The prevalence, causes, and consequences of experiencing a life crisis during medical school

BACKGROUND

Little is known about the prevalence, causes, and consequences of experiencing a major life crisis during medical school.

PURPOSE

The objective is to describe the prevalence, causes, and consequences through internship of experiencing a major life crisis while enrolled as a medical student at Uniformed Services University (USU).

METHOD

USU graduates from 1980 to 1999 were surveyed regarding their experiences at USU and career milestones. Predictor markers were obtained from the USU Admissions, Promotions, and Registrar's office. Outcome data were derived from a survey of intern program directors from the years 1993 to 1999.

RESULTS

There were 1,807 (67%) of USU graduates who responded to our survey. There were 394 (22%) who reported experiencing a major life crisis during medical school. Graduates reporting a major life crisis performed slightly poorer in terms of basic science GPAs (2.95 vs. 2.85, p <.001), USMLE exam scores, and performance ratings by their program directors than did graduates who did not experience a crisis.

CONCLUSIONS

A large fraction of medical students experience major life crises. The effects of these crises may persist throughout internship.

Medicine clerkships and portable computing: a national survey of internal medicine clerkship directors

BACKGROUND

Portable computers are widely used by medical trainees, but there is a lack of data on how these devices are used in clinical education programs.

PURPOSES

The objective is to define the current use of portable computing in internal medicine clerkships and to determine medicine clerkship directors' perceptions of the current value and future importance of portable computing.

METHODS

A 2006 national survey of institutional members of the Clerkship Directors in Internal Medicine.

RESULTS

Eighty-three of 110 (75%) of institutional members responded. An institutional requirement for portable computing was reported by 32 schools (39%), whereas only 13 (16%) provided students with a portable computer. Between 10 and 31 institutions (12-37%) reported student use for patient care activities (i.e. order entry, writing patient notes) and only 2 to 4 institutions (2-5%) required such use. The majority of respondents (59-95%) reported portable computer use for educational activities (i.e., tracking patient problems, knowledge resource), however, only in 5 to 19 (6-23%) were such educational uses required. Fifty-six respondents (68%) reported that portable computer's "added value" for teaching and 61 (73%) reported that portable computers would be important in meeting clerkship objectives in the next 3 years. Of interest, even among the institutions requiring portable computers, only 50% recommended or required specific software.

CONCLUSIONS

Portable computing is required at 39% of allopathic medical schools in the United States. However required portable computing for specific patient care or educational tasks is uncommon. In addition, guidance on specific software exists in only one half of school requiring portable computers, suggesting informal or unstructured uses of required portable computer's in the remaining half. The educational impact of formal institutional requirements for software versus informal "user-defined" applications is unknown.

Aging and cognitive performance: challenges and implications for physicians practicing in the 21st century

The demands of physician practice are growing. Some specialties face critical shortages and a significant percentage of physicians are aging. To improve health care it is paramount to understand and address challenges, including cognitive issues, facing aging physicians. In this article, we outline several issues related to cognitive performance and potential implications associated with aging. We discuss important findings from other fields and draw parallels to the practice of medicine. In particular, we discuss the possible effects of aging through the lens of situated cognition theory, and we outline the potential impact of aging on expertise, information processing, neurobiology, intelligence, and self-regulated learning. We believe that work done in related fields can provide a better understanding of physician aging and cognition, and thus can inform more effective approaches to continuous professional development and lifelong learning in medicine. We conclude with implications for the health care system and areas of future research.

AMEE 2009 spotlight on educational research

The AMEE meeting is unique among the medical education conferences in that it is truly international. Educational research presented at the 2009 AMEE Meeting was both diverse and robust. In this article, we will present an overview of educational research from the meeting. We will begin with outlining our methods for the selection and categorization of themes, discuss some highpoints from some of the respective themes, and finally from the conference overall.

Use of electronic medical records by physicians and students in academic internal medicine settings

PURPOSE

Electronic medical records (EMRs) have been touted as one method to improve quality and safety in medical care, and their use has recently increased. The purpose of this study is to describe current use of EMRs by medical students at U.S. and Canadian medical schools.

METHOD

In 2006 the authors performed a cross-sectional survey of the Clerkship Directors in Internal Medicine institutional members at U.S. and Canadian academic health centers. Outcome measures included implementation of EHRs, EHR use by students, and the challenges of having students use EMRs.

RESULTS

Of 110 members, 82 (74.5%) responded. Of those 82, 48 (58%) reported using an EMR in the ambulatory setting (excluding Veterans' Affairs medical centers) of their institutions, and only 21 of those 48 (44%) had policies regarding medical student documentation of progress notes in the EMR during the ambulatory internal medicine (IM) clerkship. Schools were dichotomously split; about half (23/48, 48%) required and about half (25/48, 52%) prohibited allowing students to document in the EMR. The programs that prohibited medical students from documenting in the EMR primarily cited billing concerns. Other issues regarding student use of EMRs included student access, faculty concerns, and note quality.

CONCLUSIONS

Use of EMRs by IM clerkship students is common, yet many institutions do not have policies regarding student use. Where policies do exist, they vary, and many prohibit students from using EMRs. Concerns about documentation as it relates to billing seem to be a significant factor in prohibiting students' use of EMRs.

Patient safety education at U.S. and Canadian medical schools: results from the 2006 Clerkship Directors in Internal Medicine survey

PURPOSE

To describe current patient safety curricula at U.S. and Canadian medical schools and identify factors associated with adoption of these programs.

METHOD

A survey was mailed to institutional members of the Clerkship Directors in Internal Medicine at U.S. and Canadian academic medical schools in 2006. Respondents self-reported implementation of patient safety curricula and associated methods of instruction at the institution level.

RESULTS

The survey had a 76% response rate (83/110). Only 25% of institutional members reported that their schools had explicit patient safety curricula. All respondents that reported having curricula use lectures and small-group instruction, and these were more likely to occur in preclinical settings. Topics and methods of instruction included reporting adverse incidents and analysis of medical errors; improvement of physician order writing to prevent medication errors; core measures; national patient safety goals; and standardization of medical care through the use of clinical guidelines and order set templates. Although only 25% of respondents reported having explicit curricula, 72% agreed that patient safety instruction should occur during medical school.

CONCLUSIONS

Despite calls from regulatory, medical, and educational organizations to increase patient safety training of medical students, internal medicine clerkship directors report that few schools in the United States and Canada have implemented specific patient safety curricula. Most existing patient safety curricula use lecture and small-group discussion as preferred methods of instruction.

Internal medicine core clerkships experience with core problem lists: results from a national survey of clerkship directors in internal medicine

BACKGROUND

The Liaison Committee on Medical Education (LCME) requires clinical clerkships in North American Medical Schools to define and monitor core problems and clinical conditions for medical students and adjust the clerkships to ensure that all students meet those objectives at all instructional sites. Clinical clerkships usually use medical student generated logbooks to meet these requirements. It is not clear what clinical clerkship directors are doing to meet these standards.

PURPOSE

To determine how internal medicine clerkship directors develop problem lists, whether and how they verify student problem list entry, and how missed core problems are covered.

METHODS

The Clerkship Directors in Internal Medicine (CDIM) organization conducts an annual survey of its institutional members (one member per medical school). In 2007, 75% of North American medical schools (82 of 110) responded to the survey, which included questions on core problem lists and medical student logbooks.

RESULTS

Ninety-four percent of responding medical schools had a core problem list for the core internal medicine clerkship. Most schools used an electronic logbook and verified student exposure to core problems (76%). The clerkship director usually did the verification (63%). Clerkships offered a variety of options to remedy lack of exposure to core problems and usually offered more than one option.

CONCLUSIONS

Clerkship directors in internal medicine develop, verify, and ensure exposure to core problems in internal medicine. Most clerkship directors used the CDIM recommended core problem list as a basis for their local core problem list. Emerging computer-assisted learning options may simplify clerkship adjustments for lack of exposure to core problems. It appears that clerkship directors are using logbooks appropriately to meet the LCME charge to monitor core problems and clinical conditions.

Commentary: On regulation and medical education: sociology, learning, and accountability

The topic of regulation is commonplace in society, yet it seems to receive little explicit consideration in discussions on undergraduate medical education. The accompanying articles by Hauer and colleagues, White and colleagues, and Bloodgood and colleagues approach the topic of regulation from several different viewpoints. In this commentary, we too approach the topic of regulation from several different viewpoints: sociology, learning (self-regulated learning), and accountability. In this commentary, we present both theoretical and practical issues with the aim of initiating an open, scholarly discussion in the field of medical education. Ultimately, we hope other medical educators will seriously contemplate the questions raised and, more importantly, will consider employing these theoretical perspectives into future research efforts.

Resident run journal club: a model based on the adult learning theory

BACKGROUND

Multiple formats of journal club exist but data is lacking regarding which model is most effective. Many residents are dissatisfied with their current format, which was the case at our institution.

AIM

This article discusses a resident run model, residents' perceptions following its implementation, and recommendations for running a successful journal club. Practice points Journal club formats vary extensively without a clearly superior method. Defining goals is the first step to a successful journal club. Structured review instruments for articles enhance journal club. The presence of subspecialty staff may augment learning. Resident-run models of journal club can be successfully implemented.

METHODS

A resident run model of journal club was developed based on Adult Learning Theory. A 30-question survey was created to assess residents' attitudes and satisfaction with the new model.

RESULTS

All respondents preferred the new model compared to the old model. Residents reported the new model increased their medical knowledge (88%) and they were able to apply the methods learned in journal club to actual patients (82%).

CONCLUSIONS

A resident run model of journal club may be a viable option for those attempting to start or improve their current club.

Training and assessment of ECG interpretation skills: results from the 2005 CDIM survey

BACKGROUND

Despite published consensus-based statements on assessment of ECG interpretation skills, studies and curricula regarding the training needed to obtain basic ECG interpretation skills are lacking. These consensus statements have focused on attaining competency in ECG interpretation during postgraduate training; however, recommendations regarding assessment of competency in the undergraduate curriculum are not discussed.

PURPOSE

The purpose is to describe the current methods of teaching and assessing ECG interpretation skills across institutions on the 3rd-year internal medicine (IM) clerkship.

METHOD

In 2005, the Clerkship Directors in Internal Medicine surveyed its institutional members. Twelve questions on the survey dealt with ECG interpretation. Descriptive statistics, chi-square, and Mann-Whitney U were used for analysis.

RESULTS

Eighty-eight of 109 members (81%) responded to the survey. Overall, 89% of institutional respondents feel that ECG interpretation is an important clinical skill for medical students with 92% indicating that instruction occurs on the IM clerkship. Lectures (75%) and teaching rounds (44%) were the most cited methods of instruction. Most schools spend 1 to 6 hr during the IM clerkship on formal ECG instruction. Over 63% indicated that ECG interpretation skills are assessed during the clerkship. The most common assessment methods were written exam (40%) and OSCE (23%).

CONCLUSIONS

Objective data regarding attainment and assessment of basic ECG interpretation competency in the undergraduate curriculum are lacking; our report provides preliminary descriptive data regarding ECG teaching and assessment on the 3rd-year IM clerkship. Further studies are needed to determine the ideal method of instruction and evaluation of this important clinical skill.

Letters of recommendation: rating, writing, and reading by clerkship directors of internal medicine

BACKGROUND

Letters of Recommendations (LORs) are used for applications to medical school and graduate medical education, but how they are used by current internal medicine educators is unknown.

DESCRIPTION

In 2006, the Clerkship Directors of Internal Medicine conducted its annual, voluntary survey, and one section pertained to LORs. Survey items were categorized into questions regarding rating, writing, and reading LORs with answers on 3- to 5-point scales.

EVALUATION

The response rate for the 110 institution members was 75%. When rating LORs, the most important factor was depth of understanding of the trainee (98% essential or important), followed by a numerical comparison to other students (94%), grade distribution (92%), and summary statement (91%). Although most (78%) agreed that reading LORs in general were important for trainee selection, few agreed that this was because of the ability to discern marginal performance (31%) or predict future performance (25%).

CONCLUSIONS

LORs remain an important part of the application process for medical school and internal medicine residency. Letter writers should convey a great depth of understanding of the applicant, provide a numerical comparison with other students (including a denominator), and give a specific summary statement.

Expectations for oral case presentations for clinical clerks: opinions of internal medicine clerkship directors

BACKGROUND

Little is known about the expectations of undergraduate internal medicine educators for oral case presentations (OCPs).

OBJECTIVE

We surveyed undergraduate internal medicine educational leaders to determine the degree to which they share the same expectations for oral case presentations.

SUBJECTS

Participants were institutional members of the Clerkship Directors of Internal Medicine (CDIM).

DESIGN

We included 20 questions relating to the OCP within the CDIM annual survey of its institutional members. We asked about the relative importance of specific attributes in a third-year medical student OCP of a new patient as well as its expected length. Percentage of respondents rating attributes as "very important" were compared using chi-squared analysis.

RESULTS

Survey response rate was 82/110 (75%). Some attributes were more often considered very important than others (p < .001). Eight items, including aspects of the history of present illness, organization, a directed physical exam, and a prioritized assessment and plan focused on the most important problems, were rated as very important by >50% of respondents. Respondents expected the OCP to last a median of 7 minutes.

CONCLUSIONS

Undergraduate internal medicine education leaders from a geographically diverse group of North American medical schools share common expectations for OCPs which can guide instruction and evaluation of this skill.

Factors associated with medical students' career choices regarding internal medicine

CONTEXT

Shortfalls in the US physician workforce are anticipated as the population ages and medical students' interest in careers in internal medicine (IM) has declined (particularly general IM, the primary specialty serving older adults). The factors influencing current students' career choices regarding IM are unclear.

OBJECTIVES

To describe medical students' career decision making regarding IM and to identify modifiable factors related to this decision making.

DESIGN, SETTING, AND PARTICIPANTS

Web-based cross-sectional survey of 1177 fourth-year medical students (82% response rate) at 11 US medical schools in spring 2007.

MAIN OUTCOME MEASURES

Demographics, debt, educational experiences, and number who chose or considered IM careers were measured. Factor analysis was performed to assess influences on career chosen. Logistic regression analysis was conducted to assess independent association of variables with IM career choice.

RESULTS

Of 1177 respondents, 274 (23.2%) planned careers in IM, including 24 (2.0%) in general IM. Only 228 (19.4%) responded that their core IM clerkship made a career in general IM seem more attractive, whereas 574 (48.8%) responded that it made a career in subspecialty IM more attractive. Three factors influenced career choice regarding IM: educational experiences in IM, the nature of patient care in IM, and lifestyle. Students were more likely to pursue careers in IM if they were male (odds ratio [OR] 1.75; 95% confidence interval [CI], 1.20-2.56), were attending a private school (OR, 1.88; 95% CI, 1.26-2.83), were favorably impressed with their educational experience in IM (OR, 4.57; 95% CI, 3.01-6.93), reported favorable feelings about caring for IM patients (OR, 8.72; 95% CI, 6.03-12.62), or reported a favorable impression of internists' lifestyle (OR, 2.00; 95% CI, 1.39-2.87).

CONCLUSIONS

Medical students valued the teaching during IM clerkships but expressed serious reservations about IM as a career. Students who reported more favorable impressions of the patients cared for by internists, the IM practice environment, and internists' lifestyle were more likely to pursue a career in IM.

Medical school policies regarding struggling medical students during the internal medicine clerkships: results of a national survey

PURPOSE

To characterize policies of medical schools regarding struggling medical students: those at risk of receiving a grade of less than pass because of problems with knowledge, clinical skills, professionalism, or a combination of these items.

METHOD

The annual 2006 Clerkship Directors in Internal Medicine (CDIM) survey included a section about how clerkship directors handle struggling third- and fourth-year medical students. The section contained 14 structured questions and five items requiring free-text responses. The items explored both core and fourth-year clerkship perspectives. Data were analyzed using descriptive statistics.

RESULTS

Eighty-three of the 110 (76%) institutional members responded. Respondents identified 0% to 15% of students as struggling each year during the required core internal medicine clerkship and 0% to 11% of fourth-year students. Two thirds of respondents present struggling students to a medical school promotion committee. More than half (64%) of respondents feel they should share information about struggling students with other clerkship directors, and 51% of respondents do share information. Clerkship directors are divided about whether it is in students' best interests to disclose information about them with current teachers or other clerkship directors. Only 14% of institutions have written policies about sharing information, and 57% of clerkship directors design remediation plans for struggling students.

CONCLUSIONS

Internal medicine clerkship directors handle struggling students in widely varying ways. Many clerkship directors share information about struggling students; opinions are divided about whether this is appropriate. Future research is needed to determine the effectiveness of identifying and remediating struggling students and to determine effective remediation plans.

Psychogenic coma following upper endoscopy: a case report and review of the literature

BACKGROUND

Failure to regain consciousness after general anesthesia has a multitude of life-threatening causes, including neurological injury, metabolic derangements, or drug effects. Failure to promptly recognize the cause of unconsciousness after anesthesia can result in significant patient morbidity or mortality, costly laboratory and radiographic evaluation, and physician anxiety. Rarely, patients fail to awaken after anesthesia due to a psychiatric cause. The early recognition of psychogenic coma can result in reduced iatrogenic complications, hospital cost, and physician anxiety.

CASE

We present a case of a 28-year-old female who became unresponsive after general anesthesia for an upper endoscopy. Physical, laboratory, and radiographic examination after the procedure revealed no apparent organic cause for her failure to awaken. The patient spontaneously awoke after 16 hours without neurological deficit.

DISCUSSION

We reviewed the literature and identified 10 previously reported cases of postanesthesia psychogenic coma. We have compared and contrasted our case with the 10 previous reports and propose bedside clues to assist the physician with diagnosing this unusual condition.

Internal medicine clerkship directors' perceptions about student interest in internal medicine careers

BACKGROUND

Experienced medical student educators may have insight into the reasons for declining interest in internal medicine (IM) careers, particularly general IM.

OBJECTIVE

To identify factors that, according to IM clerkship directors, influence students' decisions for specialty training in IM.

DESIGN

Cross-sectional national survey.

PARTICIPANTS

One hundred ten institutional members of Clerkship Directors in IM.

MEASUREMENTS

Frequency counts and percentages were reported for descriptive features of clerkships, residency match results, and clerkship directors' perceptions of factors influencing IM career choice at participating schools. Perceptions were rated on a five-point scale (1 = very much pushes students away from IM careers; 5 = very much attracts students toward IM careers).

RESULTS

Survey response rate was 83/110 (76%); 80 answered IM career-choice questions. Clerkship directors identified three educational items attracting students to IM careers: quality of IM faculty (mean score 4.3, SD = 0.56) and IM rotation (4.1, SD = 0.67), and experiences with IM residents (3.9, SD = 0.94). Items felt most strongly to push students away from IM careers were current practice environment for internists (mean score 2.1, SD = 0.94), income (2.1, SD = 1.08), medical school debt (2.3, SD = 0.89), and work hours in IM (2.4, SD = 1.05). Factor analysis indicated three factors explaining students' career choices: value/prestige of IM, clerkship experience, and exposure to internists.

CONCLUSIONS

IM clerkship directors believe that IM clerkship experiences attract students toward IM, whereas the income and lifestyle for practicing internists dissuade them. These results suggest that interventions to enhance the practice environment for IM could increase student interest in the field.

Does student promotions committee appearance predict below-average performance during internship? A seven-year study

BACKGROUND

Medical educators grapple with predicting performance of graduates identified as struggling during medical school. Students appear before student promotions committees (SPCs) for multiple cognitive and noncognitive reasons and performance outcomes for this cohort have not been well defined in the literature.

PURPOSE

To determine the predictive validity of SPC appearance with respect to performance on a Program Director's (PD's) Evaluation Form completed at the end of internship (PGY-1).

METHOD

Residents were classified as "below average," "average," or "above average" based on PD Evaluation Form ratings. This PD instrument has been shown to be feasible, reliable, and valid. Below-average residents were defined as having a below-average rating on any question on the PD Evaluation Form. We compared SPC and non-SPC cohorts with respect to these PD Evaluation Form ratings. The t test was used for statistical analysis.

RESULTS

Seven years of graduating classes from our institution were included. Of students who graduated from our institution, 119 of 856 students (14%) were presented at our SPC during medical school during our study period. There were 196 residents (23%) identified as below average. The PD Evaluation Form response rate for this period was 77%. Students who appeared at our SPC were significantly more likely to have below-average scores for almost all PD Evaluation Form questions with small to moderate effect sizes.

CONCLUSIONS

Students who appear before SPCs are at higher risk of below-average performance as rated by a PD Evaluation Form at the end of PGY-1. However, only a minority of trainees that appeared before our SPC received below-average ratings during internship. These data provide predictive validity evidence that SPC appearance during medical school does identify below average performance during internship. Our data support that SPC appearance during medical school, regardless of cause, is a risk for below average performance during internship.

Clinician educators' experiences with institutional review boards: results of a national survey

PURPOSE

To explore clinician educators' perceptions and experiences in obtaining institutional review board (IRB) approval to conduct medical education research (MER).

METHOD

Institutional members of the Clerkship Directors in Internal Medicine (CDIM; n = 110) were surveyed in 2006. The survey included questions about familiarity with and clarity of IRB policies, satisfaction with review of education research protocols, and how MER might be facilitated.

RESULTS

Of 83 respondents (response rate 76%), 50 had submitted a MER protocol to an IRB. Nearly all were deemed exempt (74/154) or minimal risk (71/154). No protocols were rejected or not approved. Nearly a fourth of respondents were unfamiliar with specific IRB policies directly applicable to MER. Among those respondents who had some familiarity with the IRB policies specified, 47% to 52% considered the IRB policies clear. Eighteen of 30 (60%) respondents with recent experience in multiinstitutional MER agreed there were notable differences in the expectations of various institutional IRBs; only two reported that multiple IRB reviews resulted in improvements to the protocol. Half (37/73) indicated they would be more likely to conduct MER if they had a better understanding of the IRB's role and requirements in MER. Sixty-six of 73 (90%) agreed they would benefit from a national consensus statement regarding the IRB's role in MER.

CONCLUSIONS

A high percentage of clinician educators in CDIM are conducting IRB-approved MER. They report several challenges with working with IRBs, and they agree that IRBs and clinician educators would benefit from a national consensus on the IRB's role in MER.

The impact of increasing medical school class size on clinical clerkships: a national survey of internal medicine clerkship directors

PURPOSE

To determine the impact of increasing medical school class size on the internal medicine clerkship.

METHOD

In 2006, the Clerkship Directors in Internal Medicine surveyed its 110 institutional members to discover whether their medical school class size had increased (or would increase) and the impact of increasing class size on number of students per teaching site, number of clerkship sites needed, and resources needed. Respondents rated their agreement or disagreement with statements about increasing class size, and they provided free-text responses. Analyses included descriptive statistics and qualitative analysis.

RESULTS

Response rate was 76% (83/110). In the three years preceding the survey, one medical school decreased class size; 43% increased by a mean of 14 students per year (10%). Most respondents (51%) expected class size to increase by a mean of 17 students per year (12%) through 2009; none expected class size to decrease. Increasing class size by 15% would mean adding 3.7 (standard deviation = 2.2) students per inpatient site, 2.9 (2.9) new inpatient sites, 3.0 (2.2) students per ambulatory site, and 4.9 (5.5) ambulatory sites. Respondents disagreed with the questionnaire statements that they would have more resources, teachers, and protected time; they agreed with statements that recruiting teachers would be harder as class size increases. Free-text responses to the challenges of increasing class size revealed two themes: strain on resources (space, time, faculty), and the impact on the educational experience.

CONCLUSIONS

Internal medicine clerkship directors believe increasing medical school class size will dramatically increase resources needed during clerkships and may adversely impact education.

Training and assessment of CXR/basic radiology interpretation skills: results from the 2005 CDIM Survey

BACKGROUND

Despite published literature demonstrating deficiencies in chest radiograph (CXR)/basic radiology interpretation skills of 4th-year medical students, studies and subsequent curricula regarding the training needed to obtain these skills are lacking. Terms such as clinical exposure and radiology teaching have been used to describe the experience for these basic interpretive skills, but best practice methods of delivery, let alone common methods, have yet to be defined.

PURPOSE

The objective is to describe the current methods of teaching and assessing CXR/basic radiology interpretation skills across institutions on the 3rd-year internal medicine (IM) clerkship.

METHODS

In 2005, the Clerkship Directors in Internal Medicine (CDIM), an international organization representing U.S. and Canadian medical schools, surveyed its institutional members. Twelve questions on the survey dealt with X-ray interpretation.

RESULTS

Eighty-eight of 109 members (81%) responded to the survey. Overall, 81% of respondents felt that CXR interpretation is an important clinical skill for medical students. Seventy-six percent indicated that instruction in these skills occurs on the IM clerkship. The most cited methods of instruction were lectures (56%) and teaching rounds (48%). Most schools spent on average of 2 to 4 hr during the IM clerkship on formal radiology instruction. Only 33% indicated that radiology interpretation skills are assessed during the clerkship. The most common assessment methods were written examination (19%) and OSCE (19%).

CONCLUSION

Substantive data regarding attainment and assessment of CXR/basic radiology interpretation skills in the undergraduate curriculum are lacking. Our study provides preliminary descriptive data regarding CXR instruction and assessment on the 3rd-year IM clerkship.

An internal medicine interest group research program can improve scholarly productivity of medical students and foster mentoring relationships with internists

BACKGROUND

Shortages in primary care careers such as internal medicine are projected in the future. Conducting research is an explicit requirement for graduate medical education and interest in research is growing in undergraduate medical education.

PURPOSE

We hypothesized that a medical student research initiative could increase student research productivity and foster mentoring relationships with internists.

METHOD

We compared the number of medical student presentations, awards, and peer-reviewed publications before and after a brief research initiative at a single institution and recorded comments from student participants; data collected before the initiative were retrospective, and data after the initiative were collected prospectively. Mann-Whitney U was used for statistical analysis.

RESULTS

Twenty-seven students participated in our workshop initiative during the study period (2000-2005). Eighteen (67%) subsequently had presentations, research awards, and/or publications during the study period. Mann-Whitney U testing of groups (all pre-initiative Uniformed Services University students and initiative participants) showed a statistically significant increase in regional presentations (p = .003), research awards (p = .01), and publications (p = .02) after the research initiative. Student comments not only revealed research mentoring benefits but also commented on receiving career counseling advice from mentors.

CONCLUSIONS

Our study findings support the feasibility of this initiative as well as produced significant outcomes in terms of quantified research productivity and student mentoring.

The subinternship curriculum in internal medicine: a national survey of clerkship directors

BACKGROUND

The 4th-year internal medicine subinternship (subI), with its strong emphasis on experience-based learning and increased patient responsibilities, is an important component of undergraduate medical education. Discussions have begun amongst educational leaders on the importance of standardizing curriculum and evaluation tools utilized during the subinternship.

PURPOSE

The objective of this survey was to describe the current state of educational practices regarding the subI curriculum, use of Clerkship Directors in Internal Medicine (CDIM) curricular guidelines, evaluation methodologies, and subintern call frequency and duty hours.

METHODS

The survey was a part of the CDIM annual survey sent to 109 institutional members in 2005. The subinternship survey included 17 questions that addressed the prevalence of formal curricula in the subinternship, use of CDIM curricular guidelines and resources, and the evaluation tools utilized for assessment of the subinternship. Two questions examined the call frequency and duty hours of the subinterns.

RESULTS

Eighty-eight members responded (81%). Of the respondents, 37% have a formal curriculum and 35% used CDIM curricular guidelines for the subinternship. More than half of the respondents agreed that the curricular guide helped organize their subI rotations (53%), and 48% agreed that it enhanced the quality of subI education. A global rating summative evaluation form (56%) was the most commonly used evaluation tool in the subinternship. Objective Structured Clinical Examinations (1%) and Mini-Clinical Evaluation Exercise (mini-CEX)(2%) were much less utilized during the subinternship. The respondents expressed an interest in the development of a standardized exam (47%) and clinical assessment tools such as the mini-CEX (59%). The vast majority of IM subinterns participate in 3 to 9 calls per rotation and spend less than 80 hr in the hospital per week.

CONCLUSIONS

A formal curriculum is offered in slightly more than one third of subIs. Clerkship directors expressed interest in developing standardized evaluation tools to assess subintern competencies. The majority of IM subinterns spend less than 80 hr in the hospital per week. Further studies are needed to assess barriers to incorporating a formal curriculum and develop standardized tools to assess subintern competencies.

Evaluation, grading, and use of the RIME vocabulary on internal medicine clerkships: results of a national survey and comparison to other clinical clerkships

BACKGROUND

Evaluation methods within and across clerkships are rapidly evolving, including greater emphasis or frameworks for descriptive evaluation and direct observation of competence.

PURPOSE

The purpose of this study is to describe current evaluation methods, use of the Reporter-Interpreter-Manager/Educator (RIME) framework, and grade assignment by internal medicine clerkship directors.

METHODS

In 2005, the Clerkship Directors in Internal Medicine surveyed its 109 institutional members. Topics included evaluation methods and grade contribution, use of evaluation sessions and/or RIME, and grade assignment (criterion referenced or normative).

RESULTS

Response rate was 81% (88/109). The evaluation methods were as follows: teachers' evaluations, 93% (64% of grade); National Board of Medical Examiners subject examination, 81% (25% of grade); faculty written exam, 34% (14% of grade); objective structured clinical examinations, 32% (12% of grade); direct observation, 22% (7% of grade). RIME is used by 42% of respondents. Many clerkship directors (43%) meet with teachers to discuss student performance. Criterion-referenced grading is used by 59%, and normative grading is used by 27%. Unsatisfactory grades are given for examination failures (72%), unprofessional behavior (49%), poor clinical performance (42%), and failure to meet requirements (18%).

CONCLUSIONS

Internal medicine clerkship directors emphasize description and observation of students. RIME and discussions with teachers are becoming commonplace.

Changes in clinical skills education resulting from the introduction of the USMLE step 2 clinical skills (CS) examination

BACKGROUND

Step 2 Clinical Skills (CS) was recently introduced into the United States Medical Licensing Examination (USMLE) to ensure that successful candidates for licensure possess the clinical skills to provide safe and effective patient care.

AIMS

To explore if medical schools had changed the objectives, content, or emphasis in their pre-clinical curriculum in response to its implementation.

METHODS

In April 2005, the Clerkship Directors in Internal Medicine (CDIM) sent an electronic survey to a single member from each medical school with a CDIM member. The survey instrument included 26 pre-clinical curricular questions with nine questions specifically addressing changes in response to implementation of the Step 2 CS.

RESULTS

Forty-five percent of respondents reported changes to the Introduction to Clinical Medicine (ICM) course objectives while 39% and 40% reported changes in content and emphasis. Seventy-four percent felt their students were adequately prepared for the Step 2 CS and 18% were unsure.

CONCLUSIONS

Over a third of medical schools are implementing changes to the objectives, content, and/or emphasis of their curriculum, at least partially in response to the institution of Step 2 CS.

Identifying medical students likely to exhibit poor professionalism and knowledge during internship

CONTEXT

Identifying medical students who will perform poorly during residency is difficult.

OBJECTIVE

Determine whether commonly available data predicts low performance ratings during internship by residency program directors.

DESIGN

Prospective cohort involving medical school data from graduates of the Uniformed Services University (USU), surveys about experiences at USU, and ratings of their performance during internship by their program directors.

SETTING

Uniformed Services University.

PARTICIPANTS

One thousand sixty-nine graduates between 1993 and 2002.

MAIN OUTCOME MEASURE(S)

Residency program directors completed an 18-item survey assessing intern performance. Factor analysis of these items collapsed to 2 domains: knowledge and professionalism. These domains were scored and performance dichotomized at the 10th percentile.

RESULTS

Many variables showed a univariate relationship with ratings in the bottom 10% of both domains. Multivariable logistic regression modeling revealed that grades earned during the third year predicted low ratings in both knowledge (odds ratio [OR] = 4.9; 95%CI = 2.7-9.2) and professionalism (OR = 7.3; 95%CI = 4.1-13.0). USMLE step 1 scores (OR = 1.03; 95%CI = 1.01-1.05) predicted knowledge but not professionalism. The remaining variables were not independently predictive of performance ratings. The predictive ability for the knowledge and professionalism models was modest (respective area under ROC curves = 0.735 and 0.725).

CONCLUSIONS

A strong association exists between the third year GPA and internship ratings by program directors in professionalism and knowledge. In combination with third year grades, either the USMLE step 1 or step 2 scores predict poor knowledge ratings. Despite a wealth of available markers and a large data set, predicting poor performance during internship remains difficult.

Are commonly used resident measurements associated with procedural skills in internal medicine residency training?

BACKGROUND

Acquisition of competence in performing a variety of procedures is essential during Internal Medicine (IM) residency training.

PURPOSES

Determine the rate of procedural complications by IM residents; determine whether there was a correlation between having 1 or more complications and institutional procedural certification status or attending ratings of resident procedural skill competence on the American Board of Internal Medicine (ABIM) monthly evaluation form (ABIM-MEF). Assess if an association exists between procedural complications and in-training examination and ABIM board certification scores.

METHODS

We retrospectively reviewed all procedure log sheets, procedural certification status, ABIM-MEF procedural skills ratings, in-training exam and certifying examination (ABIM-CE) scores from the period 1990-1999 for IM residency program graduates from a training program.

RESULTS

Among 69 graduates, 2,212 monthly procedure log sheets and 2,475 ABIM-MEFs were reviewed. The overall complication rate was 2.3/1,000 procedures (95% CI: 1.4-3.1/1,000 procedure). With the exception of procedural certification status as judged by institutional faculty, there was no association between our resident measurements and procedural complications.

CONCLUSIONS

Our findings support the need for a resident procedural competence certification system based on direct observation. Our data support the ABIM's action to remove resident procedural competence from the monthly ABIM-MEF ratings.

Do Residents Benefit from Participating in Internal Medicine Interest Groups? A Study of Resident Perceptions from Two Institutions

BACKGROUND

For more than a decade, primary care residency training programs have struggled to attract graduates of U.S. medical schools. Internal medicine (IM) interest groups (IMIGs) have been widely instituted to foster student interest in careers in IM. Residents can participate in many IMIG activities. Studies have not assessed the benefits gained by resident participants in such groups.

METHODS

A questionnaire was sent to residents at two IM residency training programs that contribute to IMIG activities at one medical school. Both participating and nonparticipating residents were included.

RESULTS

The questionnaire was completed by 44 of 58 IM residents (76% response rate; 25 participants and 19 nonparticipants). Free-text advantages reported were teaching (n=6), mentoring (n=8), and leadership (n=5) opportunities, staying current in IM (n=3), encouraging students to enter IM (n=6), and improving resident morale (n=6). Likert-scale responses were higher for participants than for nonparticipants for all questions; nonparticipants also reported that involvement in IMIG activities is beneficial for residents. Statistically significant results were seen for questions regarding the following: improves resident morale, fosters leadership opportunities, is a valuable experience, and feeling qualified to participate.

CONCLUSIONS

Residents perceive that participation in an IMIG confers significant benefit, providing additional justification for conducting these interest groups.

The structure of program evaluation: an approach for evaluating a course, clerkship, or components of a residency or fellowship training program

BACKGROUND

Directors of courses, clerkships, residencies, and fellowships are responsible not only for determining whether individual trainees have met educational goals but also for ensuring the quality of the training program itself. The purpose of this article is to discuss a framework for program evaluation that has sufficient rigor to satisfy accreditation requirements yet is flexible and responsive to the uniqueness of individual educational programs.

SUMMARY

We discuss key aspects of program evaluation to include cardinal definitions, measurements, needed resources, and analyses of qualitative and quantitative data. We propose a three-phase framework for data collection (Before, During, and After) that can be used across undergraduate, graduate, and continuing medical education.

CONCLUSIONS

This Before, During, and After model is a feasible and practical approach that is sufficiently rigorous to allow for conclusions that can lead to action. It can be readily implemented for new and existing medical education programs.

Expectations of and for internal medicine clerkship directors: how are we doing?

PURPOSE

The purpose of this study was to determine how well published expectations are being met for internal medicine (IM) clerkship directors (CDs).

METHOD

In 2005, the Clerkship Directors in Internal Medicine (CDIM) surveyed its institutional members. One section addressed expectations, in terms of requirements and resources, of and for CDs. Survey questions were categorical (yes, no, or unsure) addressing the essential responsibilities and resources outlined in the Alliance for Clinical Education (ACE) consensus statement. Descriptive statistics, Mann-Whitney U, and chi-square testing were used for inferential statistical procedures.

RESULTS

Eighty-eight of 109 institutional members responded to the survey (81% response rate). For each responsibility, more than 90% of respondents reported that they were required to meet the expectation; however, for each of the 8 essential resources, the percentage of respondents who were meeting the expectation varied from 41% for additional time and resources for administering other courses to 95% for sufficient material resources to support clerkship requirements. With the exception of larger institutions having greater access to new technology (p = .038, Mann-Whitney U) and a defined budget (p = .012, Mann-Whitney U), there were no differences in demographics between respondents who did and did not meet expectations or resources.

CONCLUSION

IM CDs reported that they are expected to achieve essential responsibility benchmarks. Essential resources were being met in a variable fashion.

The feasibility and construct validity of graduate and supervisor surveys in a pulmonary fellowship training program

PURPOSE

The purpose of this study was to determine the feasibility and construct validity of our graduate and employer survey and its potential use in programmatic evaluation.

METHODS

An identical survey instrument was sent to fellowship graduates from our institution and their employers. We estimated feasibility through determining our survey response rate. Construct validity was assessed by comparing graduate self-ratings and employer ratings and through comparing survey ratings with passing board-certification examinations and referrals to the National Practitioner Databank.

RESULTS

Eleven years of graduates were included (n = 38 graduates). Response rates were 84% and 82% for graduates and their employers, respectively. Mean supervisor ratings were greater than graduate self-ratings on all questions. The lowest rating consistently across survey years was in graduates' self-perception of their ability to direct a PFT lab. One fellow failed his pulmonary boards and 1 failed his critical care boards on the first attempt. No graduates were referred to the National Practitioner Databank during our study period.

CONCLUSIONS

This fellowship survey appears to be feasible and have construct validity. The consistency in the relatively low self-rating of graduates in directing a PFT lab has led to important areas for curriculum reform.

Chest Pain and ST Segment Elevation Attributable to Cholecystitis: A Case Report and Review of the Literature

Chest pain with electrocardiographic changes is usually a life-threatening presentation of cardiac ischemia. There are, however, a variety of noncardiac conditions that have been reported to mimic these clinical and electrocardiographic changes. An Asian woman presented with chest pain and ST segment elevations in the distribution of the left anterior descending artery. She had persisting chest pain and ST segment elevations that were refractory to medical therapy, leading to thrombolytic therapy and rescue angiography, which revealed no evidence of coronary artery disease by coronary catherization. Cholecystitis was subsequently diagnosed with hepatobiliary scintigraphy. The patient's fever and ST segment elevations promptly resolved with antibiotic treatment. Four previous cases of ST segment elevation attributed to cholecystitis have been reported. Although the electrocardiographic changes attributed to cholecystitis have been shown to be correctable, the pathophysiological mechanism underlying these changes remains unclear. Prompt recognition of cholecystitis can ensure appropriate treatment and may prevent the performance of unnecessary diagnostic and therapeutic interventions.

Ingestion of superwarfarin leading to coagulopathy: a case report and review of the literature

Superwarfarins are found in many pesticides, including D-con, Prufe I and II, Ramik, Talon-G, Ratak, and Contrac. Ingestion of can lead to significant morbidity and even mortality. Physicians need to consider this diagnosis in any patient presenting with coagulopathy of unclear etiology. We present a patient with superwarfarin-induced coagulopathy and review previous cases in adults in the literature. The patient is a 60-year-old man who presented to our medical center with painless hematuria. Laboratory studies revealed an elevated prothrombin time (PT) (42.5 seconds), partial thromboplastin time (PTT) (64.6 seconds), and international normalized ratio (INR) of 7. Liver-associated enzymes were normal, and complete blood cell count (CBC) showed no evidence of disseminated intravascular coagulation. Subsequent work-up included the absence of an inhibitor by mixing study and deficiencies of vitamin K-dependent coagulation factors. The patient's warfarin level was negative. A brodifacoum level was positive, confirming superwarfarin-induced coagulopathy. The patient is currently doing well with normal coagulation studies after receiving high doses of vitamin K for several weeks. The cause of his exposure to superwarfarin remains uncertain. Physicians need to be cognizant of this unusual cause of coagulopathy in adults. The appropriate diagnostic work-up and unique features of therapy are discussed.

The feasibility, reliability, and validity of a program director's (supervisor's) evaluation form for medical school graduates

PURPOSE

To determine the feasibility, reliability, and validity of the supervisor's evaluation form for first-year residents as an outcome measure for programmatic evaluation.

METHOD

Prospective feedback has been sought from supervisors for the Uniformed Services University of the Health Sciences (USUHS) graduates during their internship year. Supervisors are sent yearly evaluation forms with up to three additional mailings. Using a six-point scale, supervisors rate residents on 18 items. The authors used evaluation data from 1993 to 2002. Feasibility was estimated by response rate. Internal consistency was assessed by calculating Cronbach's alpha and analyzing scores on a year-to-year and interrater basis. Validity was determined by exploratory factor analysis with oblique rotations, comparing ratings with end-of-medical school GPA and United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores (Pearson correlations), and by analyzing the range of scores to include the percentage of scores below acceptable level.

RESULTS

A total of 1,247 evaluations were collected for the 1,559 USUHS graduates (80%). Cronbach's alpha was .96 with no significant difference in scores by supervisor specialty or year. Factor analysis found that the evaluation form collapsed into two domains accounting for 68% of the variance: professionalism and expertise. End-of-medical school GPA and USMLE Step 1 and 2 scores correlated with expertise but not with professionalism. Mean scores across items were 3.5-4.31 with a median of 4.0 for all items (SD .80-1.21). Four percent of graduates received less-than-satisfactory ratings.

CONCLUSIONS

This evaluation form has high feasibility and internal consistency. Factory analysis revealed two complimentary domains supporting its validity. Correlation with end-of-medical school measurements and analysis of range of scores supports the form's validity.

A time and motion study of the effect of ambulatory medical students on the duration of general internal medicine clinics

BACKGROUND

Teaching medical students in the ambulatory setting may influence the duration or number of patients per clinic.

PURPOSE

To directly measure the time required to teach medical students in an outpatient clinic and to determine if there was a difference in activities performed by faculty when a student was present in the clinic.

METHODS

In this prospective, nonrandomized study, 83 clinic sessions were analyzed; 50 without a 3rd-year internal medicine clerkship student and 33 with a student. Seven 3rd-year internal medicine clerkship students and 7 general internists participated. The 7 general internists had both clinic sessions with and clinic sessions without a student during our study period. For every clinic session, physicians recorded duration, number of patients, presence of a student, and teaching activities. In a sub-set of 23 clinics (28%), ancillary staff independently recorded clinic duration and number of patients seen. To address time added to a clinic session by a student, we compared clinic sessions with versus clinic sessions without a student for each participating physician. Multiple linear regression was used for analysis.

RESULTS

Having a student added 32.3 min to a clinic session (p<.001). Clinic duration recorded by ancillary staff did not differ from duration recorded by physicians (p=.74), and the durations were well correlated (r=.81). Regarding additional activities, physicians were more likely to discuss patients with house staff when students were present, but other nonteaching physician activities did not change.

CONCLUSIONS

In this study, teaching a 3rd-year medical student in an internal medicine outpatient clinic required 32.3 extra min per clinic. Clerkship directors and clinic administrators should be aware of the extra time required to teach and be prepared to expect an impact on clinic productivity.

Clerkship sharing on inpatient internal medicine rotations: an emerging clerkship model

BACKGROUND

"Clerkship sharing" is the coexistence of students from 2 or more medical schools rotating on the same specialty at a single clerkship site.

PURPOSE

Clerkship sharing was characterized by answering three related questions regarding the prevalence of clerkship sharing on internal medicine inpatient rotations, stakeholders views of the advantages and disadvantages of clerkship sharing, and the ways that clerkship sharing affects medical student outcomes at an institution.

METHODS

In 2001, the Clerkship Directors in Internal Medicine (CDIM) surveyed its members; 1 section addressed clerkship sharing on inpatient rotations. In addition, the authors surveyed a convenience sample of teachers and learners at 41% of schools with clerkship sharing. Finally, using a 10-year database from one institution, we searched for differences in clerkship outcomes among students who rotated at clerkship sites with or without clerkship sharing.

RESULTS

The overall clerkship director (CD) survey response rate was 78% (96/123); 22 of 96 (23%) of CDs reported having clerkship sharing on inpatient rotations. Advantages reported included a greater diversity of clinical exposure for students (77%) and a fostering of collegial relationships (73%). We also collected 79 teacher and 77 medical student surveys from 9 (41%) medical schools identified as having clerkship sharing. The majority of these teachers and learners believed that sharing improves teaching and the overall rotation quality. All surveyed groups were concerned that clerkship sharing affected the clarity of clerkship goals, objectives, and grading. However, clerkship outcomes from 1 institution demonstrated no effect of clerkship sharing on faculty ratings of students or student examination performance.

CONCLUSIONS

Clerkship sharing appears to be an emerging clerkship model, and, although it may have inherent advantages that benefit student education, CDs should address challenges such as common goals and expectations for students and teachers.

Exercise-induced syncope associated with QT prolongation and ephedra-free Xenadrine

The Food and Drug Administration recently banned the sale of ephedra alkaloids because of their association with arrhythmic sudden death, myocardial infarction, and stroke. This has resulted in the emergence of formulations marketed for weight loss and performance enhancement that are "ephedra free" but contain other sympathomimetic substances, the safety of which has not been established. We report a case of exercise-induced syncope in a healthy 22-year-old woman that occurred 1 hour after she took the second dose of Xenadrine EFX, an ephedra-free weight-loss supplement. Electrocardiography revealed prolongation of the QT interval (corrected QT, 516 milliseconds); this resolved in 24 hours. Results of echocardiography and exercise stress testing were normal. Nine months of monitoring with an implanted loop recorder revealed no arrhythmias in the absence of Xenadrine EFX. Although this product contains a number of compounds whose pharmacologic effect is poorly characterized, notable quantities of phenylephrine are present, and the proarrhythmic potential of this compound in the setting of exercise is discussed.

A resident research director can improve internal medicine resident research productivity

BACKGROUND

Resident participation in research projects is felt to be an important component of internal medicine residency training, and accreditation organizations require that residency programs show that their residents and faculty participate in scholarly activity.

PURPOSE

To determine the impact of a Resident Research Director (RRD) on scholarly productivity of our internal medicine residents.

METHODS

We reviewed the number of presentations and publications of all residents from our institution over a 10-year study period (1992-2001). We used a historical control, comparing resident presentations and publications 5 years before (1992-1996) and after (1997-2001) implementation of the RRD position. We compared cohorts in terms of number of individuals in Alpha Omega Alpha and the number of individuals coming from a top 50 medical school as baseline measurements. We also compared these cohorts in regards to faculty to learner ratio, percentage of residents applying for fellowship, and American Board of Internal Medicine Certifying Examination performance. The Mann-Whitney U test was used for statistical inferences. Eighty-nine residents trained at our institution during the study period.

RESULTS

There was a significant increase in the number of regional and national presentations as well as publications after instituting the RRD position.

CONCLUSION

Our analysis suggests that an RRD can enhance resident scholarly productivity.