Sara B. Fazio

Longitudinal pedagogy: a successful response to the fragmentation of the third-year medical student clerkship experience.

A longitudinal clerkship was designed at Harvard Medical School (HMS) in 2004–2005 to emphasize continuity, empathy, learner-centeredness, and patient-centered care. In 2005–2006, the curriculum was piloted with eight students who voluntarily enrolled in the third-year curriculum, which focused on longitudinal mentorship and feedback, interdisciplinary care, integration of clinical and basic science, and humanism in patient care. Eighteen traditional curriculum (TC) students at HMS who were comparable at baseline served as a comparison group. SHELF exams and OSCE performance, monthly and end-of-year surveys, and focus groups provided comparisons between pilot and TC students on their performance, perceptions, attitudes, and satisfaction. Pilot students performed as well as or better than their peers in standardized measures of clinical aptitude. They demonstrated statistically significant greater preservation of patient-centered attitudes compared with declining values for TC students. Pilot students rated the atmosphere of learning, effective integration of basic and clinical sciences, mentorship, feedback, clerkship satisfaction, and end-of-year patient-care preparedness significantly higher than TC students. The authors conclude that implementation of a longitudinal third-year curriculum, with only modest alterations in existing clinical training frameworks, is feasible and effective in meeting its stated goals. “Exposing” the hidden curriculum through specific longitudinal activities may prevent degradation of student attitudes about patient-centered care. Minimizing the disjointed nature of clinical training during a critical time in students’ training by providing a cohesive longitudinal curriculum in parallel to clinical clerkships, led by faculty with consistent contact with students, can have positive effects on both professional performance and satisfaction.

ACCF/AHA/ACP 2009 Competence and Training Statement: A Curriculum on Prevention of Cardiovascular Disease

Jonathan L. Halperin, MD, FACC, Chair Mark A. Creager, MD, FACC, FAHA[†††][1] Gordon L. Fung, MD, PhD, FACC, FAHA David R. Holmes, Jr, MD, FACC[‡‡‡][2] Geno J. Merli, MD, FACP Ira S. Nash, MD, FACC, FACP L. Kristin Newby, MD, FACC, FAHA Ileana Pina, MD, FACC, FAHA George P.

ACCF/AHA/ACP 2009 Competence and Training Statement: A Curriculum on Prevention of Cardiovascular Disease: A Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Competence and Training (Writing Committee to Develop a Competence and Training Statement on Prevention of Cardiovascular Disease)

The mission of many organizations is the optimal care to those with or at risk for developing CVD (primary and secondary prevention). Over the past two decades, there have been dramatic increases in knowledge concerning specific risk factors in atherosclerosis, hypertension, thrombosis, and other forms of vascular dysfunction. Clinical trials have proven that strategies aimed at the appropriate detection and modification of risk factors can slow progression of atherosclerosis, diabetes mellitus, and hypertension and reduce the occurrence of clinical cardiovascular events in both primary and secondary prevention settings. More recently, it has been shown that atherosclerosis can be stabilized or even modestly reversed. Finally, a new and growing knowledge base of molecular genetics applied to the study of the cardiovascular system has potential relevance to the clinical practice of preventive cardiovascular medicine. Despite the fact that clinical outcomes can be improved by promotion of favorable life habits and behaviors and by the proper use of drug treatment, the application of primary and secondary preventive interventions in clinical practice is not optimal. Prevention of CVD in both the primary and secondary prevention setting, while dominantly the responsibility of the primary care provider, is increasingly challenged given this ever expanding new knowledge as well as the ongoing problems related to adherence to recommendations. New knowledge in the area of pre-clinical disease detection has presented increasingly challenging scenarios to primary care healthcare providers relative to the decisions regarding the need for further risk stratification and aggressive medical regimens. Furthermore, increasingly complex patients are surviving with CVD, many of whom can benefit from advanced knowledge and expertise with regard to risk factor management and rehabilitation that is beyond traditional general primary and cardiology practitioners scope of practice. The prevention of cardiovascular morbidity and mortality is a shared responsibility among all health professionals involved in the care of people at risk of developing cardiovascular disease. This document is directed at those individuals seeking expertise at a leadership level in this field, and includes opportunities for formal training and alternative routes to competence and maintenance of competence in prevention of cardiovascular disease (Table 2), and educational resources for acquisition and maintenance of competence in the prevention of cardiovascular disease (Table 3). To address the expanding fund of knowledge in the area and to ensure that an adequately trained force of preventive cardiovascular leaders will be available to primary care providers, as well as provide a pool of providers with expertise in running rehabilitation and other programs designed to address the ongoing issue of adherence, the formulation of clinical competency criteria for the cardiovascular preventive specialist is needed. These competency criteria are expected to address issues of expert clinical and scientific leadership, specialty patient care and consultation, and directorship of primary and secondary preventive cardiac programs. Of note and similar to other subspecialty areas of medicine, cardiovascular preventive specialists will have varying areas of expertise and will not necessarily achieve all the outlined areas of competencies. These clinical competency criteria in the area of specialty treatment and prevention of CVD are needed given the current setting of a rapidly growing field of knowledge ranging from molecular and cellular mechanisms to clinical outcomes in order to translate into improved patient care. Table 2 Opportunities for Formal Training and Alternative Routes to Competence and Maintenance of Competence in Prevention of Cardiovascular Disease Table 3 Educational Resources for Acquisition and Maintenance of Competence in the Prevention of Cardiovascular Disease C. Noel Bairey Merz, MD, FACC, FAHA Chair, ACCF/AHA/ACP Clinical Competence Statement on Prevention of CVD

Grade Inflation in the Internal Medicine Clerkship: A National Survey

Background: Grade inflation is a growing concern, but the degree to which it continues to exist in 3rd-year internal medicine (IM) clerkships is unknown. Purpose: The authors sought to determine the degree to which grade inflation is perceived to exist in IM clerkships in North American medical schools. Methods: A national survey of all Clerkship Directors in Internal Medicine members was administered in 2009. The authors assessed key aspects of grading. Results: Response rate was 64%. Fifty-five percent of respondents agreed that grade inflation exists in the Internal Medicine clerkship at their school. Seventy-eight percent reported it as a serious/somewhat serious problem, and 38% noted students have passed the IM clerkship at their school who should have failed. Conclusions: A majority of clerkship directors report that grade inflation still exists. In addition, many note students who passed despite the clerkship director believing they should have failed. Interventions should be developed to address both of these problems.

SOAP-V: Introducing a method to empower medical students to be change agents in bending the cost curve.

Medical students must learn how to practice high-value, cost-conscious care. By modifying the traditional SOAP (Subjective-Objective-Assessment-Plan) presentation to include a discussion of value (SOAP-V), we developed a cognitive forcing function designed to promote discussion of high-value, cost-conscious care during patient delivery. The SOAP-V model prompts the student to consider (1) the evidence that supports a test or treatment, (2) the patients preferences and values, and (3) the financial cost of a test or treatment compared to alternatives. Students report their findings to their teams during patient care rounds. This tool has been successfully used at 3 medical schools. Preliminary results find that students who have been trained in SOAP-V feel more empowered to address the economic healthcare crisis, are more comfortable in initiating discussions about value, and are more likely to consider potential costs to the healthcare system.

A 40-Year-Old Woman With an Asymptomatic Cystic Lesion in Her Right Lung

(CHEST 2009; 136:622–627) A 40-year-old woman presented to the pulmonary clinic with abnormal chest radiograph findings. She had longstanding primary Raynaud phenomenon, and 3 years prior to this presentation she had experienced transient, right knee inflammatory arthritis of unclear etiology. One month prior to the clinic visit, bilateral knee and wrist arthralgias developed with subjective fevers; the patient presented to her primary care doctor with these complaints. In retrospect, her 4-year-old son had experienced fevers and a rash, and had been subsequently diagnosed with Fifth disease. Her physician was concerned about sarcoidosis and obtained a chest radiograph. Based on these results, a chest CT scan was performed, and the patient was referred to the pulmonary clinic for further evaluation. The patient was born after 37 weeks’ gestation with an uncomplicated course in the postpartum period. Her medical history was notable for wellcontrolled, insulin-dependent diabetes and vestibular migraines. She had never had upper respiratory infections or pneumonias requiring antibiotic treatment. Her only prior hospitalization had been to undergo a cesarean section 4 years previously for the delivery of healthy twins. To her knowledge, she had never undergone chest imaging. The patient is a lifetime nonsmoker, and at baseline was active and healthy. She denied chest pain, cough, hemoptysis, dyspnea, or any limitations of her activity level. On physical examination, she had a heart rate of 90 beats/min, a BP of 100/62 mm Hg, respiratory rate of 12 breaths/min, and oxygen saturation of 99% while breathing room air at rest. Her chest was completely clear to auscultation and percussion without wheezes, rhonchi, or rales. The rest of her examination was unremarkable. Office spirometry was notable for an FEV1 of 2.36 L (76% predicted), an FVC of 3.53 L (88% predicted), and an FEV1/FVC ratio

A New Era for Residency Training in Internal Medicine.

“Disruptive change” is a buzzword for many industries, and health care is no exception. Changes in practice payment methodologies and locations of service affect the learning environment and settings for medical education, as well as the knowledge and skills that residents in internal medicine should acquire during their training. At the same time, graduate medical education (GME) is undergoing an internal evolution to make programs more based on the development of competencies and centered on the educational needs of individual trainees.

Guidelines for Writing Department of Medicine Summary Letters

AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.

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.

Grading Practices and Distributions Across Internal Medicine Clerkships

ABSTRACT Theory: Clerkship evaluation and grading practices vary widely between U.S. medical schools. Grade inflation continues to exist, and grade distribution is likely to be different among U.S. medical schools. Hypotheses: Increasing the number of available grades curtails “grade inflation.” Method: A national survey of all Clerkship Directors in Internal Medicine members was administered in 2011. The authors assessed key aspects of grading. Results: Response rate was 76%. Among clerkship directors (CDs), 61% of respondents agreed that grade inflation existed in the internal medicine clerkship at their school, and 43% believed that it helped students obtain better residency positions. With respect to grading practices, 79% of CDs define specific behaviors needed to achieve each grade, and 36% specify an ideal grade distribution. In addition, 44% have a trained core faculty responsible for evaluating students, 35% describe formal grading meetings, and 39% use the Reporter-Interpreter-Manager-Educator (RIME) scheme. Grading scales were described as follows: 4% utilize a pass/fail system, 13% a 3-tier (e.g., Honors/Pass/Fail), 45% 4-tier, 35% 5-tier, and 4% 6+-tier system. There was a trend to higher grades with more tiers available. Conclusions: Grade inflation continues in the internal medicine clerkship. Almost half of CDs feel that this practice assists students to obtain better residency positions. A minority of programs have a trained core faculty who are responsible for evaluation. About one third have formal grading meetings and use the RIME system; both have been associated with more robust and balanced grading practices. In particular, there is a wide variation between schools in the percentage of students who are awarded the highest grade, which has implications for residency applications. Downstream users of clinical clerkship grades must be fully aware of these variations in grading in order to appropriately judge medical student performance.