Eva Aagaard

What training is needed in the fourth year of medical school? Views of residency program directors.

Purpose To identify common struggles of interns, determine residency program directors’ (PDs’) views of the competencies to be gained in the fourth year of medical school, and apply this information to formulate goals of curricular reform and student advising. Method In 2007, semistructured interviews were conducted with 30 PDs in the 10 most common specialty choices of students at the University of California, San Francisco, School of Medicine to assess the PDs’ priorities for knowledge, skills, and attitudes to be acquired in the fourth year. Interviews were coded to identify major themes. Results Common struggles of interns were lack of self-reflection and improvement, poor organizational skills, underdeveloped professionalism, and lack of medical knowledge. The Accreditation Council for Graduate Medical Education competencies of patient care, practice-based learning and improvement, interpersonal and communication skills, and professionalism were deemed fundamental to fourth-year students’ development. Rotations recommended across specialties were a subinternship in a student’s future field and in internal medicine (IM), rotations in an IM subspecialty, critical care, and emergency and ambulatory medicine. PDs encouraged minimizing additional time spent in the student’s future field. Suggested coursework included an intensively coached transitional subinternship and courses to improve students’ medical knowledge. Conclusions PDs deemed the fourth year to have a critical role in the curriculum. There was consensus about expected fourth-year competencies and the common clinical experiences that best prepare students for residency training. These findings support using the fourth year to transition students to graduate medical training and highlight areas for curricular innovation.

Effectiveness of the one-minute preceptor model for diagnosing the patient and the learner: proof of concept.

Purpose To compare the One-Minute Preceptor (OMP) and traditional models of ambulatory teaching in terms of the preceptors’ (1) ability to correctly diagnose patients’ medical problems, (2) ability to rate students’ skills and confidence in doing so, and (3) satisfaction with both models. Method A within-groups experimental design study was conducted with 116 preceptors at seven universities in 2000. Participants viewed scripted, videotaped precepting encounters of both models using two cases and were asked to rate students’ abilities, their confidence in rating the students’ abilities, and the effectiveness and efficiency of the teaching encounters. Results Preceptors who viewed the videotapes of the OMP model were equally or better able to correctly diagnose the patients’ medical conditions than those viewing the traditional model. Preceptors viewing the OMP rated students’ abilities higher on history taking/physical examination, presentations, clinical reasoning, and fund of knowledge than did those viewing the traditional model. Preceptors viewing the OMP rated themselves as more confident in rating students’ abilities in presentation, clinical reasoning, and fund of knowledge. Preceptors rated the OMP as more effective and more efficient than the traditional model. Conclusions Preceptors viewing scripted, videotaped teaching encounters using the OMP model were equal to or better able to correctly diagnose patients’ medical problems, had greater self-confidence in rating students, and rated the encounter as more effective and efficient than when viewing the traditional model.

A Cross-sectional Descriptive Study of Mentoring Relationships Formed by Medical Students

To describe medical students’ mentoring relationships and determine characteristics associated with having mentors, 232/302 (77%) of third- and fourth-year medical students at the University of California at San Francisco (UCSF) were surveyed. Twenty-six percent of third-year and 45% of fourth-year students had mentors. Most met their mentors during inpatient clerkships (28%), research (19%), or sought them on the basis of similar interests (23%). On multivariate analysis, students who performed research prior to (odds ratio [OR], 4.8; 95% confidence interval [95% CI], 1.4 to 16.7; P=.01) or during medical school (OR, 2.4; 95% CI, 1.1 to 5.6; P=.03) and students satisfied with advising from all sources at UCSF (OR, 1.8; 95% CI, 1.4 to 2.4; P<.001) were more likely to have mentors.

Teaching points identified by preceptors observing one-minute preceptor and traditional preceptor encounters.

Purpose This study examined the teaching points made by preceptors in response to two videotaped teaching encounters to determine if (1) different preceptors use similar teaching points in response to the same case, (2) preceptors’ teaching points vary by case, and (3) preceptors’ teaching points vary by teaching model (One-Minute Preceptor and traditional preceptor models). Method Preceptors (n = 116) at seven universities participated in a within-groups experimental design study in 2000. The preceptors viewed videotaped encounters depicting two cases and two precepting models. They were asked to list two teaching points after viewing the initial case presentations and after the teaching encounters were completed. Frequency of teaching points listed by preceptors was examined for each case and teaching model. Teaching points were coded using qualitative methods and then analyzed using repeated-measures analysis of variance. Results Of the 843 total teaching points identified by preceptors, 63 were discrete teaching points that were aggregated into 15 categories. Most preceptors (82%) listed three to five separate teaching points, which varied significantly by case and model. Those observing the traditional precepting model were more likely to teach generic skills such as history-taking skills, presentation skills, and risk factors, and those observing the One-Minute Preceptor were more likely to teach about the illness focusing on a broader differential diagnosis, further diagnostic tests, and the natural presentation of disease. Conclusions Preceptors use three to five common teaching points that vary by case and teaching model. The One-Minute Preceptor model shifted teaching points away from generic clinical skills toward disease-specific teaching.

Attending Rounds in the Current Era: What Is and Is Not Happening

IMPORTANCE General medicine rounds by attending physicians provide the foundation for patient care and education in teaching hospitals. However, the detailed activities of these rounds in the current era are not well characterized. OBJECTIVE To describe the characteristics of attending rounds for internal medicine inpatients in a large teaching hospital system. DESIGN A cross-sectional observational study of attending rounds in internal medicine. Rounds were observed directly by research assistants. SETTING Four teaching hospitals associated with a large public medical school. PARTICIPANTS Fifty-six attending physicians and 279 trainees treating 807 general medicine inpatients. MAIN OUTCOMES AND MEASURES Duration and location of rounds, composition of teams, and frequency of 19 potential activities during rounds. RESULTS We observed 90 days of rounds. A typical rounding day consisted of 1 attending with 3 trainees visiting a median of 9 (range, 2-18 [SD, 2.9]) patients for a median of 2.0 hours (range, 25-241 [SD, 2.7] minutes). On rounds, teams most frequently discussed the patient care plan (96.7% of patients), reviewed diagnostic studies (90.7%), communicated with patients (73.4%), and discussed the medication list (68.8%). Teams infrequently discussed invasive lines or tubes (9.3%) or nursing notes (6.2%) and rarely communicated with nurses (12.0%) or taught physical examination skills (14.6%), evidence-based medicine topics (7.2%), or learner-identified topics (3.2%). Many commonly performed activities occurred infrequently at the bedside. CONCLUSIONS AND RELEVANCE Most activities on attending rounds do not take place at the bedside. The teams discuss patient care plans and test results most of the time but fail to include many items that may be of significant value, including specific aspects of patient care, interprofessional communication, and learner-centered education. Future studies are needed to further assess the implications of these observations.

Medical students' perceptions of mentoring: a focus-group analysis

Characteristics of medical students’ mentoring relationships and factors that affect mentoring during medical school are poorly understood. The authors conducted four focus groups with fourth-year medical students to explore what students sought from mentors, perceived barriers to mentoring and suggestions for improvement. Data were analyzed using grounded theory. Students with and without mentors described a mentoring relationship as a personal connection with a faculty member invested in helping the student achieve a personal and professional vision. The short duration of courses, abrupt change from classroom learning to clerkships and limited exposure to clinicians were perceived as barriers to mentoring. Students recommended that the school explicitly promote mentoring with early education about finding mentors, placing the responsibility on students while also expanding the pool of potential mentors. It is concluded that medical students characterize mentoring in terms of the interpersonal dynamics of the relationship, emphasizing personal connection and advocacy. Educating and empowering students along with faculty education regarding students’ needs may improve mentoring.

The Internal Medicine Reporting Milestones and the Next Accreditation System

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones Project to facilitate more synthetic and narrative-based assessments of educational outcomes. This commenta...

Learner deficits and academic outcomes of medical students, residents, fellows, and attending physicians referred to a remediation program, 2006-2012.

Purpose To identify deficit types and predictors of poor academic outcomes among students, residents, fellows, and physicians referred to the University of Colorado School of Medicine’s remediation program. Method During 2006–2012, 151 learners were referred. After a standardized assessment process, program faculty developed individualized learning plans that incorporated deliberate practice, feedback, and reflection, followed by independent reassessment. The authors collected data on training levels, identified deficits, remediation plan details, outcomes, and faculty time invested. They examined relationships between gender, training level, and specific deficits. They analyzed faculty time by deficit and explored predictors of negative outcomes. Results Most learners had more than one deficit; medical knowledge, clinical reasoning, and professionalism were most common. Medical students were more likely than others to have mental well-being issues (P = .03), whereas the prevalence of professionalism deficits increased steadily as training level increased. Men struggled more than women with communication (P = .01) and mental well-being. Poor professionalism was the only predictor of probationary status (P < .001), and probation was a predictor of other negative outcomes (P < .0001). Remediation of clinical reasoning and mental well-being deficits required significantly more faculty time (P < .001 and P = .03, respectively). Per hour, faculty face time reduced the odds of probation by 3.1% (95% CI, 0.09–0.63) and all negative outcomes by 2.6% (95% CI, 0.96–0.99). Conclusions Remediation required substantial resources but was successful for 90% of learners. Future studies should compare remediation strategies and assess how to optimize faculty time.

Toward Safe Hospital Discharge: A Transitions in Care Curriculum for Medical Students

BACKGROUNDMedical errors often occur when patients move between care settings. Physicians generally receive little formal education on improving patient care transitions.OBJECTIVETo develop a sustainable and effective Transition in Care Curriculum (TICC). Specific goals were to increase student confidence in and knowledge of skills necessary during care transitions at the time of hospital discharge, and to quantify the frequency of student-identified medication discrepancies during a post-discharge home visit.DesignTICC was delivered to 136 3rd-year medical students during their required inpatient medicine clerkship at six urban Denver hospitals. TICC consists of small and large group interactive sessions and self-directed learning exercises to provide foundational knowledge of care transitions. Experiential learning occurs through direct patient care at the time of discharge and during a follow-up home, hospice, or skilled nursing visit. Students completed a pre-post confidence measure, short answer and multiple choice questions, a post-clerkship satisfaction survey, and a standardized medication discrepancy tool.MAIN RESULTSOverall combined confidence in transitional care skills improved following the TICC from an average score of 2.7 (SD 0.9) to 4.0 (SD 0.8) (p < 0.01) on a 5-point confidence scale. They scored an average of 77% on the written discharge plan portion of the final exam. Students rated the usefulness of TICC at a mean of 3.1 (SD 0.7), above the combined mean of 2.7 for project work in all required clerkships. Students identified medication discrepancies during 43% of post-discharge visits (58 of 136). The most common reasons for discrepancies were patient lack of understanding of instructions and intentional non-adherence to medication plan.CONCLUSIONTICC represents a feasible and effective program to teach evidence-based transitional care.

Student perceptions of the one minute preceptor and traditional preceptor models.

Background: The one-minute preceptor (OMP) model was developed to effectively and efficiently teach learners while simultaneously addressing patient needs. This study was conducted to determine if third- and fourth-year medical students prefer the OMP model over the traditional precepting model and what teaching points they needed from the clinical encounters. Methods: Third- and fourth-year students (N = 164) at two medical schools completed a questionnaire and prompts on teaching points in response to viewing two videotaped precepting encounters. Differences between OMP and traditional precepting scores were computed using a factorial repeated measures analysis of co-variance (ANCOVA). Teaching points were coded and counted. Results: Students preferred the OMP precepting model to the traditional teaching model (p = 0.001). While the desired teaching points changed as the case presentation/discussion progressed, students were most interested in learning about the clinical presentation or natural progression of the disease regardless of teaching model used. Conclusions: Students rate the OMP as a more effective model of teaching than the traditional model. The teaching points desired by students change as the case presentation/discussion unfolds. Work carried out at: University of California, San Francisco, Office of Medical Education and University of California, Irvine, Department of Family Medicine