Moving Beyond the Dichotomous Assessment of Professionalism in the Internal Medicine Clerkship: Results of a National Survey of Clerkship Directors.

PURPOSE: This study examines how internal medicine clerkship faculty and leadership conceptualize professionalism and professional behaviors and attitudes, identifies whether and how faculty use metrics to assess professionalism and factor it into clerkship grades, and describes barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students. METHOD: The Clerkship Directors in Internal Medicine opened a call for thematic survey section proposals to its physician-faculty members, blind-reviewed all submissions, and selected 4 based on internal medicine clinical clerkship training experience relevance. The survey launched on October 5 and closed on December 7, 2021. Data were analyzed using descriptive statistics. RESULTS: Of 137 core clerkship directors (CDs) at Liaison Committee on Medical Education-accredited medical schools, 103 (75.2%) responded to the survey. Of 102 respondents (1 nonrespondent), 84 (82.4%) identified professional behavior lapses in involvement and 60 (58.8%) identified introspection lapses. Of 103 respondents, 97 (94.2%) reported that their clerkships ask clinical faculty and residents to formally evaluate professionalism, and 64 (62.1%) reported that they factor professionalism assessments into final clerkship grades. CDs reported multiple barriers to addressing professionalism directly with students, including logistical barriers, professionalism assessment subjectivity concerns, and the possible adverse effect of an unprofessional label for students. CONCLUSIONS: Professionalism assessment and remediation in medical education currently center on a deficit model that seeks to identify and remediate professionalism lapses, rather than a developmental model that seeks to nurture growth. This dichotomous characterization of behaviors as professional or unprofessional limits assessment and can adversely affect the learning environment. The authors propose a shift to a developmental model that considers professionalism as a continuous process parallel to the acquisition of clinical skills and medical knowledge.

Transitions curriculum impact on students and care.

BACKGROUND: Transitions of patient care from the inpatient to outpatient setting is a high-risk time often resulting in medical errors and adverse events. Transitions of care programmes have been demonstrated to reduce negative outcomes. Several professional societies have highlighted care transitions as a central pillar of patient care and therefore a crucial aspect of health professional education; however, little data exist on medical student education in this area. APPROACH: The Transitions of Care Curriculum was developed and delivered to all Harvard Medical School Core I Internal Medicine Clerkship students at Beth Israel Deaconess Medical Center, Boston, MA between January 2017 and March 2019, where 12-14 students participated each quarter and included didactic teaching followed by experiential learning. Student data were collected via postclerkship survey. Patient data were collected via chart review. Student self-reported comfort level with transitions in care skills and medical errors were analysed. EVALUATION: All student measures related to comfort with transitions in care skills demonstrated statistically significant improvement after curriculum participation(p < 0.001). Of the patients with a completed postdischarge note, students identified ≥1 postdischarge related issue in 33 of 70 patients, with multiple issues identified in many of these patients. Seventy-six total issues were identified. IMPLICATIONS: The Transitions of Care Curriculum demonstrated promising student and patient outcomes, suggesting that students can successfully learn and advance clinical skills while having a positive impact on a highly needed and important aspect of patient care by reducing postdischarge errors and adverse events.

Opportunities and challenges for a standardized curriculum in a student-run clinic network.

PURPOSE: Student-run clinics (SRCs) are prevalent in medical schools. Although these are popular among students and provide ample learning opportunities, these opportunities are not well-characterized. SRCs are poised to support medical schools' ability to meet accreditation standards and student growth and learning, particularly in areas missing from traditional curricula, such as social determinants of health, interprofessional education and inequities. MATERIALS AND METHODS: At the Crimson Care Collaborative (CCC), a network of 7 Harvard Medical School affiliated student-faculty practices in the greater Boston area, we sought to understand what learning opportunities and challenges exist and if a standardized curriculum could improve learning and result in less duplication of teaching efforts. We conducted semi-structured individual interviews of student and faculty leaders and conducted a thematic analysis of the data. RESULTS: Four key themes emerged: (1) Standardization provides opportunities and challenges, (2) Embrace the unique learning opportunities of each clinic, (3) Educational coaches enhance learning opportunities and increase efficiency, (4) Reflection is a useful tool for improvement & learning. DISCUSSION: Our results demonstrate a benefit to both a standardized curriculum for all SRC sites focused on broad clinical, skill-based training and site-specific teaching focusing on the unique clinical needs of each student-run clinic.

Integration of systematic clinical interprofessional training in a student-faculty collaborative primary care practice.

The changing healthcare environment and movement toward team-based care are contemporary challenges confronting health professional education. The primary care workforce must be prepared with recent national interprofessional competencies to practice and lead in this changing environment. From 2012 to 2014, the weekly Beth Israel Deaconess Crimson Care Collaborative Student-Faculty Practice collaborated with Northeastern University to develop, implement and evaluate an innovative model that incorporated interprofessional education into primary care practice with the goal of improving student understanding of, and ability to deliver quality, team-based care. In the monthly interprofessional clinic, an educational curriculum empowered students with evidence-based, team-based care principles. Integration of nursing, pharmacy, medicine, and masters of public health students and faculty into direct patient care, provided the opportunity to practice skills. The TeamSTEPPS® Teamwork Attitudes Questionnaire was administered pre- and post-intervention to assess its perceived impact. Seventeen students completed the post-intervention survey. Survey data indicated very positive attitudes towards team-based care at baseline. Significant improvements were reported in attitudes towards situation monitoring, limiting personal conflict, administration support and communication. However, small, but statistically significant declines were seen on one team structure and two communication items. Our program provides further evidence for the use of interprofessional training in primary care.

Defining curricular priorities for student-as-teacher programs: A National Delphi Study.

BACKGROUND: "Student-as-Teacher" (SaT) programs have been growing in number to prepare medical students for their teaching roles in residency and beyond, but it remains unknown what content areas should be covered in SaT curricula. AIM: To determine five to ten "essential" content areas for inclusion in SaT curricula using expert opinion. METHODS: Using a three-round Delphi process, moderators iteratively surveyed a panel of 28 medical educators (25 academy directors and three individuals identified as having expertise in undergraduate medical education) representing 25 medical schools in the United States. This "SaT Delphi Working Group" was tasked with rating topics for inclusion in SaT curricula on a 3-point scale (i.e. 1. "essential," 2. "important, but not essential" 3. "not important"). Topics achieving ≥70% consensus as "essential," "important" or "not important" were accepted by the moderators and removed from subsequent rounds. RESULTS: Hundred per cent response rate (n = 28) was achieved for all survey rounds. Five content areas reached consensus as "essential" for inclusion in a SaT curriculum: feedback, bedside teaching and clinical precepting, small-group teaching, case-based teaching and professionalism as a medical educator. CONCLUSION: This consensus from a group of leaders in medical education is a first step toward the implementation of more developmentally-appropriate SaT competencies.

Assessing Interprofessional education in a student-faculty collaborative practice network.

Although interprofessional relationships are ubiquitous in clinical practice, undergraduate medical students have limited opportunities to develop these relationships in the clinical setting. A few student-faculty collaborative practice networks (SFCPNs) have been working to address this issue, but limited data exist examining the nature and extent of these practices. A systematic survey at a Harvard-affiliated SFCPN is utilised to evaluate the quantity and quality of interprofessional interactions, isolate improvements, and identify challenges in undergraduate interprofessional education (IPE). Our data corroborate previous findings in which interprofessional clinical learning was shown to have positive effects on student development and align with all four domains of Interprofessional Education Collaborative core competencies, including interprofessional ethics and values, roles and responsibilities, interprofessional communication, and teams and teamwork. These results highlight the unique opportunity and growing necessity of integrating IPE in SFCPNs to endorse the development of collaborative and professional competencies in clinical modalities of patient care.

A Chronic Disease Management Student-Faculty Collaborative Practice: Educating Students on Innovation in Health Care Delivery.

PROBLEM: In the current transformative health care landscape, it is imperative that clinician educators inspire future clinicians to practice primary care in a dynamic environment. A focus on patient-centered, goal-oriented care for patients with chronic conditions is critical. APPROACH: In 2009, Harvard Medical School founded the Crimson Care Collaborative, a student-faculty collaborative practice (SFCP) network. With the aim of expanding clinical and educational opportunities for medical students and improving patient control of chronic disease (i.e., hypertension, obesity, and diabetes) in an innovative learning environment, in 2012, the authors developed a novel SFCP at their hospital-based academic primary care practice. In this SFCP, students learn to explore patient priorities, provide focused counseling and education, and assist patients with self-management goals during clinical visits. OUTCOMES: From 2012 to 2014, 250 student volunteers participated in the SFCP as clinicians, innovators, educators, and leaders, with between 80 and 95 medical students engaging each semester. Between January 2012 and March 2014, there were 476 urgent care or chronic disease management visits. Patients with chronic diseases were seen at least twice on average, and by 2014, chronic disease management visits accounted for approximately 74% of visits. NEXT STEPS: Work is under way to create assessment tools to evaluate the practice's educa tional impact and student understanding of the current health care system, develop interdisciplinary care teams, expand efforts in registry management and broaden the patient recruitment scope, further emphasize patient engage ment and retention, and evaluate chronic disease management and patient satisfaction effectiveness.

How we used a patient visit tracker tool to advance experiential learning in systems-based practice and quality improvement in a medical student clinic.

Poorly designed healthcare systems increase costs and preventable medical errors. To address these issues, systems-based practice (SBP) education provides future physicians with the tools to identify systemic errors and implement quality improvement (QI) initiatives to enhance the delivery of cost-effective, safe and multi-disciplinary care. Although SBP education is being implemented in residency programs and is mandated by the Accreditation Council for Graduate Medical Education (ACGME) as one of its core competencies, it has largely not been integrated into undergraduate medical education. We propose that Medical Student-Faculty Collaborative Clinics (MSFCCs) may be the ideal environment in which to train medical students in SBPs and QI initiatives, as they allow students to play pivotal roles in project development, administration, and management. Here we describe a process of experiential learning that was developed within a newly established MSFCC, which challenged students to identify inefficiencies, implement interventions, and track the results. After identifying bottlenecks in clinic operations, our students designed a patient visit tracker tool to monitor clinic flow and implemented solutions to decrease patient visit times. Our model allowed students to drive their own active learning in a practical clinical setting, providing early and unique training in crucial QI skills.

Successful implementation of a longitudinal, integrated pathology curriculum during the third year of medical school.

CONTEXT: There are few published examples of pathology instruction during the clinical years of medical student training. This lack of exposure to pathology may lead to poor understanding of laboratory testing and the role of pathologists in patient care. OBJECTIVE: To design, implement, and evaluate a pathology curriculum integrated into a longitudinal clerkship for third-year medical students. DESIGN: The curriculum includes an introductory session during the transition week course, pathologist participation in longitudinal student case conferences, and a pathology elective. The curriculum was evaluated by using surveys consisting of both multiple choice and written responses. RESULTS: A total of 55 students participated in the longitudinal curriculum during the 2009-2010 academic year and 8 students, only one of whom stated a career interest in pathology, participated in the elective. More than 80 pathology topics were discussed and, for the first time, pathologists received teaching awards from the third-year students. All elective students would recommend the elective to colleagues; feedback also suggested an improved understanding of pathology as a profession. At the end of the year, 31% of all students, compared to only 19% in the initial survey, knew that most of an anatomic pathologist's caseload consists of specimens from living patients (P  =  .13). In addition, elective student interaction with a pathology faculty member directly led to an improvement in test reporting. CONCLUSIONS: A novel longitudinal curriculum allowed for the creative integration of pathology into third-year students' clinical training and led to better student understanding of the role of pathologists in patient care.

Teaching medical students about obesity: a pilot program to address an unmet need through longitudinal relationships with bariatric surgery patients.

BACKGROUND: Despite obesity's relevance and impact, curricula addressing obesity are underrepresented in clinical medical education. A novel pilot program to begin teaching medical students about care of the obese patient was developed and student attitudes toward obesity and bariatric surgery were assessed. METHODS: The authors paired third-year students with obese patients undergoing bariatric surgery. Students established a longitudinal patient relationship, received faculty mentorship, and kept a reflections journal. An attitude assessment survey was administered before and after third year. Reflections were analyzed for common themes. RESULTS: Baseline student responses differed from those previously reported for practicing physicians on many survey statements, including more strongly agreeing with the relationship between obesity and serious medical conditions (P < .001), the need to educate patients about obesity risks (P < .001), and willingness to recommend bariatric surgery evaluation (P = .004). These differences were maintained after clinical clerkships. Reflection themes included recognition of obesity stereotypes, improved estimation of body mass index, and awareness of physicians' attitudes about obesity. CONCLUSION: Development and assessment of a novel pilot program to teach third-year medical students about obesity and bariatric surgery suggests a potential impact on student attitudes and understanding of obesity and obesity surgery. Students today may have different attitudes toward obesity than those reflected in prior data for physicians in practice, and programs such as this may help maintain positive attitudes.

Relation of heart rate response to exercise with prognosis and atherosclerotic progression after coronary artery bypass grafting.

Impaired heart rate response to exercise is associated with adverse clinical outcomes in healthy adults and those with established coronary artery disease. It is unclear whether this association persists in subjects who have undergone coronary artery bypass grafting (CABG). In this study, 920 subjects enrolled in the Post CABG trial who had undergone CABG with patent saphenous vein grafts at baseline and known to have discontinued beta blockers before exercise were studied. A maximal symptom-limited exercise treadmill test was performed on study entry. Chronotropic variables were measured at peak exercise. Participants were followed for a composite end point of death, myocardial infarction, stroke, or revascularization. Quantitative coronary angiography was performed at follow-up and compared with baseline angiography, with prespecified angiographic end points of the substantial progression of graft disease and complete occlusion. In multivariate analysis, a low chronotropic index was strongly associated with an increased risk for the composite clinical end point (p for trend = 0.04) and angiographic complete occlusion (p for trend = 0.007) but only weakly associated with angiographic substantial progression (p for trend = 0.07). In conclusion, impaired chronotropic response to exercise identifies subjects at risk for clinical outcomes and graft occlusion, even after revascularization with CABG.

The relationship between obesity and atherosclerotic progression and prognosis among patients with coronary artery bypass grafts the effect of aggressive statin therapy.

OBJECTIVES: This study examines whether obesity accelerates atherogenic progression or adverse outcomes after coronary artery bypass graft (CABG) surgery. BACKGROUND: Obesity is a major risk factor for developing coronary heart disease. Whether obesity accelerates disease progression after CABG is unclear. METHODS: We examined how body mass index (BMI) related to atherosclerotic graft progression and a clinical composite outcome of death, nonfatal myocardial infarction, stroke, CABG surgery, or angioplasty among 1,314 participants in the Post CABG trial. Participants who had undergone CABG surgery were randomly assigned in a 2 x 2 factorial design to warfarin versus placebo and aggressive low-density lipoprotein cholesterol (LDL-C) lowering with lovastatin 40 to 80 mg/day (to achieve LDL-C of 60 to 85 mg/dl) versus moderate LDL-C lowering with lovastatin 2.5 to 5 mg/day (to achieve LDL-C of 130 to 140 mg/dl). Angiographic progression was assessed by coronary angiography at 4 to 5 years. RESULTS: Higher BMI was associated with a higher likelihood of angiographic progression (p trend = 0.003) after adjustment for demographic factors, treatment assignment, smoking status, and years since CABG surgery, but not with clinical events (p trend = 0.81). In stratified analyses, higher BMI was associated with angiographic progression in the low-dose lovastatin group (p trend <0.001) but not in the high-dose group (p = 0.03 for test for interaction of BMI and statin treatment). In the high-dose lovastatin group, higher BMI appeared to be protective against clinical events (p trend = 0.06, test of interaction: 0.02). CONCLUSIONS: Higher BMI is strongly associated with atherogenic progression after CABG surgery. Aggressive statin therapy may be protective against obesity-related acceleration of coronary heart disease.

The joint effects of physical activity and body mass index on coronary heart disease risk in women.

BACKGROUND: Physical activity and body mass index (calculated as weight in kilograms divided by height in meters squared) independently alter the risk of coronary heart disease (CHD); however, their combined effect on CHD is not established. Our objective was to study the combined association of physical activity and body mass index on CHD. METHODS: Prospective cohort study of 38,987 women free of cardiovascular disease, cancer, and diabetes at baseline in the Women's Health Study, with 10.9 mean years of follow-up. Weight, height, and recreational activities were reported on entry. Body mass index was categorized as normal weight (<25), overweight (25 to <30), and obese (> or =30). Active was defined as 1000 kilocalories or more expended on recreational activities weekly. Six joint body weight-physical activity categories were defined. The main outcome measure was the occurrence of incident CHD during follow-up, defined as a cardiovascular event including nonfatal myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, or CHD death. RESULTS: A total of 948 cases of incident CHD occurred during follow-up. Higher body mass index and physical inactivity were individual predictors of CHD. In joint analyses, compared with active normal-weight individuals, the multivariate-adjusted hazard ratios (95% confidence intervals) were 1.54 (1.14-2.08) for overweight-active; 1.87 (1.29-2.71) for obese-active; 1.08 (0.84-1.39) for normal weight-inactive; 1.88 (1.46-2.42) for overweight-inactive; and 2.53 (1.94-3.30) for obese-inactive. Increasing levels of walking also resulted in significant reductions in CHD risk for overweight and obese individuals. CONCLUSIONS: The risk of CHD associated with elevated body mass index is considerably reduced by increased physical activity levels. However, the risk is not completely eliminated, reinforcing the importance of being lean and physically active.

Joint effects of physical activity and body weight on diabetes and cardiovascular disease.

Recent studies have evaluated the interrelationship between physical activity and body weight on the incidence of chronic diseases such as diabetes and cardiovascular disease (CVD). The combined effect seems to be different and to be dependent on the disease mechanism. Studies reveal that body weight has a greater influence on diabetes, and physical activity plays a greater role in CVD.

Relationship of physical activity vs body mass index with type 2 diabetes in women.

CONTEXT: Physical inactivity and body mass index (BMI) are established independent risk factors in the development of type 2 diabetes; however, their comparative importance and joint relationship with diabetes are unclear. OBJECTIVE: To examine the relative contributions and joint association of physical activity and BMI with diabetes. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 37 878 women free of cardiovascular disease, cancer, and diabetes with 6.9 years of mean follow-up. Weight, height, and recreational activities were reported at study entry. Normal weight was defined as a BMI of less than 25; overweight, 25 to less than 30; and obese, 30 or higher. Active was defined as expending more than 1000 kcal on recreational activities per week. MAIN OUTCOME MEASURE: Incident type 2 diabetes, defined as a new self-reported diagnosis of diabetes. RESULTS: During the follow-up, 1361 cases of incident diabetes occurred. Individually, BMI and physical activity were significant predictors of incident diabetes. Compared with normal-weight individuals, the multivariate-adjusted hazard ratio (HR) was 3.22 (95% confidence interval [CI], 2.69-3.87) for overweight individuals and 9.09 (95% CI, 7.62-10.8) for obese individuals. For overall activity (kilocalories expended per week), compared with the least active first quartile, the multivariate-adjusted HRs were 0.91 (95% CI, 0.79-1.06) for the second quartile, 0.86 (95% CI, 0.74-1.01) for the third, and 0.82 (95% CI, 0.70-0.97) for the fourth (P for trend =.01). In the combined analyses, overweight and obese participants, whether active or inactive, had significantly elevated risks, compared with normal-weight active individuals. The multivariate-adjusted HRs were 1.15 (95% CI, 0.83-1.59) for normal-weight inactive, 3.68 (95% CI, 2.63-5.15) for overweight active, 4.16 (95% CI, 3.05-5.66) for overweight inactive, 11.5 (95% CI, 8.34-15.9) for obese active, and 11.8 (95% CI, 8.75-16.0) for obese inactive participants. CONCLUSIONS: Although BMI and physical inactivity are independent predictors of incident diabetes, the magnitude of the association with BMI was greater than with physical activity in combined analyses. These findings underscore the critical importance of adiposity as a determinant of diabetes.