Gretchen Diemer

Lifestyle factors and primary care specialty selection: comparing 2012-2013 graduating and matriculating medical students' thoughts on specialty lifestyle.

Purpose To compare how first-year (MS1) and fourth-year students (MS4) ascribe importance to lifestyle domains and specialty characteristics in specialty selection, and compare students’ ratings with their primary care (PC) interest. Method In March 2013, MS4s from 11 U.S. MD-granting medical schools were surveyed. Using a five-point Likert-type scale (1 = not important at all; 5 = extremely important), respondents rated the importance of 5 lifestyle domains and 21 specialty selection characteristics. One-way analysis of variance was used to assess differences by PC interest among MS4s. Using logistic regression, ratings from MS4s were compared with prior analyses of ratings by MS1s who matriculated to the same 11 schools in 2012. Results The response rate was 57% (965/1,701). MS4s, as compared with MS1s, rated as more important to good lifestyle: time off (4.3 versus 4.0), schedule control (4.2 versus 3.9), and financial compensation (3.4 versus 3.2). More MS4s than MS1s selected “time-off” (262/906 [30%] versus 136/969 [14%]) and “control of work schedule” (169/906 [19%] versus 146/969 [15%]) as the most important lifestyle domains. In both classes, PC interest was associated with higher ratings of working with the underserved and lower ratings of prestige and salary. Conclusions In the 2012–2013 academic year, matriculating students and graduating students had similar perceptions of lifestyle and specialty characteristics associated with PC interest. Graduating students placed more importance on schedule control and time off than matriculating students. Specialties should consider addressing a perceived lack of schedule control or inadequate time off to attract students.

Primary Care, the ROAD Less Traveled: What First-Year Medical Students Want in a Specialty

Purpose Medical students are increasingly choosing non-primary-care specialties. Students consider lifestyle in selecting their specialty, but how entering medical students perceive lifestyle is unknown. This study investigates how first-year students value or rate lifestyle domains and specialty-selection characteristics and whether their ratings vary by interest in primary care (PC). Method During the 2012–2013 academic year, the authors conducted a cross-sectional survey of first-year medical students from 11 MD-granting medical schools. Using a five-point Likert-type scale (1 = not important at all; 5 = extremely important), respondents rated the importance of 5 domains of good lifestyle and 21 characteristics related to specialty selection. The authors classified students into five groups by PC interest and assessed differences by PC interest using one-way analysis of variance. Results Of 1,704 participants, 1,020 responded (60%). The option “type of work I am doing” was the highest-rated lifestyle domain (mean 4.8, standard deviation [SD] 0.6). “Being satisfied with the job” was the highest-rated specialty-selection characteristic (mean 4.7, SD 0.5). “Availability of practice locations in rural areas” was rated lowest (mean 2.0, SD 1.1). As PC interest decreased, the importance of “opportunities to work with underserved populations” also decreased, but importance of “average salary earned” increased (effect sizes of 0.98 and 0.94, respectively). Conclusions First-year students valued enjoying work. The importance of financial compensation was inversely associated with interest in PC. Examining the determinants of enjoyable work may inform interventions to help students attain professional fulfillment in PC.

The Effect of Resident Duty-Hours Restrictions on Internal Medicine Clerkship Experiences: Surveys of Medical Students and Clerkship Directors

Phenomenon: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students’ and clerkship directors’ perceptions of the effects of the 2011 DHR on internal medicine clerkship students’ experiences with teaching, feedback and evaluation, and patient care. Approach: Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation. Findings: Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. Insights: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student–patient relationship and students’ clinical skills acquisition.

Routine Blood Cultures for the Febrile Inpatient: A Teachable Moment

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Medical student perceptions of hospital discharge transitions in care

Improved coordination of care after hospitalizations is essential to decrease readmissions and costs, and most importantly, to prevent undesirable patient outcomes. Changes in care plans may be lost through ineffective communication to the patient or providers, making this transition particularly critical (Kripalani et al. 2007). Thirdyear medical students are frequently involved in discharges though rarely have opportunities to follow patients after the hospitalization and receive little formal training in transitional care. Students’ self-assessed competency in transitional care has been shown to increase after introducing curriculum designed to focus on discharge planning (Bray-Hall 2010). This study aims to assess third-year medical student perceptions of transitional care following an educational exercise. Students identified a patient and completed a semistructured telephone interview within 3–5 days after discharge to assess patients’ adherence with discharge instructions. The survey involved questions about the discharge process guiding the students to: assess the patient’s understanding of perceived need, benefit and disadvantages of the hospitalization, reconcile medications, determine adherence to home services and follow-up appointments, and ascertain if the patient returned to the ED. Students were then asked to comment on their experiences in order to provide an opportunity for reflection. Three independent reviewers analyzed the qualitative data from the students’ reflections for emerging themes. Themes included coordination of care, empathy and patient relationships, in addition to recognition of logistical challenges in patient continuity. Students articulated many components of the discharge process in which difficulties arise and noted that they were more thoughtful in preparing discharge-related documentation when they knew they would be contacting the patient. Several students also highlighted continuity of care and patient relationships as the aspects of this exercise that they found to be most valuable. This exercise serves as an innovative model for incorporating discharge planning into the curriculum of inpatient clerkships and was found to increase insight into the complexities of transitional care. Transitional care is pivotal in decreasing adverse events and readmission, and we recommend that this education be incorporated into undergraduate medical training.

Leveraging Structural Changes in an Electronic Health Record Tool to Standardize Written Handoff

Miscommunications during patient handoff can lead to harm. The I-PASS bundle has been shown to improve safety outcomes. Although effective training reliably improves verbal handoffs, research has demonstrated a lack of effect on written handoffs. The objective was to compare written handoff before and after integration of a standardized electronic health record (EHR) tool. Interns at a large urban academic medical center underwent I-PASS handoff training. The EHR handoff tool was then revised to prompt the I-PASS components. Handoff documents were obtained before and after the intervention. More handoffs included Illness Severity (33% to 59%, P < .001) and Action List (65% to 83%, P = .005) after the intervention. There was no change in handoffs with miscommunications (12.5% to 10%, P = .566) or omissions (8% to 11%, P = .447). Handoffs including tangential or unrelated information decreased (20% to 4%, P = .001). A written handoff tool can reinforce the effect of training and increase adherence to I-PASS.

Creating Provider-Level Quality Reports for Residents to Improve the Clinical Learning Environment

Access to personal performance data is hypothesized to drive engagement in quality improvement and lead to improved quality of care. In the Common Program Requirements, the Accreditation Council for Graduate Medical Education (ACGME) sets an expectation that residents receive specialty-specific data on quality metrics. During the Clinical Learning Environment Review the level of specificity of such data is assessed, with a goal that residents receive feedback regarding their individual performance. Compared to inpatient care, it is often easier to collect individual performance data in the outpatient setting, where patient care is more closely attributed to individual providers. Individual inpatient quality data are more difficult to acquire due to complicated attribution and data collection strategies that focus on units/departments rather than providers/teams. On our institution’s most recent ACGME survey, a mean of 64% of residents in core programs reported access to their own performance data, indicating opportunities for improvement.

Changes in the preferences of US physicians-in-training for medical interventions throughout medical education

There exists a disparity between the views of physicians and the views of their patients on end‐of‐life decisions. However, the timing of when the end‐of‐life preferences of physicians and non‐medically‐trained individuals diverge is currently unknown. The objective of this paper is to characterise how preferences for medical interventions change throughout medical education and residency or fellowship training when confronted with scenarios of critical or terminal illness.