Positive Outcomes of Optimizing Student–Preceptor Continuity in a Traditional Block Clerkship

Problem: Student–preceptor discontinuity during 3rd-year clerkships limits the quality and quantity of supervision, teaching, and feedback. Although longitudinal integrative clerkships increase continuity and are associated with improved student and preceptor experience, they require schoolwide curricular reform. Alternative innovations enhancing student–preceptor relationships within the constraints of a traditional block clerkship may demonstrate similar benefits. Intervention: We piloted a continuity-enhanced general pediatric ambulatory schedule during 2 consecutive clerkship blocks in 2013. Students in the continuity-enhanced model (n = 29) were assigned 1–3 primary clinic preceptors, whereas those in the traditional model (n = 30) worked with 5–8. Data were gathered from student assessments and anonymous student and preceptor surveys. We used t and Fisher's exact tests to compare the two groups and performed thematic analysis of free-text survey comments. Context: Our school utilizes a block clerkship model with approximately 30 students rotating through the pediatric clerkship every 8 weeks. During the 3-week ambulatory portion, students spend 8 half days in the general pediatric ambulatory clinic. At the conclusion of each clinic, attendings completed brief student evaluation cards. Traditionally, student and attending schedules were created independently, resulting in transient supervisory relationships and dissatisfaction with clinical engagement, feedback, and evaluation. Outcome: Seventy-three percent (43/59) of the students completed the survey. Ten general ambulatory attendings collectively completed 87.5% (35/40) of the monthly surveys. Continuity students received significantly more narrative evaluation comments (10.6 vs. 5.8, p <. 001) from general ambulatory clinic attendings and were more likely to have at least one general ambulatory clinic attending endorse being able to provide meaningful feedback and evaluation (n = 29, 100% vs. n = 20, 66.7%, p <. 001). Continuity students were also more likely to endorse being able to ask at least one of these attendings for a letter of recommendation (71.4% vs. 9.1%, p <. 001) and to have at least one general ambulatory clinic attending endorse being able to provide a meaningful letter of recommendation if asked (62.1% vs. 3.3%, p <. 001). Students (88.4%) and attendings (85.7%) preferred the continuity-enhanced schedule. The most frequent theme of both student and attending free-text survey remarks were relationships and assessment. Lessons Learned: Intentional scheduling of clerkship students to enhance preceptor continuity resulted in significant positive outcomes echoing the relationship-based educational benefits of longitudinal clerkships, particularly in regards to student assessment and feedback. Clerkship directors and other medical educators should consider implementing small changes within block clerkships to maximize student–preceptor continuity.     

Nurse–physician collaboration in an academic medical centre: The influence of organisational and individual factors

Ineffective physician–nurse collaboration has been recognised to adversely impact patient and organisational outcomes, and some studies suggest an underlying factor may be that nurses and physicians have different perceptions of interprofessional collaboration (IPC). The objectives of this study were to evaluate for a difference in the perception of IPC between physicians and nurses and to explore potential contributing factors at the individual and organisational levels to any observed difference. Data including measures of perceptions of IPC were collected from a convenience sample of resident physicians (n = 47), attending physicians (n = 18), and nurses (n = 54) providing care for internal medicine patients in a large tertiary care academic medical centre. Regression analysis revealed significantly lower perceptions of IPC scores for nurses in comparison to the scores of both the resident and attending physician groups (p = .0001 for both). Although demographic and workload factors also differed by profession, only profession and workload remained significant in regression analysis. Given the known relationships between effective physician–nurse collaboration and superior patient and organisational outcomes, better defining the individual and organisational predictors of IPC scores may support development of more effective interventions targeting improvements in IPC.     

Beyond the Ivory Tower: A Comparison of Grades Across Academic and Community OB/GYN Clerkship Sites

Construct: Decentralized clinical education is the use of community facilities and community physicians to educate medical students. The theory behind decentralized clinical education is that academic and community sites will provide educational equivalency as determined by objective and subjective performance measures, while training more medical students and exposing students to rural or underserved communities. One of the major challenges of decentralized clinical education is ensuring site comparability in both learning opportunities and evaluation of students. Background: Previous research has examined objective measures of student performance, but less is known about subjective performance measures, particularly in the field of obstetrics and gynecology (OB/GYN). This study explores the implications of clinical site on the adequacy of subjective and objective performance measures. Approach: This was a retrospective cohort study of 801 students in the University of Washington School of Medicine OB/GYN clerkship from 2008 to 2012. Academic sites included those with OB/GYN residency programs (n = 2) and community sites included those without residency programs (n = 29). The association between clerkship site and National Board of Medical Examiners (NBME) grade was assessed using linear regression and clinical and final grade using multinomial regression, estimating β coefficient and relative risks (RR), respectively, and 95% confidence intervals (CIs), adjusting for gender, academic quarter of clerkship, and year of clerkship. Results: There were no differences in NBME exam grades of students at academic sites (76.4 (7.3) versus 74.6 (8.0), β = –0.11, 95% CI [1.35, 1.12] compared to community sites. For clinical grade, students at community sites were 2.4 times more likely to receive honors relative to high pass (RR 2.45), 95% CI [1.72, 3.50], and for final grade, students at community sites were 1.9 times more likely to receive honors relative to pass (RR 1.98), 95% CI [1.27, 3.09], and 1.6 times more likely to receive honors relative to high pass (RR 1.62), 95% CI [1.05, 2.50], compared to those at academic sites. Conclusions: Students at community sites receive higher clinical and final grades in the OB/GYN clerkship. This highlights a significant challenge in decentralized clinical education—ensuring site comparability in clinical grading, Further work should examine the differences in sites, as well as improve standardization of clinical grading. This also underscores an important consideration, as the final grade can influence medical school rank, nomination into honor societies, and ranking of residency applicants.     

Relationships Matter: Enhancing Trainee Development with a (Simple) Clerkship Curriculum Reform

Problem: The traditional clerkship model of brief encounters between faculty and students results in reduced meaningful learning opportunities due to the lack of a relationship that enables repeated observation, supervisor feedback, trust formation, and growth. Intervention: Clinical clerkships at our institution were restructured to decrease fragmentation of supervision and foster an educational alliance between faculty and student. A mixed-methods approach was used to study the impact of this curriculum reform on the student experience in the obstetrics and gynecology clerkship. Student participation in patient care was assessed by comparing the number of common obstetric procedures performed before and after clerkship reform. Separate qualitative analyses of comments from student surveys and a faculty focus group revealed themes impacting student involvement. The supervisor–trainee relationship was further investigated by analysis of “rich picture” discussions with students and faculty. Context: Clerkships in the 3rd year of our 4-year undergraduate medical curriculum were converted from an experience fragmented by both didactic activities and multiple faculty supervisors to one with a single supervisor and the elimination of competing activities. Outcomes: Students in the revised clerkship performed twice the number of obstetric procedures. Objective measures (United States Medical Licensing Examination Step 1 scores, receiving clerkship honors, self-reported interest in obstetrics, and gender) did not correlate with the number of procedures performed by students. Qualitative analysis of student survey comments revealed that procedure numbers were influenced by being proactive, having a supervisor with a propensity to teach (trust), and contextual factors (busy service or competition with other learners). Themes identified by faculty that influenced student participation included relationship continuity; growth of patient care skills; and observed student engagement, interest, and confidence. The quality of the relationship was cited by both students and faculty as a factor influencing meaningful clinical participation. Discussions of “rich pictures” drawn by students and faculty revealed that relationships are influenced by continuity, early alignment of goals, and the engagement and attitude of both student and faculty. Lessons Learned: Clinical curricular reforms that strengthen the continuity of the supervisor–trainee relationship promote mutual trust and can result in a more meaningful training experience in less time. Reciprocal engagement and early alignment of goals between supervisor and trainee are critical for creating a positive relationship.     

When Professors Don't Return Essays

Issue: Students devote hundreds of hours to writing notes during medical school clerkships but receive very limited feedback on that work. Medical student notes are like college essays—both are persuasive compositions. But attending physicians rarely scrutinize student notes like college professors analyze essays. This is a missed opportunity to teach clinical reasoning. Evidence: A survey at our institution showed that only 16% of students received written feedback and 31% received oral feedback on their notes from more than 3 attending physicians during the first 8 months of 3rd-year clerkships. Many studies have reported a paucity of feedback across multiple domains and a sense among students that clinical reasoning is not being adequately taught during clerkships. Meanwhile, college professors teach written composition and reasoning through interactive methods that help students to develop structured, well-reasoned arguments. A recent study showed that 85% of Oxford undergraduates favored these demanding and time-intensive tutorials. Implications: Attending physicians who adopt a tutorial-based approach toward their students' notes would have a forum to teach clinical reasoning and emphasize the importance of written composition in medical practice.     

Creating a contemporary clerkship curriculum: the flipped classroom model in emergency medicine

Background

The teaching modality of “flipping the classroom” has garnered recent attention in medical education. In this model, the lecture and homework components are reversed. The flipped classroom lends itself to more interaction in “class” and theoretically improved clinical decision-making. Data is lacking for this model for students in emergency medicine clerkships. We trialed the flipped classroom in our fourth-year student clerkship. Our aim was to learn student and faculty facilitator perceptions of the experience, as it has not been done previously in this setting. We evaluated this in two ways: (1) participant perception of the experience and (2) facilitator (EM physician educator) perception of student preparation, participation, and knowledge synthesis.

Methods

With permission from its creators, we utilized an online video series derived from the Clerkship Directors in Emergency Medicine. Students were provided the link to these 1 week prior to the classroom experience as the “homework.” We developed patient cases generated from the videos that we discussed during class in small-group format. Afterward, students were surveyed about the experience using four-point Likert items and free-text comments and also were evaluated by the facilitator on a nine-point scale.

Results

Forty-six clerkship students participated. Students deemed the online modules useful at 2.9 (95 % CI 2.7–3.2). Further, they reported the in-class discussion to be of high value at 3.9 (95 % CI 3.8–4.0), much preferred the flipped classroom to traditional lecturing at 3.8 (95 % CI 3.6–3.9), and rated the overall experience highly at 3.8 (95 % CI 3.7–3.9). Based on preparation, participation, and knowledge synthesis, the facilitator judged participants favorably at 7.4 (95 % CI 7.0–7.8). Students commented that the interactivity, discussion, and medical decision-making were advantages of this format.

Conclusions

Students found high value in the flipped classroom and prefer it to traditional lecturing, citing interactivity and discussion as the main reasons. The facilitator also viewed that the students were not only well prepared for the flipped classroom but that they also actively participated in and synthesized knowledge adequately during this experience. This study supports the use of the flipped classroom for EM clerkship students as a valuable, preferable teaching technique.

     

The Effect of Resident Duty-Hours Restrictions on Internal Medicine Clerkship Experiences: Surveys of Medical Students and Clerkship Directors

Phenomenon: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students’ and clerkship directors’ perceptions of the effects of the 2011 DHR on internal medicine clerkship students’ experiences with teaching, feedback and evaluation, and patient care. Approach: Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation. Findings: Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. Insights: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student–patient relationship and students’ clinical skills acquisition.     

Emergency Physician–Administered Sedation for Pneumatic Reduction of Ileocolic Intussusception in Children: A Case Series

Background

Ileocolic intussusception is a major cause for intestinal obstruction in early childhood. Reduction of intussusception, in the vast majority of institutions, is performed on awake children, without sedation.

The Impact of the Demand for Clinical Productivity on Student Teaching in Academic Emergency Departments

OBJECTIVE: Because many emergency medicine (EM) attending physicians believe the time demands of clinical productivity limit their ability to effectively teach medical students in the emergency department (ED), the purpose of this study was to determine if there is an inverse relationship between clinical productivity and teaching evaluations. METHODS: The authors conducted a prospective, observational, double-blind study. They asked senior medical students enrolled in their EM clerkship to evaluate each EM attending physician who precepted them at three academic EDs. After each shift, students anonymously evaluated 10 characteristics of clinical teaching by their supervising attending physician. Each attending physician's clinical productivity was measured by calculating their total relative value units per hour (RVUs/hr) during the nine-month study interval. The authors compared the total RVUs/hr for each attending physician to the medians of their teaching evaluation scores at each ED using a Spearman rank correlation test. RESULTS: Seventy of 92 students returned surveys, evaluating 580 shifts taught by 53 EM attending physicians. Each attending physician received an average of 11 evaluations (median score, 5 of 6) and generated a mean of 5.68 RVUs/hr during the study period. The correlation between evaluation median scores and RVUs/hr was -0.08 (p = 0.44). CONCLUSIONS: The authors found no statistically significant relationship between clinical productivity and teaching evaluations. While many EM attending physicians perceive patient care responsibilities to be too time consuming to allow them to be good teachers, the authors found that a subset of our more productive attending physicians are also highly rated teachers. Determining what characteristics distinguish faculty who are both clinically productive and highly rated teachers should help drive objectives for faculty development programs.     

What Do Medical Students Do and Want When Caring for “Difficult Patients”?

Phenomenon: Medical students, like physicians, experience negative emotions such as frustration when interacting with some patients, and many of these interactions occur for the first time during clinical clerkships. Students receive preclinical training in the social and behavioral sciences, often including learning about “difficult patient” interactions, yet little is known about their desire for training during clinical education. We explored students’ strategies in these difficult clinical interactions, whether they felt prepared by the curriculum, and what support they would have liked. These data inform proposed strategies for supporting clinical learning. Approach: We interviewed 4th-year students about interactions with patients toward whom they felt negative emotions and sought to identify strategies and supports needed in these interactions. Interviews ended when theoretical sufficiency was achieved. We used qualitative content analysis to organize strategies into themes about areas benefiting from curricular supports. We mapped students’ desired curricular support examples to cognitive apprenticeship teaching methods—modeling, coaching, reflection, scaffolding, exploration, and articulation—and aligned them with traditional pedagogical techniques. Findings: We interviewed 26 medical students (44 volunteered/180 invited). Their strategies formed five themes: finding empathy (with a subtheme of focusing on social determinants of health), using learned communication approaches, anticipating challenging interactions, seeking support, and considering it an opportunity for more responsibility. Students described ideal clinical teaching, including postinteraction debriefs with an emphasis on validating their emotional reactions and challenges. Students mentioned all cognitive apprenticeship teaching methods, most prominently modeling (observing supervisors in such interactions) and supported oral reflection. They also identified a need for faculty and resident development to enact these teaching methods. Insights: Although students use some learned strategies in interactions in which they feel negative emotions toward patients, they desire more preparation and support during their clinical rotations. Their desires map to traditional pedagogical techniques and to methods of cognitive apprenticeship. Our findings point to the need to use these techniques to enhance clinical learning for students who experience emotionally challenging patient interactions.     

Physicians declining patient enrollment in a critical care trial: a case study in thromboprophylaxis

Purpose

To analyze the frequency, rationale and determinants of attending physicians requesting that their eligible patients not be approached for participation in a thromboprophylaxis trial.

Methods

Research personnel in 67 centers prospectively documented eligible non-randomized patients due to physicians declining to allow their patients to be approached.

Results

In 67 centers, 3,764 patients were enrolled, but 1,460 eligible patients had no consent encounter. For 218 (14.9 %) of these, attending physicians requested that their patients not be approached. The most common reasons included a high risk of bleeding (31.2 %) related to fear of heparin bioaccumulation in renal failure, the presence of an epidural catheter, peri-operative status or other factors; specific preferences for thromboprophylaxis (12.4 %); morbid obesity (9.6 %); uncertain prognosis (6.4 %); general discomfort with research (3.7 %) and unclear reasons (17.0 %). Physicians were more likely to decline when approached by less experienced research personnel; considering those with >10 years of experience as the reference category, the odds ratios (OR) for physician refusals to personnel without trial experience was 10.47 [95 % confidence interval (CI) 2.19–50.02] and those with less than 10 years experience was 1.72 (95 % CI 0.61–4.84). Physicians in open rather than closed units were more likely to decline (OR 4.26; 95 % CI 1.27–14.34). Refusals decreased each year of enrollment compared to the pilot phase.

Conclusions

Tracking, analyzing, interpreting and reporting the rates and reasons for physicians declining to allow their patients to be approached for enrollment provides insights into clinicians’ concerns and attitudes to trials. This information can encourage physician communication and education, and potentially enhance efficient recruitment.     

Intensive care decisions about level of aggressiveness of care

Questionnaires were used to assess (a) the factors intensive care unit resident physicians (N = 33) and nurses (N = 57) perceived as influential in making decisions about level of aggressiveness of patient care (LAC), (b) who residents and nurses believed should be involved versus who was involved in decision making, and (c) the amount of collaboration they perceived in their practices. Questionnaires then were used to assess decision making about 314 patients. All providers agreed that patient request influenced their LAC decisions, with possibility of benefit and diagnosis ranked second and third. Although both nurses and residents believed capable patients should be making LAC decisions, providers identified attending physicians as the most common participants in decision making for specific patients. Residents were more satisfied with the decision making process than nurses, t = 2.05 (88), p =.04. There was no relationship between perceptions of nurse–resident collaboration and providers' inclusion of others in the LAC decision process. ©1995 John Wiley & Sons, Inc.     

The Impact of Two Clinical Shift Allocation Models on Student Experiences in an Emergency Medicine Clerkship

Background: Medical students on Emergency Medicine (EM) clerkships are traditionally assigned work shifts in a manner that provides a mix of daytime, evening, overnight, and weekend shifts. Whether or not this shift allocation model provides the optimal educational experience remains unclear. Purpose: The purpose of this study was to compare the impact of two different shift allocation models on the student's clerkship experience. Specifically, we set out to compare the traditional shift allocation model to a novel model designed to maximize teacher–learner continuity. Methods: This was a prospective, crossover, cohort study of medical students participating in an EM clerkship at one institution from January 1 through April 31, 2010. All students completed 2 weeks of shifts under the “traditional shift model” and 2 weeks of shifts under the “continuity-based shift model.” In the latter, the guiding principle of student shift allocation was continuity between teacher and learner. Students completed coded surveys after each 2-week block that were later matched and analyzed using 2-way ANOVAs with 1 repeated measure. In addition, all students participated in a semistructured group interview at the completion of both blocks. The interviews were recorded, transcribed, and analyzed using qualitative methods. Themes and subthemes that emerged were assessed for frequency of occurrence. Results: Eighteen medical students consented to participate. Students rated the continuity-based shift model higher on all 10 survey items. However, only the items that asked specifically about “faculty”—faculty teaching, faculty interaction, frequency and quality of faculty feedback—were rated significantly higher when students worked under the continuity-based shift model. Qualitative analysis of group interviews revealed 6 major themes and 16 subthemes. Students described feedback (N = 16/117) and the teacher–learner relationship (N = 21/117) as superior under the continuity-based shift model. Conclusions: Changes in shift allocation affects student experience in an EM clerkship. A shift allocation model that maximizes the continuity between teacher and learner is perceived by students to improve feedback and the teacher–learner relationship.     

An Investigation of the Generalizability of Medical School Grades

Construct/Background: Medical school grades are currently unstandardized, and their level of reliability is unknown. This means their usefulness for reporting on student achievement is also not well documented. This study investigates grade reliability within 1 medical school. Approach: Generalizability analyses are conducted on grades awarded. Grades from didactic and clerkship-based courses were treated as 2 levels of a fixed facet within a univariate mixed model. Grades from within the 2 levels (didactic and clerkship) were also entered in a multivariate generalizability study. Results: Grades from didactic courses were shown to produce a highly reliable mean score (G = .79) when averaged over as few as 5 courses. Although the universe score correlation between didactic and clerkship courses was high (r = .80), the clerkship courses required almost twice as many grades to reach a comparable level of reliability. When grades were converted to a Pass/Fail metric, almost all information contained in the grades was lost. Conclusions: Although it has been suggested that the imprecision of medical school grades precludes their use as a reliable indicator of student achievement, these results suggest otherwise. While it is true that a Pass/Fail system of grading provides very little information about a student's level of performance, a multi-tiered grading system was shown to be a highly reliable indicator of student achievement within the medical school. Although grades awarded during the first 2 didactic years appear to be more reliable than clerkship grades, both yield useful information about student performance within the medical college.     

Learning in a High-Stress Clinical Environment: Stressors Associated with Medical Students’ Clerkship Training on Labor and Delivery

Abstract

Phenomenon: Obstetrics and gynecology can be a high-stress clinical environment for medical students due to the specialty’s fast-paced and unpredictable nature. Little is known about learning stressors for medical students on the obstetrics and gynecology clerkship to inform stress-reducing interventions and improve learning experience. This study investigated (a) which aspects of the learning environment are most stressful for obstetrics and gynecology clerkship students, (b) how perceived learning stressors in this environment differ for medical students and teachers (residents, fellows, and faculty), and (c) what interventions students propose to address these stressors. Approach: From May 2015 to April 2016, we conducted semistructured individual interviews with 3rd-year medical students from obstetrics and gynecology clerkship cohorts (n?=?52) as well as clerkship teachers (n?=?10) at an academic medical center. Two investigators used a qualitative Framework Method approach to analyze the interview data and agree upon final themes. Findings: We identified labor and delivery as the most stressful learning environment and four labor and delivery–related themes of students’ learning stressors: context (pace, logistics, nature of childbirth, and nonroutine schedule), learning tasks (student role and assignments and the amount of new knowledge and skills), communication (terminology used in conversation and interacting with the labor and delivery team), and clinical scenario (crisis, emergency, and patient refusal of student involvement). Whereas students identified context as causing most of the stress, teachers concentrated on stressors related to learning tasks. Insights: Learning stressors associated with students’ educational experience in the clinical context of labor and delivery are challenging for medical students. In addition to the specific content of these challenges, the recognition that teachers’ assumptions about sources of stressors are different from those of students is an important finding and has implications for changing the learning environment. Clerkship programs are encouraged to provide practical guidelines and embed an introduction of the clinical learning environment into the Obstetrics and Gynecology clerkship orientation curriculum.