Easing the Transition From Medical School to Residency: Using Deliberate Practice to Improve Senior Medical Students' Performance Responding to Urgent Pages From Registered Nurses.

Abstract

Purpose: New interns are expected to perform initial evaluation and management of medical emergencies for hospitalized patients, 1 yet many are unprepared to care for such patients. 2 To address this gap, we designed a specialty-specific simulated paging curriculum based on Ericsson’s model of deliberate practice 3 for senior medical students. The purpose was to assess whether this curriculum leads to improved performance handling specialty-specific medical emergencies. Approach: Graduating senior medical students enrolled in 1 of 6 required specialty-specific residency preparation courses (emergency medicine, family medicine, internal medicine, obstetrics and gynecology, pediatrics, and procedures) in 2020 and 2021 participated. Students received an electronic handover with information about simulated patients. Throughout the course, students received 4–6 urgent pages about these patients that were specific for each specialty (e.g., atrial fibrillation case in internal medicine course, postoperative pain case in procedures course). Upon receiving each page, students called a standardized registered nurse (SRN) who used a script to answer questions about the patient. Students explained next steps in evaluation and management. Immediately after the page was complete, the SRNs delivered verbal feedback about performance. Students also received written feedback by the SRNs within the week. Additionally, the gold standard approach to the case was reviewed with the class by course instructors. Clinical performance was graded by SRNs using a predefined weighted rubric for each case. The rubric consists of “must do” (+2 points), “should do” (+1 point), “could do” (0 points), “should not do” (−1 point), or “must not do” (−2 points) diagnostic, therapeutic, and communication items. 4 “Must do” items represented the most critical actions for new interns to take. Each rubric was based on clinical guidelines and was reviewed by at least 2 faculty members. All variables were analyzed using descriptive statistics including medians and proportions overall and by specialty. Continuous variables were expressed using median and interquartile range. The relationship between clinical performance scores and case number was evaluated with the Jonckheere–Terpstra test. Outcomes: There were 1,403 pages sent to 265 students (84.1%) during the study period. Clinical performance improved over time from median (interquartile range) of 59.4% (46.9%, 75.0%) on case 1 to 80.0% (68.0%, 86.7%) on case 6 (P < .001). The proportion of “must do” items improved significantly from 69.2% (53.8%, 81.8%) to 80.0% (66.7%, 88.9%) (P < .001). Discussion: This novel simulated paging curriculum allowed senior medical students to practice and improve handling medical emergencies in a safe setting before entering the clinical setting as a resident. The highly realistic scripts and guideline-based scoring rubrics cover common intern-level patient care scenarios, representing content validity. Limitations include that this was a single-institution study and thus may not be generalizable to courses at other institutions. Additionally, the cases were different throughout the RPCs with varied case order and difficulty which limits analysis. Significance: The Coalition for Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee recently advised that specialty-specific just-in-time training is necessary for all incoming first-year residents and that meaningful assessment data be collected about each graduate to help serve as a baseline and inform tailored learning plans. 5 Our curriculum achieves both of these objectives by providing advanced specialty-specific training and also collecting valuable assessment information. To our knowledge, this is the only paging curriculum that has demonstrated evidence for students entering multiple specialties. This curriculum could be easily expanded to other medical schools as well as residency programs as the cases are administered by phone and the grading is electronic. Given how common these paging scenarios are for new interns, this curriculum fills an important gap in the transition to residency.