Gerald D. Denton

LITERATURE REVIEWS: Narrative Review: Use of Student-Generated Logbooks in Undergraduate Medical Education

Background: Logbooks are used by clinical clerkships in undergraduate medical education as tools for individual student guidance, programmatic evaluation, and Liaison Committee on Medical Education (LCME) accreditation. The purpose of this narrative review was to summarize the published literature on the form and function of logbooks and to review logbook validity and reliability. We performed a literature search from 1980 through 2004 and reviewed 50 articles on logbook use during clinical clerkships. Summary: Articles were categorized into 5 themes: description and feasibility of logbooks (27 articles), accuracy and completeness of logbook entries (14 articles), utility to student education (11 articles), utility to program evaluation (26 articles), and connecting logbook process measures to clerkship outcomes (2 articles). Conclusions: A feasible and acceptable logbook system is an attainable goal, although students usually did not complete logbooks unless required. The available literature does not establish that logbooks currently in use have sufficient reliability or validity to allow for the routine use of the information for program change or accreditation purposes. The ideal logbook should be inexpensive, feasible, and acceptable to students and should allow rapid collation of accurate, relevant data for timely analysis and feedback to the student and clerkship director.

A Prospective Controlled Trial of the Influence of a Geriatrics Home Visit Program on Medical Student Knowledge, Skills, and Attitudes Towards Care of the Elderly

ABSTRACTPURPOSETo determine the impact of a geriatrics home visit program for third-year medical students on attitudes, skills, and knowledge.METHODSUsing a mixed methods, prospective, controlled trial, volunteer control group students (n = 17) at two sites and intervention group students (n = 16) at two different sites within the same internal medicine clerkship were given Internet and CDROM-based geriatric self-study materials. Intervention group students identified a geriatrics patient from their clinical experience, performed one “home” visit (home, nursing home, or rehabilitation facility) to practice geriatric assessment skills, wrote a structured, reflective paper, and presented their findings in small-group teaching settings. Papers were qualitatively analyzed using the constant comparative method for themes. All students took a pre-test and post-test to measure changes in geriatrics knowledge and attitudes.RESULTSGeneral attitudes towards caring for the elderly improved more in the intervention group than in the control group (9.8 vs 0.5%; p = 0.04, effect size 0.78). Medical student attitudes towards their home care training in medical school (21.7 vs 3.2%; p = 0.02, effect size 0.94) improved, as did attitudes towards time and reimbursement issues surrounding home visits (10.1 vs −0.2%; p = 0.02, effect size 0.89). Knowledge of geriatrics improved in both groups (13.4 vs 15.2% improvement; p = 0.73). Students described performing a mean of seven separate geriatric assessments (range 4–13) during the home visit. Themes that emerged from the qualitative analysis of the reflective papers added depth and understanding to the quantitative data and supported results concerning attitudinal change.CONCLUSIONSWhile all participants gained geriatrics knowledge during their internal medicine clerkship, students who performed a home visit had improved attitudes towards the elderly and described performing geriatric assessment skills. Requiring little faculty time, a geriatrics home visit program like this one may be a useful clerkship addition to foster medical students’ professional growth.

An internal medicine interest group research program can improve scholarly productivity of medical students and foster mentoring relationships with internists.

Background: Shortages in primary care careers such as internal medicine are projected in the future. Conducting research is an explicit requirement for graduate medical education and interest in research is growing in undergraduate medical education. Purpose: We hypothesized that a medical student research initiative could increase student research productivity and foster mentoring relationships with internists. Method: We compared the number of medical student presentations, awards, and peer-reviewed publications before and after a brief research initiative at a single institution and recorded comments from student participants; data collected before the initiative were retrospective, and data after the initiative were collected prospectively. Mann–Whitney U was used for statistical analysis. Results: Twenty-seven students participated in our workshop initiative during the study period (2000–2005). Eighteen (67%) subsequently had presentations, research awards, and/or publications during the study period. Mann–Whitney U testing of groups (all pre-initiative Uniformed Services University students and initiative participants) showed a statistically significant increase in regional presentations (p = .003), research awards (p = .01), and publications (p = .02) after the research initiative. Student comments not only revealed research mentoring benefits but also commented on receiving career counseling advice from mentors. Conclusions: Our study findings support the feasibility of this initiative as well as produced significant outcomes in terms of quantified research productivity and student mentoring.

RESEARCH BASIC TO MEDICAL EDUCATION: A Time and Motion Study of the Effect of Ambulatory Medical Students on the Duration of General Internal Medicine Clinics

Background: Teaching medical students in the ambulatory setting may influence the duration or number of patients per clinic. Purpose: To directly measure the time required to teach medical students in an outpatient clinic and to determine if there was a difference in activities performed by faculty when a student was present in the clinic. Methods: In this prospective, nonrandomized study, 83 clinic sessions were analyzed; 50 without a 3rd-year internal medicine clerkship student and 33 with a student. Seven 3rd-year internal medicine clerkship students and 7 general internists participated. The 7 general internists had both clinic sessions with and clinic sessions without a student during our study period. For every clinic session, physicians recorded duration, number of patients, presence of a student, and teaching activities. In a subset of 23 clinics (28%), ancillary staff independently recorded clinic duration and number of patients seen. To address time added to a clinic session by a student, we compared clinic sessions with versus clinic sessions without a student for each participating physician. Multiple linear regression was used for analysis. Results: Having a student added 32.3 min to a clinic session (p <. 001). Clinic duration recorded by ancillary staff did not differ from duration recorded by physicians (p =. 74), and the durations were well correlated (r =. 81). Regarding additional activities, physicians were more likely to discuss patients with house staff when students were present, but other nonteaching physician activities did not change. Conclusions: In this study, teaching a 3rd-year medical student in an internal medicine outpatient clinic required 32.3 extra min per clinic. Clerkship directors and clinic administrators should be aware of the extra time required to teach and be prepared to expect an impact on clinic productivity.

Intersite consistency as a measurement of programmatic evaluation in a medicine clerkship with multiple, geographically separated sites.

Purpose. This study introduces “intersite consistency” as a measurement of programmatic evaluation and demonstrates its feasibility and construct validity. Method. Student data in our multisite, geographically separated clerkship were collected prospectively over a ten-year period (1990–2000). We calculated mean scores for each clerkship measurement and analyzed these data on both a yearly and a 10-year cumulative basis. Analyses of variance (ANOVA) and linear regression were used for statistical analysis. Results. Data for 1,632 (98%) students were included in our study. During this ten-year study period, we had 22 different on-site clerkship directors at seven clerkship sites. ANOVA and linear regression of year-to-year and cumulative data did not demonstrate an effect of site on student outcomes. Conclusions. Intersite consistency can be used as one measure of programmatic evaluation for multisite clerkships.

Comparing a Script Concordance Examination to a Multiple-Choice Examination on a Core Internal Medicine Clerkship

Background: Script concordance (SC) questions, in which a learner is given a brief clinical scenario then asked if additional information makes one hypothesis more or less likely, with answers compared to a panel of experts, are designed to reflect a learners clinical reasoning. Purpose: The purpose is to compare reliability, validity, and learner satisfaction between a three-option modified SC examination to a multiple-choice question (MCQ) examination among medical students during a 3rd-year internal medicine clerkship, to compare reliability and learner satisfaction of SC between medical students and a convenience sample of house staff, and to compare learner satisfaction with SC between 1st- and 4th-quarter medical students. Methods: Using a prospective cohort design, we compared the reliability of 20-item SC and MCQ examinations, sequentially administered on the same day. To measure validity, scores were compared to scores on the National Board of Medical Examiners (NBME) subject examination in medicine and to a clinical performance measure. SC and MCQ were also administered to a convenience sample of internal medicine house staff. Medical student and house staff were anonymously surveyed regarding satisfaction with the examinations. Results: There were 163 students who completed the examinations. With students, the initial reliability of the SC was half that of MCQ (KR20 0.19 vs. 0.41), but with house staff (n = 15), reliability was the same (KR20 = 0.52 for both examinations). SC performance correlated with student clinical performance, whereas MCQ did not (r = .22, p = .005 vs. .11, p = .159). Students reported that SC questions were no more difficult and were answered more quickly than MCQ questions. Both exams were considered easier than NBME, and all 3 were considered equally fair. More students preferred MCQ over SC (55.8% vs. 18.0%), whereas house staff preferred SC (46% vs. 23%; p = .03). Conclusions: This SC examination was feasible and was more valid than the MCQ examination because of better correlation with clinical performance, despite being initially less reliable and less preferred by students. SC was more reliable and preferred when administered to house staff.

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.

The Required Written History and Physical is Alive, but Not Entirely Well, in Internal Medicine Clerkships

Background: Effective written communication is a core competency for medical students, but it is unclear whether or how this skill is evaluated in clinical clerkships. Purpose: This study identifies current requirements and practices regarding required written work during internal medicine clerkships. Methods: In 2010, Clerkship Directors of Internal Medicine (CDIM) surveyed its institutional members; one section asked questions about students’ written work. Results were compared to similar, unpublished CDIM 2001 survey questions. Results: Requirements for student-written work were nearly universal (96% in 2001 and 100% in 2010). Only 23% used structured evaluation forms and 16% reported written work was weighted as a percentage of the final grade, although 72% of respondents reported that written work was “factored” into global ratings. Conclusions: Despite near universal requirements for student written work, structured evaluation was not commonly performed, raising concern about the validity of factoring these assessments into grades.

Internal medicine core clerkships experience with core problem lists: results from a national survey of clerkship directors in internal medicine.

Background: The Liaison Committee on Medical Education (LCME) requires clinical clerkships in North American Medical Schools to define and monitor core problems and clinical conditions for medical students and adjust the clerkships to ensure that all students meet those objectives at all instructional sites. Clinical clerkships usually use medical student generated logbooks to meet these requirements. It is not clear what clinical clerkship directors are doing to meet these standards. Purpose: To determine how internal medicine clerkship directors develop problem lists, whether and how they verify student problem list entry, and how missed core problems are covered. Methods: The Clerkship Directors in Internal Medicine (CDIM) organization conducts an annual survey of its institutional members (one member per medical school). In 2007, 75% of North American medical schools (82 of 110) responded to the survey, which included questions on core problem lists and medical student logbooks. Results: Ninety-four percent of responding medical schools had a core problem list for the core internal medicine clerkship. Most schools used an electronic logbook and verified student exposure to core problems (76%). The clerkship director usually did the verification (63%). Clerkships offered a variety of options to remedy lack of exposure to core problems and usually offered more than one option. Conclusions: Clerkship directors in internal medicine develop, verify, and ensure exposure to core problems in internal medicine. Most clerkship directors used the CDIM recommended core problem list as a basis for their local core problem list. Emerging computer-assisted learning options may simplify clerkship adjustments for lack of exposure to core problems. It appears that clerkship directors are using logbooks appropriately to meet the LCME charge to monitor core problems and clinical conditions.

Relationship between clinical experiences and internal medicine clerkship performance

Medical Education 2012: 46:689–697