Teaching and evaluation of physical examination skills on the surgical clerkship

It is presumed that graduating medical students possess adequate physical examination skills, although they are rarely evaluated during the clinical years. In this study we assessed the physical examination skills of third‐year medical students at the beginning and end of a surgical clerkship and investigated the effect of clerkship experiences and formal feedback on maturation of these skills. Sixty‐seven third‐year students completed a course on physical examination during their second year of medical school and achieved a 90% performance level on a physical examination performed on a patient instructor. This group subsequently performed a focused physical examination (chest, abdomen, groin [hernia], and external genitalia) during Week 1 and Week 6 of a 6‐week third‐year surgical clerkship. The physical examination was observed and evaluated using a 38‐item checklist; feedback was provided immediately after the first examination. Pretest performance was significantly poorer than that achieved in the second‐year course. Statistically significant improvement was noted from pretest to posttest for all areas except the external genitalia examination. Students in later rotations in the academic year did not perform significantly better than students in early rotations. We concluded that deterioration of learned physical examination skills occurs from the preclinical to the clinical years and that this deficiency is not corrected by clerkship experiences. Evaluation and feedback during the clerkship resulted in improvements in skills back to the levels demonstrated during the second year.     

An alternative clerkship model for ambulatory training: An interdisciplinary primary care experience

The Primary Care Clerkship of George Washington University is the only required ambulatory experience in the medical school curriculum. This 6‐week clerkship for third‐year medical students blends exposure to several primary care disciplines: family practice, internal medicine, pediatrics, and geriatrics. In addition to addressing epidemiologically common conditions, the curricular goals emphasize primary care concerns such as the doctor‐patient relationship, clinical epidemiology, the natural history of disease, appropriate and cost‐effective use of resources and consultants, quality assessment, screening strategies, and critical thinking skills. Each student is assigned two primary preceptors for the entire clerkship and spends 80% of his or her time in patient care. Typically, one of each student's preceptors works in the Medical Center's faculty practice; the other is a physician in private practice or in an inner‐city clinic for the medically underserved and homeless. Students may also work with geriatricians in nursing homes and on home visits in the Washington, DC area.     

An experiment in outpatient subspecialty medical student education

We developed a 1‐month subspecialty outpatient clinic program for third‐year medical students. The program was based on the premise that clinical education should be built on the preclinical foundation of organ‐oriented pathophysiology. The clerkship featured high volume (60 to 70 patients), library research (12 short papers), and close supervision by a mentor. Total teaching time was 10 hr/week/student. Student evaluations were obtained at the end of the rotation and on graduation. Pretest and posttest National Board of Medical Examiners scores did not distinguish clinic students from their ward peers. A year after the experience, the students reported that library research was the area in which the program had the most impact on their subsequent learning.     

Standardized Patient Assessment of Ambulatory Clerks: Effect of Timing and Order of the Clerkship

Background: A standardized patient examination may assess unique learning in an ambulatory clerkship but, as with written tests, may be affected by student maturation. Purpose: To explore the effect of timing and order of a medicine ambulatory clerkship on student performance of a standardized patient examination (SPE). Methods: All students rotating through an ambulatory medicine clerkship in 1 academic year completed an SPE designed to reflect specific learning objectives of the clerkship as well as nonclerkship case content. Students were grouped according to prior inpatient clerkship experience. Results: When compared to students with only ambulatory experience, students with both inpatient and ambulatory experiences in internal medicine did not perform better on the ambulatory cases of the SPE but did perform better on nonclerkship cases. Performance on the SPE was not affected by month of training. At completion of the inpatient clerkship, students with prior ambulatory experience did not perform better than students with inpatient-only experience on the National Board of Medical Examiners Medicine Subject Examination. Conclusions: The SPE is an appropriate assessment tool for the ambulatory clerkship when case content is linked to learning objectives of the clerkship. Unlike other knowledge-based assessments, the SPE is not affected by student maturation.     

Smoking assessment and cessation skills in the inpatient medicine clerkship

Effective disease prevention skills are essential for practicing physicians. One specific area of disease prevention skills underutilized by physicians is smoking assessment and cessation. A study of medical students’ ability to perform and opportunity to practice these skills during a core medicine clerkship was conducted to determine how well the program prepared students to practice these skills. An analysis of 61 patient medical writeups completed by 23 third‐year medicine clerks in a required, 3‐month, inpatient medicine clerkship was conducted. Although smoking history was noted in 74% of the charts, patient exposure was quantified in only 26% of the appropriate writeups. None of the writeups from the 9 currently smoking patients detailed an assessment of the patient's addiction, willingness to quit, or included smoking cessation in the therapeutic plan. We concluded that students’ smoking assessment and cessation skills are not well developed and that there is little opportunity to practice these skills in the inpatient setting.     

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.     

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.     

Medical students’ needs for feedback from residents during the clinical clerkship year

Feedback from residents may be an important component of the learning process for medical students in the clerkship year. In this study, we investigated what kind of feedback medical students in the clerkship year desired from residents and whether these needs changed over the course of the clerkship year. Over the course of 1 year, 69 students from one medical school class participated in meetings in which the nominal group technique was used to identify their feedback needs. Six students were also individually interviewed. Feedback needs early in the clerkship year were closely linked with students’ needs for goals clarification. As the year progressed, students required less communication from residents regarding expectations and more feedback on specific skills, notably physical examination skills, clinical skills, or both and written communication. Feedback either early or at a midpoint in the clerkship appeared to be an important need. Both positive and negative feedback were frequently mentioned. These results appear to validate theoretical guidelines for feedback previously described in the medical education literature.     

Pelvic examination using professional patients: An analysis of medical students’ evaluation of the program

This study evaluated students’ responses to the use of professional teaching assistants or models for the instruction of pelvic examination. Third‐year medical students rated the program on its value as an introduction to the obstetrics/gynecology clerkship, the specific techniques that were taught, their anxiety level, the value (or lack thereof) of having other students in the room, the amount of feedback they received, and the appropriateness of the program in the junior year.

The responses from the questionnaire were overwhelmingly positive for this method of instruction. This type of program is usually given during the sophomore year at most medical schools in the United States; however, 52% of the students felt that it was most appropriately introduced at the beginning of the junior year. A majority, 76%, felt that other departments would also benefit from using teaching assistants or models.

We conclude that these data support the widespread acceptance of this type of instructional method and discuss implications for its expansion to other areas of medical education.     

Grade Inflation and the Internal Medicine Subinternship: A National Survey of Clerkship Directors

Background: Grade inflation has been demonstrated in certain medical school clerkships but never studied in the internal medicine subinternship.

Purposes: The purpose is to determine the existence, extent, and possible causes of subinternship grade inflation.

Methods: We surveyed clerkship directors as part of the 2004 Clerkship Directors in Internal Medicine national member survey.

Results: The majority of clerkship directors agree that subinternship grade inflation exists. Half of SI students receive Honors and one third receive High Pass. Eighteen percent admitted passing a student that they felt should have failed. Difficulty delivering negative feedback is the top explanation for grade inflation.

Conclusion: Clerkship directors agree that grade inflation exists in the internal medicine subinternship. Faculty development and further analysis of our current subinternship evaluation and grading system may help to minimize this problem.     

Words of thanks

Background: Many factors influence medical students’ career choice.

Purpose: Determining the influence of an office‐based component to the 3rd‐year internal medicine clerkship on selection of primary care.

Methods: A prospective study using surveys and internship match information.

Results: Thirty‐seven percent entered primary care; 44% completing the office‐based rotation vs. 36% of others: odds ratio (OR) = 1.6 (1.0, 2.7). Among those interested in family medicine or pediatrics, students completing the office‐based rotation were twice as likely to enter primary care as their peers: family medicine OR = 1.8 (1.1, 3.2); pediatrics OR = 2.2 (1.1, 4.4). Among those not interested in internal medicine, students completing the office‐based rotation were four times more likely to enter internal medicine than their peers: OR = 4.2 (1.6, 11.0).

Conclusions: This office‐based internal medicine clerkship is associated with primary care career choice for students expressing interest in family medicine or pediatrics, and students not identifying internal medicine as a choice.     

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.     

Informed consent for blood transfusion as a transfusion medicine educational intervention

SUMMARY. The aim here was to determine the effectiveness of a transfusion medicine educational intervention in a medicine core clerkship program.
Third-year medical students enrolled in their medicine core clerkship rotations at tertiary care hospitals affiliated with our institution underwent a two-part educational intervention that incorporated a transfusion medicine curriculum within the context of the medicolegal, ethical and educational elements of informed consent. Part one was a 1-h didactic session on standards of practice for red blood cell transfusion. Part two was a 90-min multidisciplinary workshop on informed consent. The effectiveness of the educational intervention was analysed by an objective structured clinical evaluation.
The student group receiving the educational intervention scored significantly higher than in the comparison group (65.8 ± 9.2 vs. 54.1 ± 10.56, P <0.001). When student scores were used to determine changes in student response patterns over time, the largest change occurred in identifying possible other options to allogeneic blood transfusion.
These results suggest that a transfusion medicine curriculum using an informed consent model can be used effectively as an educational intervention in a medicine core clerkship programme.     

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.     

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.     

Understanding Clerkship Student Roles in the Context of 21st-Century Healthcare Systems and Curricular Reform

ABSTRACT

Phenomenon: Preclerkship medical education has undergone extensive reform, and the clerkship years are growing targets for curricular innovation. As institutions implement new preclerkship curricula to better prepare medical students to practice medicine in the context of modern healthcare systems, the perspective of clerkship leaders regarding clerkship student roles and potential for change will facilitate redefining these roles so that preclerkship educational innovations can continue into clerkships. Approach: In this qualitative exploratory study, authors conducted semistructured interviews with clerkship and site directors for eight core clerkships from April to May 2016. Questions addressed how clerkship leaders perceive current student roles and the potential for change. Through iterative consensus building, authors identified themes describing current ideal clerkship student roles applicable to future roles. Findings: Twenty-three of 24 (96%) directors participated. Findings fell into four themes: factors influencing the clerkship role, clerkship student role archetypes, workplace authenticity and value, and potential for change. Student, supervisor, and context factors determine the clerkship student role. Three role archetypes emerged: the apprentice (an assistant completing concrete patient care tasks), the academic (a researcher bringing literature back to the team), and the communicator (an interdisciplinary and patient liaison). Each archetype was considered authentic and valuable. Positive attitudes toward preclerkship curricular changes were associated with openness to evolution of the clerkship students' role. These emerging roles mapped to the archetypes. Insights: Clerkship leaders perceive that student, supervisor, and context factors result in varying emphasis on role archetypes, which in turn lead to different types of learning. Medical educators can use the archetypes to articulate how expanded student roles align learning with clinical needs, particularly as they relate to health systems science and inquiry.     

Service user involvement in pre-registration mental health nurse education classroom settings: a review of the literature

ACCESSIBLE SUMMARY: ? Service user involvement is an important part of pre-registration nursing programmes, as it can give students the opportunity to learn from users about their experiences of health and illness, but so far there have been limited studies in this area. ? This literature review provides an opportunity to explore how service user involvement in classroom settings can impact on student learning, and describes methods of best practice. ? Further research is needed to understand the influence of service user involvement on student nurses' clinical practice. ABSTRACT: Service user involvement in pre-registration nurse education is now a requirement, yet little is known about how students engage with users in the classroom, how such initiatives are being evaluated, how service users are prepared themselves to teach students, or the potential influence on clinical practice. The aim of this literature review was to bring together published articles on service user involvement in classroom settings in pre-registration mental health nurse education programmes, including their evaluations. A comprehensive review of the literature was carried out via computer search engines and the Internet, as well as a hand search of pertinent journals and references. This produced eight papers that fitted the inclusion criteria, comprising four empirical studies and four review articles, which were then reviewed using a seven-item checklist. The articles revealed a range of teaching and learning strategies had been employed, ranging from exposure to users' personal stories, to students being required to demonstrate awareness of user perspectives in case study presentations, with others involving eLearning and assessment skills initiatives. This review concludes that further longitudinal research is needed to establish the influence of user involvement in the classroom over time.