Stephen R. Pelletier

Educational Outcomes of the Harvard Medical School-Cambridge Integrated Clerkship: A Way Forward for Medical Education

Purpose The authors report data from the Harvard Medical School–Cambridge Integrated Clerkship (CIC), a model of medical education in which students’ entire third year consists of a longitudinal, integrated curriculum. The authors compare the knowledge, skills, and attitudes of students completing the CIC with those of students completing traditional third-year clerkships. Method The authors compared 27 students completing the first three years of the CIC (2004–2007) with 45 students completing clerkships at other Harvard teaching hospitals during the same period. At baseline, no significant between-group differences existed (Medical College Admission Test and Step 1 scores, second-year objective structured clinical examination [OSCE] performance, attitudes toward patient-centered care, and plans for future practice) in any year. The authors compared students’ National Board of Medical Examiners Subject and Step 2 Clinical Knowledge scores, OSCE performance, perceptions of the learning environment, and attitudes toward patient-centeredness. Results CIC students performed as well as or better than their traditionally trained peers on measures of content knowledge and clinical skills. CIC students expressed higher satisfaction with the learning environment, more confidence in dealing with numerous domains of patient care, and a stronger sense of patient-centeredness. Conclusions CIC students are at least as well as and in several ways better prepared than their peers. CIC students also demonstrate richer perspectives on the course of illness, more insight into social determinants of illness and recovery, and increased commitment to patients. These data suggest that longitudinal integrated clerkships offer students important intellectual, professional, and personal benefits.

Into the future: patient-centredness endures in longitudinal integrated clerkship graduates

This study was intended to determine if previously identified educational benefits of the Harvard Medical School (HMS) Cambridge Integrated Clerkship (CIC) endure over time.

Caring attitudes in medical education: perceptions of deans and curriculum leaders.

BACKGROUNDSystems of undergraduate medical education and patient care can create barriers to fostering caring attitudes.OBJECTIVEThe aim of this study is to survey associate deans and curriculum leaders about teaching and assessment of caring attitudes in their medical schools.PARTICIPANTSThe participants of this study include 134 leaders of medical education in the USA and Canada.METHODSWe developed a survey with 26 quantitative questions and 1 open-ended question. In September to October 2005, the Association of American Medical Colleges distributed it electronically to curricular leaders. We used descriptive statistics to analyze quantitative data, and the constant comparison technique for qualitative analysis.RESULTSWe received 73 responses from 134 medical schools. Most respondents believed that their schools strongly emphasized caring attitudes. At the same time, 35% thought caring attitudes were emphasized less than scientific knowledge. Frequently used methods to teach caring attitudes included small-group discussion and didactics in the preclinical years, role modeling and mentoring in the clinical years, and skills training with feedback throughout all years. Barriers to fostering caring attitudes included time and productivity pressures and lack of faculty development. Respondents with supportive learning environments were more likely to screen applicants’ caring attitudes, encourage collaborative learning, give humanism awards to faculty, and provide faculty development that emphasized teaching of caring attitudes.CONCLUSIONSThe majority of educational leaders value caring attitudes, but overall, educational systems inconsistently foster them. Schools may facilitate caring learning environments by providing faculty development and support, by assessing students and applicants for caring attitudes, and by encouraging collaboration.

A Faculty Development Program to Train Tutors to Be Discussion Leaders Rather Than Facilitators

Purpose During 2003, 2004, and 2005, the role of 70 tutors was changed from that of facilitator to discussion leader, in a preclinical PBL learning course, Gastrointestinal Pathophysiology, by use of three key business school teaching strategies: questions, summaries, and schematics. The purpose of this study was to learn what difference this new approach made. Method During each of the three study years, 171 (2003), 167 (2004), and 170 (2005) students were given Likert-scale attitudinal questionnaires to rate whether their tutors encouraged student direction of the tutorials and whether the summaries and closure schematics benefited their learning. Students’ overall course evaluations and mean USMLE scores were quantitatively analyzed, pre- and postintervention. A variety of statistical tests were used to assess the statistical significance of means at the confidence level of .05. Results In the third year of the program, student ratings indicated that their tutors were significantly better at encouraging student direction of the tutorials than in the first year (P < .05). The students reported that the tutorial made a more important contribution to their learning (P < .05), and the course objectives were better stated (P = .038) and better met (P = .007). Overall satisfaction with the course also improved significantly (P = .006). Part I gastrointestinal system mean scores of the USMLE showed a statistically significant increase in 2005 compared with 2001 or 2002. Conclusions The tutor as a discussion leader who questions, summarizes, and uses schematics to illustrate concepts had a significant and positive impact on learning in tutorials, achieving course objectives, improving overall course satisfaction, and increasing a standardized national exam’s mean score.

Disparities in Evaluation of Patients With Rectal Bleeding 40 Years and Older

BACKGROUND & AIMS Rectal bleeding is associated with colorectal cancer. We characterized the evaluation of patients aged 40 years and older with rectal bleeding and identified characteristics associated with inadequate evaluation. METHODS We conducted a retrospective review of records of outpatient visits that contained reports of rectal bleeding for patients aged 40 years and older (N = 480). We studied whether patient characteristics affected whether or not they received a colonoscopy examination within 90 days of presentation with rectal bleeding. Patient characteristics included demographics; family history of colon cancer and polyps; and histories of screening colonoscopies, physical examinations, referrals to specialists at the index visit, and communication of laboratory results. Data were collected from medical records, and patient income levels were estimated based on Zip codes. RESULTS Nearly half of the patients presenting with rectal bleeding received colonoscopies (48.1%); 81.7% received the procedure within 90 days. A history of a colonoscopy examination was more likely to be reported in white patients compared with Hispanic or Asian patients (P = .012 and P = .006, respectively), and in high-income compared with low-income patients (P = .022). A family history was more likely to be documented among patients with private insurance than those with Medicaid or Medicare (P = .004). A rectal examination was performed more often for patients who were white or Asian, male, and with high or middle incomes, compared with those who were black, Hispanic, female, or with low incomes (P = .027). White patients were more likely to have their laboratory results communicated to them than black patients (P = .001). CONCLUSIONS Sex, race, ethnicity, patient income, and insurance status were associated with disparities in evaluation of rectal bleeding. There is a need to standardize the evaluation of patients with rectal bleeding.

Psychiatric OSCE Performance of Students With and Without a Previous Core Psychiatry Clerkship

ObjectiveThe OSCE has been demonstrated to be a reliable and valid method by which to assess students’ clinical skills. An OSCE station was used to determine whether or not students who had completed a core psychiatry clerkship demonstrated skills that were superior to those who had not taken the clerkship and which areas discriminated between clerkship completers and noncompleters.MethodsOne hundred thirty- six students took a 48- item, fourth- year OSCE with one psychiatry station. Sixty- three (46%) had already completed psychiatry, and 70 (51%) had not, with three unknown. Students were to take histories, perform mental status examinations, assess dangerousness, and propose the differential diagnosis and treatment plans.ResultsNine items differed significantly between completers and noncompleters, six concerning phenomenology and mental status and three concerning differential diagnosis. There were no differences regarding history, communication skills, or recommended interventions.ConclusionStudents may learn history taking, communication, and treatment planning in many settings. However, for the mental status examination, phenomenology, and differential diagnosis, completing a psychiatry clerkship was associated with better OSCE performance.

Revitalizing pathology laboratories in a gastrointestinal pathophysiology course using multimedia and team-based learning techniques

In 2008, we changed the gastrointestinal pathology laboratories in a gastrointestinal pathophysiology course to a more interactive format using modified team-based learning techniques and multimedia presentations. The results were remarkably positive and can be used as a model for pathology laboratory improvement in any organ system. Over a two-year period, engaging and interactive pathology laboratories were designed. The initial restructuring of the laboratories included new case material, Digital Atlas of Video Education Project videos, animations and overlays. Subsequent changes included USMLE board-style quizzes at the beginning of each laboratory, with individual readiness assessment testing and group readiness assessment testing, incorporation of a clinician as a co-teacher and role playing for the student groups. Student responses for pathology laboratory contribution to learning improved significantly compared to baseline. Increased voluntary attendance at pathology laboratories was observed. Spontaneous student comments noted the positive impact of the laboratories on their learning. Pathology laboratory innovations, including modified team-based learning techniques with individual and group self-assessment quizzes, multimedia presentations, and paired teaching by a pathologist and clinical gastroenterologist led to improvement in student perceptions of pathology laboratory contributions to their learning and better pathology faculty evaluations. These changes can be universally applied to other pathology laboratories to improve student satisfaction.

Immigration and the U.S. Economy

Immigration has long been one of the burning economic and social issues of American history. We think of ourselves as a nation of immigrants. But in times of economic pressure, we have turned off the immigrant valve. The many coauthors of the following piece, all opinion survey experts, analyze current surveys and historical ones. Mythology aside, how do Americans view immigration? Read on.

A pilot study of team learning on in‐patient rounds

Medical trainees often do not receive structured teaching during in‐patient rounds.

Academic Performance on First-Year Medical School Exams: How Well Does It Predict Later Performance on Knowledge-Based and Clinical Assessments?

ABSTRACT Number of appearances in the bottom quartile of 1st-year medical school exams were used to represent the extent to which students were having academic difficulties. Medical educators have long expressed a desire to have indicators of medical student performance that have strong predictive validity. Predictors traditionally used fell into 4 general categories: demographic (e.g., gender), other background factors (e.g., college major), performance/aptitude (e.g., medical college admission test scores), and noncognitive factors (e.g., curiosity). These factors, however, have an inconsistent record of predicting student performance. In comparison to traditional predictive factors, we sought to determine the extent to which academic performance in the 1st-year of medical school, as measured by examination performance in the bottom quartile of the class in 7 required courses, predicted later performance on a variety of assessments, both knowledge based (e.g., United States Medical Licensing Examination Step 1 and Step IICK) and clinical skills based (e.g., clerkship grades and objective structured clinical exam performance). Of all predictors measured, number of appearances in the bottom quartile in Year 1 was the most strongly related to performance in knowledge-based assessments, as well as clinically related outcomes, and, for each outcome, bottom-quartile performance accounted for additional variance beyond that of the traditional predictors. Low academic performance in the 1st year of medical school is a meaningful risk factor with both predictive validity and predictive utility for low performance later in medical school. The question remains as to how we can incorporate this indicator into a system of formative assessment that effectively addresses the challenges of medical students once they have been identified.