Academic and professional career outcomes of medical school graduates who failed USMLE Step 1 on the first attempt.

This study sought to determine the academic and professional outcomes of medical school graduates who failed the United States Licensing Examination Step 1 on the first attempt. This retrospective cohort study was based on pooled data from 2,003 graduates of six Midwestern medical schools in the classes of 1997-2002. Demographic, academic, and career characteristics of graduates who failed Step 1 on the first attempt were compared to graduates who initially passed. Fifty medical school graduates (2.5 %) initially failed Step 1. Compared to graduates who initially passed Step 1, a higher proportion of graduates who initially failed Step 1 became primary care physicians (26/49 [53 %] vs. 766/1,870 [40.9 %]), were more likely at graduation to report intent to practice in underserved areas (28/50 [56 %] vs. 419/1,939 [ 21.6 %]), and more likely to take 5 or more years to graduate (11/50 [22.0 %] vs. 79/1,953 [4.0 %]). The relative risk of first attempt Step 1 failure for medical school graduates was 13.4 for African Americans, 7.4 for Latinos, 3.6 for matriculants >22 years of age, 3.2 for women, and 2.3 for first generation college graduates. The relative risk of not being specialty board certified for those graduates who initially failed Step 1 was 2.2. Our observations regarding characteristics of graduates in our study cohort who initially failed Step 1 can inform efforts by medical schools to identify and assist students who are at particular risk of failing Step 1.

Variables associated with full-time faculty appointment among contemporary U.S. Medical school graduates: implications for academic medicine workforce diversity.

PURPOSE: The authors sought to identify variables independently associated with full-time faculty appointment among recent medical graduates. METHOD: With institutional review board approval, the authors developed a database of individualized records for six midwestern medical schools' 1997-2002 graduates. Using multivariate logistic regression, they identified variables independently associated with full-time faculty appointment from among demographic, medical-school-related, and career-intention variables. They report adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Of 1,965 graduates in the sample, 263 (13.4%) held full-time faculty appointments in 2007-2008, including 14.4% (123/853) of women graduates and 8.6% (17/198) of underrepresented minority (URM) graduates. Women (OR: 1.386; 95% CI: 1.023-1.878), MD/PhD program graduates (OR: 2.331; 95% CI: 1.160-4.683), and graduates who reported a career-setting preference for "full-time university faculty" on the Association of American Medical Colleges' Graduation Questionnaire (OR: 3.164; 95% CI: 2.231-4.486) were more likely to have a full-time faculty appointment. Graduates who chose family medicine (OR: 0.433; 95% CI: 0.231-0.811) and surgical specialties (OR: 0.497; 95% CI: 0.249-0.994) were less likely to have a full-time faculty appointment. URM race/ethnicity was not independently associated with full-time faculty appointment (OR: 0.788; 95% CI: 0.452-1.375). CONCLUSIONS: Efforts to increase representation of women graduates in academic medicine seem to have met with greater success than efforts to increase representation of URM graduates. Greater participation of URM students in MD/PhD programs and in interventions during medical school that promote interest in academic medicine careers may increase URM graduates' representation in academic medicine.

Core clerkship directors: their current resources and the rewards of the role.

PURPOSE: To conduct a national multidisciplinary investigation assessing core clinical clerkships and their directors, variances in resources from national guidelines, and the impact of the clerkship director role on faculty members' academic productivity, advancement, and satisfaction. METHOD: A multidisciplinary working group of the Alliance for Clinical Education (ACE), representing all seven core clinical disciplines, created and distributed a survey to clerkship directors at 125 U.S. MD-granting medical schools, in academic year 2006-2007. RESULTS: A total of 544 clerkship directors from Internal Medicine (96), Family Medicine (91), Psychiatry, (91), Pediatrics (79), Surgery (71), Neurology (60), and Obstetrics-Gynecology (56) responded, representing over 60% of U.S. core clinical clerkships. The clerkship directors were similar across disciplines in demographics and academic productivity, though clinical and clerkship activities varied. Departmental staff support for clerkships averaged 0.69 people, distinctly less than the ACE's 2003 guideline of a full-time coordinator in all disciplines' clerkships. Clerkship directors reported heavy clinical responsibilities, which, as in previous studies, were negatively related to academic productivity. However, many clerkship directors felt the role enhanced their academic advancement; a large majority felt it significantly enhanced their career satisfaction. CONCLUSIONS: The resources and rewards of the clerkship director role were similar across disciplines. Expectations of clerkship directors were considerable, including responsibility for clinical material and the learning environment. Resources for many fall short of those stated in the ACE guidelines, particularly regarding support staff. However, the findings indicate that the clerkship director role can have benefits for academic advancement and strongly enhances career satisfaction.

Resources and rewards for clerkship directors: how surgery compares.

BACKGROUND: Clerkship directors (CDs) are key educators and active clinicians. In 2003, the Alliance for Clinical Education published standards for CD resources and responsibilities, but how reality compares is unknown. METHODS: Representatives from each core clinical disciplines' CD organizations created an electronic survey that CDs received in 2006-2007. RESULTS: More than 500 CDs responded, including 71 surgeons. Surgeons reported spending approximately 27% of professional time on education. Most have codirectors, so total CD effort approximates the greater than 50% Alliance for Clinical Education guidelines. No disciplines' CDs have more than one support staff as recommended. Surgeons have the least clinic time, but the most inpatient weeks and many publications. Surgery CD concerns are curricula and simulation; few believe being a CD impairs academic advancement and more than 95% believe it enhances work satisfaction. CONCLUSIONS: Surgery CDs are clinically active and academically productive. Although few surgery CDs have the recommended support staff, more than 95% report being a CD enhances work satisfaction.

Depressive symptoms in medical students and residents: a multischool study.

BACKGROUND: This multisite, anonymous study assessed depressive symptoms and suicidal ideation in medical trainees (medical students and residents). METHOD: In 2003-2004, the authors surveyed medical trainees at six sites. Surveys included content from the Center for Epidemiologic Studies-Depression scale (CES-D) and the Primary Care Evaluation of Mental Disorders (PRIME-MD) (measures for depression), as well as demographic content. Rates of reported major and minor depression and of suicidal ideation were calculated. Responses were compared by level of training, gender, and ethnicity. RESULTS: More than 2,000 medical students and residents responded, for an overall response rate of 89%. Based on categorical levels from the CES-D, 12% had probable major depression and 9.2% had probable mild/moderate depression. There were significant differences in depression by trainee level, with a higher rate among medical students; and gender, with higher rates among women (chi2 = 10.42, df = 2, and P = .005 and chi2 = 22.1, df = 2, and P < .001, respectively). Nearly 6% reported suicidal ideation, with differences by trainee level, with a higher rate among medical students; and ethnicity, with the highest rate among black/African American respondents and the lowest among Caucasian respondents (chi2 = 5.19, df = 1, and P = .023 and chi2 = 10.42, df = 3, and P = .015, respectively). CONCLUSIONS: Depression remains a significant issue for medical trainees. This study highlights the importance of ongoing mental health assessment, treatment, and education for medical trainees.

Are students learning what faculty are intending to teach?

BACKGROUND: Lectures are common in surgical clerkships, although faculty members rarely are trained in this skill. Previous authors have addressed the impact of lecture format, length, etc. on post-test performance, but little work has addressed students' free recall of information. This study was designed to explore what junior surgery students recall in relation to faculty objectives and lecture ratings. METHODS: Prior to surgery clerkship teaching sessions, faculty submitted three to six learning objectives. Immediately following these sessions, students completed lecture evaluations and described three to six concepts they learned. These qualitative data were coded as "general, specific," or "very specific," and categorized according to aspects such as "Treatment, Work-Up, Basic Science," etc. Student-derived themes and session ratings were analyzed relative to faculty objectives. RESULTS: Students provided 16-79 surveys for each of 10 faculty members, whose lecture ratings ranged from 4.9 to 6.1 on a scale of 7. Most of the 1818 statements were "very specific" or "specific" rather than "general" (14.4%). Students commonly recalled concepts related to treatment (28.6%), indications (12.1%), work-up (11.9%), basic science (9.5%), and prognosis/course of disease (9.2%). Four to 10 themes (mean 8, median 7, and mode 7) emerged for each lecture. The percentage of concepts provided by faculty that emerged from student themes (congruence) ranged from 50% to 100%. CONCLUSIONS: Surgery students freely recalled 50% to 100% of faculty teaching objectives, and the degree of congruence was loosely linked to lecture ratings. Future research is warranted regarding what influences congruence between faculty objectives and student recall.

Extra-intestinal manifestations of Crohn's disease.

Extra-intestinal manifestations occur in at least 25% of Crohn's disease patients. Some extra-intestinal manifestations, such as erythema nodusum and peripheral arthropathy, will wax and wane in keeping with bowel inflammation. The more severe cutaneous ulcerations, uveitis, and axial arthropathy may precede bowel disease or persist after it subsides. Screening may be appropriate for eye disease and for osteoporosis to prevent complications. Medical management for extra-intestinal manifestations is similar to treatment for the bowel symptoms of Crohn's disease, with corticosteroids the mainstay. Pain and depression are associated with inflammatory bowel disease, and their control benefits patients. Recent small studies with anti-tumor necrosis factor (TNF) agents are promising for most extra-intestinal manifestations of Crohn's disease, and may permit more steroid-sparing disease control in the future.

Which U.S. medical graduates plan to become specialty-board certified? Analysis of the 1997-2004 national association of American Medical Colleges Graduation Questionnaire database.

BACKGROUND: Predictors of U.S. allopathic medical-school graduates' board-certification plans have not been characterized. METHOD: Using multivariable logistic regression, graduates' responses to 11 questions on the 1997-2004 Association of American Medical Colleges Graduation Questionnaire were analyzed to identify independent predictors of plans for specialty-board certification. RESULTS: The proportion of 108,408 graduates planning specialty-board certification decreased from 97.3% in 1997 to 88.4% in 2004. Among 101,805 (93.9%) graduates with complete data, graduates who were Hispanic, rated their clinical clerkships, quality of medical education, and confidence in clinical skills more highly, had any debt, and planned "University-faculty" careers were more likely to plan becoming board certified. Females, Asians/Pacific Islanders, and graduates who planned to practice in underserved areas, planned "other" nonclinical-practice careers, and graduated with MD/other (non-PhD) degrees were less likely to plan becoming board certified. CONCLUSION: Specialty-board certification does not appear to be among the professional goals for a growing proportion of U.S. medical graduates.

The resident view of professionalism behavior frequency in outstanding and "not outstanding" faculty.

BACKGROUND: Professionalism assessment has become necessary for all postgraduate training programs because it is now required for accreditation. To validate the novel items we generated to assess professionalism, we tested whether residents' ratings of faculty they judged as outstanding in professionalism would be distinguishable from those they judged as not outstanding. METHODS: Educators from core clinical disciplines generated 20 items assessing professionalism behaviors on a 7-point frequency scale anchored by "always" and "never." Thirty-five surgical and pediatric residents completed the form twice, anonymously rating 1 faculty member they judged as outstanding and another they judged as not outstanding. RESULTS: The residents produced 69 faculty ratings with means that differed significantly on all items between the outstanding and not-outstanding faculty. The form was highly unidimensional, with the primary factor's eigenvalue being 11.5 and Cronbach's alpha being 0.97. Groups differed most on items, ie, "listens well," "inspires trust," "answers questions directly," and "demonstrates respect for all." CONCLUSION: The behaviors that best distinguished clinical faculty judged by residents as outstanding professionals were listening, trustworthiness, answering directly, and respect.

Temporarily impaired surgeons and calling for help.

Surgeons who are ill must sometimes make their own judgments about their fitness to operate. The profession might consider more explicitly how surgeons make such judgments.

Intracerebroventricular calcitonin prevents stress-induced gastric dysfunction.

BACKGROUND: Restraint stress produces gastric hypercontractility and acidity leading to stress ulceration. Intracerebroventricular (ICV) salmon calcitonin (sCT) decreases restraint injury and acidity, but its effects on restraint-induced hypercontractility are unknown. METHODS: Using stereotactic guidance, ICV catheters were placed into the lateral ventricle of adult male rats and calibrated gastric strain gauge transducers were implanted 5 days prior to restraint stress. sCT rats (n = 8) were pretreated with 5 microg of calcitonin ICV (10 microl volume), while controls (n = 10) received 10 microl of ICV saline prior to restraint for 2 h at 20 degrees C followed by 2 h at 4 degrees C. Gastric motility data were collected with AT-CODAS and analyzed with ADVANCED CODAS. Gastric volume, pH, and lesions were recorded following the stress. RESULTS: ICV calcitonin prevented gastric mucosal injury in all animals (0% vs 100%, P <.01) and elevated pH slightly (2.5 +/-.3 vs 1.6 +/-.1, P <.05). Stress caused the force of contractions to increase from 0.35 +/-.1 to 1.38 +/-.4 g in controls (P <.01), while treated animal's force fell from.42 +/-.1 to 0.2 +/-.05 g (P <.01 vs control). Stress did not affect contractions/min (3.4 +.6 vs 3.5 +.3), but sCT increased frequency (2.5 +.4 to 5.0 +.2, P <.01). Stress prolonged contraction duration (11.5 + 1 to 16.5 + 1.7 s, P <.01), but stress's effect was prevented by sCT (11.0 +.5 to 11.2 +.3, P <.01 vs control). CONCLUSIONS: Pretreatment with 5 microg central sCT prevents the increased amplitude and duration of gastric contractions produced by restraint stress for 2 h, in association with gastroprotection.

Mechanisms of impaired gallbladder contractile response in chronic acalculous cholecystitis.

The mechanisms involved in the impaired gallbladder contractile response in chronic acalculous cholecystitis are unknown. To determine the mechanisms that may lead to impaired gallbladder emptying in chronic acalculous cholecystitis, gallbladder specimens removed during hepatic resection (controls) and after cholecystectomy for chronic acalculous cholecystitis were attached to force transducers and placed in tissue baths with oxygenated Krebs solution. Electrical field stimulation (EFS) (1 to 10 Hz, 0.1 msec, 70 V) or the contractile agonists, CCK-8 (10(-9) to 10(-5)) or K(+) (80 mmol/L), were placed separately in the tissue baths and changes in tension were determined. Patients with chronic acalculous cholecystitis had a mean gallbladder ejection fraction of 12% +/- 4%. Pathologic examination of all gallbladders removed for chronic acalculous cholecystitis revealed chronic cholecystitis. Spontaneous contractile activity was present in gallbladder strips in 83% of control specimens but only 29% of gallbladder strips from patients with chronic acalculous cholecystitis (P < 0.05 vs. controls). CCK-8 contractions were decreased by 54% and EFS-stimulated contractions were decreased by 50% in the presence of chronic acalculous cholecystitis (P < 0.05 vs. controls). K(+)-induced contractions were similar between control and chronic acalculous cholecystitis gallbladder strips. The impaired gallbladder emptying in chronic acalculous cholecystitis appears to be due to diminished spontaneous contractile activity and decreased contractile responsiveness to both CCK and EFS.