Meenakshy K. Aiyer

Change in residents' perceptions of teaching: following a one day "Residents as Teachers" (RasT) workshop.

Objectives: The objective of this study was to assess the perceptions and attitudes of resident physicians toward teaching before and after participation in a mandatory “Residents as Teachers” (RasT) workshop in four domains: (1) setting goals and expectations, (2) use of clinical microskills in teaching, (3) evaluation and feedback, and (4) enthusiasm and preparedness toward teaching. Methods: Pre- and postintervention questionnaires were utilized. Data were analyzed for all respondents. Subgroup analyses were performed for each academic year and for primary care versus nonprimary care specialties. Results: Over a 5-year period, 15 RasT workshops were presented to 276 residents from 10 different residency programs. Eighty-six percent completed the questionnaire before participation in the workshop, and 88% completed the questionnaire immediately after participation. The difference between the mean post-RasT and pre-RasT ratings on each item was used to measure the change in that item resulting from participation in the workshop. Conclusion: Overall, residents’ self-assessed ratings of their attitudes toward teaching were positively impacted by participation in a RasT workshop. Further subanalysis showed that residents in primary care specialties showed a significantly greater increase in their ratings than residents in nonprimary care specialties.

The Subinternship Curriculum in Internal Medicine: A National Survey of Clerkship Directors

Background: The 4th-year internal medicine subinternship (subI), with its strong emphasis on experience-based learning and increased patient responsibilities, is an important component of undergraduate medical education. Discussions have begun amongst educational leaders on the importance of standardizing curriculum and evaluation tools utilized during the subinternship. Purpose: The objective of this survey was to describe the current state of educational practices regarding the subI curriculum, use of Clerkship Directors in Internal Medicine (CDIM) curricular guidelines, evaluation methodologies, and subintern call frequency and duty hours. Methods: The survey was a part of the CDIM annual survey sent to 109 institutional members in 2005. The subinternship survey included 17 questions that addressed the prevalence of formal curricula in the subinternship, use of CDIM curricular guidelines and resources, and the evaluation tools utilized for assessment of the subinternship. Two questions examined the call frequency and duty hours of the subinterns. Results: Eighty-eight members responded (81%). Of the respondents, 37% have a formal curriculum and 35% used CDIM curricular guidelines for the subinternship. More than half of the respondents agreed that the curricular guide helped organize their subI rotations (53%), and 48% agreed that it enhanced the quality of subI education. A global rating summative evaluation form (56%) was the most commonly used evaluation tool in the subinternship. Objective Structured Clinical Examinations 1−3 (1%) and Mini-Clinical Evaluation Exercise (mini-CEX) 4 (2%) were much less utilized during the subinternship. The respondents expressed an interest in the development of a standardized exam (47%) and clinical assessment tools such as the mini-CEX (59%). The vast majority of IM subinterns participate in 3 to 9 calls per rotation and spend less than 80 hr in the hospital per week. Conclusions: A formal curriculum is offered in slightly more than one third of subIs. Clerkship directors expressed interest in developing standardized evaluation tools to assess subintern competencies. The majority of IM subinterns spend less than 80 hr in the hospital per week. Further studies are needed to assess barriers to incorporating a formal curriculum and develop standardized tools to assess subintern competencies.

The transformation of an EBM curriculum: a 10-year experience

Background: Evidence-based medicine (EBM) is an essential tool for students across the medical education continuum. Incorporation of EBM skills into core competencies by national educational organizations denotes their vital role. Aim: The main purpose is to describe the transformation of an EBM curriculum in an Internal Medicine clerkship and the educational principles that influenced changes over ten years. Methods: The EBM curriculum over ten years was reviewed. This retrospective review was divided into four phases, based on the educational interventions used. Associated outcomes of the curriculum, student skills, and satisfaction with the course and faculty involvement were assessed. Results: A majority of the 493 students felt they received adequate and appropriate exposure to EBM. The curriculum evolved from a teacher-centered approach using computer-based case scenarios to a learner-centered, and patient centric approach. Student skills in EBM improved, as was evidenced by the pre- and post-tests and the evaluations of critically appraised topic assignments. Conclusions: EBM is an essential tool to develop life-long learners. A learner-centered, patient centric approach is well received by students. Long-term studies are needed to assess the impact of these teaching interventions on patient outcomes.

Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship.

The fourth year of medical school remains controversial, despite efforts to reform it. A committee from the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine examined transitions from medical school to internship with the goal of better academic advising for students. In 2013 and 2014, the committee examined published literature and the Web sites of 136 Liaison Committee on Medical Education–accredited schools for information on current course offerings for the fourth year of medical school. The authors summarized temporal trends and outcomes when available. Subinternships were required by 122 (90%) of the 136 schools and allow students to experience the intern’s role. Capstone courses are increasingly used to fill curricular gaps. Revisiting basic sciences in fourth-year rotations helps to reinforce concepts from earlier years. Many schools require rotations in specific settings, like emergency departments, intensive care units, or ambulatory clinics. A growing number of schools require participation in research, including during the fourth year. Students traditionally take fourth-year clinical electives to improve skills, both within their chosen specialties and in other disciplines. Some students work with underserved populations or seek experiences that will be henceforth unavailable, whereas others use electives to “audition” at desired residency sites. Fourth-year requirements vary considerably among medical schools, reflecting different missions and varied student needs. Few objective outcomes data exist to guide students’ choices. Nevertheless, both medical students and educators value the fourth year of medical school and feel it can fill diverse functions in preparing for residency.

Educating Clerkship Students in the Era of Resident Duty Hour Restrictions

This Article is brought to you for free and open access by the US Department of Defense at DigitalCommons@University of Nebraska - Lincoln. It hasbeen accepted for inclusion in Uniformed Services University of the Health Sciences by an authorized administrator of DigitalCommons@Universityof Nebraska - Lincoln.

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.

Last Chance to Observe: Assessing Residency Preparedness Following the 4th-Year Subinternship

Background: The subinternship is an integral part of the 4th year of medical school. There is little description of innovations aimed at assessing the preparedness and confidence of graduating students as they move on the next step in their training. Description: An innovation including an Objective Structured Clinical Examination (OSCE) at the conclusion of the subinternship was designed. We focused on key themes of transitions of care, communication within the health care system, and communication with patients and providers. Evaluation: A pre- and postsurvey addressed student self-perceived skill, confidence, and overall perception of importance. Improvement (p < .05) was seen across all themes from pre- to postsurvey, with more favorable scores on the postsurvey. Conclusions: A subinternship innovation including an OSCE was feasible and had a positive effect on student assessment, perception and confidence. As the landscape of medical education evolves, assessing students’ preparedness for residency will become increasingly imperative.

Medical informatics in the internal medicine clerkship: Results of a national survey

Background: Medical Informatics (MI) is increasingly a critical aspect of medical education and patient care. Aims: This study assessed the status of MI training, perception of needs and barriers for the implementation of MI curricula and utilization of information technology (IT) in patient care and medical education. Method: The MI questionnaire was a part of the 2006 Clerkship Directors in Internal Medicine survey of 110 institutional members. Descriptive statistics were calculated using Statistical Package for the Social Sciences (SPSS), version 12 and all p-values are two-tailed. Results: Eighty-three (75%) members responded. Out of this, 52, 32.5 and 12% report that students receive MI training for patient care activities during pre-clinical years, third-year internal medicine clerkship or intersession, respectively. House staff critiques (46.4%), patient billing (44.1%), radiographic imaging (40.8%), accessing clinical data (37.3%), and student evaluations (36.1%) were areas in which 35% of respondents use IT ‘all the time.’ Fifty-one percent of respondents rate the adequacy of training in MI as average. Cost, time and lack of trained faculty were primary barriers for the implementation. Conclusions: Significant variations exist in timing of MI curricula. IT is utilized more frequently for non-patient activities. Studies are needed to examine the needs, processes and outcomes of MI curricula.

An Entrustable Professional Activity (EPA)-Based Framework to Prepare Fourth-Year Medical Students for Internal Medicine Careers

The purpose of the fourth year of medical school remains controversial. Competing demands during this transitional phase cause confusion for students and educators. In 2014, the Association of American Medical Colleges (AAMC) released 13 Core Entrustable Professional Activities for Entering Residency (CEPAERs). A committee comprising members of the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine applied these principles to preparing students for internal medicine residencies. The authors propose a curricular framework based on five CEPAERs that were felt to be most relevant to residency preparation, informed by prior stakeholder surveys. The critical areas outlined include entering orders, forming and answering clinical questions, conducting patient care handovers, collaborating interprofessionally, and recognizing patients requiring urgent care and initiating that care. For each CEPAER, the authors offer suggestions about instruction and assessment of competency. The fourth year of medical school can be rewarding for students, while adequately preparing them to begin residency, by addressing important elements defined in the core entrustable activities. Thus prepared, new residents can function safely and competently in supervised postgraduate settings.

Cryptococcemia in an HIV-negative patient with decompensated liver cirrhosis

Background Cryptococcal infections have been mostly associated with immunocompromised individuals, 80–90% of whom have been HIV-positive patients. Increasingly, cryptococcal infections are being reported in cirrhotic patients who are HIV-negative. The underlying immunologic defects in cirrhotic patients seem to play an important role in predisposing them to cryptococcosis and affecting their morbidity and mortality. Case presentation We present a case of disseminated cryptococcosis in an HIV-negative patient with underlying cirrhosis, who had rapid worsening of his hyponatremia with renal failure and was unable to recover, despite aggressive measures. Conclusion Cryptococcus is a more common culprit of infections seen in cirrhotic patients than what it was previously known, and a high index of suspicion is required to diagnose these patients. Identification of poor prognostic factors, early diagnosis and intervention is crucial in the management of these patients.