A Case–based Emergency Medicine Curriculum for Senior Medical Students

Objective: To determine the effects of a case–based, core content–oriented emergency medicine (EM) curriculum on the basic EM knowledge of senior medical students.
Methods: All senior medical students rotating through the Milwaukee County EM elective during the 1992–1993 academic year were assigned specific chapter readings from a case–oriented EM textbook. A course curriculum consisting of goals and objectives for each chapter and two to three representative cases for the discussion topic also was distributed to each student. Interspersed with the cases was a series of questions directed at pathophysiology, diagnosis, management, and disposition. The EM faculty and residents conducted case discussions three times per week. AH students completing the rotation were given a pretest at the beginning and a final examination at the end of the rotation. In addition, the students rated the textbook, coursebook, and lecture series at the end of the rotation using a five–point Likert scale.
Results: Seventy–five students rotated through the elective. The students showed a significant improvement in their EM knowledge base as judged by improvement in final examination scores compared with pretest scores (pretest score 62.2 ± 7.1%; final examination score 76.2 ± 6.3%; p < 0.0001). The mean change in scores was 14.8%, with a range of –1.6% to 34%. The students also rated the textbook, coursebook, and lecture series as effective, as shown by high median scores on a Likert scale.
Conclusions: A case–based EM curriculum coupled with ED clinical experience improves basic EM diagnostic and management knowledge of senior medical students.     

Faculty Evaluations Correlate Poorly with Medical Student Examination Performance in a Fourth-Year Emergency Medicine Clerkship

Background

Clerkship directors routinely evaluate medical students using multiple modalities, including faculty assessment of clinical performance and written examinations. Both forms of evaluation often play a prominent role in final clerkship grade. The degree to which these modalities correlate in an emergency medicine (EM) clerkship is unclear.

Book reviews

Background: As medical schools continue to strive to deliver high quality education with diminishing resources, the need to evaluate long-standing teaching techniques becomes imperative. The use of gynecological teaching associates to teach pelvic exam skills to medical students is an example of an education intervention that deserves thorough evaluation. Purpose: The objective was to evaluate effects of two pelvic examination training methods on OB/GYN clerkship students with respect to costs, students’ performance, and perception. Method: During the academic year 2007–08, 106 medical students were randomized to receive either pelvic examination training by a gynecological teaching associate (GTA) alone or a standardized patient (SP) accompanied by an obstetrics and gynecology faculty member. Students participated in an objective structured clinical exam (OSCE) and completed questionnaires regarding the educational intervention at the end of the clerkship. Results: The two training methods produced comparable OSCE scores, and students in both groups felt more confident after training and found the training sessions to be valuable. There was a significant cost-savings associated with using GTAs for pelvic exam training. Conclusions: Faculty time and effort need not be utilized for pelvic exam training exercises, since using GTAs for pelvic exam training produces comparable results.     

Evaluation of computerized simulations in a pediatric clerkship

Computer‐assisted instruction (CAI) using patient simulations was introduced on a pediatric clerkship to teach clinical knowledge and problem‐solving skills. To evaluate the efficacy of this educational tool, 151 students were alternately assigned either to complete two CAI exercises or to review the same information in text format. As part of the clerkship examination, all participants completed a latent‐image simulation and 10 multiple‐choice questions on the specific clinical information presented. After adjusting for prestudy differences in National Board of Medical Examiners Part I scores and cumulative grade point averages, scores on the overall final exam and on the outcome measures were similar for the two groups. In conclusion, CAI simulated patients, when applied in this limited fashion, were as effective but no more effective than text reading in teaching clinical information and problem solving on a pediatric clerkship.     

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.     

Effect of Electronic Versus Print Format and Different Reading Resources on Knowledge Acquisition in the Third-Year Medicine Clerkship

Background: Many medical students have access to electronic and print resources. It is not known if the format or the choice of resources effects knowledge acquisition over an entire clerkship. Purpose: To determine if the format (electronic or print) or choice of reading materials is associated with knowledge acquisition during the 3-year internal medicine clerkship. Methods: This was a prospective cohort study. During the last week of the clerkship, students took the National Board of Medical Examiners (NBME) exam and completed a survey ranking the reading materials used. Results: One hundred and fourteen 3rd-year internal medicine clerkship students participated. The most commonly reported resources were UpToDate® (99%), a review or question book (93%), and Harrison's Principles of Internal Medicine (82%). Multivariate analysis showed a significant beneficial effect of any use of Harrison's (linear regression, p <. 04, absolute difference 3 points, SD = 1.4) on NBME score. The format of the most important resource-electronic (61%) or print (39%)-did not predict the NBME score, p >. 80. Conclusions: The format (electronic or print) of resources did not appear to effect NBME score in the medicine clerkship. A secondary analysis showed the use of Harrison's textbook was associated with improved knowledge acquisition.     

Abstracts From the Proceedings of the 2005 Annual Meeting of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP)

Background: Educational theories predict conflicting results for the effect of increasing the authenticity of the teaching format of complex information on educational outcomes. We sought to determine the effect of increasingly authentic small-group, preclerkship teaching format on clerkship outcomes to further enlighten this debate. Summary: Students enrolled in a prospective randomized crossover trial that involved three content areas. For each content area, three teaching formats were tested. Participants were randomized to teaching format by content area. Clerkship outcomes were performance on an objective structured clinical exam, a DVD exam, internal medicine clerkship grades, and performance on the subject examination. The data were analyzed using a multivariate analysis of covariance. One hundred and thirty-three (78%) students participated. Teaching format did not have a statistically significant effect on any of the specified clerkship outcomes. However, number of patients seen was significantly associated with higher scores in respective outcomes by topic. Conclusions: Second-year teaching format did not directly influence subsequent clerkship performance. Our study adds to the literature by demonstrating that the authenticity of preclinical teaching format does not appear to matter for clerkship performance; however, the number of actual patients seen does appear to influence related clerkship outcomes.     

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.     

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.     

Internal Medicine Clerkship Directors' Use of and Opinions About Clerkship Examinations

Background: For years, quantifiable examinations have been a core component of assessing medical student competence during the internal medicine clerkship.

Purpose: To determine how internal medicine clerkship directors use and view examinations and how uses of examinations have changed.

Methods: In 1999, the Clerkship Directors in Internal Medicine conducted a confidential survey of its 123 institutional members.

Results: Survey response rate was 89% (109/123). The National Board of Medical Examiners subject examination was used by 83%, alone (49%) or in combination with a faculty developed examination or a standardized patient examination (34%). Minimum passing scores were required for the subject exam by 80%, for faculty-developed examinations by 65%, and for the standardized patient exam by 63%. Examinations contribute approximately 25% toward a student's final grade. Students with acceptable clerkship performances but who fail an exam typically retest after self-study. Students who fail a retest receive unsatisfactory grades and require additional medicine experience.

Of the clerkship directors who reported using the National Board of Medical Examiners subject examination, 45 (50%) provided comments on ways to improve the examination. Comments focused on examination content, reporting results, basing the exam on a published core curriculum, and general administrative issues. Over the past decade, use of the National Board of Medical Examiners subject examination has increased (66% to 83%), use of faculty-developed examinations has declined (46% to 27%), and the use of a clerkship standardized patient examination increased sharply (2% to 27%).

Conclusions: Internal medicine clerkship directors commonly require students to pass standardized or locally developed exams and use test results to make academic decisions. The use of standardized patient examinations has increased significantly and likely reflects a broadening of competency assessment. Our results can serve as a basis for individual programmatic evaluation, for internal medicine and other clerkship directors.     

Creation and Implementation of a National Emergency Medicine Fourth-Year Student Examination

Background

A National Board of Medical Examiners examination does not exist for Emergency Medicine (EM) students. To fill this void, the Clerkship Directors in Emergency Medicine tasked a committee with development of an examination for 4th-year (M4) EM students, based on a published syllabus, and consisting of questions written according to published question-writing guidelines.

Study Objectives

Describe examination development and statistics at 9 months.

Methods

The committee reviewed an existing EM student question database at www.saemtests.org for statistical performance, compliance with item-writing guidelines, and topic inclusion within the published EM M4 syllabus. For syllabus topics without existing questions, committee members wrote new items. LXR 6.0 software (Applied Measurement Professionals, Inc., Georgetown, SC) was used for examination administration. Data gathered included numbers of examinations completed, mean scores with SD, and point biserial correlation (rpb).

Results

Of the 553 questions assessed, 157 questions met the stated criteria, and 37 were included in the examination. Thirteen new questions were written by committee members to cover all curriculum topics. The National EM M4 Examination was released online August 1, 2011. Nine months later, the examination had been completed 1642 times by students from 27 clerkships. Mean score was 79.69% (SD 3.89). Individual question difficulties ranged from 26% to 99%. Question rpbs ranged from 0.067 to 0.353, mean 0.213 (SD 0.066).

Conclusions

A national group of EM educators developed an examination to assess a published clerkship syllabus. The examination contains questions written according to published item-writing guidelines, and exhibits content validity, appropriate difficulty levels, and adequate question discriminatory ability.     

Clerkships in Emergency Medicine

Planning for clerkships in emergency medicine (EM) can be stressful, prolonged, and challenging. Therefore, medical students should start planning for them early. In this article, we offer guidance regarding several issues pertinent to the EM clerkship, such as the best time to schedule one (or more) during medical school, the most appropriate institution or program to schedule it, the process of selecting and applying for the clerkship, and the number of EM clerkships to consider. We will explain why an EM clerkship should be scheduled between June and October and the reason that 2 EM clerkships at different sites are sufficient for the majority of students. Additionally, we emphasize that clerkships in emergency departments associated with EM residency programs or with reputations for outstanding student teaching tend to be most beneficial. Above all, students interested in EM should attempt to leave a great impression after completing their clerkships by providing stellar patient care, demonstrating enthusiasm at all times, and maintaining professionalism. In turn, they will gain knowledge and clinical experiences that should prove valuable in their future.     

Exposure and attitudes toward interprofessional teams: a three-year prospective study of longitudinal integrated clerkship versus rotation-based clerkship students

Abstract

This study explored exposure to, and attitudes toward, interprofessional (IP) teams between third-year longitudinal integrated clerkship (LIC) and traditional rotation-based clerkship (RBC) students at the University of Calgary medical school. Students completed a survey pre-post 32-week LIC or 6-week rural, regional or urban RBC family medicine rotations. Pre and post rotation surveys were completed by 213 (48%) students (LIC?=?33/34; rural?=?76/152; regional?=?24/46; urban?=?80/208). More LIC students (76%) reported participating on six or more IP teams than RBC students (rural?=?38%; regional?=?25%; urban?=?21%). At pre rotation, the mean attitude to IP teams score of LIC and rural RBC students was high and did not differ. At post rotation, the mean attitude score of LIC students was significantly greater than the mean reported by rural RBC students. Only LIC students reported a significant pre-post rotation increase in attitude. Exposure to IP teams, possibly facilitated by a longer duration of rotation, appears to be an important factor in affecting attitude to IP teams.     

Dedicated emergency department ultrasound rotation improves residents' ultrasound knowledge and interpretation skills

Background

Graduates of Emergency Medicine (EM) residency training programs are expected to be proficient in ultrasound. However, best practices for teaching residents ultrasonography has yet to be determined.

Study Objectives

To determine if a dedicated Emergency Department (ED) ultrasound rotation objectively improves residents’ EM ultrasound knowledge, interpretation accuracy, and clinical decision-making based on ultrasound findings.

Methods

EM residents completing a required ED-based ultrasound rotation were prospectively studied. Before the start of the rotation, each resident completed a 20-question pre-test. At the end of the rotation, residents completed a 20-question post-test. Both tests covered physics, trauma (focused assessment with sonography for trauma), first-trimester pregnancy, aorta, biliary, echocardiography, and vascular sonography, using a multiple-choice format. In both tests, ultrasound images were included in 11 of the 20 questions. The questions were divided into three categories: knowledge-based (8 questions), interpretation (9 questions), and clinical decision-making (3 questions), for both tests. Scores on pre-tests and post-tests were compared using a Wilcoxon signed-rank test.

Results

During the 2-year study period, 21 residents completed the rotation. The median pre-test score was 16 (interquartile range [IQR] 14.5–17), compared to a median post-test score of 19 (IQR 18–20), p < 0.001.

Conclusions

A dedicated ED ultrasound rotation improves residents’ EM ultrasound knowledge and interpretation accuracy based on ultrasound findings, as measured by improvement on ultrasound test scores.     

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.     

Evidence-based strategies for standardized exam remediation in nursing: An integrative review

Many nursing programs use standardized exams to prepare students for the National Council Licensure Examination (NCLEX). Often, students are encouraged or required to remediate based on results. The value and common use of remediation in nursing education is well documented. However, evidence is less clear regarding remediation best practices. The purpose of this integrative review of literature was to identify evidence-based standardized exam remediation strategies and policies that help students achieve higher standardized exam scores and pass the NCLEX. Five computerized databases were systematically searched for primary research and quality improvement studies that examined remediation strategies following the administration of standardized nursing exams. Results were screened using a three-phase process, leading to a final sample of 24 articles. Three remediation strategy themes were identified: self-guided activities and assignments; faculty-guided group activities; and faculty-guided individual activities. Four remediation policy categories were revealed: required remediation if benchmark score is not met; required retesting if benchmark score is not met; delay in progression if benchmark score is not met; and credit awarded for completing remediation. These findings provide guidance for nursing programs seeking to develop or refine remediation policies and practices to better support students’ learning and increase NCLEX pass rates.