Medicine Exam Research Articles

Why I Wrote the New Royal College General Internal Medicine Exam: Redefining Our Identity and Revalidation

In 2010, the Royal College of Physicians and Surgeons of Canada (RCPSC) recognized General Internal Medicine (GIM) as a distinct subspecialty. Soon after this recognition came a new written certificationexam, the successful completion of which awards the applicant the title of General Internist. For those of us who trained prior to the new status and examination, GIM was the default designation after four years of internal medicine training if a subspecialty was not pursued.What does this new subspecialty status mean for our professional identity, qualifications, and public credibility? Twelve years aftermy successful completion of the Internal Medicine (IM) certification exams, I voluntarily applied for consideration to write the first RCPSC exam in GIM, without a clear reason why. My reflection on the days leading up to the exam and writing the exam itself led me to understand why I did it. The process addressed my skepticism around designating GIM as a unique subspecialty, and through this I have come to appreciate the need for our profession to embrace revalidation.

Development and evaluation of a virtual patient-based exam in occupational medicine

Abstract Occupational medicine (OM), especially the ability to recognize potentially workplace-related diseases or accidents, is important for medical students to learn. The assessment in OM at the Ludwig-Maximilians-University is implemented as a paper-based, multiple-choice question exam that does not assess the students’ ability to remember occupational aspects in clinical contexts. Therefore, the aim of this study was to create and evaluate an online exam based on 19 virtual patients to assess the aspects of OM in an interdisciplinary setting. Thirty-nine medical students participated in the exam with an average score of 65%. The score for freetext questions assessing OM aspects was low (39%). The study showed that the implementation of an interdisciplinary VP-based exam is feasible. The integration of such an interdisciplinary exam would be feasible, for example, as an open-book assessment.

Stress Evaluation of Dental Clinic Students and Its Related Factors

Background: Nowadays dentistry has been discussed in the most of the studies as a challenge and stressful fields. So the aim of this study was to evaluate the stress level of Dental clinic Students and its related factors in the two different periods of time with 5-years interval times. Materials and methods: This descriptive-analytic cross sectional study was done at the two different periods of times and their results were compared. A questionnaire was given to the all dental clinic students in the middle of the academic term for the 2005-2006 and 2010-2011 years. Data analysis was performed by using SPSS software and consisted of descriptive, chi-square, student t-test and Anova (using Tukey, post Hock comparison and linear regression) Results: Statistical population of this descriptive-analytic cross sectional study consisted of 124 clinical students included 74 females and 50 males (P=0.031)in the first step and 100 students included 61 females and 39 males (P=0.028)in second assess. Overall the main stress factors were qualification created by professors of the departments, oral medicine department, exams and grades, restorative department, orthodontic department, large volume of educational materials. Conclusion: Dentistry and specially it education is a stressful experience and we should try to create a calm environment without the additional stress.

Evaluating the quality of multiple-choice questions used for final exams at the Department of Internal Medicine, College of Medicine, King Khalid University

Background: The multiple-choice questions (MCQs) part of the final exam in internal medicine at the College of Medicine, King Khalid University is composed of 100 questions of the one best answer type with four options. Although some basic forms of item analysis have been carried out by the department of internal medicine before, the data generated has not been used regularly to assess the quality of the questions or for feedback for the purpose of quality improvement. Aim: The aim of this study was to assess the quality of MCQs used in the final exam in internal medicine during the 1 st week of January 2013. Methods: The total number of the students of this batch was 58, and the total number of MCQs was 100. Item analysis was done using Microsoft Excel 2007. The parameters obtained included difficulty index, discrimination index, point biserial correlation, and reliability of the exam using Kuder-Richardson formula (KR-20), in addition to analysis of distractors. Results: The mean difficulty of the questions was 0.55 (STD = 0.2) and the mean discrimination index was 0.24 (STD = 0.2) with 41 questions having values below 0.20. Regarding point biserial correlation, the mean was 0.16 (STD = 0.12). KR-20 was found to be 0.79; indicating good reliability and the student scores were believed to be reliable. From the 300 distractors assessed, 41% were nonfunctioning. The mean number of functioning distractors per item was 1.76. Conclusion: The MCQs exam was quite reliable, and the difficulty of the questions was reasonable. The discrimination power of most of the questions was acceptable; however, a relatively high proportion of the questions had unacceptable discrimination index values.

A time-efficient web-based teaching tool to improve medical knowledge and decrease ABIM failure rate in select residents

AimThe American Board of Internal Medicine (ABIM) exam's pass rate is considered a quality measure of a residency program, yet few interventions have shown benefit in reducing the failure rate. We developed a web-based Directed Reading (DR) program with an aim to increase medical knowledge and reduce ABIM exam failure rate.MethodsInternal medicine residents at our academic medical center with In-Training Examination (ITE) scores ≤35th percentile from 2007 to 2013 were enrolled in DR. The program matches residents to reading assignments based on their own ITE-failed educational objectives and provides direct electronic feedback from their teaching physicians. ABIM exam pass rates were analyzed across various groups between 2002 and 2013 to examine the effect of the DR program on residents with ITE scores ≤35 percentile pre- (2002–2006) and post-intervention (2007–2013). A time commitment survey was also given to physicians and DR residents at the end of the study.ResultsResidents who never scored ≤35 percentile on ITE were the most likely to pass the ABIM exam on first attempt regardless of time period. For those who ever scored ≤35 percentile on ITE, 91.9% of residents who participated in DR passed the ABIM exam on first attempt vs 85.2% of their counterparts pre-intervention (p<0.001). This showed an improvement in ABIM exam pass rate for this subset of residents after introduction of the DR program. The time survey showed that faculty used an average of 40±18 min per week to participate in DR and residents required an average of 25 min to search/read about the objective and 20 min to write a response.ConclusionsAlthough residents who ever scored ≤35 percentile on ITE were more likely to fail ABIM exam on first attempt, those who participated in the DR program were less likely to fail than the historical control counterparts. The web-based teaching method required little time commitment by faculty.

Estimation of the collective ionizing dose in the Portuguese population for the years 2011 and 2012, due to nuclear medicine exams

ObjectivesIn 2009–2010 a Portuguese consortium was created to implement the methodologies proposed by the Dose Datamed II (DDM2) project, aiming to collect data from diagnostic X-ray and nuclear medicine (NM) procedures, in order to determine the most frequently prescribed exams and the associated ionizing radiation doses for the Portuguese population. The current study is the continuation of this work, although it focuses only on NM exams for the years 2011 and 2012. Material and methodsThe annual frequency of each of the 28 selected NM exams and the average administered activity per procedure was obtained by means of a nationwide survey sent to the 35 NM centres in Portugal. ResultsThe results show a reduction of the number of cardiac exams performed in the last two years compared with 2010, leading to a reduction of the annual average effective dose of Portuguese population due to NM exams from 0.08mSv±0.017mSv/caput to 0.059±0.011mSv/caput in 2011 and 0.054±0.011mSv/caput in 2012. Portuguese total annual average collective effective dose due to medical procedures was estimated to be 625.6±110.9manSv in 2011 and 565.1±117.3manSv in 2012, a reduction in comparison with 2010 (840.3±183.8manSv). ConclusionsThe most frequent exams and the ones that contributed the most for total population dose were the cardiac and bone exams, although a decrease observed in 2011 and in 2012 was verified. The authors intend to perform this study periodically to identify trends in the annual Portuguese average effective dose and to help to raise awareness about the potential dose optimization.

Design and application of the training method of first aid medicine in one minute

Objective To design the training method of first aid medicine in one minute and observe its application effect. Methods To count the number of taking first aid medicine in one minute according to the instruction and answer the accuracy dose. To answer one or two related knowledge of first aid medicine including the effect, usage, dosage, adverse reactions and observation points. To design the score of taking first aid medicine in one minute, and the clinical nurses were trained and assessed according to the standard of the score in every quarter, and which were as the basis for judgment whether the project was up to standard in nurses and award the excellent department or individual nurse. Results Before and after the training, the number of taking first aid medicine in one minute in 80 nurses were respectively （12 ± 2.52）, （22 ±4.19 ）, and the difference was statistically significant （ U = 18.29 ,P 〈 0.01 ） ; the accuracy rate of medicine dose were respectively 77% and 98%, and the difference was statistically significant （χ2 = 20.16,P 〈 0.01 ）; the average score of the knowledge of first-aid medicine exam were respectively （ 67 ± 2.66 ）, （ 93 ± 3.73 ）, and the difference was statistically significant （ U = 50.76, P 〈 0.01 ）. Conclusions The training method of first aid medicine in one minute is fun and can quickly improve the familiarity with first aid medicine in nurses. Training again at a given time can solve the problem of forgetting because the nurses did not use the first aid skills for a long time, and which provide the force guarantee for the rapid and effective clinical first aid. Key words: One minute; First aid medicine; Training method; Nurse

Evaluation of internal clinical skills assessment in five-year clinical interns

Objective To evaluate the assessment index system of internal medicine, and to analyze the factors of practical effects on internal medicine. Methods The assessment index system of clinical skills was developed by expert group based on the clinical syllabus and objectives. Internal medicine index system was divided into four items such as history-taking, physical examination, hospital records and case questions. 49 five-year clinical interns who took internal medicine exams were researched. Reliability, validity, discrimination, difficulty were used to analyze the quality of assess-ment index system. Gender, teaching hospital and the preparation of postgraduate examination were used to explore the influencing factors of practical effects with independent t-test and Wilcoxon signed rank tests. Results The reliability, discrimination, difficulty of the assessment index system were 0.50, 0.15 and 0.85, respectively. The removing item coefficient of history collection, physical examination, hospital records, case questions were 0.38, 0.26, 0.47 and 0.53, separately, and the discrimination were 0.18, 0.17,0.27 and 0.37, separately, and the difficulty were 0.87, 0.89, 0.79, and 0.78, respectively. The scores of assessment index system of girls were higher than those of the boys（P〈0.05）. Moreover, the girls scored higher in history collection and physical examination, compared with the boys（P〈0.05）. The discrepancy scores were not statistically significant among teaching hospitals （P〉0.05）. The students who prepared the postgraduate examination scored lower than the others（P〈0.05）. Conclusions The assessment index system of internal medicine is reasonable and reliable, but the assessment of case questions still needs to be standardized. Teaching hospitals have little effect on internship while gender and the preparation for postgraduate examination influence practice effects in internal medicine. Key words: Clinical practice; Clinical skills; Effects; Evaluation

Estimation of the collective ionizing dose in the Portuguese population for the years 2011 and 2012, due to nuclear medicine exams.

In 2009-2010 a Portuguese consortium was created to implement the methodologies proposed by the Dose Datamed II (DDM2) project, aiming to collect data from diagnostic X-ray and nuclear medicine (NM) procedures, in order to determine the most frequently prescribed exams and the associated ionizing radiation doses for the Portuguese population. The current study is the continuation of this work, although it focuses only on NM exams for the years 2011 and 2012. The annual frequency of each of the 28 selected NM exams and the average administered activity per procedure was obtained by means of a nationwide survey sent to the 35 NM centres in Portugal. The results show a reduction of the number of cardiac exams performed in the last two years compared with 2010, leading to a reduction of the annual average effective dose of Portuguese population due to NM exams from 0.08 mSv ± 0.017 mSv/caput to 0.059 ± 0.011 mSv/caput in 2011 and 0.054 ± 0.011 mSv/caput in 2012. Portuguese total annual average collective effective dose due to medical procedures was estimated to be 625.6 ± 110.9 manSv in 2011 and 565.1 ± 117.3 manSv in 2012, a reduction in comparison with 2010 (840.3 ± 183.8 manSv). The most frequent exams and the ones that contributed the most for total population dose were the cardiac and bone exams, although a decrease observed in 2011 and in 2012 was verified. The authors intend to perform this study periodically to identify trends in the annual Portuguese average effective dose and to help to raise awareness about the potential dose optimization.

Students benefit from developing their own emergency medicine OSCE stations: a comparative study using the matched-pair method

BackgroundStudents can improve the learning process by developing their own multiple choice questions. If a similar effect occurred when creating OSCE (objective structured clinical examination) stations by themselves it could be beneficial to involve them in the development of OSCE stations. This study investigates the effect of students developing emergency medicine OSCE stations on their test performance.MethodIn the 2011/12 winter semester, an emergency medicine OSCE was held for the first time at the Faculty of Medicine at the University of Leipzig. When preparing for the OSCE, 13 students (the intervention group) developed and tested emergency medicine examination stations as a learning experience. Their subsequent OSCE performance was compared to that of 13 other students (the control group), who were parallelized in terms of age, gender, semester and level of previous knowledge using the matched-pair method. In addition, both groups were compared to 20 students who tested the OSCE prior to regular emergency medicine training (test OSCE group).ResultsThere were no differences between the three groups regarding age (24.3 ± 2.6; 24.2 ± 3.4 and 24 ± 2.3 years) or previous knowledge (29.3 ± 3.4; 29.3 ± 3.2 and 28.9 ± 4.7 points in the multiple choice [MC] exam in emergency medicine). Merely the gender distribution differed (8 female and 5 male students in the intervention and control group vs. 3 males and 17 females in the test OSCE group).In the exam OSCE, participants in the intervention group scored 233.4 ± 6.3 points (mean ± SD) compared to 223.8 ± 9.2 points (p < 0.01) in the control group. Cohen’s effect size was d = 1.24. The students of the test OSCE group scored 223.2 ± 13.4 points.ConclusionsStudents who actively develop OSCE stations when preparing for an emergency medicine OSCE achieve better exam results.

Is there a need for a European graduate exam in geriatric medicine: A cross-national survey

Is there a need for a European graduate exam in geriatric medicine: A cross-national survey

Effects and sustainability of trainings for the oral and practical part of the German final exam in medicine.

Study Goals: It is known that the manifold limitations of oral and practical examinations can be improved by specific training. With the help of an online survey, our present study analyzes the effects that can be achieved by the training conducted at the University of Ulm for examiners in the final medical examination, the long-lasting impact of the training, and differences among participant subgroups.Method: All 367 participants in the training at Ulm (2007- 2012) were contacted via email. Sixty-three persons responded to the survey that included 28 items concerning demographic data, effectiveness, and sustainability.Results: Six main effects of the training were identified (meaning effects rated with a grade of 1 or 2 on a 6-point scale by two thirds of the participants, with 1=“applicable” and 6=“not applicable”; cumulated percentage of answers of 1 or 2 in parentheses):Conscious handling of strengths and weaknesses of oral examinations (71%),Knowledge of factors contributing to the reliability of oral/practical examinations (76%),Knowledge of factors contributing to the validity of oral/practical examinations (75%),Improvement of competence in task construction (68%),Improvement of competence in respect to examination formalities (75%),Implementation of the concept of “structured oral examinations” (a priori planning of examination subjects, tasks, levels of expectation and grading criteria) (86%).The responses of participants trained more than two years ago were not significantly different from the answers given by recently trained persons. This is an argument for the sustainability of the training effects.Furthermore, participants without relevant prior experience in oral/practical examinations profited significantly more from the trainings, especially in the areas of stress reduction, confidence in grading, and competence in critical discrimination of grading.Conclusion: The positive and sustained effects of the examiner training argue for continuing the training program, especially for inexperienced examiners. Expansion of the successful training program to include the first medical exam should be considered.

Estimation of the collective dose in the Portuguese population due to medical procedures in 2010

In a wide range of medical fields, technological advancements have led to an increase in the average collective dose in national populations worldwide. Periodic estimations of the average collective population dose due to medical exposure is, therefore of utmost importance, and is now mandatory in countries within the European Union (article 12 of EURATOM directive 97/43). Presented in this work is a report on the estimation of the collective dose in the Portuguese population due to nuclear medicine diagnostic procedures and the Top 20 diagnostic radiology examinations, which represent the 20 exams that contribute the most to the total collective dose in diagnostic radiology and interventional procedures in Europe. This work involved the collaboration of a multidisciplinary taskforce comprising representatives of all major Portuguese stakeholders (universities, research institutions, public and private healthcare providers, administrative services of the National Healthcare System, scientific and professional associations and private service providers). This allowed us to gather a comprehensive amount of data necessary for a robust estimation of the collective effective dose to the Portuguese population. The methodology used for data collection and dose estimation was based on European Commission recommendations, as this work was performed in the framework of the European wide Dose Datamed II project. This is the first study estimating the collective dose for the population in Portugal, considering such a wide national coverage and range of procedures and consisting of important baseline reference data. The taskforce intends to continue developing periodic collective dose estimations in the future. The estimated annual average effective dose for the Portuguese population was of 0.080±0.017 mSv caput(-1) for nuclear medicine exams and of 0.96±0.68 mSv caput(-1) for the Top 20 diagnostic radiology exams.

Editorial introductions

Editorial introductions

Imaging for evaluation of urologic abnormalities in infants with fetal hydronephrosis: advances and controversies

Recent advances in prenatal diagnosis resulted in an improvement of detection and management of urinary tract abnormalities. Prenatal ultrasonography allows to identify urological abnormalities that otherwise would not be seen until later in life, when complications occur. The voiding cystourethrogram can be reserved for selected patients. Nuclear medicine exams should be performed in cases of moderate and severe hydronephrosis. A review of the current literature on postnatal approach of prenatal hydronephrosis was performed. Data obtained were compared with the records of the Pediatric Nephrology Unit HC/UFMG regarding management and follow-up of children with uropathies detected while investigating for fetal hydronephrosis.

Estimation of Radiation Dosimetry for some Common SPECT-CT Exams

Single photon emission computed tomography associated to X ray computed tomography (SPECT-CT) is a nuclear medicine tomographic imaging technique which improves diagnostic accuracy for particular clinical indications due to the possible attenuation and/or scatter correction of the SPECT functional images and the availability of helpful anatomic information. However, the introduction of CT in the nuclear diagnostic process results in a significant increase of the patient dose. Ideally is to establish sufficient image quality for a specific diagnostic task with the lowest effective dose to the patient in order to reduce stochastic effects. Indication of SPECT-CT should be made to adhere to the “As Low as Reasonably Achievable (ALARA)” principle and ensure that the patient is not subjected to unnecessarily high levels of radiation. In this study, we evaluate effective doses received during some standard nuclear medicine exams from 100 patients who underwent SPECT-CT in our department and analyze parameters involved in variation of these doses according to the literature data.

La bronchoscopie souple comme elle est vécue par le patient

Flexible bronchoscopy is an indispensable complementary exam in respiratory medicine for both diagnosis of many pulmonary diseases and their treatment. Only a few studies in literature have been conducted to evaluate the safety and acceptability of this act. Prospective, mono-center, non-comparative study involving 120 patients who underwent a flexible bronchoscopy for diagnostic. During the study, flexible bronchoscopy has caused neither deaths nor major complications. However, minor incidents have been deplored: hemoptysis (13.3%), epistaxis (3.3%), desaturation less than 90% (4.2%), laryngospasm (3.3%) and vagal discomfort (1.7%). 56.7% of patients were anxious before the exam and 24% of patients preferred to have general anesthesia. The patients reported cough in 78.3% of cases, difficulty in breathing in 55% of cases and pain in 13.3% of cases. The occurrence of nausea, noted in 15.8% of cases, was correlated with the pathway of the bronchoscope (P=0.002). At the end of the endoscopy, 67.5% of patients agreed to repeat the examination, if necessary, under the same conditions. The results of our study confirm that many complications during a flexible bronchoscopy are rare and generally mild failing in life-threatening. However, the occurrence of discomfort (cough, pain, vomiting, dyspnea) or incidents (asphyxia, vagal discomfort, laryngeal spasm) are likely to alter patient comfort during the exam.

Implementation Of Hematology-Oncology Lecture Series For Housestaff

Abstract Abstract 4554 BACKGROUND Currently, the hospital has a floor dedicated to cancer patients. The housestaff taking care of these patients includes three interns and one hematology-oncology fellow. In addition, there is a consult service comprising another fellow, an intern, and a resident. There was a paucity of formal, didactic, teaching in place devoted to the subjects of hematology and oncology. OBJECTIVE the development of a monthly lecture series for housestaff rotating on a hematology-oncology rotation that would focus on three key areas: a. What housestaff need to know to manage the patients on the hematology-oncology service b. What housestaff are most likely to encounter in the practice of medicine, regardless of eventual subspecialty field. c. What housestaff need to know for American Board of Internal Medicine exams. METHODS Topics were chosen based on pertinence. These included: leukemia, lymphoma, multiple myeloma, stem cell transplantation (these first four comprising at least 50% of patients on the unit), coagulation, breast cancer, lung cancer, colon cancer, gynecological malignancies, and pain management/supportive care. Potential speakers included full-time faculty as well as private physicians affiliated with the cancer center. Emails and/or phone calls were placed to the physicians and announcements made at division meetings and schedules developed. The plan was also for the development of a series of questions testing the housestaff at the start of their one month rotation and at the end of the rotation. Lectures were scheduled for afternoons if possible to avoid conflicts with morning rounds. Occasional morning talks were necessary to accommodate lecturers. Format of lectures was flexible (power point, dry-eraser board). RESULTS Overall feedback was positive for the lecture series. The two conditions affecting optimal success of the program concerned scheduling, including intern and fellow schedules as they relate to rounds and housestaff clinics and availability of when speakers could lecture and recruitment of speakers appropriate to the relevant topics. In addition, repeating the topics every month proved challenging for finding lecturing participants. The question/answer testing is still early in testing and no conclusion can be made. CONCLUSION A didactic lecture series is an important aspect of hematology-oncology education for housestaff. Repeating lectures every month is a challenge for several reasons. Possible interventions in the future may include: a. Focusing lecturing duties to full-time faculty, with an emphasis on faculty currently on service b. Creating power point presentations and handouts on file for use by multiple people so that rotating faculty may use these materials for talks c. Statistical analysis of scores from pre-rotation and post-rotation exams Disclosures: No relevant conflicts of interest to declare.

Implementation of Hematology-Oncology Lecture Series for Housestaff.

Abstract 4554 BACKGROUNDCurrently, the hospital has a floor dedicated to cancer patients. The housestaff taking care of these patients includes three interns and one hematology-oncology fellow. In addition, there is a consult service comprising another fellow, an intern, and a resident. There was a paucity of formal, didactic, teaching in place devoted to the subjects of hematology and oncology. OBJECTIVEthe development of a monthly lecture series for housestaff rotating on a hematology-oncology rotation that would focus on three key areas:a.What housestaff need to know to manage the patients on the hematology-oncology serviceb.What housestaff are most likely to encounter in the practice of medicine, regardless of eventual subspecialty field.c.What housestaff need to know for American Board of Internal Medicine exams. METHODSTopics were chosen based on pertinence. These included: leukemia, lymphoma, multiple myeloma, stem cell transplantation (these first four comprising at least 50% of patients on the unit), coagulation, breast cancer, lung cancer, colon cancer, gynecological malignancies, and pain management/supportive care. Potential speakers included full-time faculty as well as private physicians affiliated with the cancer center. Emails and/or phone calls were placed to the physicians and announcements made at division meetings and schedules developed. The plan was also for the development of a series of questions testing the housestaff at the start of their one month rotation and at the end of the rotation. Lectures were scheduled for afternoons if possible to avoid conflicts with morning rounds. Occasional morning talks were necessary to accommodate lecturers. Format of lectures was flexible (power point, dry-eraser board). RESULTSOverall feedback was positive for the lecture series. The two conditions affecting optimal success of the program concerned scheduling, including intern and fellow schedules as they relate to rounds and housestaff clinics and availability of when speakers could lecture and recruitment of speakers appropriate to the relevant topics. In addition, repeating the topics every month proved challenging for finding lecturing participants. The question/answer testing is still early in testing and no conclusion can be made. CONCLUSIONA didactic lecture series is an important aspect of hematology-oncology education for housestaff. Repeating lectures every month is a challenge for several reasons. Possible interventions in the future may include:a.Focusing lecturing duties to full-time faculty, with an emphasis on faculty currently on serviceb.Creating power point presentations and handouts on file for use by multiple people so that rotating faculty may use these materials for talksc.Statistical analysis of scores from pre-rotation and post-rotation exams Disclosures:No relevant conflicts of interest to declare.

Clerkship Directors’ Practices With Respect to Preparing Students for and Using the National Board of Medical Examiners Subject Exam in Medicine: Results of a United States and Canadian Survey

Clerkship directors' practices regarding the National Board of Medical Examiners (NBME) subject exam in medicine are important in enhancing educational evaluation policy. The study's purpose was to determine clerkship directors' use of the subject exam in medicine and related learning activities in the context of curricula and outcomes of the directors' internal medicine clerkships. The authors conducted a survey of directors of internal medicine clerkships in 2007. They performed descriptive statistical and multivariate analyses on all responses. Of 110 clerkship directors, 82 responded to the survey, for an overall response rate of 75%. Eighty-eight percent of the clerkship directors required the NBME subject examination in medicine. The mean minimum passing score was 62 (SD = 4.2); this score was not adjusted throughout the academic year, and it contributed 20% to 25% of the final grade. Most (89%) clerkships allowed students a retake after a failed first attempt. Most clerkship directors prepared students for the NBME subject exam in their programs through some combination of lectures, independent self-study, and review sessions with exam-preparation review books. However, 42% of clerkship directors lacked a specific strategy for a retake after a failure. Clerkship directors' use of the NBME subject exam in medicine is high. Most allow a retake after a first failure, and a combination of strategies is currently provided to help students prepare. A need exists to develop remediation plans for students who fail the exam. This report may serve as a reference for curricular and programmatic clerkship decisions.