Regular Formal Evaluation Sessions are Effective as Frame-of-Reference Training for Faculty Evaluators of Clerkship Medical Students.

BACKGROUND: Face-to-face formal evaluation sessions between clerkship directors and faculty can facilitate the collection of trainee performance data and provide frame-of-reference training for faculty. OBJECTIVE: We hypothesized that ambulatory faculty who attended evaluation sessions at least once in an academic year (attendees) would use the Reporter-Interpreter-Manager/Educator (RIME) terminology more appropriately than faculty who did not attend evaluation sessions (non-attendees). DESIGN: Investigators conducted a retrospective cohort study using the narrative assessments of ambulatory internal medicine clerkship students during the 2008-2009 academic year. PARTICIPANTS: The study included assessments of 49 clerkship medical students, which comprised 293 individual teacher narratives. MAIN MEASURES: Single-teacher written and transcribed verbal comments about student performance were masked and reviewed by a panel of experts who, by consensus, (1) determined whether RIME was used, (2) counted the number of RIME utterances, and (3) assigned a grade based on the comments. Analysis included descriptive statistics and Pearson correlation coefficients. KEY RESULTS: The authors reviewed 293 individual teacher narratives regarding the performance of 49 students. Attendees explicitly used RIME more frequently than non-attendees (69.8 vs. 40.4 %; p < 0.0001). Grades recommended by attendees correlated more strongly with grades assigned by experts than grades recommended by non-attendees (r = 0.72; 95 % CI (0.65, 0.78) vs. 0.47; 95 % CI (0.26, 0.64); p = 0.005). Grade recommendations from individual attendees and non-attendees each correlated significantly with overall student clerkship clinical performance [r = 0.63; 95 % CI (0.54, 0.71) vs. 0.52 (0.36, 0.66), respectively], although the difference between the groups was not statistically significant (p = 0.21). CONCLUSIONS: On an ambulatory clerkship, teachers who attended evaluation sessions used RIME terminology more frequently and provided more accurate grade recommendations than teachers who did not attend. Formal evaluation sessions may provide frame-of-reference training for the RIME framework, a method that improves the validity and reliability of workplace assessment.

A prospective controlled trial of the influence of a geriatrics home visit program on medical student knowledge, skills, and attitudes towards care of the elderly.

PURPOSE: To determine the impact of a geriatrics home visit program for third-year medical students on attitudes, skills, and knowledge. METHODS: Using a mixed methods, prospective, controlled trial, volunteer control group students (n = 17) at two sites and intervention group students (n = 16) at two different sites within the same internal medicine clerkship were given Internet and CDROM-based geriatric self-study materials. Intervention group students identified a geriatrics patient from their clinical experience, performed one "home" visit (home, nursing home, or rehabilitation facility) to practice geriatric assessment skills, wrote a structured, reflective paper, and presented their findings in small-group teaching settings. Papers were qualitatively analyzed using the constant comparative method for themes. All students took a pre-test and post-test to measure changes in geriatrics knowledge and attitudes. RESULTS: General attitudes towards caring for the elderly improved more in the intervention group than in the control group (9.8 vs 0.5%; p = 0.04, effect size 0.78). Medical student attitudes towards their home care training in medical school (21.7 vs 3.2%; p = 0.02, effect size 0.94) improved, as did attitudes towards time and reimbursement issues surrounding home visits (10.1 vs -0.2%; p = 0.02, effect size 0.89). Knowledge of geriatrics improved in both groups (13.4 vs 15.2% improvement; p = 0.73). Students described performing a mean of seven separate geriatric assessments (range 4-13) during the home visit. Themes that emerged from the qualitative analysis of the reflective papers added depth and understanding to the quantitative data and supported results concerning attitudinal change. CONCLUSIONS: While all participants gained geriatrics knowledge during their internal medicine clerkship, students who performed a home visit had improved attitudes towards the elderly and described performing geriatric assessment skills. Requiring little faculty time, a geriatrics home visit program like this one may be a useful clerkship addition to foster medical students' professional growth.

Thyrotoxicosis and Choledocholithiasis Masquerading as Thyroid Storm.

A 26-year-old female, thirteen months postpartum, presented to the emergency department for four weeks of epigastric abdominal pain, pruritus, new onset jaundice, and 11.3 kgs (25 lbs) unintentional weight loss. On examination, she was afebrile, tachycardic, alert, and oriented and had jaundice with scleral icterus. Labs were significant for undetectable TSH, FT4 that was too high to measure, and elevated total bilirubin, direct bilirubin, alkaline phosphatase, and transaminases. Abdominal ultrasound revealed cholelithiasis without biliary ductal dilation. Treatment for presumed thyroid storm was initiated. Further work-up with magnetic resonance cholangiopancreatography (MRCP) revealed an obstructing cholelith within the distal common bile duct. With the presence of choledocholithiasis explaining the jaundice and abdominal pain, plus the absence of CNS alterations, the diagnosis of thyroid storm was revised to thyrotoxicosis complicated by choledocholithiasis. Endoscopic retrograde cholangiopancreatogram (ERCP) with sphincterotomy was performed to alleviate the biliary obstruction, with prompt symptomatic improvement. Thyroid storm is a rare manifestation of hyperthyroidism with a high rate of morbidity and mortality. The diagnosis of thyroid storm is based on clinical examination, and abnormal thyroid function tests do not correlate with disease severity. Knowledge of the many manifestations of thyroid storm will facilitate a quick and accurate diagnosis and treatment.

An End-of-Year Oral Examination for Internal Medicine Residents: An Assessment Tool for the Clinical Competency Committee.

BACKGROUND: Comprehensive evaluations of clinical competency consume a large amount of time and resources. An oral examination is a unique evaluation tool that can augment a global performance assessment by the Clinical Competency Committee (CCC). OBJECTIVE: We developed an oral examination to aid our CCC in evaluating resident performance. METHODS: We reviewed tools used in our internal medicine residency program and other training programs in our institution. A literature search failed to identify reports of a similar evaluation tool used in internal medicine programs. We developed and administered an internal medicine oral examination (IMOE) to our postgraduate year-1 and postgraduate year-2 internal medicine residents annually over a 3-year period. The results were used to enhance our CCC's discussion of overall resident performance. We estimated the costs in terms of faculty time away from patient care activities. RESULTS: Of the 54 residents, 46 (86%) passed the IMOE on their first attempt. Of the 8 (14%) residents who failed, all but 1 successfully passed after a mentored study period and retest. Less than 0.1 annual full-time equivalent per faculty member was committed by most faculty involved, and the time spent on the IMOE replaced regular resident daily conference activities. CONCLUSIONS: The results of the IMOE were added to other assessment tools and used by the CCC for a global assessment of resident performance. An oral examination is feasible in terms of cost and can be easily modified to fit the needs of various competency committees.

Species distribution of Burkholderia cepacia complex isolates in cystic fibrosis and non-cystic fibrosis patients in New Zealand.

Burkholderia cepacia complex (Bcc) isolates from 39 CF patients and 25 non-CF patients in New Zealand were speciated and characterised using the multilocus sequence typing (MLST) scheme for Bcc. B. multivorans predominated in CF patients (31/39, 79.5%) and in non-CF patients (7/25, 28%). Sequence types (ST) with an international distribution were identified (27/64, 42.2%) among the New Zealand Bcc isolates. MLST revealed a high level of diversity among Bcc isolates in CF patients indicating a lack of person-to-person transmission. Non-CF patients showed less diversity in MLST types, however, individuals with shared STs were geographically and chronologically separated. The use of MLST analysis allows continued surveillance of isolates with the potential to identify outbreaks. The identification of internationally distributed strains may provide an indicator of the relative transmissibility and infectivity of these strains and warrants further investigation.

Assessing colonoscopy training outcomes using quality indicators.

PURPOSE: Training numbers for colonoscopy vary among specialties. Tracking colonoscopy quality indicators for program graduates may provide reliable outcome data to improve educational programs and establish training requirements. The purpose of this study was to measure specific colonoscopy quality indicators for a family medicine graduate to determine if outcome can be used to assess the quality of procedure training and contribute to more objective means of establishing training numbers. METHODS: We present a case series of the first 800 colonoscopies performed by a newly credentialed family physician who had performed 101 procedures during residency training. Procedure reports and medical records were reviewed for all patients receiving a colonoscopy by this physician from September 2003 to September 2007. Selected quality indicators were compared to recommended colonoscopy standards. RESULTS: The overall reach-the-cecum rate was 98.6%. Adenomas were detected in 21.6% of females and 33.7% of males. All polyps measuring less than 2 cm were removed. Epinephrine was used for 3 patients with hemostasis after polypectomy. There were no perforations. CONCLUSIONS: Quality indicators for colonoscopy were met after 101 supervised procedures. Postgraduate tracking of nationally recognized colonoscopy quality indicators can provide valuable outcome data to improve residency training and assist in establishing uniform training requirements among specialties.