15 Assessing the Clinical Reasoning Skills of Emergency Medicine Clerkship Students Using a Script Concordance Test

Fourth-year medical students in emergency medicine (EM) clerkships are evaluated by various methods. Multiple choice examinations are frequently used to supplement clinical evaluations. These are limited in their ability to evaluate students' clinical reasoning skills. The Script Concordance Test (SCT) is an innovative assessment method developed to evaluate clinical reasoning. The SCT consists of a series of clinical vignettes, each followed by a series of specific questions that present an additional piece of data (a lab result, a physical finding, etc.) to the student. The students then indicate how the additional data affect their thinking regarding a possible diagnosis, an investigational strategy, or a therapeutic intervention, using a 5 point Likert scale (-2,-1,0,+1,+2). SCT questions have no single correct answer; instead, students receive credit based upon the level of agreement between their answers and those of a panel of 10 to 20 expert physicians who take the test to derive the answer key. The SCT is easily administered. In other disciplines, the SCT has demonstrated the ability to differentiate between the clinical reasoning skills of experienced and novice clinicians. The clerkship directors developed an EM SCT using an expert panel of 10 EM attending physicians. For the 07-08 academic year, SCT questions have been incorporated into the EM clerkship end-of-rotation written examination. The EM SCT shows promise as a measure of a student's clinical reasoning ability. Future studies will assess in greater detail the performance and statistical properties of the SCT in the setting of the EM clerkship.     

Core Practical Objectives: A Means to Standardize the 4th-Year Emergency Medicine Clerkship

Background: Core Practical Objectives (CPOs) are clinical emergency medicine (EM) experiences (including suggested number of patient encounters) that students use to self-direct clerkship progress. Purpose: This study investigates feasibility of implementing EM clerkship CPOs, describes characteristics of students fulfilling CPO guidelines, and relates CPO completion to outcome measures (exam scores and grades). Methods: Cross-sectional research was conducted comparing students completing and not completing CPOs by gender, month of rotation, total patients evaluated, clerkship exam score, and final grade. Results: Over 4 years, 117 students completed an EM clerkship utilizing CPO guidelines. Gender and clerkship month were not associated with fulfilling CPOs. Total CPOs completed correlated positively with percent score on written exam and grade for rotation. Completion of specific CPOs was associated with exam scores and final grade. Conclusions: CPOs were successfully integrated into an EM clerkship. Preliminary data suggest that CPO guidelines can be used to standardize EM clerkships.     

Designing the Third- and Fourth-Years Clerkship Schedule

Deciding on a specialty may be one of the most daunting parts of medical school. Accordingly, it is important for medical students to make informed decisions regarding their choice of specialty. To do so, they should start planning early by contemplating possible career choices during the first 2 years of medical school, followed by properly designing their third- and fourth-year schedules. This article provides guidance and advice to medical students on how to schedule their clinical clerkships in order to optimize their ability to decide on a field of medicine to study and, ideally, to prepare them for a career in emergency medicine.     

Medical education: a required clerkship in rehabilitation and chronic disease.

For seven years the University of Rochester Medical School has required a four-week clerkship in rehabilitation and chronic disease as part of the fourth year curriculum. Students have a choice of clerkships ranging from traditional physical medicine and rehabilitation to chronic disease experience in several other specialties. Data have been systematically collected for five years from the students in regard to the following: (1) rating of this clerkship relative to all other required clerkships for educational value; (2) opinion whether the clerkship should continue to be required; (3) value to other students with similar career goals; (4) attitudes towards rehabilitation and changes therein resulting from the clerkship experience; and (5) open-ended comments about the clerkship. Response rate to the questionnaire has been about 80%. The purpose of the questionnaire was to aid in improving the clerkship and to determine the settings where students would respond most positively to a chronic disease experience. Nearly half of the respondents felt the clerkship should continue to be required, and an overwhelming majority felt it would be valuable to students with career interests similar to theirs.     

Adaptation of Medical Students During Clinical Training: Effects of Holistic Preclinical Education on Clerkship Performance

Theory: Taiwan’s medical undergraduate program at a university or medical center is a continuation of 12?years of compulsory citizenship education rooted in holistic philosophies. Students acquire both technical knowledge and nontechnical attributes, which are necessary for success in further work and life. The early clinical learning experiences of medical students are primarily acquired through clerkships. These clerkships require medical students to apply and extend what they learned during their preclinical education; however, previous studies have explored this issue through examining fragmentary factors such as preclinical course grades and traits but not undertaking comprehensive, whole-person investigations. Hypotheses: To account for the potential benefits of a holistic approach in medical students’ learning, we propose three hypotheses: Medical students’ preclinical performance on Taiwan’s technical and nontechnical higher education assessments are positively associated with their clinical competence (Hypothesis 1) and psychological well-being (Hypothesis 2) during clerkships, and medical students’ psychological well-being during clerkships is positively associated with their clinical competence (Hypothesis 3). Method: We studied a cohort of 65 medical students engaged in clerkships from September 2013 to April 2015. Their preclinical technical knowledge scores—formal curricular grades received from course instructors—were obtained from their medical school’s archival dataset. Their nontechnical attributes—moral and social performance scores received from student mentors and physical performance scores received from course instructors—were also obtained from the school’s archival data set. The medical students’ competence in their 2-year clinical clerkships was measured using the objective structured clinical examination scores from the end of both clerkship years. The medical students’ psychological well-being during their 2-year clerkships was measured according to burnout level, which was determined using routine online surveys that employed validated, structured, and self-administered questionnaires at each specialty rotation. Multiple regressions and linear mixed-effects model were employed for statistical analysis. Results: Our study revealed that higher preclinical technical knowledge predicted superior clinical competence and a higher level of burnout during clerkships. By contrast, higher preclinical nontechnical attributes (i.e., higher preclinical moral, social, and physical performance) predicted lower level of burnout. However, no relationship was discovered between clerkship burnout and the clinical competence of the medical students. Conclusions: Our study verified the value of a holistic education that encompasses both technical knowledge and nontechnical attributes during the preclinical learning stage for medical students. Our findings can serve as a reference for medical educators designing preclinical educational programs for medical students.     

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.     

The Medical School Years

Medical school can be very challenging, especially when students are considering applying to competitive specialties, like emergency medicine. Once medical students know that emergency medicine is the field they want to specialize in, a multitude of other questions arise, including how many EM rotations should they do? How can they shine during their EM rotations? When should they schedule their rotations, electives, and sub-internships? How can they get the strongest letters of recommendation? What are residency program directors looking for? Therefore, we are going to present in the Medical Student Forum section of the Journal of Emergency Medicine a series of six articles covering this and more.     

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.     

Emergency Medicine Clerkship Curriculum: An Update and Revision

In 2006, the latest version of a national curriculum for the fourth‐year emergency medicine (EM) clerkship was published. Over the past several years, that curriculum has been implemented across multiple clerkships. The previous curriculum was found to be too long and detailed to cover in 4 weeks. As well, updates to the Liaison Committee on Medical Education (LCME)’s form and function document, which guides the structure of a clerkship, have occurred. Combining experience, updated guidelines, and the collective wisdom of members of the national organization of the Clerkship Directors in Emergency Medicine (CDEM), an update and revision of the fourth‐year EM clerkship educational syllabi has been developed. ACADEMIC EMERGENCY MEDICINE 2010; 17:638–643 © 2010 by the Society for Academic Emergency Medicine     

Grade Inflation in Internal Medicine Clerkships: Results of a National Survey

Background: There has been a discussion among medical educators concerning grade inflation; however, little has been written about it in the medical education literature. Purpose: A survey was developed to determine if grade inflation exists by gathering data about grading practices and by gathering the opinions of course directors from Internal Medicine clerkships. Methods: The survey was administered during the 1996-1997 academic year to all 125 LCME accredited medical school Internal Medicine Clerkship Directors. Grading practices for 3 separate academic years were obtained plus responses to questions about causes of and solutions for grade inflation. Results: Eighty-three surveys were returned for a 66% response rate. There was a trend towards higher grades across the 3 study years, with the 1995-1996 year being statistically significant. Forty-eight percent of the clerkship directors felt that grade inflation existed in their courses, and 43% felt that some students passed who should have failed. Conclusion: Statistically significant grade inflation exists in Internal Medicine clerkships. Most disturbingly, 43% feel we are unable appropriately to identify incompetent students.     

Medical Student Education in Emergency Medicine: Do Students Meet the National Standards for Clinical Encounters of Selected Core Conditions?

Background

Establishing a core curriculum for undergraduate Emergency Medicine (EM) education is crucial to development of the specialty. The Clerkship Directors in Emergency Medicine (CDEM) National Curriculum Task Force recommended that all students in a 4^th-year EM clerkship be exposed to 10 emergent clinical conditions.

Objectives

To evaluate the feasibility of encountering recommended core conditions in a clinical setting during a 4^th-year EM clerkship.

Methods

Students from three institutions participated in this ongoing, prospective observation study. Students' patient logs were collected during 4-week EM clerkships between July 2011 and June 2012. De-identified logs were reviewed and the number of patient encounters for each of the CDEM-identified emergent conditions was recorded. The percentage of students who saw each of the core complaints was calculated, as was the average number of core complaints seen by each.

Results

Data from 130 students at three institutions were captured; 15.4% of students saw all 10 conditions during their rotation, and 76.9% saw at least eight. The average number of conditions seen per student was 8.4 (range of 7.0–8.6). The percentage of students who saw each condition varied, ranging from 100% (chest pain and abdominal pain) to 31% (cardiac arrest).

Conclusions

Most students do not encounter all 10 conditions during patient encounters throughout a 4-week EM rotation, although most have exposure to at least eight. Certain conditions are far less likely than others to be encountered, and may need to be taught in a nonclinical setting.     

University and Community Hospital Medical Student Emergency Medicine Clerkship Experiences

Objective : To determine whether there is a significant difference between educational opportunities for fourth-year medical students rotating at a university hospital (UH) compared with several community hospitals (CHs) during a mandatory emergency medicine (EM) clerkship.
Methods : A self-reported clinical tool was completed in real time by each student rotating for 2 weeks at the UH and 2 weeks at 1 of 4 CHs (3 affiliated and 1 unaffiliated). Students are required to document the number of patients seen and the number of procedures performed on each of 20 six-hour shifts. They rated the EM attending clinical teaching by site using a 5-point scale at the end of the clerkship.
Results : Most (95%) of the 87 students in the 7 clerkship blocks of the 1996–97 academic year rotated at the UH and a CH. Most (71%) students rated both the UH and the CH for the quality of teaching by attendings. There was a significant difference in the mean number of patients evaluated/shift (2.2 ± 0.10 vs 2.8 ± 0.10, UH vs CH; p < 0.001) and the mean number of procedures performed/shift (0.36 ± 0.04 vs 0.56 ± 0.05, UH vs CH; p < 0.001). Attending clinical teaching scores were significantly higher (p = 0.03) at the CHs.
Conclusions : The educational opportunities for students in an EM clerkship to evaluate patients and perform procedures were significantly greater at the community hospitals. Inclusion of community hospital settings in a medical student EM clerkship may optimize the clinical experience.     

A window of opportunity: ethics and professionalism in the obstetrics and gynecology clerkship

Educational experiences of short duration may have substantial educational impact if they occur when the learner is at an appropriate maturational level. Medical educators agree that students rapidly internalize professional values and attitudes during clinical clerkships, thus making clerkships the ideal time to teach ethics and professionalism in medicine. At Stony Brook School of Medicine, we utilize these concepts by incorporating a structured ethics and professionalism exercise into the 3rd-year obstetrics-gynecology clerkship. Students utilize a team approach in a Medicine in Contemporary Society exercise that requires them to work up and present a patient case from an ethical, social, cultural, legal, and/or economic perspective in an interactive setting. In this report, we describe our 12 years of experience with this program including nearly 1,300 medical students.     

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.     

An Educator''s Guide to Teaching Emergency Medicine to Medical Students

There is a need for every medical school graduate to handle emergencies as they arise in the daily practice of medicine. Emergency medicine (EM) educators are in a unique position to provide students with basic life support skills, guidance in assessing the undifferentiated patient, and exposure to the specialty of EM during all years of medical school. Emergency physicians can become involved in a variety of education experiences that can supplement the preclinical curriculum and provide access to our specialty at an early stage. A well-designed course in the senior year allows students to develop critical thinking and patient management skills that are necessary for any medical career path. It can ensure that all medical students are exposed to the skills essential for evaluating and stabilizing the acutely ill patient. To implement this type of course, learning objectives and evaluation methods must be set when the curriculum is developed. An effective course combines didactic and clinical components that draw on the strengths of the teaching institution and faculty of the department. A structured clerkship orientation session and system for feedback to students are essential in nurturing the development of student learners. This article provides an approach to assist the medical student clerkship director in planning and implementing EM education experiences for students at all levels of training, with an emphasis on the senior-year rotation.     

Effectiveness of a Clinical Intervention for MD/PhD Students Re-entering Medical School

Background and Purpose: For MD/PhD students, the transition to medical school following graduate research can be difficult. We developed a clinical intervention, the Clinical Preceptorship Program (CPP), for MD/PhD students at Vanderbilt to ease the transition to the core clinical clerkship year (the 3rd medical year) following graduate training. In this study, we determined whether the CPP prepared MD/PhD students adequately for medical school reentry. Methods: Clerkship grades were obtained for 680 medical students and 50 MD/PhD students for academic years 2004–2010. A student's unpaired t test was used to analyze differences between group grades. Results: We did not detect significant differences in the grades of the MD versus MD/PhD students. No differences in individual clerkships were detected with the exception of the Surgery clerkship. Conclusions: These data suggest that the CPP intervention was successful in preparing MD/PhD students for the core clerkship year. Such a clinical intervention can be an effective preparation for MD/PhD students returning to medical school.     

Advanced Opportunities for Student Education in Emergency Medicine

Many medical students are excited about emergency medicine (EM) following a standard clerkship and seek out additional learning opportunities. An advanced EM elective may accomplish several educational goals, including development of clinical skills in evaluating the undifferentiated patient, broader exploration of the field of EM, and more focused study of one particular aspect of EM. Previously cited examples include pediatric EM, medical toxicology, occupational medicine, sports medicine, and EM research. Numerous other EM specialty courses for senior medical students are emerging, as reflected in the “Undergraduate Rotations” listings on the Society for Academic Emergency Medicine. A few examples drawn from the list include emergency ultrasound, international EM, wilderness medicine, disaster medicine, geriatric EM, and hyperbaric medicine. Educators aspiring to develop, or in the process of developing, an advanced EM elective may benefit from a brief overview of necessary course considerations, including didactic format, the clinical role of the medical student in the emergency department, and involvement with patient procedures. Suggestions are made regarding additional educational opportunities, including follow‐up of patients seen in the emergency department and development of an emergency department radiology case file. This article also addresses several related concerns, including suggested prerequisites, administration and cost considerations, appropriate didactic topics, and methods for evaluating students. Several EM subspecialty areas, namely pediatric EM, medical toxicology, and out‐of‐hospital care, are specifically discussed. Formal advanced cardiac life support training is also often included in an advanced EM elective and is briefly discussed. The overall intent of this article is to provide medical student educators with resources and ideas to assist them in developing a unique advanced EM elective.