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CDIM Proceedings from Academic Internal Medicine Week 2017

At the meeting in Baltimore, MD, CDIM continued its tradition of high quality internal medical education scholarship. Of the 59 innovations and research submissions, four were accepted for oral presentation and 22 for posters. We are pleased to present the four oral abstracts and the highest-scored posters. Included are studies of longitudinal programs supporting internal medicine intern preparation, integrated clerkships in a large medical school, evolution of primary care impressions, and pre-clinical preceptors. We also present findings from transitions of care assignments, grading committees, and a narrative medicine curriculum as well as an update of clerkship directors’ duties since 1999. CDIM is confident that readers will find these contributions relevant to medical student education in every discipline.

Abstracts

  1. The Activities and Responsibilities of Internal Medicine Clerkship Directors in 2015, An Update from 1999
  2. Medical Knowledge Outcomes in Integrated Clerkships in a Large Medical School
  3. Lessons Learned by Medical Students in Systems-Based Practice as Patients Transition Their Care
  4. Developing Consistency with Honors Grade Assignments Through a Medicine Clerkship Grading Committee 
  5. Impact of Longitudinal Preceptors in Pre-Clerkship Clinical Skills and Clinical Reasoning Teaching
  6. An Analysis of the Evolution of Impressions of Primary Care Medicine throughout Medical School
  7. Project 6-55: A Reflective Writing Workshop for Professional and Personal Growth
  8. Internal Medicine Clinical Track: Senior Medical Students and Entry Level ACGME Milestones

The Activities and Responsibilities of Internal Medicine Clerkship Directors in 2015, An Update from 1999 

Temple Ratcliffe
University of Texas Health Science Center

Karen Szauter
University of Texas Medical Branch at Galveston

D. Michael Elnicki
University of Pittsburgh School of Medicine

Steven J. Durning, Louis N. Pangaro, and Paul A. Hemmer
F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

Background: Increased clinical and administrative demands may adversely impact clerkship directors’ (CD) academic achievement. In 1999, ≤ 3 clinic half-days, fellowship training, and teaching in other courses predicted CD scholarship1. We sought to characterize current responsibilities and activities of internal medicine CDs.

Methods: In 2015, CDIM surveyed its institutional members. Questions included demographics, responsibilities, and academic productivity. Descriptive and comparative statistics were conducted with SPSS (IBM, version 23).

Results: Survey response rate was 77% (95/123). 83% were the CD, women comprised half (49.4%), 65% were under the age of 50, 30% completed fellowship. Academic ranks were: Assistant 26%, Associate 45%, and Professor 23%. 63% directed at least one other course.  98% served on at least one medical school committee (median = 4).  Respondents spent 2.6 half-days per week in clinic (0-7, median = 3) and 11.1 weeks per year on inpatient wards (0-52, median = 8.5). In the prior 48 months, respondents published 2.5 manuscripts (0-16, median = 2) with 1.95 (median = 1) on medical education topics. They made 3.4 presentations (0-16, median = 2), essentially all about medical education.  Factors associated with manuscript publication: fellowship training (3.6 vs. 2.0, p=.001, Mann Whitney U); ≤ 35% of time for academic position (3.3 vs. 1.6, p=.005, Mann Whitney U); and number of medical school committees (Spearman’s rho = .25, p=.02), with ≥ 3 committees significant (3.2 vs. 1.7, p=.02, t-test). Factors associated with presentations: number of medical school committees (Spearman’s rho = .25, p=.02), with ≥ 3 committees significant (4.4 vs. 2.3, p=.02, t-test); and spending ≤ 2 half-days in clinic per week (4.6 vs. 2.3, p=.01, t-test). 

Conclusions: Overall CD academic productivity is stable since 1999; fellowship training and measures reflecting time availability are again associated with scholarship. Committee work may be a source of ideas for scholarship.

References

  1. Hemmer PA, Elnicki DM, Albritton TA, Kovach R, Udden MM, Wong RY, Battistone MJ, Szauter K. The responsibilities and activities of internal medicine clerkship directors. Acad Med. 2001 Jul;76(7):715-21.

Medical Knowledge Outcomes in Integrated Clerkships in a Large Medical School

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Katherine Walsh, Kim Tartaglia, J. Chad Hoyle, Alan Harzman, Holly Cronau, Curt Walker
Ohio State University College of Medicine

Background: Integrated, longitudinal curricula have demonstrated increased student satisfaction, higher scores on some clinical skill measures, and easier facilitation of student mastery of entrustable activities. In June 2014, OSU College of Medicine developed a hybrid integrated clerkship model for all third year medical students that consisted of three four-month integrated curricular units (outpatient adult ambulatory medicine/family medicine and pediatrics, surgery and obstetrics/gynecology, and inpatient internal medicine, neurology, and psychiatry).  The purpose of this study was to examine differences in student performance on NBME subject exams during our integrated clerkships, compared to historical control students with traditional clerkships.

Methods: We examined differences in mean scores for NBME Subject exams (total of 7) and the USMLE Step 2 Clinical Knowledge (CK) exam and compared performance between traditional versus integrated clerkships. We used ANCOVA to control for USMLE Step 1 scores and ANOVA to determine differences in student scores between an integrated clerkship (2014-15 AY) and a traditional clerkship model (2012-2014 AY).

Results: Results of a Welch’s ANOVA test indicated Internal Medicine NBME exam scores were significantly higher in the integrated clerkship than the traditional clerkship (Mean Traditional (MT)=80.48, Mean Integrated (MI)=83.27, p<0.01). After adjustment for USMLE Step 1 scores, three NBME subject exam scores were significantly higher in the integrated clerkship: Surgery (MT=77.93, MI=80.14, p<0.01), Pediatrics (MT=81.42, MI=84.54, p<0.01), and Psychiatry (MT=82.43, MI=85.22, p<0.01). Clerkship differences in Obstetrics/Gynecology, Neurology, Family Medicine, and USMLE Step 2 CK exam scores were not statistically significant.

Conclusions: Overall, implementation of our integrated third year clerkship curriculum demonstrated statistically significant increases in 4 out of 7 NBME exam scores, including three with significance beyond effects of Step 1 scores. This integrated clerkship model did not impair performance and had many positive effects on medical knowledge measures, supporting our plans for continued use and model refinement.

Lessons Learned by Medical Students in Systems-Based Practice as Patients Transition Their Care

Ernie Esquivel, Diego Sierra, Eduard Pey, Deanna Pereira Jannat-Khah, Shelene Stine 
Weill Cornell Medical College

Background: As patients transition from one health care setting or provider to another, studies have shown that as many as one in five suffer an adverse event within two weeks of discharge. These include medication error and inadequate understanding of diagnosis or post-discharge instructions.  Regulatory bodies have included systems-based practice as a core competency of physicians. We asked whether a structured post-discharge phone call and students’ reflections on barriers to discharge and practice improvement can be an effectively enhance students’ understanding of systems-based practice. 

Methods: A graded “Transitions of Care” assignment was developed for students enrolled in the medicine clerkship.  Students were asked to conduct a post-discharge follow-up phone call using the Agency for Healthcare Research and Quality (AHRQ) tool.  Students also identified barriers to safe discharge of their patient and considered ways in which future practice could be improved. Qualitative analysis of these assignments was performed and themes and sub-themes were developed.

Results: Ninety students enrolled in the medicine clerkship identified a total of 201 barriers to discharge among 86 patients. These included issues with scheduling follow-up, poor care coordination, inadequate social support systems and access to medications or treatments. The post-discharge phone call revealed problems with patients’ understanding of their discharge diagnosis.  A majority of patients had medication-related issues, most commonly incomplete understanding of indications, inability to obtain medications, noncompliance and side effects. The phone call revealed failure to attend post-discharge follow-up in half of the patients. Finally, students proposed 240 practice improvement interventions to improve transitions of care, including increased patient education, and enhanced communication with patients and their families. Improved interdisciplinary collaboration and care coordination were frequently noted, as well as greater attention to patient’s psychosocial and financial status. 

Conclusions: Medical students learned robustly about systems-based practice from a transitions of care assignment, which included a post-discharge phone call.  We believe that self-reflective practice and learning within the context of direct patient care offers opportunities for future practice improvement as medical students transition their patients’ care.

Developing Consistency with Honors Grade Assignments through a Medicine Clerkship Grading Committee 

Cindy J. Lai, Gurpreet Dhaliwal, Margaret Wheeler, Tali A. Ziv, Steven Stoltz, Lisa Carella, Karen E. Hauer
University of California at San Francisco School of Medicine

Background: Grading clinical performance is a skill that requires repeated practice and feedback. When site directors (SDs) assign grades independently, they receive little feedback and calibration is difficult. Imprecise grading arises from both inaccurate assessments by supervisors and inconsistent processing of assessments by graders. Group decision-making can improve calibration and feedback for graders. We are a five-site medicine clerkship with honors grades assigned by each SD using supervisor assessments and exam score. Assigning grades requires considering differences in use of the scoring system among supervisors, weighing numerical and narrative assessments, and understanding site characteristics. 

Methods: We created a grading committee (GC) comprised of SDs to discuss honors grade candidates after each block.  Prior to the meeting, students’ files are circulated to each SD for independent review.  During the meeting, one SD summarizes other members’ grading recommendations and analyses.  Majority agreement during discussion is required to assign honors.  Group discussions enable the committee to refine grading criteria using exemplar cases that highlight grading principles.  We also piloted a quantitative report of attendings’ scoring tendencies, which is more accurate than SDs’ impressions of those propensities.

Results: In 2015-16, 60 of all 164 (37%) of third-year medicine clerkship students were discussed in GC. The attendings’ score report revealed a wide variance between the average scores given by evaluators (100-point scale): -10.25 (strict evaluator) to +6.93 (lenient).  All SDs found that the six GC discussions per year substantially increased their understanding of honors criteria and the consistency of grading procedures across sites.

Conclusions: Grading has formal criteria but interpretation of those criteria is not straightforward. Group decision-making, exemplar cases, and attendings’ score reports increase grading consistency when assigning honors grades. The GC format was adopted by all clerkships at our school to improve grading consistency, increase transparency to students, and capitalize on group decision-making.

Impact of Longitudinal Preceptors in Pre-Clerkship Clinical Skills and Clinical Reasoning Teaching

Jeff LaRochelle, Louis N. Pangaro, Steven J. Durning, Paul A. Hemmer
F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

Background: Studies on integrated, longitudinal clerkships demonstrate development of supportive relationships between students and preceptors (1).  Students and preceptors perceive improvements in validity, quality of clinical skills evaluations, and ability to provide constructive feedback on longitudinal clerkships (2). We sought to determine the impact of longitudinal preceptors on student performance in pre-clerkship clinical skills and clinical reasoning courses.

Methods: As part of the Integrated Clinical Skills (ICS) and Introduction to Clinical Reasoning courses at USUHS, students participate in clinical encounters with standardized patients followed by small group discussions in five modules over an 18-month pre-clerkship curriculum.  Students were randomly assigned to a longitudinal preceptor or to preceptors that change with each module (standard), and were evaluated on clinical skills and clinical reasoning for each modular session. Students completed a six station OSCE at the end of the pre-clerkship period. Comparisons of student performances were accomplished with a paired student’s t-test or analysis of variance as appropriate. 

Results: Sixty four students had longitudinal preceptors and 111 students had standard small groups.  Overall clinical skills performance on the first modular session for students with longitudinal preceptors was similar to those with standard preceptors (73±10 v 76±11; NS).  Struggling students were identified by longitudinal preceptors at a higher rate than standard small group preceptors (10.3% v 5.4%; RR 1.73, 95% CI 0.58-5.15).  Students with longitudinal preceptors demonstrated better improvement in clinical skills as measured by the final overall modular session performance (81±11 v 77±8.4; p=0.016, d=0.41), and by overall performance on the end of pre-clerkship OSCE (67±5.8 v 65±5.7, p=0.048, d=0.35). 

Conclusions: Student’s assigned to longitudinal preceptors demonstrated significant improvements in clinical skills over the pre-clerkship periods with moderate effect sizes.  Additionally, longitudinal preceptors appear to identify struggling students at a higher rate than standard preceptors.  This suggests students benefit from longitudinal preceptors in pre-clerkship clinical skills and reasoning courses.  Studies looking at these students’ performance on clerkships would further elucidate the long-term impact of longitudinal preceptors.

References

  1. Bates J, Konkin J, Suddards C, Dobson S, Pratt D. Student perceptions of assessment and feedback in longitudinal integrated clerkships. Med Educ. 2013 Apr;47(4):362-74. doi: 10.1111/medu.12087.
  2. Mazotti L, O'Brien B, Tong L, Hauer KE. Perceptions of evaluation in longitudinal versus traditional clerkships. Med Educ. 2011 May;45(5):464-70. doi: 10.1111/j.1365-2923.2010.03904.x.

An Analysis of the Evolution of Impressions of Primary Care Medicine throughout Medical School

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Melissa Brook
University of Illinois at Chicago

Jason A. Benedict
 Ohio State University

Barry A. Brook
Jewish Hospital-Mercy Health

Jared Moore
Ohio State University College of Medicine 

Background: The demand for primary care physicians is projected to grow by 17% between 2013 and 2025. Despite increased medical school enrollment, there has been a decline in the percentage of residents ultimately entering primary care.  The goal was to identify factors that influence student interest in primary care.

Methods: One hundred and eighty three first and fourth year medical students completed a survey regarding their interest in primary care. Fourth year students rated their level of interest during their first year and fourth year, and were divided into four cohorts based on how their interest compared between these two time points: consistently uninterested, consistently interested, gained interest, and lost interest.  

Results: Physicians in the community most positively affected students’ impressions, while news and social media most negatively affected students’ impressions of primary care, The odds of a student being interested in primary care in years one and two were 3.1 times the odds of them being interested in their 4th year fourth {p=0.002; 95% CI:(1.5, 6.6)}. Comparing fourth year students consistently interested in primary care and those who lost interest, preventative healthcare focus {1.59 (1.11, 2.08) vs 0.37 (-0.44, 1.18)}, breadth of material {1.19 (0.65, 1.73) vs 0.63 (0.00, 1.26)}, the hospitalist system {0.41 (-0.14, 0.95) vs  -0.10 (-0.62, 0.42)}, and variety of pathology encountered {1.11 (0.64, 1.57) vs 0.42 (-0.23, 1.07)} appeared to be more negative factors for those that lost interest.  Those who lost interest were 2.7 times as likely to mark “increased salary” as the primary change that would make them consider primary care {p = 0.08; 95% CI:(0.9, 8.4)}.

Conclusions: Interest in primary care declined as students progressed through school. Establishing early mentorship, changing social media messages regarding the value of primary care, and altering financial disparities between primary care and other fields may help to maintain medical students’ interest.

Project 6-55: A Reflective Writing Workshop for Professional and Personal Growth

Kristy Kosub, Sara Noble, Lauren Michael, Paul Williams
University of Texas Health Science Center

Background: Narrative medicine provides a rich opportunity to reflect on one's medical training and identity as a physician.  Writing nurtures reflection on emotional connections to patients and new clinical experiences.  Inspired by six-word and 55-word story flash fiction, Project 6-55 was created to engage learners in guided reflective writing and collective professional identity development.  We used existing time within the curriculum to promote the value of expression of one's experiences among peers in an emotionally safe environment.

Methods: Students participate in a  one-hour workshop during the medicine clerkship and use near-peer teaching with senior students.  After an introduction about reflective writing, leaners compose six-word stories and one expanded 55-word story that explores more context and emotions about a patient care experience within 20 minutes.  Stories are shared, and students discuss the significance of the incident and impact on personal growth.  They complete anonymous pre- and post-surveys to assess attitudes toward reflective writing and impact of the workshop. Demographic data includes gender and self-reported prior humanities experience.

Results: Two hunder and eighty nine students participated in Project 6-55. Pre-workshop, 51.5% reported favorable attitudes toward reflective writing for personal growth, 37.1% had favorable attitudes toward reflective writing in medical education, and 71.6% did not engage in reflective writing. Post-workshop, there was positive attitude change toward value of reflective writing for personal growth (77.9%) and medical education (69.1%), and 64.6% noted greater likelihood to engage in writing. Majority of students felt writing stories promoted self-reflection (88%) and meaning as medical professionals (89%).

Conclusions: Project 6-55 is an efficient framework to share meaningful experiences and supports the effectiveness of narrative tools for professional and personal development.  Providing dedicated time within curriculum reinforces importance of shared reflection and creates a culture of professional wellness.  Our method highlights the learner's involvement in patient stories, identifies a shared vulnerability, and fosters empathic listening skills through reading of stories.

References

  1. Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ Theory Pract. 2009;14(4):595-621.
  2. Shapiro J, Kasman D, Shafer A. Words and wards: a model of reflective writing and its uses in medical education. J Med Humanit. 2006;27(4):231-244.
  3. Fogarty CT. (2010). Fifty-five word stories: “Small Jewels” for personal reflection and teaching. Family Medicine. 42(6):401-402.
  4. Charon R. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001;286(15):1897-1902.
  5. Wald HS. Professional Identity (Trans)Formation in Medical Education: Reflection, Relationship, Resilience. Acad Med. 2015;90:701-706.
  6. Sandars J. The use of reflection in medical education: AMEE Guide No. 44. Med Teach 2009; 31: 685–695.
  7. Brady DW et al. What’s important to you? The use of narratives to promote self-reflection and to understand the experience of medical residents. Ann Int Med 2002;137(3):220-3.
  8. Christianson AL. (2009). Years of Stories. JAMA. 302(10):1042.

Internal Medicine Clinical Track: Senior Medical Students and Entry Level ACGME Milestones

Sarah Tapyrik
Ohio State University Wexner Medical Center

Background: In 2013, the Accreditation Council of Graduate Medical Education (ACGME) rolled out the Next Accreditation System (NAS), for continuous accreditation of graduate medical programs. Core to the NAS are outcome-based milestones for determining resident and fellow performance within the six ACGME Core Competencies. Ohio State formed Clinical Tracks (CT) to ensure that senior medical students are working towards entry-level ACGME milestones. A CT was developed for each medical specialty and every senior student is required complete required elements within their track.

Methods: For the internal medicine (IM) CT, the first step was to expand the ACGME milestone verbiage into concrete, specific examples of clinical and educational tasks that exemplified the milestones. A Student Clinical Competency Committee (SCCC) was formed to review the data for each student in the IM Clinical Track and assign where the evidence would place them along the continuum of the IM Milestones.

Results: We had over 50 students in our inaugural IM Clinical Track. We used a “milestone map” that provided a shortcut to matching student evidence to the specific curricular tasks. However, it remained a time intensive endeavor and the assessments for all students within the Clinical Track could not be completed. While we did not have enough data for statistical analysis, we were able to identify patterns of strength of evidence and confidence in assignment for individual milestones.

Conclusions: As we move forward in our IM Clinical Track program, we plan to streamline the mapping of evidence to the milestones. We will evaluate the students only along the milestones for which we can consistently obtain high quality evidence to support a confident assessment. We will use this data to create courses within the IM CT that will help us to more accurately assure that our senior students excel in their IM residency programs, as determined by the milestone system.

References

  1. Khan, et al. Transition to Residency: Using Specialty-Specific Clinical Tracks and Advanced Competencies to Prepare Medical Students for Internship. Med. Sci. Educ., 2016
  2. http://www.acgme.org/What-We-Do/Accreditation/Milestones/Overview