Using Patient Encounter Logs for Mandated Clinical Encounters in an Internal Medicine Clerkship

Background: Patient encounter logs help assess a student's educational experience. The use of a grading incentive linked to the mandatory documentation of prespecified clinical encounters has been insufficiently studied. Purposes: Given this, our objectives were to determine (a) if mandating student exposure to patients with 18 key training problems leads to the successful documentation of these encounters, (b) the degree of difficulty students and clerkship directors experienced in meeting these mandates, (c) the accuracy of mandated log entries, and (d) how often the log entries were questioned or rejected by preceptors. Methods: Ninety-two 3rd-year internal medicine students and 6 internal medicine clerkship directors at 9 geographically dispersed hospitals and 30 ambulatory sites participated in the study. Over a single academic year, we directly measured the completion rate of mandated logs, the degree of their accuracy as judged against faculty-generated logs of two required videotaped standardized patient encounters, and the percentage of logs that were not validated. We surveyed students and directors on the perceived degree of difficulty in meeting mandated requirements. Results: Ninety-eight percent of students met our mandated requirements and 93.8% of students found it “easy” or “very easy” to meet this requirement. The amount of estimated time spent by clerkship directors helping students meet mandated requirements for the entire year was 4.5 hr. The accuracy of submitted logs was 77%; however, almost all inaccurate log entries were “validated” by preceptors. Conclusions: Mandating encounters is effective in assuring that students document encounters with patients who present with specific clinical problems. The accuracy of our students' mandated logs is similar to previously published data. However, even inaccurate logs were rarely questioned or rejected by preceptors.     

Medical student deployment to a single metropolitan hospital during the COVID-19 pandemic: A mixed methods analysis

Objectives

To explore student and staff satisfaction with the use of medical students as a surge workforce during the COVID-19 pandemic.

Method

We conducted a mixed methods analysis of staff and student experiences with the medical student workforce at a single metropolitan ED over an 8-month period between December 2021 and July 2022, using an online survey tool. Students were invited to complete the survey fortnightly, whereas senior medical and nursing staff were invited weekly.

Results

There was a 32% response rate for surveys sent to medical student assistants (MSAs) and 18% and 15% for medical and nursing staff, respectively. Most students felt well prepared and supported in the role and would recommend it to other students. They reported that the role allowed them to gain experience and confidence within the ED, especially after much of their learning had moved online throughout the pandemic. Senior nurses and doctors found MSAs to be useful members of the team, largely through their assistance with task completion. Both staff and students recommended a more comprehensive orientation, changes to the supervision model and increased clarity in the students' scope of practice.

Conclusions

The results of the present study provide insight into the use of medical students as an emergency surge workforce. Responses from medical students and staff suggested that the project was beneficial for both groups as well as for overall departmental performance. These findings are likely to be translatable beyond the COVID-19 pandemic setting.     

Clinical nursing instructors' use of handheld computers for student recordkeeping and evaluation

I have found the Palm IIIc to be useful in tracking undergraduate student progress in the clinical area. Entrepreneurial thinkers continue to develop new ideas in software, so the possibilities for using these devices will only grow. Future possibilities for handheld computers include built-in Internet connections or providing students with devices to record and analyze their experiences or complete assignments. Many nurses and physicians who have learned to use handheld computers are sure they never want to go back to using paper and pen (Labkoff & O'Mahony, 1997; Wilson & Fulmer, 1998). I will continue to depend on and find new uses for this pocket-sized, yet powerful, device.     

EMCyberSchool An Evaluation of Computer-assisted Instruction on the Internet

OBJECTIVES: To test the hypothesis that integration of the EMCyberSchool, a computer-assisted instruction (CAI) tool available on the Internet, into the curriculum of a senior medical student subinternship in emergency medicine (EM) would improve exam scores and course satisfaction. METHODS: Students were prospectively randomized, by four-week blocks, into a CAI group and a no-CAI group. All students were surveyed on previous computer experience and their use and opinion of the EMCyberSchool. RESULTS: Completed data were obtained from 100 of 120 students. Sixty-five percent of the students said they wanted CAI as an adjunct to their course curricula; only 28% actually used the educational tool. The students who used the site rated it useful (4.2/5), easy to use (4.4/5), and easy to access (4.1/5). Of the students who had access, and chose not to use the EMCyberSchool, 77.8% reported not having enough time as the reason for not using the site. The mean exam scores were 72.8% for the students in the CAI group and 68.2% for those in the no-CAI group (p = 0.058). In the CAI group, 77.5% (31/40) of the students rated the course as outstanding or excellent; compared with 66% (33/50) in the no-CAI group (p = 0.23). CONCLUSIONS: Although desired, it remains unclear whether CAI on the Internet is a useful adjunct for teaching EM to medical students.     

Feedback to emergency medical services providers: the good, the bad, and the ignored

HYPOTHESIS: To determine the type and frequency of immediate unsolicited feedback received by emergency medical service (EMS) providers from patients or their family members and emergency department (ED) personnel. METHODS: Prospective, observational study of 69 emergency medical services providers in an urban emergency medical service system and 12 metropolitan emergency departments. Feedback was rated by two medical student observers using a prospectively devised original scale. RESULTS: In 295 encounters with patients or family, feedback was rated as follows: 1) none in 224 (76%); 2) positive in 51 (17%); 3) negative in 19 (6%); and 4) mixed in one (< 1%). Feedback from 254 encounters with emergency department personnel was rated as: 1) none in 185 (73%); 2) positive in 46 (18%); 3) negative in 21 (8%); and 4) mixed in 2 (1%). Patients who had consumed alcohol were more likely to give negative feedback than were patients who had not consumed alcohol. Feedback from emergency department personnel occurred more often when the emergency medical service provider considered the patient to be critically ill. CONCLUSIONS: The two groups provided feedback to emergency medical service providers in approximately one quarter of the calls. When feedback was provided, it was positive more than twice as often as it was negative. Emergency physicians should give regular and constructive feedback to emergency medical services providers more often than currently is the case.     

Clinical and educational uses of handheld computers

Handheld computers, also known as personal digital assistants (PDAs), are becoming an increasingly valuable aid to physicians at the point of care. We review the use of handheld computers and their impact in clinical practice and medical education. Clinicians commonly use PDAs to access patient data and as a clinical reference tool. In medical education, handheld computers are most frequently used to track patient encounters and procedures done during medical school rotations and residency training. This report describes some interesting applications for present and future use of PDAs in inpatient care and medical education. Physicians and educational programs not using PDAs may wish to consider incorporating this technology.     

Use of Standardized Patients in,Undergraduate Medical Genetics Education

Background and Purpose: To study the effectiveness of a standardized patient (SP) program in increasing the competence of medical students in assessing genetic risks and communicating genetic information to patients. Methods: Third-year medical students at the Mount Sinai School of Medicine had two encounters from 2001 to 2003 with the same SP, who portrayed a woman at risk for hereditary breast cancer. Assessment instruments included student self-assessment of skills, SP assessment of student communication skills, an observer checklist, grading of the student-drawn pedigree, and a knowledge test. Students also completed an evaluation form after the debriefing session at the end of each of the SP sessions. Results: The SP program was completed by 136 students. The student self-evaluation of skills instrument revealed that students who completed the SP program felt more competent in their ability to draw a pedigree, assess genetic risks based on family history and pedigree information, and communicate genetic risks compared to students at the same level of training who did not participate in the SP program. Of participating students, 90% agreed that the program allowed them to identify areas for improvement in their skills, and 95% agreed that the exercise increased their confidence for having a similar patient interaction in the future. Conclusions: The use of SPs in undergraduate medical genetics education may be one means for increasing the confidence of medical students in skills that are related to genetic encounters.     

Feedback

The emergency department provides a rich environment for diverse patient encounters, rapid clinical decision making, and opportunities to hone procedural skills. Well-prepared faculty can utilize this environment to teach residents and medical students and gain institutional recognition for their incomparable role and teamwork. Giving effective feedback is an essential skill for all teaching faculty. Feedback is ongoing appraisal of performance based on direct observation aimed at changing or sustaining a behavior. Tips from the literature and the author's experience are reviewed to provide formats for feedback, review of objectives, and elements of professionalism and how to deal with poorly performing students. Although the following examples pertain to medical student education, these techniques are applicable to the education of all adult learners, including residents and colleagues. Specific examples of redirection and reflection are offered, and pitfalls are reviewed. Suggestions for streamlining verbal and written feedback and obtaining feedback from others in a fast-paced environment are given. Ideas for further individual and group faculty development are presented.     

Introducing Final-Year Medical Students to Pocket-Sized Ultrasound Imaging: Teaching Transthoracic Echocardiography on a 2-Week Anesthesia Rotation

Problem: The availability of less expensive and smaller ultrasound machines has enabled the use of ultrasound in virtually all major medical/surgical disciplines. Some medical schools have incorporated point-of-care ultrasound training into their undergraduate curriculum, whereas many postgraduate programs have made ultrasound training a standard. The Chinese University of Hong Kong has charged its Department of Anaesthesia and Intensive Care to spearhead the introduction of ultrasound into the final-year medical curriculum by introducing handheld transthoracic echocardiography as part of perioperative assessment. Intervention: All 133 final-year students completed a 2-week anesthesia rotation, which began with a half-day session consisting of a lecture and hands-on practice session during which they learned 9 basic transthoracic echocardiography views using 4 basic ultrasound probe positions. Context: Each student was required to perform a transthoracic echocardiography-examine under supervision of 1 patient/week for 2 weeks, and their results were compared against that of the supervisor's. Most patients were elective cardiac surgery patients. One long question on transthoracic echocardiography was included in their end-of-year surgery examination paper. Students provided feedback on their experience. Outcome: Most students learned the basic transthoracic echocardiography views fairly efficiently and had variable, though generally favorable, success rates in identifying obvious cardiac anomalies, including use of color Doppler. A few common mistakes were identified but were easily correctable. Logistics for mobilizing enough bedside supervision were challenging. Students reported positive feedback on the teaching initiative. Lessons Learned: We were able to execute a successful short training course on transthoracic echocardiography during the final-year medical degree anesthesia rotation. Our initiative may set an example for other clinical departments to design similar courses pertinent to their specialties and syllabuses.     

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.     

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.     

Mobile Technology for the Facilitation of Direct Observation and Assessment of Student Performance

Background: We developed, implemented, and assessed a web-based clinical evaluation application (i.e., CEX app) for Internet-enabled mobile devices, including mobile phones. The app displays problem-specific checklists that correspond to training problems created by the Clerkship Directors in Internal Medicine. Purpose: We hypothesized that use of the CEX app for directly observing students’ clinical skills would be feasible and acceptable, and would demonstrate adequate reliability and validity. Methods: Between July 2010 and February 2012, 266 third-year medical students completed 5 to 10 formative CEXs during their internal medicine clerkship. The observers (attendings and residents), who performed the CEX, used the app to guide and document their observations, record their time observing and giving feedback to the students, and their overall satisfaction with the CEX app. Interrater reliability and validity were assessed with 17 observers who viewed 6 videotaped student–patient encounters, and by measuring the correlation between student CEX scores and their scores on subsequent standardized-patient Objective Structured Clinical Examination (OSCE) exams. Results: A total of 2,523 CEXs were completed by 411 observers. The average number of evaluations per student was 9.8 (± 1.8 SD), and the average number of CEXs completed per observer was 6 (± 11.8 SD). Observers spent less than 10 min on 45.3% of the CEXs and 68.6% of the feedback sessions. An overwhelming majority of observers (90.6%) reported satisfaction with the CEX. Interrater reliability was measured at 0.69 among the observers viewing the videotapes, and their ratings discriminated between competent and noncompetent performances. Student CEX grades, however, did not correlate with their end of 3rd-year OSCE scores. Conclusions: The use of this CEX app is feasible and it captures students’ clinical performance data with a high rate of user satisfaction. Our embedded checklists had adequate interrater reliability and concurrent validity. The grades measured on this app, however, were not predictive of subsequent student performance.     

Evaluation of a multischool collaborative COVID-19 vaccination project

To describe experiences of student nurses and faculty who participated in COVID-19 vaccine delivery through a multischool collaboration. Cross-sectional survey. Student nurses and faculty members from five university schools and colleges of nursing who participated in one or more COVID-19 vaccination or education events in 2021. Surveys were designed for students and faculty to document process and outcome experiences associated with project participation. Surveys were administered through an online survey platform. Overall, 648 students and 68 faculty members participated in the project. The evaluation survey was completed by 115 students (18%) and 58 faculty members (85%). Students valued increasing their clinical skills and reported the experience influenced their perspectives on nursing, fueling their passion and informing future career choices. Students reported that it was personally important to contribute to the vaccination effort. Few students reported challenges in participating in the project. Faculty reported positive experiences including gaining knowledge about public health and their communities, fueling their passion for nursing education, feeling a deeper connection with students, and experiencing personal satisfaction from contributing to the pandemic response. This project resulted in meaningful student learning opportunities, enhanced capacity for the public health emergency response, and strengthened partnerships among nursing programs and between academia and public health community partners.     

Medical Student Career Advice Related to Emergency Medicine

Objective: To describe the advisors and the advice given to residency candidate interviewees interested in specializing in emergency medicine (EM).
Methods: All interviewees at a university-based EM residency program were surveyed. Data were collected anonymously and included demographic information, characteristics of each applicant's medical school, career advice by non-EM faculty, and access to advisors who are residency-trained in and practicing EM.
Results: Of 114 interviewees, 104 (91%) completed the survey. Only 45% of the respondents reported they were assigned an emergency physician (EP) advisor by their school, and 38% sought advice informally from an EP. Of those students receiving advice from an EP, 70% reported their advisor was residency-trained in EM. Most (57%) respondents reported receiving negative advice concerning a career in EM from non-EM medical school faculty. Of the 59 students reporting negative advice, 18 (31%) received negative comments from non-EM residency program directors, 23 (39%) from non-EM department chairs, and 4 (7%) from medical school deans. The presence of a residency training program increased the chances of a student's being assigned an EP advisor, but neither an EP advisor nor the departmental status of EM within the students' institutions was associated with receipt of negative advice.
Conclusions: Students considering specializing in EM often receive negative advice or have no assigned EP advisor. These factors may adversely affect entry into the field of EM.     

Accuracy of Medical Student Electronic Logbook Problem List Entry

Background: The accuracy of medical student logbooks has not been extensively studied.

Purpose: The purpose of this study was to determine accuracy of student entry of core problems and completeness of patient entry in an electronic logbook.

Methods: Third-year internal medicine clerkship students entered patient encounters as required by the clerkship. Experts entered information from the same encounters.

Results: A total of 1,440 patient entries generated by 37 consecutive students were compared to expert entries. Sensitivity (core problem underreporting) was low (60%, SD = 22%). Percent agreement (87%, SD = 7%), kappa (0.46, SD = 0.19), and specificity (core problem overreporting; 95%, SD = 5%) were good to excellent. Students both omitted (underreported 14%, SD = 12%) and overreported (23%, sd 17%) patients.

Conclusions: Under ideal study circumstances, there was significant underreporting of core problems by students. Although the high specificity, meaning that students are not reporting problems they have not encountered, is reassuring, logbook sensitivity in this study was not good enough for high-stakes evaluations of students or for medical school licensing.     

Improved Medical Student Engagement with EHR Documentation following the 2018 Centers for Medicare and Medicaid Billing Changes

Background  Medical student note writing is an important part of the training process but has suffered in the electronic health record (EHR) era as a result of student notes being excluded from the billable encounter. The 2018 CMS billing changes allow for medical student notes to be used for billable services provided that physical presence requirements are met, and attending physicians satisfy performance requirements and verify documentation. This has the potential to improve medical student engagement and decrease physician documentation burden. Methods  Our institution implemented medical student notes as part of the billable encounter in August 2018 with support of our compliance department. Note characteristics including number, type, length, and time in note were analyzed before and after implementation. Rotating medical students were surveyed regarding their experience following implementation. Results  There was a statistically significant increase in the number of student-authored notes following implementation. Attending physicians'' interactions with student notes greatly increased following the change (4% of student notes reviewed vs. 84% of student notes). Surveyed students reported that having their notes as part of the billable record made their notes more meaningful and enhanced their learning. The majority of surveyed students also agreed that they received more feedback following the change. Conclusion  Medical students are interested in writing notes for education and feedback. Inclusion of their notes as part of the billable record can facilitate their learning and increase their participation in the note writing process.