Internal Medicine Rotation Research Articles

Timing of Surgery and Internal Medicine Clerkships and Surgery Shelf Examination Scores

BackgroundMany medical students believe that third-year clerkship rotation sequence affects their success. We hypothesized that students who completed the internal medicine clerkship before the surgery clerkship received higher surgery shelf examination scores compared with the students who did not. Materials and methodsDeidentified academic data including preclinical data and National Board of Medical Examiners shelf examination scores for surgery for all third-year medical students at a single institution from 2012 to 2017 were analyzed. Students who did not complete all six core clerkships during the standard third-year time frame were excluded. Data were analyzed using 2-tailed t-tests and Z-scores. ResultsFour hundred and twenty four students were included in the study. Average undergraduate grade point average, Medical College Admission Test scores, and United States Medical Licensing Examination Step 1 scores showed no significant differences between groups. In aggregate, average shelf examination scores of students who completed the internal medicine clerkship before the surgery clerkship were significantly higher than those of students who did not. When the average shelf examination scores for the two groups were analyzed by individual rotation slot, no significant difference was found between the two groups. ConclusionsInitially, it appeared that students who completed the internal medicine clerkship before the surgery clerkship scored higher on their surgery shelf examinations. When the data were analyzed by individual rotation slot, we found no difference between the students who had already completed the internal medicine clerkship and those who had not. Experience over the year rather than completion of the internal medicine rotation was associated with higher surgery shelf examination scores.

“Residents get no… satisfaction” a problem to face during internal medicine rotations: development and psychometric properties of the IMPRINT-15

Clinical rotations are an essential part of Internal Medicine (IM) residency programmes, where curricular objectives are carried out. To our knowledge, there are no validated instruments to assess IM clinical...

Psychiatry: My Answer to Reincarnation

Psychiatry: My Answer to Reincarnation

Point of care ultrasound training for medical students: Is it beneficial?

Point of care ultrasound (POCUS) has oftentimes been touted as the stethoscope of the future. Improvements in technology have now lowered costs, making it more accessible to all physicians. Currently, there is no structured training program for POCUS and most POCUS users acquire knowledge during their respective specialist training by learning from peers or by attending ad-hoc courses. As POCUS gains traction, there is increasing interest in introducing training during medical school. We conducted an introductory course to POCUS for a batch of 9 medical students during their Internal Medicine rotation. The session was focused on orienting students to the ultrasound machine, knobology and imaging acquisition of the venous system. The instructors also shared with the students the scenarios whereby POCUS may aid diagnosis and clinical management. A survey was conducted after the course to assess the students’ understanding and interest in further sessions. Prior to this session, the medical students were only introduced to ultrasound during their obstetrics rotation. After the session, 89% of the students have a better understanding of how POCUS can be integrated into daily clinical practice. 89% of the students were also more confident in handling the ultrasound machine. All the students felt that POCUS can enhance their learning, and should be included in the Internal Medicine curriculum. As POCUS becomes more widely practised, consideration should be made to include it as a component of medical school training. While there are concerns that it will divert attention and resources in a packed curriculum, the interactive nature of ultrasound training, its direct correlation with anatomy, integration with clinical scenarios, makes it a powerful tool to potentially enhance clinical teaching.

The PROFILE of assessment program for internal medicine internship of Sun Yat-Sen University

Objective: To reflectively look at the present methods by which the clinical competence of 5th-year medical students (i.e. interns) in Sun Yat-Sen University (SYSU) are assessed upon finishing internship rotation in internal medicine (IM).Methods: Current procedures for the competence assessment of end-of-rotation IM interns in the First Affiliated Hospital of SYSU were reviewed, along with a point-by-point appraisal based on the PROFILE approach to structured assessment, and, whenever possible, suggestions for future improvement.Results and discussions: On a scale of 1–10, with 10 being the best or the most ideal, our marks for current methods to assess end-of-rotation IM interns in terms of being Programmatic, Real-World, Outcome-based, Formative, Impactful, Learner-engaged, and Evaluation-guaranteed were 7, 9, 3, 4, 6, 8, and 1, respectively. The strengths, weaknesses as well as potential solutions in each of the seven aspects are also discussed separately.Conclusions: Current assessment program for IM internship is strong in being programmatic, real-world, educationally impactful and learner engaged, and has room for further improvement in its time-based arrangements, relative shortage of feedback provision, as well as a systematic lack of quality control measures.

Ready to run the wards? \u2013 A descriptive follow-up study assessing future doctors\u2019 clinical skills

BackgroundRecent studies have shown that clinical tasks only represent a small percentage in the scope of final-year medical students’ activities and often lack sufficient supervision. It appears that final-year medical students are frequently deployed to perform “routine tasks” and show deficits in the performance of more complex activities. This study aimed to evaluate final-year students’ clinical performance in multiple impromptu clinical scenarios using video-based assessment.MethodsWe assessed final-year medical students’ clinical performance in a prospective, descriptive, clinical follow-up study with 24 final-year medical students during their Internal Medicine rotation. Participating students were videotaped while practicing history taking, physical examination, IV cannulation, and case presentation at the beginning and end of their rotation. Clinical performance was rated by two independent, blinded video assessors using binary checklists, activity specific rating scales and a five-point global rating scale for clinical competence.ResultsStudents’ performance, assessed by the global rating scale for clinical competence, improved significantly during their rotation. However, their task performance was not rated as sufficient for independent practice in most cases. Analysis of average scores revealed that overall performance levels differed significantly, whereby average performance was better for less complex and more frequently performed activities.ConclusionsWe were able to show that students’ performance levels differ significantly depending on the frequency and complexity of activities. Hence, to ensure adequate job preparedness for clinical practice, students need sufficiently supervised and comprehensive on-ward medical training.

Case-Based PowerPoint to Improve Knowledge and Comfort of Having Code Status Discussions by Physician Assistant and Nurse Practitioner Students.

Little is known about how certain educational interventions may improve informed code status discussions by physician assistant (PA) and nurse practitioner students. This is a prospective, prospective, single academic center pilot study utilizing a short case-based PowerPoint that reviewed the differences between code status choices and the likelihood of survival to hospital discharge of attempted resuscitation after a cardiac arrest. Training occurred between September 1, 2017, and May 31, 2018. The study population included PA and adult gerontology acute care nurse practitioner (AGACNP) students during their inpatient internal medicine rotation (n = 9) and preclinical PA students (n = 5). After training, there was a significant increase in knowledge in the likelihood of survival to hospital discharge (P = .01) and comfort level in having an informed code status discussion (3.36 ± 0.81 vs 4.10 ± 0.80, P = .02). For questions related to identification of the correct code status, there were no significant differences before and after the intervention. A short case-based PowerPoint viewed by PA and AGACNP students increased the knowledge about the likelihood of survival to hospital discharge of attempted resuscitation after a cardiac arrest and increased the comfort level of having code status discussions with patients by PA and AGACNP students.

Teaching Residents how to Effectively Prescribe Nicotine Replacement Therapy on the Clinical Teaching Unit

Residents and medical students identified a lack of knowledge regarding Nicotine Replacement Therapy (NRT) as a barrier to smoking cessation counselling. We hypothesized that a teaching session on NRT during an inpatient Internal Medicine rotation would increase learner comfort in prescribing these products.
 Medical trainees on the Internal Medicine Clinical Teaching Unit (CTU) attended a teaching session during week 4 of an 8-week rotation. Pharmacy records from the 8-week period were retrospectively analyzed to determine NRT prescribing behaviour.
 Pre-intervention, 5.8% (13/225) of new admissions received a NRT prescription. Post-intervention, 17% (31/182) of new admissions received a NRT prescription. Using a Fisher’s exact test, the percentage of new admissions that received a prescription was significantly different (p<0.001) between the pre- and post-intervention time frames.
 This data suggests that integrating education on NRT into CTU teaching can significantly alter prescribing behaviour and improve access to NRT for patients who need it.

Informing the Revolution: A Needs Assessment of Ultrasound Knowledge and Skills Among Graduating Physician Assistant Students.

We performed a needs assessment to understand how existing physician assistant (PA) program curricula and clinical training affect students' ultrasound knowledge, skills, and competence and prepare students for performing ultrasound techniques in clinical practice. Students graduating from a PA program completed a 23-item questionnaire examining their ultrasound training experiences, their self-assessment of competency, and their demographics. Students also completed a 15-item ultrasound knowledge assessment. Thirty-eight of 39 students (97%) completed the survey. Students received little hands-on ultrasound training, with the most hands-on training being offered during emergency medicine (44.7%), obstetrics and gynecology (42.1%), and inpatient internal medicine (39.5%) rotations. This lack of preparedness was reflected in a mean score of 47.1% (±16.4%) on the ultrasound knowledge assessment. Most students (84.2%) indicated that the ultrasound instruction they received during clinical rotations was insufficient to prepare them for clinical practice, and 84.2% desired a formal ultrasound training program in the PA program curriculum. Existing PA program curricula are insufficient for developing critical skills related to ultrasonography.

Distribution of Clinical Rotations Among Emergency Medicine Residency Programs in the United States.

There are over 200 emergency medicine (EM) residency programs in the United States. While there are basic criteria defined by the Accreditation Council for Graduate Medical Education (ACGME), there can be significant variation between programs with regard to rotation distribution. Therefore, it would be valuable to have a benchmark for programs to understand their rotation mix in the context of the national landscape. This study aimed to provide a breakdown of the length and percentage of EM residency programs with each clinical rotation in the United States. This study also sought to examine trends and changes in EM residency programs since 1986. A list of all current EM residency programs was obtained using the ACGME website. All program websites were reviewed, and data were independently dual extracted by two investigators with discrepancies resolved by consensus with a third investigator. Programs without curricular data available online were queried via e-mail for the data. Programs were separated into 3- versus 4-year lengths. Mean, standard deviation, and range were calculated for each rotation. A total of 200 of 202 programs (99%) had data available. Of these programs, 84.5% had a dedicated pediatric EM rotation with mean length of 9.7 weeks among 3-year programs and 12.1 weeks among 4-year programs. A total of 88% had a dedicated ultrasound rotation, 60% had a dedicated toxicology rotation, 73.5% had a dedicated emergency medical services rotation, 74% had a dedicated orthopedics rotation, 60% had a dedicated administration rotation, 29% had a dedicated research rotation, and 95% had dedicated elective time. This study provides summative data regarding the rotation distribution among EM programs in the United States. Compared with prior data, there is less time dedicated to internal medicine rotations and increased pediatric, trauma, ultrasound, toxicology, and critical care experiences. These data will inform current and new EM residency programs when determining rotation selection.

Characterization of Pharmacy Resident Interventions on an Academic Inpatient Internal Medicine Rotation

Purpose: To characterize the clinical interventions of postgraduate year 1 (PGY-1) pharmacy residents on a required, 1-month, inpatient adult internal medicine service at an academic medical center. Methods: The interventions completed by PGY-1 pharmacy residents on a required, adult internal medicine rotation were analyzed. Documentation of clinical interventions was performed by the PGY-1 residents, and the significance of the intervention was subsequently determined. Acceptance rates of clinical interventions were also documented and reviewed. Results: A total of 2161 interventions were documented by 14 PGY-1 pharmacy residents between January 2016 and May 2017. Of these interventions, 2016 (93.3%) had a positive, or accepted, outcome. The significance of the majority of interventions was moderate (93.5%), indicating that either an improvement in drug therapy effectiveness, decreased hospital length of stay, reduction in cost, or prevention in harm had occurred. The most common intervention types were recommendations to add, change, or discontinue a medication therapy, completion of a pharmacy dosing consult or conducting an admission medication reconciliation. Conclusion: PGY-1 pharmacy residents have a positive impact on patient care in the inpatient adult internal medicine setting.

A Prescription for Note Bloat: An Effective Progress Note Template.

United States hospitals have widely adopted electronic health records (EHRs). Despite the potential for EHRs to increase efficiency, there is concern that documentation quality has suffered. To examine the impact of an educational session bundled with a progress note template on note quality, length, and timeliness. A multicenter, nonrandomized prospective trial. Four academic hospitals across the United States. Intern physicians on inpatient internal medicine rotations at participating hospitals. A task force delivered a lecture on current issues with documentation and suggested that interns use a newly designed best practice progress note template when writing daily progress notes. Note quality was rated using a tool designed by the task force comprising a general impression score, the validated Physician Documentation Quality Instrument, 9-item version (PDQI-9), and a competency questionnaire. Reviewers documented number of lines per note and time signed. Two hundred preintervention and 199 postintervention notes were collected. Seventy percent of postintervention notes used the template. Significant improvements were seen in the general impression score, all domains of the PDQI-9, and multiple competency items, including documentation of only relevant data, discussion of a discharge plan, and being concise while adequately complete. Notes had approximately 25% fewer lines and were signed on average 1.3 hours earlier in the day. The bundled intervention for progress notes significantly improved the quality, decreased the length, and resulted in earlier note completion across 4 academic medical centers.

Evaluating the Types of Pharmacy Student Interventions Made During an Interprofessional 6-Week Adult Internal Medicine Rotation

Introduction: The new standards for pharmacy education require that pharmacy students are involved in direct and interprofessional team-based care in multiple practice settings, which include “real-time” interactions with physician prescribers and medical students. Methods: From April 2014 to December 2015, fourth-year Doctor of Pharmacy (PharmD) students at University Medical Center of El Paso, Texas were assigned to an interprofessional team that was comprised of physician prescribers, medical students, and a pharmacist faculty. They recorded their interventions that were analyzed for type, number, physician acceptance, clinical importance, and time requirements for intervention recommendation. Interventions were divided into 5 main types and further divided into specific categories. Results: Twelve PharmD students contributed 531 interventions, resulting in an average of 44 interventions per student with a physician acceptance rate of 87%. The most common types of interventions performed by PharmD students were under the categories of Therapy Needed (29.8%), Too Low Dose/Frequency (21.1%), Too High Dose/Frequency (8.3%), Therapeutic Level Monitoring (6.8%), and IV to PO Conversion (4.9%). A majority of interventions were of moderate clinical importance (56.1%) and took approximately 15 minutes to complete (92.5%). Conclusion: PharmD students under the supervision of clinical faculty on an interprofessional internal medicine team are valuable collaborators and contributors in decreasing the number of drug-related problems that can negatively impact patient care.

Sleep and Alertness in Medical Interns and Residents: An Observational Study on the Role of Extended Shifts.

Fatigue from sleep loss is a risk to physician and patient safety, but objective data on physician sleep and alertness on different duty hour schedules is scarce. This study objectively quantified differences in sleep duration and alertness between medical interns working extended overnight shifts and residents not or rarely working extended overnight shifts. Sleep-wake activity of 137 interns and 87 PGY-2/3 residents on 2-week Internal Medicine and Oncology rotations was assessed with wrist-actigraphy. Alertness was assessed daily with a brief Psychomotor Vigilance Test (PVT) and the Karolinska Sleepiness Scale. Interns averaged 6.93 hours (95% confidence interval [CI] 6.84-7.03 hours) sleep per 24 hours across shifts, significantly less than residents not working overnight shifts (7.18 hours, 95% CI 7.06-7.30 hours, p = .007). Interns obtained on average 2.19 hours (95% CI 2.02-2.36 hours) sleep during on-call nights (17.5% obtained no sleep). Alertness was significantly lower on mornings after on-call nights compared to regular shifts (p < .001). Naps between 9 am and 6 pm on the first day post-call were frequent (90.8%) and averaged 2.84 hours (95% CI 2.69-3.00 hours), but interns still slept 1.66 hours less per 24 hours (95% CI 1.56-1.76 hours) compared to regular shift days (p < .001). Sleep inertia significantly affected alertness in the 60 minutes after waking on-call. Extended overnight shifts increase the likelihood of chronic sleep restriction in interns. Reduced levels of alertness after on-call nights need to be mitigated. A systematic comparison of sleep, alertness, and safety outcomes under current and past duty hour rules is encouraged.

The Association of Grade Reporting Method, Student Performance, and Student Motivation on a Veterinary Clinical Rotation

The purpose of this study was to investigate factors influencing student motivation for learning and performance on a small animal internal medicine (SAIM) rotation, with a particular emphasis on the impact of the type of grade reporting system utilized. Veterinary students rotating through 3-week SAIM rotations at the University of Georgia between March 4, 2013 and May 1, 2014 were randomized to receive either conventional pass/fail (CONV) or proxy discriminating letter grades (PROX) as their interim and final individual performance evaluations. Additionally, each student was asked to complete a motivation self-assessment questionnaire on the last day of the rotation to determine which factors contributed to their performance accomplishments and learning strategies during the rotation. A total of 157 students completed the SAIM rotation during the 14-month period, and 107 students completed the questionnaire. There was no difference in scores on interim or final performance evaluations between CONV and PROX groups. Results of questionnaire responses suggested that the type of grade reporting system utilized infrequently impacted student motivation to exceed performance standards and did not influence specific learning techniques employed during their clinical rotation. Ultimately, the value placed on patient care, client relations, and future professional success were the most commonly reported motivating factors by the clinical students.

How does feedback in mini-CEX affect students' learning response?

ObjectiveThis study was aimed to explore students’ learning response toward feedback during mini-CEX encounter.MethodsThis study used a phenomenological approach to identify the students’ experiences toward feedback during mini-CEX encounter. Data was collected using Focus Group Discussion (FGD) for all students who were in their final week of clerkship in the internal medicine rotation. There were 4 FGD groups (6 students for each group). All FGD were audio-taped and transcribed verbatim. The FGD transcripts were analyzed thematically and managed using Atlas-ti (version 7.0). ResultsFeedback content and the way of providing feedback on mini-CEX stimulated students’ internal process, including self-reflection, emotional response, and motivation. These internal processes encouraged the students to take action or do a follow-up on the feedback to improve their learning process. In addition, there was also an external factor, namely consequences, which also influenced the students’ reaction to the follow-up on feedback. In the end, this action caused several learning effects that resulted in the students’ increased self-efficacy, attitude, knowledge and clinical skill. ConclusionsFeedback content and the way of providing feedback on mini-CEX stimulates the students’ internal processes to do a follow-up on feedback. However, another external factor also affects the students’ decision on the follow-up actions. The follow-ups result in various learning effects on the students. Feedback given along with summative assessment enhances learning effects on students, as well. It is suggested that supervisors of clinical education are prepared to comprehend every factor influencing feedback on mini CEX to improve the students’ learning response.

High-fidelity medical simulation training improves medical students' knowledge and confidence levels in septic shock resuscitation.

BackgroundSeptic shock resuscitation bundles have poor compliance worldwide partly due to a lack of knowledge and clinical skills. High-fidelity simulation-based training is a new teaching technology in our faculty which may improve the performance of medical students in the resuscitation process. However, since the efficacy of this training method in our institute is limited, we organized an extra class for this evaluation.PurposeThe aim was to evaluate the effect on medical students’ knowledge and confidence levels after the high-fidelity medical simulation training in septic shock management.MethodsA retrospective study was performed in sixth year medical students during an internal medicine rotation between November 2015 and March 2016. The simulation class was a 2-hour session of a septic shock management scenario and post-training debriefing. Knowledge assessment was determined by a five-question pre-test and post-test examination. At the end of the class, the students completed their confidence evaluation questionnaire.ResultsOf the 79 medical students, the mean percentage score ± standard deviation (SD) of the post-test examination was statistically significantly higher than the pre-test (66.83%±19.7% vs 47.59%±19.7%, p<0.001). In addition, the student mean percentage confidence level ± SD in management of septic shock was significantly better after the simulation class (68.10%±12.2% vs 51.64%±13.1%, p<0.001). They also strongly suggested applying this simulation class to the current curriculum.ConclusionHigh-fidelity medical simulation improved the students’ knowledge and confidence in septic shock resuscitation. This simulation class should be included in the curriculum of the sixth year medical students in our institute.

App Use in Psychiatric Education: A Medical Student Survey.

The objective of the study is to understand and appraise app use by medical students during their clerkships. Following Creighton University IRB approval, a voluntary and anonymous paper-based, 15-question survey was distributed to third-year medical students. Data were analyzed using Microsoft Excel. Of 112 medical students available, 76.7% (86) participated in the survey. All participants owned a smartphone or tablet with 84.9% using Apple iOS, followed by 12.8% using Android platform. Students reported using the fewest number of apps during surgery, psychiatry, and obstetrics and gynecology clerkships. The largest number of apps were used during the internal medicine rotation (70.3%). The three most popular apps were Epocrates, UpToDate, and UWorld. The most common uses for these apps were as references during the clerkship, followed by improving knowledge, and test taking. Perceived major benefits included accessibility (96% of student respondents) and interactivity (39.5%). Common apps used during the psychiatry clerkship included UpToDate (71%), Epocrates (51%), and Medscape (43%). Despite less frequent app use during their psychiatry clerkship, 90% felt there was a utility for educational apps in psychiatric education. Consistent with the previous literature on medical students preferring educational apps, students suggest developers focus on question bank-type apps, followed by clinical support-focused and self-directed case-based learning apps for psychiatry clerkship learning. Educators should factor these modes of educational delivery into future educational app development. This survey shows a high degree of smartphone and tablet use among medical students, and they attest to mobile phone app utility in psychiatric education.

A Comparison of Third-year Medical Student Clinical and Examination Performances in a Traditional Psychiatry Clerkship to a Novel Pilot, LSI Curriculum

Objective: The goal of this study was to compare educational outcomes of medical students who participated in a longitudinal pilot curriculum to those who participated in the existing, traditional curriculum during their third-year of medical school. Method: The authors reviewed clinical evaluations and examination performances of 15 students enrolled in a pilot curriculum to 60 students who participated in the traditional curriculum. The nove Lead.Serve.Inspire. (LSI) curriculum consisted of a longitudinal integrated hybrid of internal medicine, neurology, and psychiatry rotations and didactic instruction spanning nearly four months. Results: The National Board of Medical Examiners (NBME) subject examination class averages of students enrolled in the combined internal medicine, neurology, and psychiatry pilot program were not significantly different compared to students completing these examinations and enrolled in the traditional block rotations during the same time period. On clinical performance measures in psychiatry, students performed above average on clinical measures of medical knowledge, communication skills, and diagnostic assessment and critical analysis skills. Conclusion: Preliminary data from the pilot program is promising, suggesting that the Lead.Serve.Inspire. (LSI) curriculum may offer an equitable alternative to the traditional discipline-specific block rotations.

Student and Faculty Perception of Objective Structured Clinical Examination: A Teaching Hospital Experience.

Introduction:The primary objective of this study was to explore student and faculty perception of the objective structured clinical examination (OSCE) to assess the clinical competence of 5th year medical students.Methods:Two validated tools were used to survey students' and faculty perception of the OSCE as an assessment tool. The questionnaires were self-administered and handed to the students immediately after the OSCE was conducted. Subjects were 29 female students who had completed their 3-week Internal Medicine rotation and 15 faculty members who had participated in evaluating the students. The response rate was 100%. The OSCE comprised of 21 active stations involving skills like history taking standardized patients were used, physical examination, and data interpretation for which real patients were used, physical examination, or management. Standardized or real patients were used in 16 stations.Results:Majority of students, 63.2% indicated that the OSCE assessed their skills fairly. This was also true for 80% thought the OSCE was a fair method of assessing students' skills as well as a better assessment tool than the traditional long/short case exams.Conclusion:The OSCE was positively perceived by 5th year medical students and faculty members as a tool that can fairly assess students' clinical skills.