Large Medical School Research Articles

Nonmedical use of stimulants among medical students.

Proliferation of the use of psychopharmacologic drugs for the treatment of individuals with attention and behavior disorders has promoted discussion of the illicit use of such drugs to enhance academic performance. Previous research has focused on the use of such drugs by undergraduate students; however, inquiry into the nonmedical use of prescription stimulants by medical students is warranted because of the unique qualities of the medical school environment (including academic pressure, stress, and competition with peers) and the demographic characteristics common to many medical students. To examine the nonmedical use of prescription stimulants among osteopathic medical students, focusing on such key associated variables as academic stress, social network connections, and use of other substances. In 2012, first- and second-year students at a large osteopathic medical school were surveyed on the nonmedical use of prescription stimulants, stress, social networks, perceptions of drug use, and related topics. Data were compared with national data and assessed using analysis of variance and χ(2) statistical tests. A total of 380 students completed the survey. Of those, 56 (15.2%) reported using prescription stimulants nonmedically to help them study in medical school. This percentage is significantly higher than the national estimated rate of diagnosis of attention-deficit/hyperactivity disorder in similar populations (t=3.72, P<.001). Both positive perceptions of the nonmedical use of stimulants (F=14.89, P<.001) and the use of other substances (χ(2)=18.00, P<.001) were positively associated with the nonmedical use of stimulants. Social network connections did not positively predict use by medical students, and certain types of social connectivity had a negative association with use. In contrast with research on undergraduate populations, addressing academic stress and feelings of competitiveness may not be viable strategies for mitigating nonmedical use of stimulants among medical students.

When do doctors follow patients’ orders? Organizational mechanisms of physician influence

Physicians, like other professionals, are expected to draw from specialized knowledge while remaining receptive to clients’ requests. Using nationally representative U.S. survey data from the Community Tracking Study, this paper examines the degree to which physicians are influenced by patients’ requests, and how physicians’ workplaces may mediate acquiescence rates through three mechanisms: constraints, protection, and incentives. We find that, based on physicians' reports of their responses to patients' suggestions, patient influence is rare. This influence is least likely to be felt in large workplaces, such as large private practices, hospitals, and medical schools. We find that the protection and incentives mechanisms mediate the relationship between workplace types and physician acquiescence but more prescriptive measures such as guidelines and formularies do not affect acquiescence. We discuss these findings in light of the ongoing changes in the structure of medicine.

Health care institutions should not exclude smokers from employment.

Some health care institutions, including academic health centers, have adopted policies excluding smokers from employment. Claims advanced on behalf of these policies include financial savings from reduced health costs and absenteeism as well as advantages consonant with their message of healthy living. The authors suggest that the institutional savings from these policies are speculative and unproven. Also, in settings where large medical schools operate, it is likely to be the poor, including members of minority groups, who, under an employee smoker ban, will lose the opportunity to work for an employer that offers health insurance and other benefits. In response to the incentives created by such bans, some will quit smoking, but most will not. Thus, at the community level, employee smoker bans are more likely to be harmful than beneficial.Although private businesses may rightly choose not to hire smokers in the 19 states where such policies are legal, health care institutions, including academic health centers, should consider hiring choices in light of the values they profess. The traditional values of medicine include service to all persons in need, even when illness results from addiction or unsafe behavior. Secular academic communities require a shared dedication to discovery without requiring strict conformity of private behavior or belief. The authors conclude that for health care institutions, policies of hiring smokers and helping them to quit are both prudent and expressive of the norms of medical care, such as inclusion, compassion, and fellowship, that academic health professionals seek to honor.

Empathy levels among first year Malaysian medical students: an observational study.

BackgroundThe literature indicates that medical practitioners experience declining empathy levels in clinical practice. This highlights the need to educate medical students about empathy as an attribute early in the academic curriculum. The objective of this study was to evaluate year one students’ self-reported empathy levels following a 2-hour empathy workshop at a large medical school in Malaysia.MethodsChanges in empathy scores were examined using a paired repeated-measures t-test in this prospective before and after study.ResultsAnalyzing the matched data, there was a statistically significant difference and moderate effect size between mean empathy scores before and 5 weeks after the workshop (112.08±10.67 versus 117.93±13.13, P<0.0001, d=0.48) using the Jefferson Scale Physician Empathy (Student Version).ConclusionThe results of this observational study indicate improved mean self-reported empathy scores following an empathy workshop.

Medical students perceive better group learning processes when large classes are made to seem small.

ObjectiveMedical schools struggle with large classes, which might interfere with the effectiveness of learning within small groups due to students being unfamiliar to fellow students. The aim of this study was to assess the effects of making a large class seem small on the students' collaborative learning processes.DesignA randomised controlled intervention study was undertaken to make a large class seem small, without the need to reduce the number of students enrolling in the medical programme. The class was divided into subsets: two small subsets (n = 50) as the intervention groups; a control group (n = 102) was mixed with the remaining students (the non-randomised group n∼100) to create one large subset.SettingThe undergraduate curriculum of the Maastricht Medical School, applying the Problem-Based Learning principles. In this learning context, students learn mainly in tutorial groups, composed randomly from a large class every 6–10 weeks.InterventionThe formal group learning activities were organised within the subsets. Students from the intervention groups met frequently within the formal groups, in contrast to the students from the large subset who hardly enrolled with the same students in formal activities.Main Outcome MeasuresThree outcome measures assessed students' group learning processes over time: learning within formally organised small groups, learning with other students in the informal context and perceptions of the intervention.ResultsFormal group learning processes were perceived more positive in the intervention groups from the second study year on, with a mean increase of β = 0.48. Informal group learning activities occurred almost exclusively within the subsets as defined by the intervention from the first week involved in the medical curriculum (E-I indexes>−0.69). Interviews tapped mainly positive effects and negligible negative side effects of the intervention.ConclusionBetter group learning processes can be achieved in large medical schools by making large classes seem small.

Anatomy education in a new distributed MD program ‐ prospects and challenges (LB28)

MD undergraduate teaching at the University of British Columbia (UBC), Canada occurs in a distributed setting, with 288 students spread across four locations in the province per year of instruction. Hence, UBC has the largest medical school in Canada. Although experienced anatomy faculty exist on each UBC campus, large class teaching must be performed using videoconferencing technology supplemented by small group interaction in the cadaver labs. The Southern Medical Program at UBC Okanagan received the first set of MD undergraduates at the Kelowna campus in January 2012 and is the newest of UBC’s distributed sites. Teaching anatomy in such a pioneer setting offers unique perspectives on anatomy education as is currently practiced provincially and nationally, along with salient lessons on the prospects and challenges of distance learning in an MD program. This paper reflects on the impacts of location, pedagogic methods and curriculum on the teaching of anatomy in this unique locus and examines wider implications for the anatomy education of future doctors in Canada.

Engaging medical students and their teachers with the determinants of health: the approaches and impact of a curriculum development at one large UK medical school

Background: Social determinants of health (‘SDH’) often underlie the health behaviours that contribute to non-communicable disease. Doctors need to be aware of health behaviours and their determinants and the evidence-based interventions to address them. Aim: Co-ordinated core curriculum modifications were instigated with explicit learning outcomes in and around health promotion and SDH. This paper reports on the research evaluation of process and outcome and sustainability of these changes in one large medical school. Method: Mixed method research data were used to inform an action research cycle. Data were analysed for content and emerging themes related to smoking cessation, obesity reduction, and global health were informed by SDH. Results and analysis: Students demonstrated knowledge and concern relating to SDH, although some initially lacked confidence in applying this knowledge. Students reported inconsistent modelling clinical environments. Attention was given to the learning environment as well as teacher training to facilitate and support self-efficacy through reflection and critical analysis. Conclusion: Newer medical education themes such as SDH need robust preparation for inclusion in core curricula, with attention to the social, cognitive and environmental impacts on learning. Teaching and experiential learning for SDH is now embedded in this curriculum. Practice points  Integrating teaching and assessment around SDH for core medical curricula is challenging, with regard to specific content, process, faculty and teacher development, defining learning outcomes and appropriate assessment.  SDH when well integrated provide students, and their teachers, with opportunities to identify and possibly address some SDHs both in clinical encounters and in population interventions.  All qualifying medical graduates should have skills to address significant determinants of health such as smoking and obesity. There is an evidence base to guide these approaches.

Why a teacher centered medical school curriculum may result in a poor educational environment?

Context: Students’ achievements, satisfaction, and success have been found to correlate with their perception of their educational environment (EE). Objectives: The objectives of the present study were to identify (a) the medical students’ perceptions of their EE at a school with a teacher-centered curriculum (b) the reasons behind the items with low ratings and (c) ways to improve the EE at this school. Methods: In this article, the focus will be on the qualitative part of the mixed method of study, which was conducted at a large medical school in Riyadh, Saudi Arabia during 2006-2007. A total of 1132 students filled out a bilingual (Arabic and English) version of the Dundee Ready Educational Environment Measure (DREEM) inventory. Five focus group discussions with 28 students were conducted. The low scoring areas of the DREEM were used as input for the discussion. Findings: The mean total DREEM score for the medical school was 94.7 (± 21.5) out of a maximum of 200. The main curriculum variables contributing to poor DREEM scores were curriculum overload, stress, lack of feedback, and poor teaching skills. The possible solutions to these problems, as suggested by the students were to involve the students in the learning process, courses to help the faculty to develop their teaching skills, assessments with provision of feedback, stronger student support system and introduction of study skills courses for student’s. Conclusions: This study provides insight into the reasons associated with a poor learning climate. The strategies to promote a healthy EE point to relatively more student-centered elements in the curriculum and the introduction of a study skills course in the 1st year.

Board 123 - Program Innovations Abstract Simulation-Based Training Manual for Internal Medicine Residents (Submission #375)

Introduction/Background Historically, medical training programs have relied on classroom teaching and hands-on training by expert physicians. Work hour restrictions have decreased the amount of time medical students and doctors in training spend with attending physicians. This shift has stimulated the growth of innovative and time effective alternatives in education. Additionally, the impact of patient discomfort and associated complications of procedures ‘practiced’ on live patients has come under closer scrutiny. Safety and quality measures have made us question the old Methods of learning. Medical simulators have been at the forefront of the change in approach to training medical students and doctors. They provide a safe environment in which procedures can be repeatedly practiced without compromising patient safety. Numerous studies have shown this to be an effective and often superior method of learning to didactic lectures followed by traditional hands-on expert training. Today most large medical training centers, hospitals and medical schools possess medical simulation facilities. Medical simulators include a variety of devices from task trainers to full body high fidelity manikins. The latter provides a fully immersive experience and can be programmed to provide a wide array of clinical scenarios. They provide immediate learning opportunities since they obviate the need to wait for real life cases. This is of particular importance given the reduced patient volume resulting from work hour restrictions. Studies have shown that simulator trained physicians outperform non-simulator trained counterparts in real life situations. They complete procedures faster and with fewer complications and have greater confidence in dealing with the ‘deteriorating’ patient. Medical simulation has played a significant role in the education of Mayo Clinic Arizona internal medicine residents since 2011. A simulation-based curriculum is used by Chief Medicine Residents to augment didactic morning report sessions. As usage of this curriculum grows, more robust research will assist in the future development of this innovative and essential teaching tool. Methods Chief Medicine Residents at Mayo Clinic Arizona collectively endeavored to increase hands-on medical training by incorporating simulation-based teaching sessions into the traditional morning report time period. Since 2011 the repertoire of scenarios has been passed down from graduating to beginning chiefs without any standardization of style or format. We compiled a series of twenty scenarios with variable learning objectives and levels of complexity. Most scenarios involve clinically deteriorating patients that would typically be managed by hospital internists. Each scenario follows a standardized format and includes learning objectives, setting and background patient information, personnel, scripts, simulator settings, diagnostics, critical action list and simulation responses to interventions. Expectations for resident performance are outlined in the "critical action list" that lends itself to effectively monitoring and documenting trainees’ progress. This compilation is ideal for use by all internal medicine programs with simulation-based training facilities. A description of the Mayo Clinic Arizona mannequin capabilities and a guide to debriefing are included in the text. Results: Conclusion Work hour restrictions, as well as safety and quality measures have impacted traditional hands-on training for internal medicine residents. Mayo Clinic Arizona Chief Medicine Residents use medical simulation training sessions to augment traditional didactic morning reports and to provide simulated hands-on experience of managing clinically deteriorating patients. Our compilation of these scenarios is now in press for publication in both print and electronic versions, with plans for distribution and use as an educational and research tool. Disclosures None.

Attending Rounds in the Current Era

General medicine rounds by attending physicians provide the foundation for patient care and education in teaching hospitals. However, the detailed activities of these rounds in the current era are not well characterized. To describe the characteristics of attending rounds for internal medicine inpatients in a large teaching hospital system. A cross-sectional observational study of attending rounds in internal medicine. Rounds were observed directly by research assistants. Four teaching hospitals associated with a large public medical school. Fifty-six attending physicians and 279 trainees treating 807 general medicine inpatients. Duration and location of rounds, composition of teams, and frequency of 19 potential activities during rounds. We observed 90 days of rounds. A typical rounding day consisted of 1 attending with 3 trainees visiting a median of 9 (range, 2-18 [SD, 2.9]) patients for a median of 2.0 hours (range, 25-241 [SD, 2.7] minutes). On rounds, teams most frequently discussed the patient care plan (96.7% of patients), reviewed diagnostic studies (90.7%), communicated with patients (73.4%), and discussed the medication list (68.8%). Teams infrequently discussed invasive lines or tubes (9.3%) or nursing notes (6.2%) and rarely communicated with nurses (12.0%) or taught physical examination skills (14.6%), evidence-based medicine topics (7.2%), or learner-identified topics (3.2%). Many commonly performed activities occurred infrequently at the bedside. Most activities on attending rounds do not take place at the bedside. The teams discuss patient care plans and test results most of the time but fail to include many items that may be of significant value, including specific aspects of patient care, interprofessional communication, and learner-centered education. Future studies are needed to further assess the implications of these observations.

What are the benefits of early patient contact? - A comparison of three preclinical patient contact settings

BackgroundDespite increasing attention to providing preclinical medical students with early patient experiences, little is known about associated outcomes for students. The authors compared three early patient experiences at a large American medical school where all preclinical students complete preceptorships and weekly bedside clinical-skills training and about half complete clinical, community-based summer immersion experiences. The authors asked, what are the relative outcomes and important educational components for students?MethodsMedical students completed surveys at end of second year 2009–2011. In 2009, students compared/contrasted two of three approaches; responses framed later survey questions. In 2010 and 2011, students rated all three experiences in relevant areas (e.g., developing comfort in clinical setting). Investigators performed qualitative and quantitative analyses.ResultsStudents rated bedside training more highly for developing comfort with clinical settings, one-on-one clinical-skills training, feedback, active clinical experience, quality of clinical training, and learning to be part of a team. They rated community clinical immersion and preceptorships more highly for understanding the life/practice of a physician and career/specialty decisions.ConclusionsPreclinical students received different benefits from the different experiences. Medical schools should define objectives of early clinical experiences and offer options accordingly. A combination of experiences may help students achieve clinical and team comfort, clinical skills, an understanding of physicians’ lives/practices, and broad exposure for career decisions.

Development and implementation of a biomedical informatics course for medical students: challenges of a large-scale blended-learning program.

Biomedical informatics (BMI) competencies are recognized as core requirements for the healthcare professional, but the amount of BMI educational interventions in the curricula of medical schools is limited. UNAM Faculty of Medicine in Mexico is a large public medical school, with more than 7000 undergraduate students. The undergraduate program recently underwent a major curricular revision, which includes BMI education. Two one-semester BMI courses (BMI-1 and BMI-2) were designed, with a blended-learning educational model. A department of BMI was created, with budget, offices and personnel. The first class of 1199 students started the course in 2010, with 32 groups of 40 students each. BMI-1 includes core conceptual notions of informatics applied to medicine (medical databases, electronic health record, telemedicine, among other topics), and BMI-2 embodies medical decision making and clinical reasoning. The program had a positive evaluation by students and teachers. BMI can be successfully incorporated in a large-scale medical school program in a developing country, using a blended-learning model and organizational change strategies.

Tips on Revitalizing Faculty Careers

Tips on Revitalizing Faculty Careers

Stopping Diabetes Through Advocacy: The Role of Health Care Professionals

G eralyn Spollett, President of Health Care and Education for the American Diabetes Association (ADA), is a busy nurse practitioner at a large New England medical school. Why did she cancel her patient hours to meet with training officers of a metropolitan police department? George Grunberger has a busy one-person diabetes private practice. As with most practicing physicians, his income depends on seeing patients. So what was he doing in a Washington, D.C., conference room discussing truck driver licenses on a busy weekday? “First of all, it gets me out of my office. I learn about new things, and the work is interesting and exciting,” Grunberger said. “Second, although much of it is pro bono , not all is. Consulting fees certainly make up much of the lost income from time away from the practice and broaden my business relationships. Third, my job as a physician and diabetologist is to help people with diabetes live their lives better. This is part of the job. If my patients are not able to work in their chosen professions, it directly affects their quality of life and, potentially, health insurance and ability to afford their diabetes supplies.” But, health care professionals (HCPs) do not have to give up office hours or travel to the nation's capital to be an effective advocate for their patients. There is a great deal we can do in our own hometowns. In the remainder of this article, the authors offer insights from their own experiences as advocates. Sam is a firefighter with type 1 diabetes in New York City, where I work. He was placed on desk duty and filed a suit against the Fire Department of New York City (FDNY) for discrimination under the Americans with Disabilities Act. He was referred to me for an independent medical …

How an online questionnaire can explore leadership teaching in an undergraduate curriculum.

ObjectivesTo design a tool to explore current leadership teaching in an undergraduate curriculum, using the medical leadership competency framework (MLCF)DesignAn online questionnaire was designed based on the MLCF competences and sent to all course leads at Imperial College, London in Autumn 2011SettingImperial College, LondonParticipantsSixty-nine course leads were invited to participate in the questionnaire studyMain outcome measuresCourse leads were asked whether they teach each MLCF competence, which teaching methods they use, and how long they spend teaching each competencyResultsOverall there was a 78% questionnaire response rate (54/69). From the questionnaires received it was possible to extrapolate results across the remaining courses to achieve a 100% response rate. We were then able to produce a map of current leadership teaching showing that all MLCF competences are taught to varying degrees across the curriculum. The tool does not however provide information on the quality of teaching provided, or what students learnConclusionsThere is a strong emphasis on the development of teaching leadership skills to undergraduates in Tomorrow's Doctors 2009 (TD09). It is difficult to know what teaching occurs across the curriculum of a large medical school. The design of a simple, electronic questionnaire will enable medical schools to map their current leadership teaching to the TD09 outcomes. This will help to inform further curriculum development and integration as well as signposting of learning opportunities

Communicating with Clinicians: The Experiences of Surrogate Decision‐Makers for Hospitalized Older Adults

To describe communication experiences of surrogates who had recently made a major medical decision for a hospitalized older adult. Semistructured interviews about a recent hospitalization. Two hospitals affiliated with one large medical school: an urban public hospital and a university-affiliated tertiary referral hospital. Surrogates were eligible if they had recently made a major medical decision for a hospitalized individual aged 65 and older and were available for an interview within 1 month (2-5 months if the patient died). Interviews were audio-recorded, transcribed, and analyzed using methods of grounded theory. Thirty-five surrogates were interviewed (80% female, 44% white, 56% African American). Three primary themes emerged. First, it was found that the nature of surrogate-clinician relationships was best characterized as a relationship with a "team" of clinicians rather than individual clinicians because of frequent staff changes and multiple clinicians. Second, surrogates reported their communication needs, including frequent communication, information, and emotional support. Surrogates valued communication from any member of the clinical team, including nurses, social workers, and physicians. Third, surrogates described trust and mistrust, which were formed largely through surrogates' communication experiences. In the hospital, surrogates form relationships with a "team" of clinicians rather than with individuals, yet effective communication and expressions of emotional support frequently occur, which surrogates value highly. Future interventions should focus on meeting surrogates' needs for frequent communication and high levels of information and emotional support.

Medical Student Career Survey—Vascular Surgery Awareness Initiative

The objectives of this survey were to identify medical students' general knowledge of vascular surgery as a career choice on entrance to medical school, and how student perspectives change during their exposure to clinical disciplines. Furthermore, we sought to determine which factors may influence the choice of a particular career path, and to apply this knowledge to improve the recruitment process of medical students into the specialty of vascular surgery. A one-time anonymous questionnaire consisting of 21 open and multiple-choice questions was distributed to first- (MS1), second- (MS2), and third-year (MS3) medical students at a large single-campus medical school. Responses were collected and subjected to analysis. Three hundred thirty-eight medical students responded to the survey (110 MS1, 126 MS2, and 102 MS3). Two hundred thirty-six MS1 and MS2 students had no clinical exposure to vascular surgery. Of 102 MS3 students having completed a general surgery rotation, 38 had exposure to vascular surgery. Of MS1 and MS2 students, 49% would consider vascular surgery. An additional 19% were willing to consider vascular surgery if the length of training was reduced. Twenty-six percent of the clinical students rotated on a vascular surgery service during their clinical general surgery rotation, of which 78% reported a positive experience. Only 26% (10 of 38) still considered vascular surgery as a career at the MS3 level. Thirty-four percent of students would consider vascular surgery if the training was reduced from 7 to 5 years. However, only 5% of MS1 and MS2 (11 of 236) and 9% of MS3 (9 of 102) students were aware of the 0 + 5 training program. As students advanced in medical school, lifestyle (31% MS1 vs. 63% MS3, P < 0.001) and length of training (19% MS1 and 2 vs. 34% MS3, P < 0.001) became a more critical factor in their career choice decision making. Medical students have minimal knowledge of vascular surgery on entry to medical school; however, many are willing to consider vascular surgery as a career. Lack of exposure in the first 2 years of medical school and lifestyle considerations may be deterrents for students to choosing vascular surgery as a career. To improve the recruitment process, focused education and interaction with preclinical medical students are needed.

Child and Adolescent Development for Medical Learners: Developmental Perspectives of Emotions and Illness

Abstract This module, Developmental Perspectives of Emotions and Illness, discusses the impact of development on a child's understanding and experience of illness. Cognitive developmental influence...

How Medical Students’ Behaviors and Attitudes affect the Impact of a Brief Curriculum on Nutrition Counseling

To evaluate a nutrition curriculum and explore the influence of medical students' own nutrition practices on its impact. An anonymous survey was given to first-year medical students attending a required course immediately prior to and 2 weeks after a 2-hour interactive nutrition curriculum intervention in a large private urban medical school in New York, New York. Main outcomes included self-reported nutrition counseling confidence, ability to assess diet, and nutrition knowledge measured using 4-point Likert scales. One hundred eleven students completed surveys pre-curriculum (69%) and 121 completed them post-curriculum (75%). The authors found overall pre-post differences in dietary assessment ability (2.65 vs 3.05, P < .001) and counseling confidence (1.86 vs 2.22, P < .001). In addition to the curricular impact, students' nutrition-related behaviors and attitudes were positively associated with outcomes. A nutrition curriculum for medical students improves students' nutrition counseling-related confidence, knowledge, and skills even when controlling for personal nutrition-related behaviors.

A Study of Knowledge & Awareness of Medical Doctors Towards Radiation Exposure Risk At Tikur Anbessa Specialized Referral And Teaching Hospital, Addis Ababa, Ethiopia.

Increasing concern has recently been expressed in the literature that the referring doctor's knowledge of radiation doses incurred during radiological procedures is inadequate. Such information may be particularly relevant when the expansion of imaging technology is considered. Hence the objective of this work is to assess the awareness of physicians about radiation dose and hazards of radiation. The study was performed among medical doctors at Tikur Anbessa Specialized Referral Teaching Hospital, the largest medical school in the country. A 135 self administered questionnaire was circulated randomly from a range of specialties; out of which 114 questionnaires were completed and used in the study giving a response rate of 85%. Participants were asked about the radiation dose from a chest radiograph, the annual dose from background radiation, and cancer risk from several common radiological procedures. A mean score of 7.1 out of 19 was achieved. 12 doctors had received formal training about ionizing radiation, and these participants scored higher than those with no previous training in this area. Our survey suggested that clinicians' awareness of radiation doses imparted during common radiological procedures, and the consequent risk to the individual patient is poor. A major curriculum revision of both undergraduate and graduate medical education regarding awareness on radiation is mandatory to improve this deficiency.