Impact of a Hybrid-Virtual Teaching Model on the Physical Examination Skills of Fourth-Year Medical Students.

ABSTRACT: A required fourth-year advanced core neurology-physical medicine and rehabilitation clerkship was adapted to hybrid format (2-wk remote; 2-wk in-person) during the COVID-19 pandemic. With teaching of the neurological physical examination being shifted to the remote component, we sought to determine whether this negatively affected student performance on an Objective Structured Clinical Examination, particularly the physical examination component. Mean pandemic-era total Objective Structured Clinical Examination scores ( n = 79, 85.1 ± 7.3) were similar to prepandemic era ( n = 137, 83.5 ± 6.0, P = 0.082). Pandemic-era physical examination scores were slightly higher than prepandemic (86.9 ± 6.5 vs. 84.9 ± 6.6). Despite conversion of the clerkship to a hybrid curriculum, the performance of the students on the Objective Structured Clinical Examination and the physical examination were unchanged. Reasons for this lack of change may include the constructiveness and integration of the case-based virtual demonstrations combined with in-person learning or the flexibility of the virtual course to allow students more time to prepare for the Objective Structured Clinical Examination and the physical examination. Our findings demonstrate that a hybrid-virtual model can be used to teach foundational skills such as the basics of the physical examination, while allowing faculty to address higher-order skills such as integration of clinical data with medical knowledge.

Impact of a Revised Curriculum Focusing on Clinical Neurology and Musculoskeletal Care on a Required Fourth-Year Medical Student Physical Medicine and Rehabilitation Clerkship.

Background. A Required Fourth-Year Medical Student Physical Medicine and Rehabilitation (PM&R) Clerkship was found to increase students' knowledge of PM&R; however the students' overall rotation evaluations were consistently lower than the other 8 required clerkships at the medical school. Objective. To describe the impact of a revised curriculum based upon Entrustable Professional Activities and focusing on basic pain management, musculoskeletal care, and neurology. Setting. Academic Medical Center. Participants. 73 fourth-year medical students. Methods. The curriculum changes included a shift in the required readings from rehabilitation specific topics toward more general content in the areas of clinical neurology and musculoskeletal care. Hands-on workshops on neurological and musculoskeletal physical examination techniques, small group case-based learning, an anatomy clinical correlation lecture, and a lecture on pain management were integrated into the curriculum. Main Outcome Measurements. Student evaluations of the clerkship. Results. Statistically significant improvements were found in the students' evaluations of usefulness of lecturers, development of patient interviewing skills, and diagnostic and patient management skills (p ≤ 0.05). Conclusions. This study suggests that students have a greater satisfaction with a required PM&R clerkship when lecturers utilize a variety of pedagogic methods to teach basic pain, neurology and musculoskeletal care skills in the rehabilitation setting rather than rehabilitation specific content.

The impact of a "search and destroy" strategy for the prevention of methicillin-resistant Staphylococcus aureus infections in an inpatient rehabilitation facility.

OBJECTIVE: To determine how the implementation of a methicillin-resistant Staphylococcus aureus (MRSA) control program in an inpatient rehabilitation facility (IRF) affects MRSA health care-associated infections (MRSA-HAIs). DESIGN: A retrospective chart review. SETTING: IRF affiliated with Vidant Medical Center, an 861-bed, acute-care teaching hospital for The Brody School of Medicine at East Carolina University. PATIENTS: Seventy-nine adult patients in the IRF who developed a MRSA-HAI from February 2005 through January 2011. INTERVENTIONS: Both the acute care hospital and the affiliated inpatient rehabilitation unit began screening 100% of admissions for MRSA nasal carriage, with decolonization of positive carriers, starting in February 2007. MAIN OUTCOME MEASUREMENTS: Yearly rates of MRSA-HAI per 1000 patient-days were compared in the IRF before and after the intervention. RESULTS: The weighted mean monthly infection rate before the intervention (February 2005 through January 2007) was 1.0714 per 1000 patient days compared with 0.6557 per 1000 patient days after the intervention (February 2007 through January 2011). The decreased infection rates after the intervention were statistically significant (P = .0315). CONCLUSIONS: The implementation of an all-admissions MRSA screening program with decolonization of positive carriers in an IRF affiliated with an acute care hospital resulted in decreased MRSA-HAI rates in the IRF. When developing surveillance guidelines for MRSA, IRFs should be cognizant of infection rate trends and of the affiliated hospital's scope of policies and practices for infection prevention and control.

Rate of return to acute care hospital based on day and time of rehabilitation admission.

OBJECTIVE: To determine if a patient's return to the acute care hospital (RTACH) from an inpatient rehabilitation facility (IRF) because of medical acuity is affected by the day of the week and time of rehabilitation admission. DESIGN: Retrospective chart review. SETTING: Inpatient rehabilitation facility. PARTICIPANTS: All adult patients admitted to the IRF from January 1, 2009, to June 30, 2011. RTACH was defined as an interruption in the patients' rehabilitation course as a result of medical and/or surgical complications requiring a higher level of care. The control group was defined as patients who completed an uninterrupted rehabilitation course. The study included 2282 patients (2026 control patients and 256 case patients). MAIN OUTCOME MEASURES: We compared patient demographics, admission impairment groups, discharge diagnosis, admission and discharge Functional Independent Measure (FIM) scores, length of stay, attached hospital versus outside hospital admissions, and RTACH rates between case patients and control patients. RESULTS: Out of 2282 patients admitted to the IRF over a 30-month period, 256 patients (10.85%) required an RTACH for a higher level of care not available in the IRF. Two statistically significant results were found for RTACH, including rehabilitation admission time and FIM scores (admission motor and cognition scores). Day of the week for inpatient rehabilitation admission was not statistically significant. CONCLUSION: This study found that the later in the day a patient was admitted to the IRF, the higher the rate of RTACH. In addition, a lower Motor FIM score was found to be correlated with a higher rate of RTACH. Admission day of the week was not found to be statistically significant with regard to the rate of RTACH. Further research is needed to determine the underlying contributing factors that would help decrease the rate of RTACH.

Implementing a multidimensional geriatric curriculum in a physical medicine and rehabilitation residency program.

Residency training in physical medicine and rehabilitation may not contain a formal curriculum in geriatric patient care. A multidimensional geriatric curriculum to third and fourth year physical medicine and rehabilitation residents was implemented to enhance their knowledge in and attitude toward geriatrics. The curriculum consisted of a 12-wk clinical rotation at various sites of geriatric care including outpatient geriatric clinic, skilled nursing facility, continuing care retirement community, and home visits. Six online self-learning modules and multiple didactic sessions were also created. The residents' knowledge and attitude were assessed by pretest and posttest design using the Geriatric Knowledge Test, the Geriatric Attitude Scale, and the Attitudes Toward Teamwork in Healthcare Scale. In addition, the residents completed rotation evaluations to rate their learning experiences. Ten postgraduate year 3 and 4 physical medicine and rehabilitation residents participated in the geriatric curriculum, which included a required rotation. The Geriatric Knowledge Test score at baseline was 67.2%. With the completion of the curriculum, the Geriatric Knowledge Test scores showed improvement to 72.7%, although not statistically significant. The residents showed more favorable attitudes toward the geriatric population and interdisciplinary teamwork as measured by the Geriatric Attitude Scale and the Attitudes Toward Teamwork in Healthcare Scale. Overall, they rated the learning experiences highly on a 1-9 rating scale, with 9 being the highest rating; the residents assigned an average rating of 7.06 to specific learning activities within the rotation and an average rating of 6.89 to the organizational aspects of the rotation itself. The implementation of this geriatric curriculum allowed for improved geriatric training in physical medicine and rehabilitation residents.

Impact of a required fourth-year medical student rotation in physical medicine and rehabilitation.

This study evaluated the impact of a 2-wk required rotation in Physical Medicine and Rehabilitation (PM&R) on fourth-year medical students' knowledge of PM&R and attitude toward teamwork in patient care. Survey results on attitudes toward a team approach to patient care and knowledge in PM&R were compared prerotation and postrotation. One hundred thirty-eight fourth-year medical students participated in this 2-yr study. The combined response rates for the attitude and knowledge surveys were 62% and 56%, respectively. As measured by a pretest and posttest self-reported knowledge assessment, the rotation increased knowledge of PM&R (P ≤ 0.05). Four aspects of the rotation that were rated higher by students from the second year of the rotation were role and responsibility definition, incorporation of current literature, enhancement of clinical skills, and general rotation satisfaction. The rotation provides an experience for medical students to increase their knowledge of PM&R.

Critical gastrointestinal bleeding at an inpatient rehabilitation center: incidence, risk factors, and the role of gastrointestinal prophylaxis.

OBJECTIVE: To determine the incidence of critical gastrointestinal bleeding at an inpatient rehabilitation center, the risk factors associated with said bleeding, and the role of gastrointestinal prophylaxis. DESIGN: This was a retrospective case-control study. Medical records and databases from November 7, 1997, to July 1, 2008, were reviewed. SETTING: Inpatient rehabilitation center. PARTICIPANTS: All adult patients admitted from November 7, 1997, to July 1, 2008, who developed critical gastrointestinal bleeding were considered case patients. Gastrointestinal bleeding was defined as "critical" if it directly led to hemodynamic instability requiring the patient's transfer from inpatient rehabilitation to a higher level of care for close monitoring and/or emergent management. The control for each case patient was a randomly chosen adult patient who was admitted on the same day or the day before but who did not develop critical gastrointestinal bleeding. Clinical information was extracted by chart review. A total of 70 patients (35 case patients and 35 control patients) were included in this study. ASSESSMENT OF RISK FACTORS: Patient demographics, comorbidities, and medication regimens were compared between case patients and control patients. RESULTS: Of 11,645 adult patients admitted to an inpatient rehabilitation center during a 10-year and 8-month period, 35 developed critical gastrointestinal bleeding, which translates to an incidence of 0.3%. Significant risk factors for critical gastrointestinal bleeding included diabetes, anticoagulant treatment, treatment with glucocorticoids, renal insufficiency, and colonic disease. Gastrointestinal prophylaxis was not found to be protective. CONCLUSIONS: The overall incidence of critical gastrointestinal bleeding was low in the inpatient rehabilitation setting. This finding is similar to a study in which the authors reported a small incidence of gastrointestinal bleeding, 0.4%, within the acute care setting. Significant risk factors included diabetes, anticoagulant treatment, treatment with glucocorticoids, renal insufficiency, and colonic disease. The mechanism of gastrointestinal bleeding from this inpatient setting may be different from what has been proposed among critically ill patients in the intensive care unit setting. Some of the emerging data now indicate the potential risks associated with long-term proton pump inhibitors and histamine-2 receptor antagonist therapy, including variations in the bioavailability of common medications, thrombocytopenia, interstitial nephritis, Clostridium difficile colitis, and nosocomial pneumonia, not to mention the expense of such medications. Gastrointestinal prophylaxis was not found to provide significant protection in the inpatient rehabilitation setting, and its routine use among most rehabilitation inpatients appears potentially to be unwarranted. Although our study does not support the use of pharmacologic treatment for gastrointestinal prophylaxis, further studies would be warranted before making a final conclusion regarding gastrointestinal prophylaxis within the inpatient rehabilitation setting.