Clerkship Directors In Internal Medicine Research Articles

Internal Medicine Clerkship Directors' Use of and Opinions About Clerkship Examinations

Background: For years, quantifiable examinations have been a core component of assessing medical student competence during the internal medicine clerkship. Purpose: To determine how internal medicine clerkship directors use and view examinations and how uses of examinations have changed. Methods: In 1999, the Clerkship Directors in Internal Medicine conducted a confidential survey of its 123 institutional members. Results: Survey response rate was 89% (109/123). The National Board of Medical Examiners subject examination was used by 83%, alone (49%) or in combination with a faculty developed examination or a standardized patient examination (34%). Minimum passing scores were required for the subject exam by 80%, for faculty-developed examinations by 65%, and for the standardized patient exam by 63%. Examinations contribute approximately 25% toward a student's final grade. Students with acceptable clerkship performances but who fail an exam typically retest after self-study. Students who fail a retest receive unsatisfactory grades and require additional medicine experience. Of the clerkship directors who reported using the National Board of Medical Examiners subject examination, 45 (50%) provided comments on ways to improve the examination. Comments focused on examination content, reporting results, basing the exam on a published core curriculum, and general administrative issues. Over the past decade, use of the National Board of Medical Examiners subject examination has increased (66% to 83%), use of faculty-developed examinations has declined (46% to 27%), and the use of a clerkship standardized patient examination increased sharply (2% to 27%). Conclusions: Internal medicine clerkship directors commonly require students to pass standardized or locally developed exams and use test results to make academic decisions. The use of standardized patient examinations has increased significantly and likely reflects a broadening of competency assessment. Our results can serve as a basis for individual programmatic evaluation, for internal medicine and other clerkship directors.

Improving the national board of medical examiners internal medicine subject exam for use in clerkship evaluation

To provide a consensus opinion on modifying the National Board of Medical Examiners (NBME) Medicine Subject Exam (Shelf) to: 1) reflect the internal medicine clerkship curriculum, developed by the Society of General Internal Medicine (SGIM) and the Clerkship Directors in Internal Medicine (CDIM); 2) emphasize knowledge important for a clerkship student; and 3) obtain feedback about students' performances on the Shelf. Two-round Delphi technique. The CDIM Research and Evaluation Committee and CDIM members on NBME Step 2 Committees. Using 1-5 Likert scales (5 = highest ratings), the group rated test question content for relevance to the SGIM-CDIM Curriculum Guide and importance for clerkship students' knowledge. The Shelf content is organized into 4 physician tasks and into 11 sections that are generally organ system based. Each iteration of the Shelf has 100 questions. Participants indicated a desired distribution of questions by physician task and section, topics critical for inclusion on each exam, and new topics to include. They specified the types of feedback clerkship directors desired on students' performances. Following the first round, participants viewed pooled results prior to submitting their second-round responses. Of 15 individuals contacted, 12 (80%) participated in each round. The desired distribution by physician task was: diagnosis (43), treatment (23), mechanism of disease (20), and health maintenance (15). The sections with the most questions requested were the cardiovascular (17), respiratory (15), and gastroenterology (12) sections. The fewest were requested in aging/ethics (4) and neurology, dermatology, and immunology (5 each). Examples of low-rated content were Wilson's Disease, chancroid and tracheal rupture (all <2.0). Health maintenance in type 2 diabetes, hypertension, and cardiovascular disease all received 5.0 ratings. Participants desired feedback by: section (4.6) and physician task (3.9), on performances of the entire class (4.0), and for individual students (3.8). Clerkship directors identified test content that was relevant to the curricular content and important for clerkship students to know, and they indicated a desired question distribution. They would most like feedback on their students' performance by organ system-based sections for the complete academic year. This collaborative effort could serve as a model for aligning national exams with course goals.

The responsibilities and activities of internal medicine clerkship directors.

To characterize the responsibilities, activities, and scholarly productivity of internal medicine clerkship directors (CDs). In 1999, internal medicine CDs from 122 U.S. medical schools and one Canadian medical school were surveyed. The instrument asked about the CDs' demo-graphics, workloads, clerkship characteristics, and scholarly productivity. The response rate was 89%; 72% of the respondents were men. Mean age was 45 years, mean time as CD was 6.5 years, and 58% of the CDs had completed fellowship training. The CDs spent 28% of their professional time on the clerkship, three half days weekly in clinic, and three months on inpatient services. The CDs had published a mean of 2.2 (range 0-20) articles and received a mean of 0.7 (range 0-4) grants. Similar factors were associated with publishing articles and receiving grants; gender (men), < or = three clinic half days weekly, fellowship training, having a faculty development program, teaching other courses, and discussing expectations with their department chairs. In a multivariate analysis, fellowship training, clinic half days, teaching other courses, and discussing expectations explained 22% of the variance for papers published. For grants received, a model with gender, clinic half days, a faculty development program, discussing expectations, and teaching other courses explained 35% of the variance. An internal medicine CD invests significant effort administering the clerkship and contributing to clinical and educational activities. The factors associated with successful scholarship may be useful for fostering CDs' academic careers.

Why what we do matters

First, to define a few terms, the “we” is the membership of the Clerkship Directors in Internal Medicine (CDIM), the directors of medical student courses in internal medicine. “What we do” is undergraduate medical education. At times, in any career, a person will stop to ponder whether efforts have meaning. I suggest that creating an excellent clerkship experience for medical students does matter.

Reforming the core clerkship in internal medicine: the SGIM/CDIM Project. Society of General Internal Medicine/Clerkship Directors in Internal Medicine.

Dramatic changes in health care have stimulated reform of undergraduate medical education. In an effort to improve the teaching of generalist competencies and encourage learning in the outpatient setting, the Society of General Internal Medicine joined with the Clerkship Directors in Internal Medicine in a federally sponsored initiative to develop a new curriculum for the internal medicine core clerkship. Using a broad-based advisory committee and working closely with key stakeholders (especially clerkship directors), the project collaborators helped forge a new national consensus on the learning agenda for the clerkship (a prioritized set of basic generalist competencies) and on the proportion of time that should be devoted to outpatient care (at least one third of the clerkship). From this consensus emerged a new curricular model that served as the basis for production of a curriculum guide and faculty resource package. The guide features the prioritized set of basic generalist competencies and specifies the requisite knowledge, skills, and attitudes/values needed to master them, as well as a list of suggested training problems. It also includes recommended training experiences, schedules, and approaches to faculty development, precepting, and student evaluation. Demand for the guide has been strong and led to production of a second edition, which includes additional materials, an electronic version, and a pocket guide for students and faculty. A follow-up survey of clerkship directors administered soon after completion of the first edition revealed widespread use of the curricular guide but also important barriers to full implementation of the new curriculum. Although this collaborative effort appears to have initiated clerkship reform, long-term success will require an enhanced educational infrastructure to support teaching in the outpatient setting.

Evaluation of a national curriculum reform effort for the medicine core clerkship.

In 1995, the Society of General Internal Medicine (SGIM) and the Clerkship Directors in Internal Medicine (CDIM) developed and disseminated a new model curriculum for the medicine core clerkship that was designed to enhance learning of generalist competencies and increase interest in general internal medicine. To evaluate the dissemination and use of the resulting SGIM/CDIM Core Medicine Clerkship Curriculum Guide. Survey of internal medicine clerkship directors at the 125 medical schools in the United States. The questionnaire elicited information about the use and usefulness of the Guide and each of its components, barriers to effective use of the Guide, and outcomes associated with use of the Guide. Responses were received from 95 clerkship directors, representing 88 (70%) of the 125 medical schools. Eighty-seven (92%) of the 95 respondents were familiar with the Guide, and 80 respondents had used it. The 4 components used most frequently were the basic generalist competencies (used by 83% of those familiar with the Guide), learning objectives for these competencies (used by 83%), learning objectives for training problems (used by 70%), and specific training problems (used by 67%); 74% to 85% of those using these components found them moderately or very useful. The most frequently identified barriers to use of the Guide were insufficient faculty time, insufficient number of ambulatory care preceptors and training sites, and need for more faculty development. About 30% or more of those familiar with the Guide reported that use of the Guide was associated with improved ability to meet clerkship accreditation criteria, improved performance of students on the clerkship exam, and increased clerkship time devoted to ambulatory care. This federally supported initiative that engaged the collaborative efforts of the SGIM and the CDIM was successful in facilitating significant changes in the medicine core clerkship across the United States.

Grade Inflation in Internal Medicine Clerkships: Results of a National Survey

Background: There has been a discussion among medical educators concerning grade inflation; however, little has been written about it in the medical education literature. Purpose: A survey was developed to determine if grade inflation exists by gathering data about grading practices and by gathering the opinions of course directors from Internal Medicine clerkships. Methods: The survey was administered during the 1996-1997 academic year to all 125 LCME accredited medical school Internal Medicine Clerkship Directors. Grading practices for 3 separate academic years were obtained plus responses to questions about causes of and solutions for grade inflation. Results: Eighty-three surveys were returned for a 66% response rate. There was a trend towards higher grades across the 3 study years, with the 1995-1996 year being statistically significant. Forty-eight percent of the clerkship directors felt that grade inflation existed in their courses, and 43% felt that some students passed who should have failed. Conclusion: Statistically significant grade inflation exists in Internal Medicine clerkships. Most disturbingly, 43% feel we are unable appropriately to identify incompetent students.

National Survey of Clerkship Directors in Internal Medicine on the Competencies That Should Be Addressed in the Medicine Core Clerkship

PURPOSE: To prioritize competencies that should be addressed in the medicine core clerkship, assess factors influencing this prioritization, and estimate the percentage of clerkship time that should be devoted to inpatient versus outpatient care.METHODS: A national survey of the Clerkship Directors in Internal Medicine (CDIM) was used. Using explicit criteria, respondents assigned priority scores, on a 1 to 5 scale, to 17 general competencies and 60 disease-specific clinical competencies pertinent to care of adult patients in inpatient. ambulatory, intensive care, and emergency settings.RESULTS: Ninety-three (75%) of 124 CDIM members responded. The highest mean priority scores were assigned to 6 general competencies: case presentation skills (4.65), diagnostic decision-making (4.64), history and physical diagnosis (4.61), test interpretation (4.47), communication with patients (4.35), and therapeutic decision-making (4.12). Disease-specific clinical competency areas receiving the highest mean priority scores were: hypertension (4.57), coronary disease (4.53), diabetes mellitus (4.45), heart failure (4.42), pneumonia (4.39), chronic obstructive pulmonary disease (4.26), acid-base/electrolyte disorders (4.19), and acute chest pain (4.08). Priorities for general competencies were moderately correlated with importance to the practice of general internists (mean Spearman rho 0.49) and with importance to students pursuing careers outside internal medicine (mean Spearman rho 0.45), but only weakly correlated with the adequacy with which a competency was addressed in other parts of the curriculum. Respondents' mean recommended allocation of clerkship time was: 52% inpatient, 33% ambulatory care, 8% intensive care, and 7% emergency medicine. This time allocation did not differ by any characteristics of respondents.CONCLUSION: There is consensus among medicine clerkship directors that the medicine core clerkship should emphasize fundamental competencies and devote at least one third of the time to clinical competencies pertinent to ambulatory care.

A Perspective on Medical Student Education for Internal Medicine

Editorials1 January 1991A Perspective on Medical Student Education for Internal MedicineDaniel D. Federman, MDDaniel D. Federman, MDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-114-1-90 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptWhatever their differences, those who lament the declining recruitment to internal medicine agree on one thing: There is no one thing. There is no single cause, and there can be no single therapy. But what better to get internists' juices flowing than a complex problem for which an innovative and integrated solution is needed?Others in this special issue deal with the overarching concerns of residency, practice, life-style, and reimbursement in internal medicine, issues of great importance. I will consider educational approaches and, in that light, discuss the core medicine clerkship, some missing visions, and some underused models.The third... This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Harvard Medical School Boston, MA 02115 PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byA Comparison of Inpatient and Outpatient Experiences during an Internal Medicine ClerkshipNational Survey of Clerkship Directors in Internal Medicine on the Competencies That Should Be Addressed in the Medicine Core ClerkshipThe State of Internal MedicineGregg Coodley, MD, Marcia Kerensky Coodley, MD 1 January 1991Volume 114, Issue 1Page: 90-90KeywordsMedical educationResidencyVision Issue Published: 1 January 1991 Copyright & Permissions© 1991 American College of PhysiciansPDF downloadLoading ...