Overnight Hospital Experiences for Medical Students: Results of the 2014 Clerkship Directors in Internal Medicine National Survey

Impact of a Pediatric Night Float on Medical Students' Education: Clerkship Student Perspectives

OBJECTIVES

A night float, in which learners work successive overnight shifts, is increasingly used in undergraduate medical education, yet few studies have examined its impact on students. The study objective was to explore third-year medical students' perspectives on the impact on learning of a pediatric night float.

METHODS

Informed by situated learning theory, we performed a qualitative study using grounded theory methodology to interview 19 third-year medical students who completed a pediatric night float between June 2019 and April 2021. Four coders analyzed data with the constant comparative method. Codes were built using an iterative approach and organized into themes. Discrepancies were resolved by consensus.

RESULTS

Analysis yielded 4 themes: professional identity formation, learning activities, clinical experiences, and work-life balance. Students described positive and negative educational experiences, which were influenced by how well students integrated into the team. For some students, the night float provided opportunities to admit patients, increase confidence, and build camaraderie, which helped form professional identity. Students felt the night float was key residency preparation. Educational activities included experiential learning, teaching, and receiving feedback. Students admitted more patients and were exposed to a greater diversity of illnesses at night compared with day shifts. Fatigue was common and sending students home before morning handoff impeded their integration into the team.

CONCLUSIONS

Students described varied impact of the night float on their education. A night float experience was felt to be key residency preparation. For students who felt included in the team a night float may promote professional identity formation.

Lower Frequency of Call Shifts Leads to Higher Attendance, Higher Academic Performance, and Less Burnout Syndrome in Surgical Clerkships

OBJECTIVE

Clinical clerkships are a fundamental component of medical education where students' learning is aided by exposure to real patients in diverse practical settings. Countless programs use overnight call shifts as an essential part of their clerkships. There has been concerns about the negative effects these shifts have on students. The study aims to determine relations between call schedule, lecture attendance, and academic and clinical performance.

METHODS

One hundred and eight medical students were followed during their surgery clerkship. Students on a Q3 schedule had an on-call shift once every 3 nights, while students on a Q4 schedule once every 4 nights. Their academic performance was evaluated using their exams grades, while their clinical performance was evaluated by their attending physicians. Burnout syndrome was measured using Maslach Inventory.

RESULTS

A total of 108 medical students attended their surgical clerkship. Sixty-nine students were under the Q3 call schedule while 39 students in the Q4 call schedule. Mean lecture attendance for students in Q3 was 82.7% (17.3%) compared to 90% (11.2%) (p = 0.020). Final exam grades were different between groups, with Q3 scoring a mean 71.55 (9.3) compared to Q4 85.07 (9.8) (p = 0.001). Clinical performance score means were similar between groups (p = 0.777). Q4 had 74% and Q3 had 49.3% of the students with >90% of attendance (p = 0.008). Q4 had 2.6% students with <70% attendance compared to Q3 with 23.2% (p = 0.008). Students with >90% attendance regardless of call schedule, scored higher in both midterms and final exams (p = 0.002; p = 0.001). Burnout prevalence was higher in students on the Q3 schedule with 28.6% compared to 4.7% of those on the Q4 schedule (p = 0.003).

CONCLUSIONS

Students with less call frequency were associated with an improvement in lecture attendance and academic performance, and a lower burnout syndrome rate, without impacting clinical performance. Students with higher attendance regardless of call schedules performed higher academically. Further studies should evaluate the impact on clinical performance and exposure more thoroughly.

A National Mixed-Methods Evaluation of Preparedness for General Surgery Residency and the Association With Resident Burnout

Importance

Differences in medical school experiences may affect how prepared residents feel themselves to be as they enter general surgery residency and may contribute to resident burnout.

Objectives

To assess preparedness for surgical residency, to identify factors associated with preparedness, to examine the association between preparedness and burnout, and to explore resident and faculty perspectives on resident preparedness.

Design, Setting, and Participants

This cross-sectional study used convergent mixed-methods analysis of data from a survey of US general surgery residents delivered at the time of the 2017 American Board of Surgery In-Training Examination (January 26 to 31, 2017) in conjunction with qualitative interviews of residents and program directors conducted as part of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial. A total of 262 Accreditation Council for Graduate Medical Education-approved US general surgery residency programs participated. Survey data were collected from 3693 postgraduate year (PGY) 1 and PGY2 surgical residents (response rate, 99%) and 98 interviews were conducted with residents and faculty from September 1 to December 15, 2018. Data were analyzed from June 1, 2017, to February 15, 2018.

Main Outcomes and Measures

Hierarchical regression models were developed to examine factors associated with preparedness and to assess the association between preparedness and resident burnout. Qualitative interviews were conducted to identify themes associated with preparation for residency.

Results

Of the 3693 PGY1 and PGY2 residents who participated (2258 male [61.1%]), 1775 (48.1%) reported feeling unprepared for residency. Approximately half of surgery residents took overnight call infrequently (≤2 per month) during their core medical student clerkship (1904 [51.6%]) or their subinternship (1600 [43.3%]); 524 (14.2%) took no call during their core clerkship. In multivariable analysis, residents were more likely to report feeling unprepared for residency if they were female (odds ratio [OR], 1.34; 95% CI, 1.15-1.57) or did not take call as a medical student (OR for 0 vs >4 calls, 2.72; 95% CI, 2.10-3.52). Residents who did not complete a subinternship were less likely to report feeling prepared for residency (OR, 0.68; 95% CI, 0.48-0.96). Feeling adequately prepared for residency was associated with a nearly 2-fold lower risk of experiencing burnout symptoms (OR, 0.57; 95% CI, 0.48-0.68). In interviews, the dominant themes associated with preparedness included the following: (1) various regulations limit the medical school experience, (2) overnight call facilitates preparation and selection of a specialty compatible with their preferences, and (3) adequate perceptions of residency improve expectations, resulting in improved preparedness, lower burnout rates, and lower risk of attrition.

Conclusions and Relevance

In this cross-sectional study, the perception of feeling unprepared was associated with inadequate exposure to resident responsibilities while in medical school. These findings suggest that effective preparation of medical students for residency may result in lower rates of subsequent burnout.

Undergraduate exposure to patient presentations on the acute medical placement: a prospective study in a London teaching hospital

OBJECTIVES

To identify the availability and variability of learning opportunities through patient presentations on an acute medical placement at a teaching hospital.

DESIGN

A prospective study evaluating all acute admissions to the Acute Medical Unit over 14 days (336 hours). Clinical presentations and the day and time of admission were recorded and compared with the learning outcomes specified in the medical school curriculum.

SETTING

An Acute Medical Unit at a London teaching hospital.

OUTCOMES

(1) Number of clinical presentations to the Acute Medical Unit over 14 days and (2) differences between the availability and variation of admissions and presentations between in-hours and out-of-hours.

RESULTS

There were 359 admissions, representing 1318 presentations. Of those presentations, 76.6% were admitted out-of-hours and 23.4% in-hours. Gastrointestinal bleeding, tachycardia, oedema and raised inflammatory markers were over three times more common per hour out-of-hours than in-hours. Hypoxia was only seen out-of-hours. Important clinical presentations in the curriculum such as chest pain and hemiparesis were not commonly seen.

CONCLUSIONS

There is greater availability of presentations seen out-of-hours and a changing landscape of presentations seen in-hours. The out-of-hours presentation profile may be due to expanded community and specialist services. Medical schools need to carefully consider the timing and location of their clinical placements to maximise undergraduate learning opportunities.

A National Survey of Undergraduate Clinical Education in Internal Medicine

BACKGROUND

In the present milieu of rapid innovation in undergraduate medical education at US medical schools, the current structure and composition of clinical education in Internal Medicine (IM) is not clear.

OBJECTIVE

To describe the current composition of undergraduate clinical education structure in IM.

DESIGN

National annual Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey.

PARTICIPANTS

One hundred twenty-nine clerkship directors at all Liaison Committee on Medical Education accredited US medical schools with CDIM membership as of September 1, 2017.

MAIN MEASURES

IM core clerkship and post-core clerkship structure descriptions, including duration, educational models, inpatient experiences, ambulatory experiences, and requirements.

KEY RESULTS

The survey response rate was 83% (107/129). The majority of schools utilized one core IM clerkship model (67%) and continued to use a traditional block model for a majority of their students (84%). Overall 26% employed a Longitudinal Integrated Clerkship model and 14% employed a shared block model for some students. The mean inpatient duration was 7.0 ± 1.7 weeks (range 3-11 weeks) and 94% of clerkships stipulated that students spend some inpatient time on general medicine. IM-specific ambulatory experiences were not required for students in 65% of IM core clerkship models. Overall 75% of schools did not require an advanced IM clinical experience after the core clerkship; however, 66% of schools reported a high percentage of students (> 40%) electing to take an IM sub-internship. About half of schools (48%) did not require overnight call or night float during the clinical IM sub-internship.

CONCLUSIONS

Although there are diverse core IM clerkship models, the majority of IM core clerkships are still traditional block models. The mean inpatient duration is 7 weeks and 65% of IM core clerkship models did not require IM-specific ambulatory education.

Medical Student Perceptions of 24-Hour Call

OBJECTIVE

To assess the medical student perception and experience of a 24-hour call requirement, and to learn if improvements can be made to improve the 24-hour call requirement.

DESIGN

Medical students completing their required surgical clerkship over 1 academic year at our institution were surveyed prior to their clerkship and on the last week of clerkship regarding their perceptions and experience with 24-hour call.

SETTING

This study was performed at the University of Minnesota, in Minneapolis, Minnesota, a medical school and tertiary medical center.

PARTICIPANTS

Two hundred one medical students were given the option to complete an anonymous survey before and after their required surgical clerkship.

RESULTS

Response rate for the preclerkship survey was 70% (n = 140) and 58% (n = 117) for the postclerkship survey. The mean age of respondents was 26 years, and the majority of students were in their third year of medical school. After completing the clerkship, students interested in surgery more often agreed the 24-hour call requirement should remain (51% versus 31%, p = 0.01). Students rotating at a Level I Trauma Center were also more likely to agree the call requirement should remain (59% versus 33%, p = 0.008). Medical students generally had less concerns (mental health, fatigue, mistakes, and grade performance) related to 24-hour call after completion of the clerkship. Concerns about the effect of 24-hour call on study schedule remained high in both pre and postclerkship groups.

CONCLUSIONS

Medical students have concerns about the experience prior to the clerkship that diminished by its completion. To improve medical student perceptions and overall experience of 24-hour call, frequency of shifts could be limited and the 24-hour call requirement sites could be shifted to Level I Trauma Centers.

The role of emergency medicine clerkship e-Portfolio to monitor the learning experience of students in different settings: a prospective cohort study

Background

Although emergency departments provide acute care learning opportunities for medical students, student exposure to recommended curriculum presentations and procedures are limited. In this perspective, clinical environments providing learning opportunities for students should be monitored as part of an ongoing quality improvement process. This study aims to analyze student exposures and their involvement levels in two different hospitals (Tawam and Al Ain) so as to improve the teaching and learning activities.

Methods

This is a prospective study on all 76 final year medical students’ electronic logbooks (e-Portfolio) of the academic year 2016/2017.

Results

Students recorded 5087 chief complaints and 3721 procedures. The average patient and procedure exposure in a shift per student in Al Ain Hospital compared with Tawam Hospital were 7.2 vs 6.4 and 5.8 vs 4.3, respectively. The highest full involvement with presentations was seen in the pediatric unit (67.1%, P < 0.0001). Urgent care shifts demonstrated the highest area of “full involvement” with procedures for our students (73.2%, P < 0.0001). Students’ highest involvement with presentations and procedures were found during the night shifts (P < 0.0001, 66.5 and 75.1%, respectively).

Conclusions

The electronic portfolio has proven to be a very useful tool in defining the learning activities of final year medical students during their emergency medicine clerkship and in comparing activities in two different clinical settings. Data collected and analyzed using this e-Portfolio has the potential to help medical educators and curriculum designers improve emergency medicine teaching and learning activities.

A simulated "Night-onCall" to assess and address the readiness-for-internship of transitioning medical students

Transitioning medical students are anxious about their readiness-for-internship, as are their residency program directors and teaching hospital leadership responsible for care quality and patient safety. A readiness-for-internship assessment program could contribute to ensuring optimal quality and safety and be a key element in implementing competency-based, time-variable medical education. In this paper, we describe the development of the Night-onCall program (NOC), a 4-h readiness-for-internship multi-instructional method simulation event. NOC was designed and implemented over the course of 3 years to provide an authentic "night on call" experience for near graduating students and build measurements of students' readiness for this transition framed by the Association of American Medical College's Core Entrustable Professional Activities for Entering Residency. The NOC is a product of a program of research focused on questions related to enabling individualized pathways through medical training. The lessons learned and modifications made to create a feasible, acceptable, flexible, and educationally rich NOC are shared to inform the discussion about transition to residency curriculum and best practices regarding educational handoffs from undergraduate to graduate education.

A night float week in a surgical clerkship improves student team cohesion

BACKGROUND

We hypothesize that night float rotations in the third-year surgical clerkship improve student learning and perceptions of team cohesion.

METHODS

A 1-week night float (NF) system was implemented during the 2013 to 2014 academic year for students. Each student completed 1 week of NF with the Trauma/Emergency General Surgery service. The Perceived Cohesion Scale survey was prospectively administered and National Board of Medical Examiners academic performance retrospectively reviewed.

RESULTS

We surveyed 70 medical students, 37 traditional call and 33 NF students, with 91% response rate. Perception of team cohesion increased significantly, without perceived loss of educational benefit. Examination scores increased significantly comparing pre- and postintervention groups, with this trend continuing in the following academic year.

CONCLUSIONS

A week-long student NF experience significantly improved perception of team cohesion and standardized examination results. A dedicated period of NF during the surgical clerkship may improve its overall educational value.

Training in General Surgery Ward Call: A Resident-Student Buddy System

There is a paucity of literature regarding medical student experiences of after hours hospital ward call. It was observed at our institution that medical students had minimal experience in ward call, yet were required to undertake such shifts as interns after graduation. We implemented a buddy system in which a medical student shadowed a general surgery resident for a ward call shift. Final year medical students were recruited from the local university at a tertiary teaching hospital after institutional approval. Each student attended a 4 hour evening shift on a general surgery ward with a supervising resident. A survey detailing attitudes and expectations of ward call was completed before and after the experience. Nine students enrolled in the project. Familiarity of expectations of what is required of an intern on a ward call shift improved significantly after the experience (3.1/5 to 4.1/5, p = 0.002). After hours work experience was reported as useful both before and after the study (4.5/5 to 4.7/5, p = 0.47). Students and doctors involved unanimously felt the experience was worthwhile. After hours ward call experience is useful for a final year medical student. More studies are required to further define the role of after hours ward call experiences during medical training.