William R. Gilliland

Achievement Goal Structures and Self-Regulated Learning: Relationships and Changes in Medical School

Purpose Practicing physicians have a societal obligation to maintain their competence. Unfortunately, the self-regulated learning skills likely required for lifelong learning are not explicitly addressed in most medical schools. The authors examined how medical students’ perceptions of the learning environment relate to their self-regulated learning behaviors. They also explored how students’ perceptions and behaviors correlate with performance and change across medical school. Method The authors collected survey data from 304 students at different phases of medical school training. The survey items assessed students’ perceptions of the learning environment, as well as their metacognition, procrastination, and avoidance-of-help-seeking behaviors. The authors operationalized achievement as cumulative medical school grade point average (GPA) and, for third- and fourth-year students, collected clerkship outcomes. Results Students’ perceptions of the learning environment were associated with their metacognition, procrastination, and help-avoidance behaviors. These behaviors were also related to academic outcomes. Specifically, avoidance of help seeking was negatively correlated with cumulative medical school GPA (r = −0.23, P < .01) as well as exam (r = −0.22, P < .05) and clinical performance (r = −0.34, P < .01) in the internal medical clerkship; these help-avoidance behaviors were also positively correlated with students’ presentation at a grade adjudication committee (r = 0.20, P < .05). Additionally, students’ perceptions of the learning environment varied as a function of their phase of training. Conclusions Medical students’ perceptions of the learning environment are related, in predictable ways, to their use of self-regulated learning behaviors; these perceptions seem to change across medical school.

Disseminated Mycobacterium marinum infection in a patient with rheumatoid arthritis receiving infliximab therapy

Tumor necrosis factor-α inhibitors are important adjunctive therapies for rheumatologic diseases. These agents increase the risk for granulomatous disease. We present a case of a woman with severe rheumatoid arthritis on infliximab who developed multiple nodular skin lesions. Biopsies grew Mycobacterium marinum. New lesions developed through therapy, necessitating surgical debulking.

Changes in clinical skills education resulting from the introduction of the USMLE™ step 2 clinical skills (CS) examination

Background: Step 2 Clinical Skills (CS) was recently introduced into the United States Medical Licensing Examination (USMLE™) to ensure that successful candidates for licensure possess the clinical skills to provide safe and effective patient care. Aims: To explore if medical schools had changed the objectives, content, or emphasis in their pre-clinical curriculum in response to its implementation. Methods: In April 2005, the Clerkship Directors in Internal Medicine (CDIM) sent an electronic survey to a single member from each medical school with a CDIM member. The survey instrument included 26 pre-clinical curricular questions with nine questions specifically addressing changes in response to implementation of the Step 2 CS. Results: Forty-five percent of respondents reported changes to the Introduction to Clinical Medicine (ICM) course objectives while 39% and 40% reported changes in content and emphasis. Seventy-four percent felt their students were adequately prepared for the Step 2 CS and 18% were unsure. Conclusions: Over a third of medical schools are implementing changes to the objectives, content, and/or emphasis of their curriculum, at least partially in response to the institution of Step 2 CS.

Emerging Biological Therapies in Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a prototypic inflammatory autoimmune disorder characterized by multisystem involvement and fluctuating disease activity. Symptoms range from rather mild manifestations such as rash or arthritis to life‐threatening end‐organ manifestations such as glomerulonephritis or thrombosis. Virtually every organ system is subject to potential damage. Symptoms typically wax and wane over the course of the disease; yet unfortunately, many patients will experience a slow decline in their health because of the ongoing systemic inflammation. Effective treatment must be individualized and is often based on the specific manifestations that are seen in each patient. In a similar manner, prognosis is also dependent on the severity and the specific organ systems involved.

Anti-Cyclic Citrullinated Peptide Assays Differ in Subjects at Elevated Risk for Rheumatoid Arthritis and Subjects with Established Disease

OBJECTIVE To compare the diagnostic accuracy and agreement of commonly available assays for anti-citrullinated protein antibodies in patients with established rheumatoid arthritis (RA) and subjects at increased risk of RA. METHODS Tests for anti-cyclic citrullinated peptide (anti-CCP) antibodies were performed using CCP2 IgG and CCP3.1 IgA/IgG enzyme-linked immunosorbent assays in the following groups: probands with established RA (n = 340) from the Studies of the Etiology of Rheumatoid Arthritis (SERA) cohort and their first-degree relatives (FDRs) without inflammatory arthritis (n = 681), Department of Defense Serum Repository (DoDSR) RA cases with pre-RA diagnosis samples (n = 83; 47 cases also had post-RA diagnosis samples), and blood donor and DoDSR control subjects (n = 283). RESULTS In patients with established RA, the CCP2 assay was more specific (99.2% versus 93.1%; P < 0.01) but less sensitive (58.7% versus 67.4%; P = 0.01) than the CCP3.1 assay; the specificity of the CCP3.1 assay increased to 97.2% when cutoff levels ≥3-fold the standard level were considered. In all subjects, CCP3.1 assay positivity (using standard cutoff levels) was more prevalent. Among DoDSR cases, the CCP2 assay was more specific than the CCP3.1 for predicting a future diagnosis of RA, and higher CCP levels trended toward increasing specificity for the development of RA within 2 years. At standard cutoff levels, assay agreement was good in patients with established RA (κ = 0.76) but poor in FDRs without inflammatory arthritis (κ = 0.25). CONCLUSION Anti-CCP assays differ to an extent that may be meaningful for diagnosing RA in patients with inflammatory arthritis and evaluating the natural history of RA development in subjects at risk of RA. The mechanisms underlying these differences in test performance need further investigation.

Using Qualitative Data From a Program Director's Evaluation Form as an Outcome Measurement for Medical School

BACKGROUND Medical education programs need outcome measurements to promote curriculum improvement and to help meet accreditation standards. PURPOSE Determine the added value of qualitative comments written by program directors (PDs) in response to a survey concerning first postgraduate year (PGY-1) graduates. We hypothesized that these comments would serve as an additional outcome measurement for our graduates, adding information not readily captured in numeric data. METHODS PD evaluation form surveys from 1993-2002. All qualitative comments offered in response to free text questions were coded and compared with numeric ratings. RESULTS A total of 1,247 surveys were included (80% response rate). Comments about specific graduates were coded as positive, negative, or neutral and were categorized into themes. Inter-rater reliability was high (kappa= 0.82). Compared with 4% of graduates who received one or more numeric ratings of less than satisfactory, 7% had one or more qualitative phrases classified as negative. CONCLUSIONS Qualitative comments can serve as a useful outcome measurement.

Does self-reported clinical experience predict performance in medical school and internship?

Medical Education 2012: 46 : 172–178

Is poor performance on NBME clinical subject examinations associated with a failing score on the USMLE step 3 examination

Purpose To investigate the association between poor performance on National Board of Medical Examiners clinical subject examinations across six core clerkships and performance on the United States Medical Licensing Examination Step 3 examination. Method In 2012, the authors studied matriculants from the Uniformed Services University of the Health Sciences with available Step 3 scores and subject exam scores on all six clerkships (Classes of 2007–2011, N = 654). Poor performance on subject exams was defined as scoring one standard deviation (SD) or more below the mean using the national norms of the corresponding test year. The association between poor performance on the subject exams and the probability of passing or failing Step 3 was tested using contingency table analyses and logistic regression modeling. Results Students performing poorly on one subject exam were significantly more likely to fail Step 3 (OR 14.23 [95% CI 1.7–119.3]) compared with students with no subject exam scores that were 1 SD below the mean. Poor performance on more than one subject exam further increased the chances of failing (OR 33.41 [95% CI 4.4–254.2]). This latter group represented 27% of the entire cohort, yet contained 70% of the students who failed Step 3. Conclusions These findings suggest that individual schools could benefit from a review of subject exam performance to develop and validate their own criteria for identifying students at risk for failing Step 3.

Progress Toward Personalized Treatment of Rheumatoid Arthritis

Treatment of rheumatoid arthritis (RA) has advanced significantly over the past decade, in part because of the identification of key elements in the immunopathogenesis of the disease, leading to the development of targeted immune‐based therapies. Despite the availability of many highly specific therapies, the process of selecting a treatment regimen for an individual patient remains empirical. Personalized treatment, focused on predicting efficacy, non‐response, and toxicity to better guide medication selection, moves closer to realization as genomic methods continue to be extended and refined.

APPLIED RESEARCH: Standardized Versus Real Hospitalized Patients to Teach History-Taking and Physical Examination Skills

Background: Despite the nearly universal practice of using standardized patients in introduction to clinical medicine (ICM) courses, no studies have compared the performance of students trained with standardized patients to that of those trained with hospitalized patients with regard to short- and long-term educational outcomes. Purpose: To examine the differential effect of the use of standardized patients in a simulation center versus the use of hospitalized patients in affiliated teaching hospitals for teaching history-taking and physical examination skills. Methods: This was a nonrandomized cohort study based on self-selection involving students from 2 academic years enrolled in an ICM course who received the final block of their ICM instruction with either standardized patients in the simulation center or hospitalized patients in affiliated hospitals. The primary, end-of-ICM (preclerkship)-outcome variables (k = 10) were data from a final observed history and physical examination, an observed structured clinical examination, a National Board of Medical Examiners subject examination for clinical medicine, and ICM preceptor evaluations. Secondary, postclerkship outcome variables (k = 5) included internal medicine clerkship scores, teacher ratings from the clerkship, and examination scores from end-of-clerkship tests. The statistical significance was set at p <. 05. Results: No statistical differences were found between the means of the 2 groups in any of the primary or secondary outcome variables; there was significant power. Conclusions: The use of standardized patients in a simulated setting compared to the use of hospitalized patients in affiliated teaching hospitals is not a disadvantage in the education of students in ICM courses.