the impact of OSUCOM curricular revision.

Bedside direct observation of medical student-performed physical examination is highly rated in student satisfaction.

This article was migrated. The article was marked as recommended. Objectives: To evaluate satisfaction among third year medical students with a bedside teaching exercise comprised of direct observation of student-performed physical examination skills and related feedback. Methods: An observational, cross-sectional study design was employed to study third year medical students undergoing the Neurology clerkship at the Ohio State University College of Medicine between June and October 2015. Immediately following the bedside physical examination teaching exercise, student satisfaction data was obtained in anonymous survey (n=21). In addition, student satisfaction data from the class cohort (n=51), regarding various learning formats in the curriculum, were collected at the end of a 16-week block of rotations including the Neurology clerkship. Data were summarized using descriptive statistics. Results: Most students felt that their level of confidence increased as a result (85.0%, n=17/21), and they felt they would use what they had learned in the future (95%, n=19/21). Only about half of the students felt strongly that reflection on the learning experience was sought (47.6%, n= 10/21). At the end of the 16 weeks block, the Neurology examination exercise was rated among the most highly in student satisfaction (3.35/4, SD=0.89) as compared to procedural workshops (2.76/4, SD= 0.76), other small group topic format (2.78/4, SD= 0.85), and traditional lecture (2.39/ 4, SD= 0.89). Conclusions: The bedside direct observation of physical examination performed by medical students is highly rated in student satisfaction, and students are most satisfied with this format of teaching among all formats studied. Increased opportunity for reflection in this setting represents an area for further development.

Medical Student Perceptions of Cost-Conscious Care in an Internal Medicine Clerkship: A Thematic Analysis.

BACKGROUND: Although as much as 87 % of all healthcare spending is directed by physicians, studies have demonstrated that they lack knowledge about the costs of medical care. Similarly, learners have not traditionally received instruction on cost-conscious care. OBJECTIVE: To examine medical students' perceptions of healthcare delivery as it relates to cost consciousness DESIGN: Retrospective qualitative analysis of medical student narratives PARTICIPANTS: Third-year medical students during their inpatient internal medicine clerkship MAIN MEASURES: Students completed a reflective exercise wherein they were asked to describe a scenario in which a patient experienced lack of attention to cost-conscious care, and were asked to identify solutions and barriers. We analyzed these reflections to learn more about students' awareness and perceptions regarding the practice of cost-conscious care within our medical center. KEY RESULTS: Eighty students submitted the assignment between July and December 2012. The most common problems identified included unnecessary tests and treatments (n = 69) and duplicative tests and treatments (n = 20.) With regards to solutions, students described 82 scenarios, with 125 potential solutions identified. Students most commonly used discussion with the team (speak up, ask why) as the process they would use (n = 28) and most often wanted to focus lab testing (n = 38) as the intervention. The most common barriers to high-value care included increased time and effort (n = 19), ingrained practices (n = 17), and defensive medicine or fear of missing something (n = 18.) CONCLUSIONS: Even with minimal clinical experience, medical students were able to identify instances of lack of attention to cost-conscious care as well as potential solutions. Although students identified the hierarchy in healthcare teams as a potential barrier to improving high value care, most students stated they would feel comfortable engaging the team in discussion. Future efforts to empower learners at all levels to question value decisions and to develop and implement solutions may result in improved healthcare.

Effectiveness of a quality improvement curriculum for medical students.

INTRODUCTION: As health systems find ways to improve quality of care, medical training programs are finding opportunities to prepare learners on principles of quality improvement (QI). The impact of QI curricula for medical students as measured by student learning is not well delineated. The aim of this study is to evaluate the effectiveness of a QI curriculum for senior medical students as measured by student knowledge and skills. METHODS: This study was an observational study that involved a self-assessment and post-test Quality Improvement Knowledge Application Tool (QIKAT) for intervention and control students. A QI curriculum consisting of online modules, live discussions, independent readings and reflective writing, and participation in a mentored QI project was offered to fourth-year medical students completing an honor's elective (intervention group). Senior medical students who received the standard QI curriculum only were recruited as controls. RESULTS: A total of 22 intervention students and 12 control students completed the self-assessment and QIKAT. At baseline, there was no difference between groups in self-reported prior exposure to QI principles. Students in the intervention group reported more comfort with their skills in QI overall and in 9 of the 12 domains (p<0.05). Additionally, intervention students performed better in each of the three case scenarios (p<0.01). DISCUSSION: A brief QI curriculum for senior medical students results in improved comfort and knowledge with QI principles. The strengths of our curriculum include effective use of classroom time and faculty mentorship with reliance on pre-existing online modules and written resources. Additionally, the curriculum is easily expandable to larger groups of students and transferable to other institutions.

Applying adult learning practices in medical education.

The application of the best practices of teaching adults to the education of adults in medical education settings is important in the process of transforming learners to become and remain effective physicians. Medical education at all levels should be designed to equip physicians with the knowledge, clinical skills, and professionalism that are required to deliver quality patient care. The ultimate outcome is the health of the patient and the health status of the society. In the translational science of medical education, improved patient outcomes linked directly to educational events are the ultimate goal and are best defined by rigorous medical education research efforts. To best develop faculty, the same principles of adult education and teaching adults apply. In a systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education, the use of experiential learning, feedback, effective relationships with peers, and diverse educational methods were found to be most important in the success of these programs. In this article, we present 5 examples of applying the best practices in teaching adults and utilizing the emerging understanding of the neurobiology of learning in teaching students, trainees, and practitioners. These include (1) use of standardized patients to develop communication skills, (2) use of online quizzes to assess knowledge and aid self-directed learning, (3) use of practice sessions and video clips to enhance significant learning of teaching skills, (4) use of case-based discussions to develop professionalism concepts and skills, and (5) use of the American Academy of Pediatrics PediaLink as a model for individualized learner-directed online learning. These examples highlight how experiential leaning, providing valuable feedback, opportunities for practice, and stimulation of self-directed learning can be utilized as medical education continues its dynamic transformation in the years ahead.

Handoff practices in undergraduate medical education.

BACKGROUND: Growing data demonstrate that inaccuracies are prevalent in current handoff practices, and that these inaccuracies contribute to medical errors. In response, the Accreditation Council for Graduate Medical Education (ACGME) now requires residency programs to monitor and assess resident competence in handoff communication. Given these changes, undergraduate medical education programs must adapt to these patient safety concerns. OBJECTIVES: To obtain up-to-date information regarding educational practices for medical students, the authors conducted a national survey of Clerkship Directors in Internal Medicine (CDIM) members. DESIGN AND PARTICIPANTS: In June 2012, CDIM surveyed its institutional members, representing 121 of 143 Departments of Medicine in the U.S. and Canada. The section on handoffs included 12 questions designed to define the handoff education and practices of third year clerkship and fourth year sub-internship students. KEY RESULTS: Ninety-nine institutional CDIM members responded (82%). The minority (15%) reported a structured handoff curriculum provided during the internal medicine (IM) core clerkship, and only 37% reported a structured handoff curriculum during the IM sub-internship. Sixty-six percent stated that third year students do not perform handoff activities. However, most respondents (93%) reported that fourth year sub-internship students perform patient handoff activities. Only twenty-six (26%) institutional educators in CDIM believe their current handoff curriculum is adequate. CONCLUSIONS: Despite the growing literature linking poor handoffs to adverse events, few medical students are taught this competency during medical school. The common practice of allowing untrained sub-interns to perform handoffs as part of a required clerkship raises safety concerns. Evidence-based education programs are needed for handoff training.

A quality project to improve compliance with AAP guidelines for inpatient management of neonatal hyperbilirubinemia.

OBJECTIVE: The goal of this study was to improve compliance with published guidelines regarding management of neonatal hyperbilirubinemia in infants admitted to a general pediatric hospital ward and to improve support for their breastfeeding mothers. METHODS: This quality improvement project was conducted by using Plan-Do-Study-Act cycles and statistical process control methods. Study subjects were infants > 35 weeks' gestation admitted for hyperbilirubinemia to the general inpatient ward of a large, freestanding pediatric hospital. We developed and implemented a guideline for the inpatient management of jaundiced neonates, with ongoing feedback given to the faculty on group performance. Outcome measures included monthly compliance scores based on American Academy of Pediatrics (AAP) guidelines for management of neonates > 35 weeks' gestation and the percentage of admitted jaundiced, breastfeeding infants whose mothers received lactation consultation during hospitalization. To determine the AAP compliance score, we reviewed and assigned points to each patient admission for completion of a standard evaluation, avoidance of unnecessary intravenous (IV) fluids and peripheral IV line placement, avoidance of rebound bilirubin checks while in the hospital, and the bilirubin level at discharge. RESULTS: Mean monthly AAP compliance scores increased from 60.5% of total possible points during the baseline period (January 2010-December 2010) to 90.4% during the intervention period (January 2011-December 2011). Lactation consultations increased from 48% during our baseline period to 63% during our early intervention period and to 90% during the last 5 months of our intervention. Length of stay was unchanged during the baseline and intervention periods. CONCLUSIONS: Interprofessional collaboration between nurses and physicians combined with a thoughtful campaign to increase awareness of published guidelines were successful in improving the care of infants admitted with unconjugated hyperbilirubinemia.

The neighborhood health exchange: developing a community partnership in residency.

BACKGROUND: The current system of residency training focuses on the hospital setting, and resident exposure to the surrounding community is often limited. However, community interaction can play an important role in ambulatory training and in learning systems-based practice, a residency core competency. The goal of the Neighborhood Health Exchange was to develop a community partnership to provide internal medicine residents with an opportunity to interface with community members through a mutually beneficial educational experience. METHODS: Internal medicine residents received training during their ambulatory block and participated in a voluntary field practicum designed to engage community members in discussions about their health. Community members participated in education sessions led by resident volunteers. RESULTS: Resident volunteers completed a survey on their experiences. All residents stated that the opportunity to lead an exchange was very useful to their overall residency training. Eight exchanges were held with a total of 61 community participants, who completed a 3-question survey following the session. This survey asked about the level of material, the helpfulness of the exchanges, and opportunities for improvement. We received 46 completed surveys from community members: 91% stated that the material was presented "at the right level" and 93% stated that the presentations were somewhat or very helpful. Eighty percent gave positive and encouraging comments about the exchange. CONCLUSION: Effective community partnerships involve assessing needs of the stakeholders, anticipating leadership turnover, and adapting the Neighborhood Health Exchange model to different groups. Community outreach can also enhance internal medicine ambulatory training experience, provide residents with patient counseling opportunities, and offer a novel method to enhance resident understanding of systems-based practice, especially within the larger community in which their patients live.

Internal medicine residents' comfort with and frequency of providing dietary counseling to diabetic patients.

BACKGROUND: Resident physicians' preparedness to provide dietary counseling for the rising number of diabetic patients is unclear. OBJECTIVE: To assess the comfort with, frequency of, and perceived effectiveness of diabetic dietary counseling by internal medicine (IM) residents. DESIGN: Cross-sectional survey. PARTICIPANTS: One hundred eleven IM residents at a single academic institution. RESULTS: Survey response rate was 94%. Fewer residents (56%) were comfortable with diabetic dietary counseling compared with counseling on symptoms of hypo/hyperglycemia (90%, p < 0.001). Residents less frequently provided diabetic dietary counseling (63%), compared with counseling for medication adherence (87%, p < 0.001). The 28% of residents reporting prior education with chronic disease self-management were more comfortable with diabetic dietary counseling (OR 3.2, 95% CI 1.4-7.3, p = 0.006), and reported counseling more frequently, although this difference was not statistically significant (OR 1.8, 95% CI 0.86-3.8, p = 0.12). More frequent counseling was reported by those residents who were more comfortable (OR 1.5, 95% CI 1.0-2.2, p = 0.03) or felt more effective (OR 3.6, 95% CI 2.1-6.1, p < 0.001) with their diabetic dietary counseling. CONCLUSION: Overall, IM residents reported low levels of comfort with and frequency of diabetic dietary counseling. However, residents who were more comfortable or who felt more effective with their dietary counseling counseled more frequently.