Identifying and Supporting Students to Prevent USMLE Step 1 Failures When Testing Follows Clerkships: Insights From 9 Schools.

Several schools have moved the United States Medical Licensing Examination Step 1 exam after core clerkships, and others are considering this change. Delaying Step 1 may improve Step 1 performance and lower Step 1 failure rates. Schools considering moving Step 1 are particularly concerned about late identification of struggling students and late Step failures, which can be particularly problematic due to reduced time to remediate and accumulated debt if remediation is ultimately unsuccessful. In the literature published to date, little attention has been given to these students. In this article, authors from 9 medical schools with a postclerkship Step 1 exam share their experiences. The authors describe curricular policies, early warning and identification strategies, and interventions to enhance success for all students and struggling students in particular. Such learners can be identified by understanding challenges that place them "at risk" and by tracking performance outcomes, particularly on other standardized assessments. All learners can benefit from early coaching and advising, mechanisms to ensure early feedback on performance, commercial study tools, learning specialists or resources to enhance learning skills, and wellness programs. Some students may need intensive tutoring, neuropsychological testing and exam accommodations, board preparation courses, deceleration pathways, and options to postpone Step 1. In rare instances, a student may need a compassionate off-ramp from medical school. With the National Board of Medical Examiner's announcement that Step 1 scoring will change to pass/fail as early as January 2022, residency program directors might use failing Step 1 scores to screen out candidates. Institutions altering the timing of Step 1 can benefit from practical guidance by those who have made the change, to both prevent Step 1 failures and minimize adverse effects on those who fail.

Building Social Capital to Foster Interprofessional Education: The Interprofessional Educator Academy.

Interprofessional education (IPE) is promoted as a necessary precursor to the implementation of the collaborative practices in patient care thought to improve teamwork and communication among health care providers, patients, their families, and communities. Yet barriers to IPE persist, due largely to a lack of understanding on the part of health care team members about the norms and practices of health professions outside their own. A by-product of social interactions within groups and networks, social capital is a collective asset that contributes to the development of trust, innovation, and coordination of efforts toward mutual goals. Duke AHEAD (Academy for Health Professions Education and Academic Development), an interprofessional educator academy, is examined through the lens of social capital theory as a viable means of breaking down barriers to IPE, thereby improving patient care.

Efficacy of an educational intervention on students' attitudes regarding spirituality in healthcare: a cohort study in the USA.

OBJECTIVE: To determine if an educational intervention focused on the role of spirituality in healthcare positively affects medical students' attitudes and perceptions relating to this topic. DESIGN: A pre-post cohort study. SETTING: An undergraduate medical institution affiliated with an academic medical center in the USA. PARTICIPANTS: A total of 110 medical students currently on their clinical rotations received the educational intervention, of whom 71 (65%) completed both the presurvey and postsurvey. Demographic variables did not significantly differ from the national average of medical students, or from a comparison group. All students who attended the intervention were given the opportunity to participate in the survey. INTERVENTIONS: The educational intervention consisted of a 60-minute lecture focusing on religion/spirituality (R/S) in healthcare, followed by a 90-minute case discussion in a small group setting. PRIMARY AND SECONDARY OUTCOME MEASURES: Assessment consisted of 18-item preintervention and postintervention survey quantifying student's attitudes towards, comfort with, and perceptions of R/S in healthcare. RESULTS: Attitudes towards, comfort with, and perceptions of R/S in healthcare were generally positive preintervention. Following the intervention, students expressed an increased willingness to include R/S competency in their future practice (p=0.001), were more comfortable sharing their own R/S beliefs with a patient when appropriate (p=0.02), and were more willing to approach a patient with R/S concern (p=0.04). The other surveyed attitudes demonstrated positive, but non-significant improvement. CONCLUSION: An educational intervention focusing on approaching patients with R/S concerns has the ability to improve the attitudes and comfort of medical students. By incorporating a total of 150 minutes of education about R/S, medical schools can help develop this particular area of cultural competence, preparing a generation of physicians to professionally approach R/S concerns of patients. Future research should move beyond quantifying attitudes and strive to understand changes in knowledge and student behaviour.

Is it a match? a novel method of evaluating medical school success.

BACKGROUND: Medical education program evaluation allows for curricular improvements to both Undergraduate (UME) and Graduate Medical Education (GME). UME programs are left with little more than match rates and self-report to evaluate success of graduates in The Match. OBJECTIVE: This manuscript shares a novel method of program evaluation through a systematic assessment of Match outcomes. DESIGN: Surveys were developed and distributed to Program Training Directors (PTDs) at our institution to classify residency programs into which our UME graduates matched using an ordinal response scale and open-ended responses. Outcomes-based measures for UME graduates were collected and analyzed. The relationship between PTD survey data and UME graduates' outcomes were explored. Open-ended response data were qualitatively analyzed using iterative cycles of coding and identifying themes. RESULTS: The PTD survey response rate was 100%. 71% of our graduates matched to programs ranked as 'elite' (36%) or 'top' (35%) tier. The mean total number of 'Honors' grades achieved by UME graduates was 2.6. Data showed that graduates entering elite and top GME programs did not consistently earn Honors in their associated clerkships. A positive correlation was identified between USMLE Step 1 score, number of honors, and residency program rankings for a majority of the programs. Qualitative analysis identified research, faculty, and clinical exposure as necessary characteristics of 'elite' programs:. Factors considered by PTDs in the rating of programs included reputation, faculty, research, national presence and quality of graduates. CONCLUSIONS: This study describes a novel outcomes-based method of evaluating the success of UME programs. Results provided useful feedback about the quality of our UME program and its ability to produce graduates who match in highly-regarded GME programs. The findings from this study can benefit Clerkship Directors, Student Affairs and Curriculam Deans, and residency PTDs as they help students determine their competitiveness forspecialties and specific residency programs.

A problem-based learning curriculum in geriatrics for medical students.

A geriatrics curriculum delivered to medical students was evaluated in this study. Students were instructed to review real patient cases, interview patients and caregivers, identify community resources to address problems, and present a final care plan. Authors evaluated the course feedback and final care plans submitted by students for evidence of learning in geriatric competencies. Students rated the efficacy of the course on a 5-point Likert scale as 3.70 for developing clinical reasoning skills and 3.69 for interdisciplinary teamwork skills. Assessment of an older adult with medical illness was rated as 3.87 and ability to perform mobility and functional assessment as 3.85. Reviews of written final care plans provided evidence of student learning across several different geriatric competencies such as falls, medication management, cognitive and behavior disorders, and self-care capacity. Assessment of the curriculum demonstrated that medical students achieved in-depth learning across multiple geriatric competencies through contact with real cases.

Roadmap for creating an accelerated three-year medical education program.

Medical education is undergoing significant transformation. Many medical schools are moving away from the concept of seat time to competency-based education and introducing flexibility in the curriculum that allows individualization. In response to rising student debt and the anticipated physician shortage, 35% of US medical schools are considering the development of accelerated pathways. The roadmap described in this paper is grounded in the experiences of the Consortium of Accelerated Medical Pathway Programs (CAMPP) members in the development, implementation, and evaluation of one type of accelerated pathway: the three-year MD program. Strategies include developing a mission that guides curricular development - meeting regulatory requirements, attaining institutional buy-in and resources necessary to support the programs, including student assessment and mentoring - and program evaluation. Accelerated programs offer opportunities to innovate and integrate a mission benefitting students and the public. ABBREVIATIONS: CAMPP: Consortium of accelerated medical pathway programs; GME: Graduate medical education; LCME: Liaison committee on medical education; NRMP: National residency matching program; UME: Undergraduate medical education.

Why Not Wait? Eight Institutions Share Their Experiences Moving United States Medical Licensing Examination Step 1 After Core Clinical Clerkships.

The majority of medical students complete the United States Medical Licensing Examination Step 1 after their foundational sciences; however, there are compelling reasons to examine this practice. This article provides the perspectives of eight MD-granting medical schools that have moved Step 1 after the core clerkships, describing their rationale, logistics of the change, outcomes, and lessons learned. The primary reasons these institutions cite for moving Step 1 after clerkships are to foster more enduring and integrated basic science learning connected to clinical care and to better prepare students for the increasingly clinical focus of Step 1. Each school provides key features of the preclerkship and clinical curricula and details concerning taking Steps 1 and 2, to allow other schools contemplating change to understand the landscape. Most schools report an increase in aggregate Step 1 scores after the change. Despite early positive outcomes, there may be unintended consequences to later scheduling of Step 1, including relatively late student reevaluations of their career choice if Step 1 scores are not competitive in the specialty area of their choice. The score increases should be interpreted with caution: These schools may not be representative with regard to mean Step 1 scores and failure rates. Other aspects of curricular transformation and rising national Step 1 scores confound the data. Although the optimal timing of Step 1 has yet to be determined, this article summarizes the perspectives of eight schools that changed Step 1 timing, filling a gap in the literature on this important topic.

CaPOW! Using Problem Sets in a Capstone Course to Improve Fourth-Year Medical Students' Confidence in Self-Directed Learning.

PROBLEM: Despite the importance of self-directed learning (SDL) in the field of medicine, individuals are rarely taught how to perform SDL or receive feedback on it. Trainee skill in SDL is limited by difficulties with self-assessment and goal setting. APPROACH: Ninety-two graduating fourth-year medical students from Duke University School of Medicine completed an individualized learning plan (ILP) for a transition-to-residency Capstone course in spring 2015 to help foster their skills in SDL. Students completed the ILP after receiving a personalized report from a designated faculty coach detailing strengths and weaknesses on specific topics (e.g., pulmonary medicine) and clinical skills (e.g., generating a differential diagnosis). These were determined by their performance on 12 Capstone Problem Sets of the Week (CaPOWs) compared with their peers. Students used transitional-year milestones to self-assess their confidence in SDL. OUTCOMES: SDL was successfully implemented in a Capstone course through the development of required clinically oriented problem sets. Coaches provided guided feedback on students' performance to help them identify knowledge deficits. Students' self-assessment of their confidence in SDL increased following course completion. However, students often chose Capstone didactic sessions according to factors other than their CaPOW performance, including perceived relevance to planned specialty and session timing. NEXT STEPS: Future Capstone curriculum changes may further enhance SDL skills of graduating students. Students will receive increased formative feedback on their CaPOW performance and be incentivized to attend sessions in areas of personal weakness.

Mystery behind the match: an undergraduate medical education-graduate medical education collaborative approach to understanding match goals and outcomes.

BACKGROUND: There is a paucity of information regarding institutional targets for the number of undergraduate medical education (UME) graduates being matched to graduate medical education (GME) programs at their home institutions. At our institution, the Duke University, the number of UME graduates matched to GME programs declined dramatically in 2011. To better understand why this decline may have happened, we sought to identify perceived quality metrics for UME and GME learners, evaluate trends in match outcomes and educational program characteristics, and explore whether there is an ideal retention rate for UME graduates in their home institutions' GME programs. METHODS: We analyzed the number of Duke University UME graduates remaining at Duke for GME training over the past 5 years. We collected data to assess for changing characteristics of UME and GME, and performed descriptive analysis of trends over time to investigate the potential impact on match outcomes. RESULTS: A one-sample t-test analysis showed no statistically significant difference in the number of Duke UME graduates who stayed for GME training. For both UME and GME, no significant changes in the characteristics of either program were found. DISCUSSION: We created a process for monitoring data related to the characteristics or perceived quality of UME and GME programs and developed a shared understanding of what may impact match lists for both UME graduates and GME programs, leaving the Match somewhat less mysterious. While we understand the trend of graduates remaining at their home institutions for GME training, we are uncertain whether setting a goal for retention is reasonable, and so some mystery remains. We believe there is an invaluable opportunity for collaboration between UME and GME stakeholders to facilitate discussion about setting shared institutional goals.

A meaningful MESS (Medical Education Scholarship Support).

BACKGROUND: Graduate medical education faculty bear the responsibility of demonstrating active research and scholarship; however, faculty who choose education-focused careers may face unique obstacles related to the lack of promotion tracks, funding, career options, and research opportunities. Our objective was to address education research and scholarship barriers by providing a collaborative peer-mentoring environment and improve the production of research and scholarly outputs. METHODS: We describe a Medical Education Scholarship Support (MESS) group created in 2013. MESS is an interprofessional, multidisciplinary peer-mentoring education research community that now spans multiple institutions. This group meets monthly to address education research and scholarship challenges. Through this process, we develop new knowledge, research, and scholarly products, in addition to meaningful collaborations. RESULTS: MESS originated with eight founding members, all of whom still actively participate. MESS has proven to be a sustainable unfunded local community of practice, encouraging faculty to pursue health professions education (HPE) careers and fostering scholarship. We have met our original objectives that involved maintaining 100% participant retention; developing increased knowledge in at least seven content areas; and contributing to the development of 13 peer-reviewed publications, eight professional presentations, one Masters of Education project, and one educational curriculum. DISCUSSION: The number of individuals engaged in HPE research continues to rise. The MESS model could be adapted for use at other institutions, thereby reducing barriers HPE researchers face, providing an effective framework for trainees interested in education-focused careers, and having a broader impact on the education research landscape.

Teaching crucial skills: An electrocardiogram teaching module for medical students.

BACKGROUND: Medical student performance in electrocardiogram (ECG) interpretation at our institution could be improved. Varied resources exist to teach students this essential skill. METHODS: We created an ECG teaching module (ECGTM) of 75 cases representing 15 diagnoses to improve medical students' performance and confidence in ECG interpretation. Students underwent pre- and post-clerkship testing to assess ECG interpretation skills and confidence and also end-of-clinical-year testing in ECG and laboratory interpretation. Performance was compared for the years before and during ECGTM availability. RESULTS: Eighty-four percent of students (total n=101) reported using the ECGTM; 98% of those who used it reported it was useful. Students' performance and confidence were higher on the post-test. Students with access to the ECGTM (n=101) performed significantly better than students from the previous year (n=90) on the end-of-year ECG test. CONCLUSIONS: The continuous availability of an ECGTM was associated with improved confidence and ability in ECG interpretation. The ECGTM may be another available tool to help students as they learn to read ECGs.

Using Transitional Year Milestones to Assess Graduating Medical Students' Skills During a Capstone Course.

BACKGROUND: Undergraduate medical education (UME) follows the lead of graduate medical education (GME) in moving to competency-based assessment. The means for and the timing of competency-based assessments in UME are unclear. OBJECTIVE: We explored the feasibility of using the Accreditation Council for Graduate Medical Education Transitional Year (TY) Milestones to assess student performance during a mandatory, fourth-year capstone course. METHODS: Our single institution, observational study involved 99 medical students who completed the course in the spring of 2014. Students' skills were assessed by self, peer, and faculty assessment for 6 existing course activities using the TY Milestones. Evaluation completion rates and mean scores were calculated. RESULTS: Students' mean milestone levels ranged between 2.2 and 3.6 (on a 5-level scoring rubric). Level 3 is the performance expected at the completion of a TY. Students performed highest in breaking bad news and developing a quality improvement project, and lowest in developing a learning plan, working in interdisciplinary teams, and stabilizing acutely ill patients. Evaluation completion rates were low for some evaluations, and precluded use of the data for assessing student performance in the capstone course. Students were less likely to complete separate online evaluations. Faculty were less likely to complete evaluations when activities did not include dedicated time for evaluations. CONCLUSIONS: Assessment of student competence on 9 TY Milestones during a capstone course was useful, but achieving acceptable evaluation completion rates was challenging. Modifications are necessary if milestone scores from a capstone are intended to be used as a handoff between UME and GME.

The Impact of a Mandatory Immersion Curriculum in Integrative Medicine for Graduating Medical Students.

BACKGROUND: Although many Americans utilize complementary and alternative medicine (CAM) services and products, few medical school curricula consistently provide instruction in counseling patients on the use of CAM or strategies for identifying credible evidence on the safety and effectiveness of CAM therapies. METHODS: This is a mixed methods study. A sustainable, mandatory, half-day CAM immersion curriculum for graduating medical students is described. Student comfort talking with patients about CAM, their willingness to refer patients to a CAM provider, and adequacy of the CAM curriculum was assessed. RESULTS: Students who participated in this mandatory curriculum, rated the medical school curriculum in CAM as more adequate than students at other medical schools without a mandatory curriculum. Students' narrative comments indicate the curriculum impacts students knowledge about CAM, patient use of CAM, and personal practice with CAM in the future. CONCLUSIONS: The timing of the CAM curriculum near to graduation, students' personal exploration of several CAM modalities through immersion, and student interaction with community CAM providers are aspects of the curriculum that make the curriculum successful and memorable.

A comparison of the effectiveness of the team-based learning readiness assessments completed at home to those completed in class.

PURPOSE: The readiness assurance process (RAP) of team-based learning (TBL) is an important element that ensures that students come prepared to learn. However, the RAP can use a significant amount of class time which could otherwise be used for application exercises. The authors administered the TBL-associated RAP in class or individual readiness assurance tests (iRATs) at home to compare medical student performance and learning preference for physiology content. METHODS: Using cross-over study design, the first year medical student TBL teams were divided into two groups. One group was administered iRATs and group readiness assurance tests (gRATs) consisting of physiology questions during scheduled class time. The other group was administered the same iRAT questions at home, and did not complete a gRAT. To compare effectiveness of the two administration methods, both groups completed the same 12-question physiology assessment during dedicated class time. Four weeks later, the entire process was repeated, with each group administered the RAP using the opposite method. RESULTS: The performance on the physiology assessment after at-home administration of the iRAT was equivalent to performance after traditional in-class administration of the RAP. In addition, a majority of students preferred the at-home method of administration and reported that the at-home method was more effective in helping them learn course content. CONCLUSION: The at-home administration of the iRAT proved effective. The at-home administration method is a promising alternative to conventional iRATs and gRATs with the goal of preserving valuable in-class time for TBL application exercises.

The emotions of graduating medical students about prior patient care experiences.

OBJECTIVES: To determine the emotional responses to patient care activities described by fourth year medical students. METHODS: Qualitative content analysis for emerging themes in letters written by graduating medical students to patients during a Capstone Course. The patient need not be alive and the letter would never be sent. RESULTS: Six themes emerged from student letters: (1) Sorrow for the depths of patient suffering; (2) Gratitude towards patients and their families; (3) Personal responsibility for care provided to patients; (4) Regret for poor care provided by the student or student's team; (5) Shattered expectations about medicine and training; and (6) Anger towards patients. Students expressed sensitivity to vulnerable patients, including those who were alone, unable to communicate, or for whom care was biased. Students' expressed powerlessness (inability to cure, managing a work-life balance, and challenges with hierarchy) in some essays. CONCLUSION: At graduation, medical students describe strong emotions about previous patient care experiences, including difficulty witnessing suffering, disappointment with medicine, and gratitude to patients and their families PRACTICE IMPLICATIONS: Providing regular opportunities for writing throughout medical education would allow students to recognize their emotions, reflect upon them and promote wellness that would benefit students and their patients.

Anxiety in first year medical students taking gross anatomy.

To study anxiety levels in first-year medical students taking gross anatomy. Thirty medical students per year, for 2 years, completed the Beck Anxiety Inventory (BAI) 10 times during a 13-week gross anatomy course. In addition, behavioral observations were made by a psychiatrist during gross anatomy for demonstrations of assertive, destructive, neutral, or passive behavior. Additional qualitative outcome measures were group exit interviews with the faculty and students. The mean BAI for all 60 students per year, for 2 years, was 2.19 ± 3.76, 93% of the scores indicated minimal anxiety, and 89% of BAI values were less than five which confirmed a minimal level of anxiety. The low level of reported BAI contrasted sharply with verbal reports by the same students and face-to-face exit interviews with the psychiatrist. Symptoms of stress and anxiety emerged as a result of these conversations. The high levels of subjective stress and anxiety revealed by the interviews were unknown to the gross anatomy faculty. The low scores of students on the BAI's stand in sharp contrast to the BAI's reported for medical students in other published reports. Although it is possible that our students were truthfully devoid of anxiety, it is more likely that our students were denying even minimal anxiety levels. There have been reports that medical students feel that admitting stress, depression, or anxiety put their competitiveness for a residency at risk. We conclude that students may be in frank denial of experiencing anxiety and, if so, this behavior is not conducive to good mental health.

Gaps in procedural experience and competency in medical school graduates.

OBJECTIVES: The goal of undergraduate medical education is to prepare medical students for residency training. Active learning approaches remain important elements of the curriculum. Active learning of technical procedures in medical schools is particularly important, because residency training time is increasingly at a premium because of changes in the Accreditation Council for Graduate Medical Education duty hour rules. Better preparation in medical school could result in higher levels of confidence in conducting procedures earlier in graduate medical education training. The hypothesis of this study was that more procedural training opportunities in medical school are associated with higher first-year resident self-reported competency with common medical procedures at the beginning of residency training. METHODS: A survey was developed to assess self-reported experience and competency with common medical procedures. The survey was administered to incoming first-year residents at three U.S. training sites. Data regarding experience, competency, and methods of medical school procedure training were collected. Overall satisfaction and confidence with procedural education were also assessed. RESULTS: There were 256 respondents to the procedures survey. Forty-four percent self-reported that they were marginally or not adequately prepared to perform common procedures. Incoming first-year residents reported the most procedural experience with suturing, Foley catheter placement, venipuncture, and vaginal delivery. The least experience was reported with thoracentesis, central venous access, and splinting. Most first-year residents had not provided basic life support, and more than one-third had not performed cardiopulmonary resuscitation (CPR). Participation in a targeted procedures course during medical school and increasing the number of procedures performed as a medical student were significantly associated with self-assessed competency at the beginning of residency training. CONCLUSIONS: Recent medical school graduates report lack of self-confidence in their ability to perform common procedures upon entering residency training. Implementation of a medical school procedure course to increase exposure to procedures may address this challenge.