Medical Error Disclosure: An Entrustable Professional Activity During an Objective Standardized Clinical Examination for Clerkship Students.

Introduction: Most health care providers will be involved in a medical error during their careers. It is critical that future physicians receive formal training on error disclosure. Methods: We designed a formative skills-based objective standardized clinical exam (OSCE) for fourth-year medical students to assess competence in disclosing an error during a required entrustable professional activity. Faculty observed the encounter and completed a checklist evaluating students' performance in communication skills and content knowledge. Students received immediate formative feedback. They then participated in a facilitated case-based experience, discussed the critical elements of disclosure, utilized role-play to reinforce skills, and reflected on self-care practices. Finally, students completed a survey evaluating their perception of the OSCE's impact on their disclosure knowledge, skills, and attitudes. Results: Ninety-two students participated in the OSCE. Of those, 67 (73%) completed a retrospective pre/post survey assessing their disclosure knowledge, skills, and attitudes. Forty-one (62%) did not identify the error. Students who identified the error (26, 39%) were more likely to use the two-patient identifier than students who did not identify the error, χ2(1) = 13.3, p < .001. Self-reported comfort and confidence in disclosure improved, as did self-care practices (ps ≤ .005). Discussion: Students agreed that health care providers should disclose an error and know how to do so. Student self-reported comfort in disclosure and knowledge of how to disclose and how to report an error all improved following the OSCE and structured debrief. The OSCE and case-based experience can be adapted for implementation in curricula about error disclosure.

A multisite randomized trial of implicit versus explicit modeling in clinical teaching.

PURPOSE: Faculty modeling of desired behaviors has historically been a part of the apprenticeship model of clinical teaching, yet little is known about best practices for modeling. This study compared the educational impact of implicitly versus explicitly modeled communication skills among U.S. medical students. METHOD: Fourth-year medical students from six U.S. academic medical centers were randomly assigned one simulated clinical encounter in which faculty provided either implicit or explicit modeling of important communication skills. Outcomes were assessed by electronic surveys immediately before and after the simulations. Students were blinded to the purpose of the study. RESULTS: Students in the explicit arm were more likely to correctly cite two of the three key specific communication elements modeled by faculty: deliberate body position (53.3% vs. 18.6%, p < 0.001) and summarizing patient understanding (62.2% vs. 11.6%, p < 0.001). More students in the explicit study arm reported faculty 'demonstrated a key behavior that they wanted me to be able to perform in the future' (93.2% versus 62.8%, p = 0.002). Participating faculty stated they would modify their teaching approach in response to their experiences in the study. CONCLUSIONS: In a multi-center randomized trial, explicit faculty role-modeling led to greater uptake of communication knowledge, greater recognition of skills, and a greater sense that faculty expected these skills to be adopted by students. These results must be considered in the context, however, of a simulated environment and a short timeframe for assessing learning with students who volunteered for a simulated experience.

Reading and Study Habits of Medical Students on Clerkships and Performance Outcomes: a Multi-institutional Study.

PURPOSE: To describe medical students' reading habits and resources used during clinical clerkships, and to assess whether these are associated with performance outcomes. METHOD: Authors administered a cross-sectional survey to medical students at 3 schools midway through the clerkship year. Closed and open-ended questions focused on resources used to read and learn during the most recent clerkship, time spent and purpose for using these resources, influencers on study habits, and barriers. A multiple regression model was used to predict performance outcomes. RESULTS: Overall response rate was 53% (158/293). Students spent most of their time studying for clerkship exams and rated question banks and board review books as most useful for exam preparation. Sixty-seven percent used textbooks (including pocket-size). For patient care, online databases and pocket-sized textbooks were rated most useful. The main barrier to reading was time. Eighty percent of students ranked classmates/senior students as most influential regarding recommended resources. Hours spent reading for exams was the only significant predictor of USMLE Step 2 scores related to study habits. The predominant advice offered to future students was to read. CONCLUSIONS: These findings can help inform students and educational leadership about resources students use, how they use them, and links to performance outcomes, in an effort to guide them on maximizing learning on busy clerkships. With peers being most influential, it is important not only to provide time to help students build strong reading and study habits early, but also to guide them towards reliable resources, so they will recommend useful information to others.

Student Perception of Case-based Teaching by Near-Peers and Faculty during the Internal Medicine Clerkship: A Noninferiority Study.

INTRODUCTION: Third-year medical students traditionally receive their didactic or small group teaching sessions from clinical faculty during clerkship rotations. Near-peer teaching is increasingly recognized as an acceptable method for teaching, however most near-peer teaching takes place during the pre-clinical curriculum. We sought to determine if fourth year medical students were noninferior to faculty in facilitating small group discussions during clerkship rotations. METHODS: Seventy-five third-year medical students participated in a small group session focused on rheumatologic diseases during their internal medicine clerkship rotation. Students were taught by fourth-year medical students who self-selected to participate as near-peer teachers at 1 clinical site (near-peers, N = 36) and by clinical faculty at another site (N = 39). At the end of the session, third-year medical students completed a survey evaluating teacher performance and effectiveness. RESULTS: There was no significant difference between the 2 groups on each of the 17 survey items assessing teacher performance, the total teaching performance score, and the teaching effectiveness rating (all P-values >.05). A mean between-group difference of 2% in favor of the near-peers indicated noninferiority of the near-peer teachers compared with faculty teachers on the total teaching performance score. An absolute difference of 14% in favor of the near-peers indicated noninferiority of the near-peer teachers compared with faculty teachers on the teaching effectiveness score. Near-peer teachers reported several benefits, including improving their own medical knowledge and skills as a future educator. DISCUSSION: Our data supports the noninferiority of the perceived performance and effectiveness of near-peer teachers compared to faculty teachers in the clerkship setting. Adding near-peer teachers to the clerkship setting is feasible and can be beneficial to all stakeholders.

Incoming Interns Perceived Preparedness for Core Entrustable Professional Activities.

INTRODUCTION: The AAMC described 13 core entrustable professional activities (EPAs) for which every graduating medical student should perform proficiently on day 1 of residency. We studied how prepared starting interns felt in the core EPAs. METHODS: Interns from a diverse health system were surveyed on how well medical school prepared them in the 13 core EPAs. Data were collected on type of medical school, participation in an acting/sub-internship (AI/SI), knowledge of EPAs, and participation in an EPA experience. RESULTS: We collected 224 surveys out of 384 (58%) interns. 61.2% attended allopathic, 14.6% attended osteopathic, and 24.2% attended international schools. 67% had not heard of EPAs. 29% had an EPA experience of which 82% were required. 80% or more felt prepared in all EPAs except orders (60.7%) and handovers (73%). Allopathic interns were significantly more likely to have heard of EPAs and participated in an EPA experience than international. Allopathic interns felt more prepared than international in oral presentations and evidence-based medicine. Interns who participated in an EPA experience felt more prepared for oral presentation and evidence-based medicine. There were small but significant differences in feeling prepared in certain EPAs and types of AI/SI taken. CONCLUSION: The majority of interns entering residency have not heard of EPAs with fewer than 1/3 of interns participating in an EPA experience. International graduates were less likely to be aware or have experience with EPAs and report being less prepared in oral presentation and evidence-based medicine compared to allopathic graduates.

Incorporation of an Interprofessional Palliative Care-Ethics Experience Into a Required Critical Care Acting Internship.

Introduction: The literature documents inadequate palliative medicine training in undergraduate and graduate medical education. As the population lives longer, many people will experience multiple chronic illnesses and the associated symptom burden. All physicians involved in clinical care of patients need to be equipped with the knowledge, attitudes, and skills necessary to provide palliative care, yet most physicians do not feel adequately prepared. We designed a curriculum to provide a meaningful palliative care-ethics (PCE) clinical experience to prepare senior medical students for future practice regardless of specialty choice. Methods: The Zucker School of Medicine at Hofstra/Northwell integrated a PCE experience into the required 4-week acting internship in critical care (AICC). Students met weekly with an interprofessional faculty member and presented clinical cases focusing on communication and/or bioethical challenges. Faculty facilitators ensured that the presentations integrated discussion of communication skills. During the final session, students shared written reflections. Students were invited to complete a satisfaction survey postrotation and 1 year after graduation. Results: The curriculum was evaluated positively by the graduating classes of 2015 (n = 28) and 2016 (n = 56) at the end of the course and 1 year postgraduation. Qualitative analysis of the class of 2018 fourth-year students' reflective writing demonstrated themes of role modeling, suffering, family, and goals of care. Discussion: It is feasible to incorporate an interprofessional PCE experience into a required AICC. Students indicated a better understanding of palliative care and, at 1 year postgraduation, reported feeling comfortable caring for patients with serious illness.

Program Director Perceptions of Proficiency in the Core Entrustable Professional Activities.

BACKGROUND: The Association of American Medical Colleges describes 13 core entrustable professional activities (EPAs) that every graduating medical student should be expected to perform proficiently on day 1 of residency, regardless of chosen specialty. Studies have shown wide variability in program director (PD) confidence in interns' abilities to perform these core EPAs. Little is known regarding comparison of United States Medical Licensing Examination (USMLE) scores with proficiency in EPAs. OBJECTIVE: We determined if PDs from a large health system felt confident in their postgraduate year 1 residents' abilities to perform the 13 core EPAs, and compared perceived EPA proficiency with USMLE Step 1 and Step 2 scores. METHODS: The PDs were asked to rate their residents' proficiency in each EPA and to provide residents' USMLE scores. Timing coincided with the reporting period for resident milestones. RESULTS: Surveys were completed on 204 of 328 residents (62%). PDs reported that 69% of residents (140 of 204) were prepared for EPA 4 (orders/prescriptions), 61% (117 of 192) for EPA 7 (form clinical questions), 68% (135 of 198) for EPA 8 (handovers), 63% (116 of 185) for EPA 11 (consent), and 38% (49 of 129) for EPA 13 (patient safety). EPA ratings and USMLE 1 and 2 were negatively correlated (r(101) = -0.23, P = .031). CONCLUSIONS: PDs felt that a significant percentage of residents were not adequately prepared in order writing, forming clinical questions, handoffs, informed consent, and promoting a culture of patient safety. We found no positive association between USMLE scores and EPA ratings.

Developing and Implementing a Multisource Feedback Tool to Assess Competencies of Emergency Medicine Residents in the United States.

OBJECTIVES: Multisource feedback (MSF) has potential value in learner assessment, but has not been broadly implemented nor studied in emergency medicine (EM). This study aimed to adapt existing MSF instruments for emergency department implementation, measure feasibility, and collect initial validity evidence to support score interpretation for learner assessment. METHODS: Residents from eight U.S. EM residency programs completed a self-assessment and were assessed by eight physicians, eight nonphysician colleagues, and 25 patients using unique instruments. Instruments included a five-point rating scale to assess interpersonal and communication skills, professionalism, systems-based practice, practice-based learning and improvement, and patient care. MSF feasibility was measured by percentage of residents who collected the target number of instruments. To develop internal structure validity evidence, Cronbach's alpha was calculated as a measure of internal consistency. RESULTS: A total of 125 residents collected a mean of 7.0 physician assessments (n = 752), 6.7 nonphysician assessments (n = 775), and 17.8 patient assessments (n = 2,100) with respective response rates of 67.2, 75.2, and 77.5%. Cronbach's alpha values for physicians, nonphysicians, patients, and self were 0.97, 0.97, 0.96, and 0.96, respectively. CONCLUSIONS: This study demonstrated that MSF implementation is feasible, although challenging. The tool and its scale demonstrated excellent internal consistency. EM educators may find the adaptation process and tools applicable to their learners.

Hypotension is uncommon in patients presenting to the emergency department with non-traumatic cardiac tamponade.

BACKGROUND: Cardiac tamponade is a life-threatening disease in which hypotension is believed to be a common finding. Prior inpatient studies have described normotensive or hypertensive cases of tamponade; however, because the data were not collected from the Emergency Department (ED), the hemodynamic spectrum may differ from those presenting to the ED. OBJECTIVES: We hypothesized that hypotension is uncommon in patients presenting to the ED with non-traumatic tamponade. METHODS: A retrospective chart review was conducted between January 2002 and December 2007 of patients presenting to our ED who were subsequently diagnosed with cardiac tamponade. RESULTS: A total of 34 patients were identified with a diagnosis of tamponade. The mean blood pressure on ED arrival was 131/79mm Hg. Upon initial presentation to the ED, 35% (n=12) of patients were hypertensive, 50% (n=17) were normotensive, and 15% (n=5) were hypotensive. Of the 5 patients who were hypotensive on ED arrival, only 2 (6% of all patients) remained hypotensive upon admission to the hospital and before a pericardiocentesis. An average of 995mL of fluid was removed from the pericardium. The chief complaint for the majority of patients in tamponade was shortness of breath (70%); 59% were tachycardic in the ED, and 72% had cardiomegaly on chest X-ray study. CONCLUSIONS: Hypotension is uncommon in patients presenting to the ED with non-traumatic cardiac tamponade. The majority of patients are normotensive or even hypertensive. Thus, the emergency physician should not exclude the diagnosis of tamponade even in light of normotension or hypertension.