Learning/feedback activities and high-quality teaching: perceptions of third-year medical students during an inpatient rotation.

PURPOSE: To identify specific learning activities (and teaching methods) that students associate with high-quality teaching in the inpatient setting. METHOD: For ten months in 2003-04, 170 third-year medical students recorded data on learning/feedback activities and teaching quality via personal digital assistants during the inpatient portion of a required two-month medicine clerkship at four sites affiliated with the Medical College of Wisconsin. Univariate and multivariate analyses were performed to assess the association between learning/feedback activities and students' perceptions of high-quality teaching. RESULTS: A total of 2,671 teaching encounters were rated by 170 students during their required inpatient medicine rotations. Bedside teaching was reported in almost two-thirds of teaching/learning encounters. Feedback on case presentation and differential diagnosis were the inpatient feedback activities most often provided by faculty. The univariate analysis revealed that students' perceptions of high-quality teaching was associated with receiving mini-lectures, developing short presentations on relevant inpatient topics, bedside teaching, case-based conferences, learning electrocardiogram and chest X-ray interpretation, teaching with other team members present (p <. 001), and receiving feedback on history and physical examination, on case presentation, at the bedside, on differential diagnosis, and on daily progress notes. Results from the regression analysis revealed that giving mini-lectures on inpatient topics, teaching electrocardiogram and chest X-ray interpretation, providing feedback on case presentation, and at the bedside were predictors of overall high-quality teaching. CONCLUSIONS: Aspects of feedback, giving mini-lectures, and learning test-interpretation skills were the learning and feedback activities associated with students' perceptions of high-quality teaching. In an increasingly time-pressured inpatient environment, clinical educators should understand which activities students value.     

How perceived risk and personal and clinical experience affect medical students' decisions to seek treatment for major depression.

PURPOSE: To examine the role of perceived risk, and personal and clinical experience in medical students' treatment seeking behavior for major depression. METHOD: In 2003, a questionnaire was administered to 173 first-year and 164 fourth-year medical students at Northwestern University's Feinberg School of Medicine to assess students' perception of risk for major depression in the general population and personal and clinical experience with major depression. Treatment-seeking behavior was examined using a hypothetical scenario. Data analysis used analysis of variance and regression models. RESULTS: A total of 157 (91%) first-year and 108 (66%) fourth-year students completed the questionnaire. The majority overestimated the risk for major depression in the general population (p <.001), although respondents were more accurate for risk in the medical student population. The significant predictors for willingness to diagnose depression in the scenario were: risk perception (beta =.176, p <.01), clinical experience (beta =.173, p <.01) and personal treatment for major depression (beta =.188, p <.01). Significant predictors for willingness to refer to a professional were personal treatment (beta =.136, p <.05) and having a close friend treated for major depression (beta =.176, p <.01). CONCLUSIONS: Students' hesitation to seek treatment may be explained by the overestimation of risk, which has been shown to cause increased anxiety and avoidance of health seeking behavior. Interestingly, personal experience was found to be a significant predictor of treatment seeking behavior. This information can be used in preparing health risk communication messages for medical students.     

Perceptions and attributions of third-year student struggles in clerkships: do students and clerkship directors agree?

PURPOSE: To explore the congruence between students' and clerkship directors' perceptions and attributions of students' struggles during the transition to clerkships. METHOD: Focus groups and interviews were conducted with third- and fourth-year medical students and clerkship directors at 10 U.S. medical schools in 2005 and 2006. Schools were selected to represent diverse locations, sizes, and missions. Interviews and focus groups were recorded, transcribed, and analyzed thematically. RESULTS: Students' struggles included understanding roles and responsibilities, adjusting to clinical cultures, performing clinical skills, learning the logistics of clinical settings, and encountering frequent changes in staff, settings, and content. Clerkship directors recognized students' struggles with roles and responsibilities, performing clinical skills, and adjusting to clinical cultures, but they also focused on students' difficulties applying knowledge to clinical reasoning and engaging in self-directed learning. CONCLUSIONS: Clerkship directors and students recognize many challenges associated with learning and performing in the clerkships. Students' perspectives suggest that these challenges may be more complex than clerkship directors and clinical teachers realize and/or are capable of addressing. The areas in which clerkship directors' and students' perspectives are not congruent point to directions for future research that can guide curricula and teaching strategies.     

Multidimensional effects of the 80-hour work week at the University of Michigan Medical School.

PURPOSE: To examine the effects of the new resident work-hour restrictions on medical students, as measured by their perceptions of the quality of their experiences during the required clerkships. METHOD: Evaluations of four clerkships were compared for two student cohorts at the University of Michigan Medical School. The first cohort, from the class of 2002-03, completed their clinical clerkships the year before the work-hour restrictions were implemented, and the second cohort, from the class of 2003-04, completed their clerkships the same year the restrictions were implemented. RESULTS: There were significant and notable differences in the experiences of the two cohorts. Students' perceptions of the quality of their experiences in the surgery-oriented clerkships (obstetrics-gynecology and surgery) in particular were significantly lower (i.e., more negative) in the 2003-04 cohort than in the previous cohort for the same clerkships. The nonsurgery-oriented clerkships (internal medicine and pediatrics) hired hospitalists, who offset the residents' workload (internal medicine) and assumed teaching responsibilities (pediatrics). Between 2002-03 and 2003-04, students' perceptions of the quality of their experience in the internal medicine clerkship remained mostly stable, and increased in several areas for the students in the pediatrics clerkship. CONCLUSIONS: Implementation of resident work-hour restrictions had significant effects on the education of the medical students studied. These effects need to be carefully analyzed and considered to ensure quality education for medical students. The findings also highlight that the nature of students' perceptions was related to preparations made (or not) by specific clerkships as restricted work-hour regulations were adopted.     

The effect of medical education on primary care orientation: results of two national surveys of students' and residents' perspectives.

PURPOSE: To examine changes among a nationally representative sample of students and residents in their orientations toward primary care as reflected in their attitudes toward the psychosocial and technical aspects of medicine and their perceptions of the academic environment for primary care. METHOD: Confidential telephone interviews of stratified national probability samples of first- and fourth-year medical students and residents were conducted in 1994 and 1997. The 1997 survey included 219 students and 241 residents who had also been interviewed in 1994. Participants were asked about their attitudes toward addressing psychosocial issues in medicine and their perceptions of faculty and peer attitudes toward primary care. Responses were compared over time and across groups. RESULTS: Between the first and fourth years of medical school, there was a decline over time in students' reported orientations to socioemotional aspects of patient care (61.6% versus 42.7%, p =.001) and their perceptions that working with psychosocial issues of patients made primary care more attractive (56.3% versus 43.5%, p =.01). This pattern continued for 1997 residents (PGY-3), who were even less likely to say that addressing psychosocial issues made primary care more attractive (26.9%). For fourth-year students in 1994 who became PGY-3 residents in 1997, there was an increased perception that non-primary-care house officers and specialty faculty had positive attitudes toward primary care (20.8% versus 33.0%, p =.005; 28.3% versus 45.7%, p <.0001; respectively). CONCLUSIONS: Between 1994 and 1997 students and residents perceived a positive shift in the attitudes of peers and faculty toward primary care. During the course of their education and training, however, the students experienced an erosion of their orientations to primary care as they progressed through medical school into residency.     

The impact of a curriculum renewal project on students' performances on a fourth-year clinical skills assessment.

PURPOSE: To study the performances of three consecutive classes of medical students on a fourth-year clinical skills assessment that remained constant during a curriculum renewal project that involved earlier clinical work, more ambulatory training, and an emphasis on lifelong learning. METHOD: Three classes were involved: 83 baseline students (class of 1997) educated in the old curriculum, 77 transitional students (class of 1998) exposed to some curricular change, and 88 renewal students (class of 1999) in the first year of full curricular change. Each class completed a fourth-year assessment, during which students performed a focused history and physical examination on 14 standardized patients. Scores for these elements were calculated as the percentages of items obtained. Each case also includes a communication skills element rated on the Arizona Clinical Interview Rating scale (ACIR). RESULTS: Small but significant improvements in the means of scores were found in all three elements of the assessment over the study period (history taking scores increased from 74% to 80%, physical exam scores increased from 51% to 58%, and ACIR scores increased from 3.7 to 4.0). More pronounced was the decline in the percentage of students who failed the assessment (from 8% to 0%), and a marked increase in those who passed over 80% of the case elements (from 65% to 89%). CONCLUSION: Renewing the curriculum to expose students to clinical skills earlier, increase the amount of ambulatory training, and promote lifelong learning resulted in small but significant increases in students' performances on a fourth-year clinical skills assessment. The major impact of the new curriculum, however, was to improve the clinical skills assessment performances of marginal and average students.     

Perceived impact of resident work hour limitations on medical student clerkships: a survey study.

PURPOSE: To assess medical students' perceptions of the impact of recent Accreditation Council for Graduate Medical Education policies limiting resident work hours on students' clerkship experiences, resident teaching, and quality of patient care. METHOD: In May/June 2003 and May/June 2004, an original questionnaire was administered to 252 medical students completing required clinical rotations at two teaching hospitals to assess students' perceptions of endpoints that might be affected by resident work hours limits. Response data were analyzed to determine statistical significance of differences between the two years studied. RESULTS: Questionnaires were completed by 129 students in 2003 (98%) and 112 students in 2004 (93%), for an overall response rate of 96%. A higher proportion of students perceived limits on work hours in 2004 [46 (41%)] than 2003 [36 (28%), p = .03]. Ratings of resident availability and primary resident's interest in teaching improved in 2004. Otherwise, ratings of the interest, skill, and availability of resident teachers and attending physicians remained stable between 2003 and 2004. Students reported spending similar amounts of time in formal teaching sessions and rated feedback similarly between 2003 and 2004. In 2004, fewer students [28 (25%)] reported considering leaving medicine due to long hours in training than in 2003 [49 (38%), p = .04]. No significant differences in the proportion of students reporting suboptimal care were found [44 (34%) in 2003, 34 (35%) in 2004, p = .57]. CONCLUSION: This small, early study suggests that reductions in resident work hours might be implemented without a significant negative impact upon medical students' self-assessed learning experiences, and that limiting resident work hours may even have a positive impact on medical students.     

Medical students' involvement in outpatient clinical encounters: a survey of patients and their obstetricians-gynecologists.

PURPOSE: To study women's prior exposure to medical students during office visits, and the association between this and other factors in the likelihood of patients consenting to medical students' involvement in obstetrical-gynecological (ob-gyn) care. Physicians also were surveyed regarding their perceptions of patients' preferences. METHOD: In 1999-2000, an anonymous questionnaire was distributed for one week to all women scheduled for an ob-gyn visit and to their providers at six community campuses of Michigan State University College of Human Medicine. The questionnaire asked for patients' demographic information and prior experience with medical students, factors important when deciding to allow medical students to participate in their care, and how knowledge of medical students' involvement influences patients' choice of an ob-gyn. RESULTS: Seventy-two physicians and 1,059 patients returned the questionnaire. Four hundred eighty-eight (49%) patients reported prior experience with medical students. Patients and physicians rated interpersonal skills as most important when deciding about medical students' participation. Forty-three (63%) physicians thought students should participate in the history and physical examination compared to 299 (31%) patients. Prior experience with medical students was a major facilitating factor for medical students' involvement while patients' needs were a limiting factor. Patients' age and medical students' gender also predicted patients' attitudes. CONCLUSIONS: Most women would allow medical students to participate in their care, a finding moderated by a number of factors. A small proportion of women were biased against participation of male medical students. Physicians overestimated patients' ratings and might themselves be a source of bias regarding medical students' involvement.     

The use of small group case-based exercises in human gross anatomy: A method for introducing active learning in a traditional course format

As part of the curricular change at the University of Rochester School of Medicine and Dentistry, we focused on active learning and greater integration of basic and clinical sciences. With these objectives in mind, this report describes the use of small-group, case-based exercises in our gross anatomy course and provides one example of integrating such activities into a traditional course. In addition to formal lectures and laboratory dissection, students meet approximately every fourth class period in small groups to discuss a clinical case which focuses on the relevant anatomy taught at that time. Two first-year students lead each small group; one fourth-year student facilitator also attends to provide clinical correlations, answer questions, and reinforce the anatomy. Formative feedback suggests students enthusiastically endorse the self-directed active learning; they feel these exercises offer both a valuable approach to learning and an opportunity to practice presentation and leadership skills. First-year students enjoy the interaction with fourth-year facilitators and the fourth-year students appreciate the opportunity to review basic science material. Our data suggest that students learn to “think” about the anatomy, and we hope learn to use their understanding and knowledge base in a practical fashion. Moreover, these case-based exercises can fit nicely into a variety of curricular formats, especially where problem-based tutorials may not be feasible or desirable. © 1994 Wiley-Liss, Inc.     

Effect of a major curriculum revision on students' perceptions of well-being

The impact of a major curriculum revision on students' perceptions of the quality of the medical school learning environment, social supports, and their own mental and social well-being was determined. First-year students' perceptions one year before the curriculum revision were compared with first-year students' perceptions two years after the introduction of the new curriculum. In the new curriculum, students reported better overall quality of the learning environment (p = .019), a trend toward fewer stresses (p = .091), no difference in social supports (p = .721), better mental well-being (p = .043), and a trend toward better social well-being (p = .099). Students at a comparison school that did not undergo curriculum revision did not have more favorable perceptions during the study period. The findings suggest that well-considered and well-executed efforts to improve the quality of a medical school's learning environment can be successful and can raise students' perceptions of their overall well-being.     

Examination room presentations in general internal medicine clinic: patients' and students' perceptions.

PURPOSE: To determine if patients are more satisfied with their health care when medical students present in the exam room to both the attending physician and patient than they are when medical students present outside the exam room to only the attending. To determine medical students' preference for location of presentation and the reasons for their preference. To determine if exam-room presentations promote the education of medical students to a greater degree than presentations outside of the exam room. METHOD: In 2001, 108 patients and 142 fourth-year medical students at internal medicine (IM) clinics affiliated with the University of Washington School of Medicine were asked to complete an 11-point ordinal scale questionnaire on their attitudes toward medical student presentations. RESULTS: One hundred patients (93%) and 68 medical students (48%) responded. Patients with in-room presentations enjoyed working with the medical student more than did patients with out-of-room presentations. Both groups expressed a preference for in-room presentations on future visits and a high level of comfort with student and physician discussing their health. Medical students reported a slight preference for presenting out of the room. When presenting in the room, students reported learning more about physical diagnosis and bedside manner and less about mechanism of disease than when presenting out-of-room. CONCLUSIONS: Patients preferred in-room case presentations and were comfortable with medical students and physicians discussing their health in their presence. In-room presentations also foster instruction on bedside manner and physical diagnosis. These data suggest that both patients and students would benefit from participating in more in-room presentations.     

Assessing correlations between black and white students' perceptions of the medical school learning environment, their academic performances, and their well-being

From 1982 to 1985, first-year students at a medical school were invited to participate in a longitudinal study that assessed the correlations between their perceptions of the learning environment, their academic performances, and their perceptions of their own well-being. Differences between black and white medical students' perceptions of the medical school's learning environment and the predictors of their academic success and mental and social well-being were determined at the end of their first year. Black and white students had similar perceptions of the learning environment's quality. Black students experienced more stress but found more support from faculty, class advisors, and administrators. Although black and white students shared some predictors of academic performance and well-being, there were important differences that should be considered when resources are developed to assist students with their academic performance and the maintenance of their social and mental well-being.     

The influence of task formats on the accuracy of medical students' self-assessments.

PURPOSE: Accurate self-assessment is an essential skill for the self-directed learning activities and appropriate patient referral decisions of practicing physicians. However, many questions about the characteristics of self-assessment remain unanswered. One is whether self-assessment is a generalizable skill or dependent on the characteristics of the task. This study examines the self-assessment skills of medical students across two task formats: performance-based and cognitive-based. METHOD: In 1997 and 1998, fourth-year medical students at the University of Michigan assessed their own performances on ten stations of a clinical examination. The examination used two formats: performance tasks (the examination or history taking of standardized patients) and cognitive tasks (interpreting vignettes or test results and then answering paper-and-pencil questions). Three measures of self-assessment accuracy were used: a bias index (average difference between the students' estimates of their performances and their actual scores), a deviation index (average absolute difference between estimate and actual score), and an actual score-estimate-of-performance correlation (the correlation between the estimate and actual scores). RESULTS: The student bias and deviation indices were similar on the cognitive and the performance tasks. The correlations also indicated similarity between the two types of tasks. CONCLUSION: The results indicate that the format of the task does not influence students' abilities to self-assess their performances, and that students' self-assessment abilities are consistent over a range of skills and tasks. The authors also emphasize the importance of sampling tasks while conducting self-assessment research.     

A student-centered, problem-based surgery clerkship

In the academic year 1989-90, the department of surgery at one college of medicine revised its third-year clerkship to focus on students' learning decision-making skills and critical thinking (cognitive skills) and acquiring knowledge about surgery. Learning to perform procedures and tasks (psychomotor skills) would be accomplished in the required fourth-year acting internships. Problem-based learning (PBL) was chosen as the clerkship's primary instructional method. Comprehensive student and program evaluation systems were established. The response by faculty and students has been very positive. Students believe that the new clerkship has helped them increase their abilities in resource use, time management, and retention of knowledge. Faculty have noted students' increased eagerness and enthusiasm for learning.     

The variable influence of lifestyle and income on medical students' career specialty choices: data from two U.S. medical schools, 1998-2004.

PURPOSE: Recent reports on medical students' career choices suggest that lifestyle increasingly influences career decisions. The authors addressed the changing influence of lifestyle and income on career choice, how these influences differ by specialty, and the specific careers students identify as lifestyle friendly. METHOD: From 1998 to 2004, 1,334 (73%) fourth-year medical students from Brody School of Medicine at East Carolina University (no. = 485 graduates) and New York Medical College (no. = 1,348 graduates) completed a questionnaire that addressed career specialty preferences, as well as income and lifestyle concerns. Students were asked to rate career choice influences on a four-point scale (1 = no influence, 4 = major influence). Factor analysis of these influences identified seven factors including one each for lifestyle and income. RESULTS: A total of 1,327 students indicated a career preference. Lifestyle (p = .018) and income (p = .011) were found to increasingly influence medical students' career choices during the study period. Overall, the authors found significant differences between specialties in the relative contribution of these factors. Students' perceptions of specialties existed on a continuum of lifestyle friendly (e.g., radiology) to lifestyle unfriendly (e.g., obstetrics-gynecology). Contrary to previous reports, the students' responses indicate they perceived the primary care specialties as lifestyle intermediate compared to other specialties. CONCLUSIONS: Lifestyle and income have become more important to medical students in their career choice, and the relative influence of these factors varies considerably between specialties. This study suggests that previous efforts to dichotomize careers into those with controllable and uncontrollable lifestyles may mask important complexities.     

Medical student gender and issues of confidence

OBJECTIVE: To review the literature on gender differences and issues of self-confidence in medical students and to present original research on observers' perceptions of medical student confidence. METHODS: One hundred forty-one 3rd year medical students at Indiana University School of Medicine were videotaped during their objective structured clinical examination (OSCE). Trained coders rated how confident the student appeared and coded a variety of nonverbal behaviors at the beginning, middle, and end of the interaction. Analysis focused on gender differences in coders' ratings of perceived confidence. RESULTS: Female medical students were viewed as significantly less confident than male medical students (F(1,133)=4.45, p<0.05), especially at the beginning of the interaction. CONCLUSION: Past research indicates that despite performing equally to their male peers, female medical students consistently report decreased self-confidence and increased anxiety, particularly over issues related to their competence. In a standardized patient interaction examination situation, female medical students also appeared significantly less confident than male medical students to independent observers. PRACTICE IMPLICATIONS: Medical educators should focus on issues of female students' confidence, increasing faculty sensitivity, and publicly recognizing and discussing perceptions of confidence.     

The use of questionnaires to assess achievement of course goals in medical students' longitudinal community-based clinical experiences.

PURPOSE: To examine the usefulness of questionnaires for assessing achievement of course goals in medical students' longitudinal community-based clinical experiences. METHOD: In 1997, the authors surveyed 114 first-year students and their preceptors in a longitudinal community-based program at The Joan and Sanford I. Weill Medical College of Cornell University. The questionnaire used a Likert scale to assess students' and preceptors' pre-course expectations for achieving specific course goals and their post-course perceptions of having met those goals. The students also rated global learning and satisfaction during each office preceptor session, and faculty assessed the students' physical examination skills at the end of the course. RESULTS: For all goals assessed, the preceptors scored their students' achievement of course goals significantly higher than did the students themselves (p < .01). The students invariably scored their post-course perceptions of having achieved the goals lower than they did their pre-course expectations (p < .001). Before the course, the preceptors were confident in their ability to teach the curricular material; this confidence remained after the course. Global learning and satisfaction scores were high and all students performed satisfactorily in the demonstration examination. CONCLUSIONS: Students and preceptors may not agree on students' achievement of course goals. Furthermore, despite students' high ratings of global satisfaction and learning, and despite their satisfactory performance of physical examination skills, their ratings of post-course performance may be affected by pre-course expectations. The authors suggest that questionnaires assessing students' and preceptors' perceptions of students' achievement of specific goals should be independently verified before making decisions to modify objectives and activities in these kinds of courses.     

The effects of patient characteristics and practice settings on students' participation in a primary care clerkship.

PURPOSE: To explore the effects of practice, patient, and encounter variables on students' participation in a third-year primary care clerkship. METHOD: In 1995-96, 154 students, randomly assigned to ambulatory teaching sites, completed for each patient encounter a scannable card indicating the patient's age range, gender, and insurance type, the setting of care, the type of visit, whether it was a repeat or first visit to the student, and the student's level of participation. Conventional measures of students' satisfaction (post-clerkship survey) and performance (preceptor ratings, USMLE Step 2, standardized-patient examination scores) were examined. RESULTS: The students reported significantly higher levels of participation for patient encounters taking place in clinic and emergency room settings than for those in private offices; for repeat rather than for first visits; for patients over 12 years old than for those 12 years old or younger; and for sick visits rather than for follow-ups or checkups. Students' participation had a modestly positive correlation with students' satisfaction and performance. CONCLUSION: Several practice and patient variables influence the level of students' participation in the care of ambulatory patients. The strongest predictor of active student participation is the clinical setting of the encounter. Monitoring students' self-reported levels of participation is an important tool for tracking the impact of practice variability on the quality of the learning environment in ambulatory clerkships.