Expanding the Traditional History and Physical Examination to Address Chronic Diseases and Social Needs: A Multisite Randomized Control Trial of 4 Medical Schools.

PURPOSE: This study gathers validity evidence of an expanded History and Physical examination (H&P 360) to address chronic diseases through incorporation of biopsychosocial elements that are lacking in traditional H&P assessments via a multisite randomized controlled trial among medical students. METHOD: Third- and fourth-year medical students (n = 159) at 4 schools participated in an Objective Structured Clinical Examination designed with 2 cases for chronic disease. Students were randomized into the treatment group, which involved brief written instructions on how to use the H&P 360 followed by a standardized patient (SP) interaction, or the control group, which used the traditional H&P in an SP interaction without additional instructions. Validity evidence was gathered for content (alignment with an empirically derived expanded history list), response process (feedback from raters and learners on the process), internal structure (reliability and item-level psychometrics), relations to other variables (comparison between treatment and control groups), and consequences (survey results from learners on experience). RESULTS: H&P 360 items were blueprinted by faculty experts. SP observation checklist grading was consistent, and postassessment debrief confirmed favorable educational experience among learners. The reliability of the H&P 360 was .76. Overall mean scores on the H&P 360 content (mean = 15.96, standard deviation [SD] = 3.66) were significantly higher compared with the traditional H&P (mean = 10.99, SD = 2.69, Cohen's d = 1.17, P < .001). CONCLUSIONS: Medical students using the H&P 360 collected significantly more biopsychosocial information compared with students using the traditional H&P, providing empirical support for teaching and assessing biopsychosocial information. The assessment demonstrated strong validity evidence supporting the use of the H&P 360 assessment in medical schools.

Do audition electives impact match success?

PURPOSE: The authors sought to determine the value of the audition elective to the overall success of medical students in the match. METHOD: The authors surveyed 1,335 fourth-year medical students at 10 medical schools in 2013. The study took place over a 2-month period immediately following the match. Medical students were emailed a 14-question survey and asked about audition electives, rank order, and cost of 'away' rotations. RESULTS: One hundred percent of students wishing to match in otolaryngology, neurosurgery, plastic surgery, radiation oncology, and urology took the audition electives. The difference by specialty in the proportion of students who took an audition was statistically significant (p<0.001). Of the students who auditioned, 71% matched at one of their top three choices compared with 84% of non-auditioners who matched to one of their top three choices (p<0.01). CONCLUSIONS: Students performed a large number of 'away' rotations as 'auditions' in order to improve their chances in the match. For certain competitive specialties, virtually all students auditioned. Overall, students who did not audition were just as successful as or more successful than students who did audition.

Reactivation of pulmonary tuberculosis following local radiation therapy of prostate cancer.

In this report, we describe the case of an 81-year-old male with reactivation tuberculosis following local radiation therapy for prostate cancer. The patient was asymptomatic except for an unintentional 20-pound weight loss and was incidentally found to have a pulmonary infiltrate in the right upper lobe on imaging for shoulder pain. The medical history was not able for recently treated prostate cancer. After further investigation, the patient was determined to have Mycobacterium tuberculosis infection. It is important to have a high level of suspicion for reactivation tuberculosis in patients with a pulmonary infiltrate following radiation therapy due to the impact of radiation on the host's immune system. We will review the literature on reactivation tuberculosis following radiation therapy and explore the mechanism of immunosuppression in this process. To our knowledge, this is the first reported case of tuberculosis reactivation following local radiation therapy for prostate cancer.

A core physical exam for medical students: results of a national survey.

PURPOSE: Medical students are traditionally taught the physical exam as a comprehensive battery of maneuvers, yet they express uncertainty about which maneuvers are "core" and should be performed routinely on patients and which ones should be performed only when clinically indicated. The authors sought to determine whether educator consensus existed on the concept and the specifics of a core physical exam for students. METHOD: The authors developed a 45-maneuver core physical exam to be performed by a medicine clerkship student on every newly admitted patient, with the expectation that it would be supplemented by clinically indicated additional maneuvers. From 2011 to 2012 they sent surveys to physical diagnosis course directors (PDCDs) and internal medicine clerkship directors (IMCDs) from all 132 U.S. allopathic medical schools to determine the extent of their agreement with the proposed 45 maneuvers and their opinions about the concept of a core exam. RESULTS: Seventy-one percent (94/132) of PDCDs and 63% (83/132) of IMCDs responded to the survey. In total, 84% (111/132) of all schools surveyed were represented by either their PDCD or IMCD. Of the 45 proposed maneuvers, 37 were deemed "core" by a majority of respondents. The majority of IMCDs preferred a slightly leaner 37-maneuver core exam than the majority of PDCDs, who voted for 41 maneuvers. CONCLUSIONS: Among PDCDs and IMCDs, there was openness to teaching medical students a streamlined core physical exam to which other maneuvers are added as clinically indicated. These educators closely agreed on the maneuvers this core exam should include.

Teaching medical students how to teach: a national survey of students-as-teachers programs in U.S. medical schools.

PURPOSE: A number of U.S. medical schools started offering formal students-as-teachers (SAT) training programs to assist medical students in their roles as future teachers. The authors report results of a national survey of such programs in the United States. METHOD: In 2008, a 23-item survey was sent to 130 MD-granting U.S. schools. Responses to selective choice questions were quantitatively analyzed. Open-ended questions about benefits and barriers to SAT programs were given qualitative analyses. RESULTS: Ninety-nine U.S. schools responded. All used their medical students as teachers, but only 44% offered a formal SAT program. Most (95%) offered formal programs in the senior year. Common teaching strategies included small-group work, lectures, role-playing, and direct observation. Common learning content areas were small-group facilitation, feedback, adult learning principles, and clinical skills teaching. Assessment methods included evaluations from student-learners (72%) and direct observation/videotaping (59%). From the qualitative analysis, benefit themes included development of future physician-educators, enhancement of learning, and teaching assistance for faculty. Obstacles were competition with other educational demands, difficulty in faculty recruitment/retention, and difficulty in convincing others of program value. CONCLUSIONS: Formal SAT programs exist for 43 of 99 U.S. medical school respondents. Such programs should be instituted in all schools that use their students as teachers. National teaching competencies, best curriculum methods, and best methods to conduct skills reinforcement need to be determined. Finally, the SAT programs' impacts on patient care, on selection decisions of residency directors, and on residents' teaching effectiveness are areas for future research.

Using web-based video to enhance physical examination skills in medical students.

BACKGROUND AND OBJECTIVES: Physical examination (PE) skills among U.S. medical students have been shown to be deficient. This study examines the effect of a Web-based physical examination curriculum on first-year medical student PE skills. METHODS: Web-based video clips, consisting of instruction in 77 elements of the physical examination, were created using Microsoft Windows Moviemaker software. Medical students' PE skills were evaluated by standardized patients before and after implementation of the Internet-based video. RESULTS: Following implementation of this curriculum, there was a higher level of competency (from 87% in 2002-2003 to 91% in 2004-2005), and poor performances on standardized patient PE exams substantially diminished (from a 14%-22%failure rate in 2002-2003, to 4% in 2004-2005. CONCLUSIONS: A significant improvement in first-year medical student performance on the adult PE occurred after implementing Web-based instructional video.

Long-term retention of smoking cessation counseling skills learned in the first year of medical school.

BACKGROUND: Tobacco use is a significant cause of preventable morbidity and mortality in the United States, yet clinicians underutilize smoking cessation counseling. Medical schools are increasingly including training for smoking cessation skills in preclinical curricula. Information about long-term retention of these skills is needed. OBJECTIVE: To assess retention of smoking cessation counseling skills learned in the first year of medical school. DESIGN: Retrospective review of data collected for routine student and curriculum assessment. PARTICIPANTS: Two cohorts of medical students at the University of Connecticut School of Medicine (total N = 112) in 1999-2001 and 2002-2004. MEASUREMENTS AND MAIN RESULTS: Scores by standardized patients were compared from first and fourth-year assessments, based on checklist items corresponding to the 5 strategies recommended by the U.S. Public Health Service (Ask, Advise, Assess, Assist, Arrange). In study cases, 97% of first-year students "asked" about smoking and retained this skill in fourth year (p = .08). Ninety-four percent of first-year students "assessed" readiness to quit and retained this skill (p = .21). Ninety-six percent of first-year students "advised" smokers to quit and retained this skill (p = .18). Eighty-six percent of first year students "assisted" smokers in quitting and retained this skill (p = 0.10). Eighty-one percent of first year students "arranged" follow-up contact and performance of this strategy improved in the fourth year to 91% (p = .03). CONCLUSIONS: Smoking cessation counseling skills demonstrated by first year medical students were, with brief formal reinforcement in the third year, well retained into the fourth year of medical school. It is appropriate to begin this training early in medical education.

Face-to-face clinical skills feedback: lessons from the analysis of standardized patient's work.

BACKGROUND: Current evidence suggests that trainees are evaluated less stringently when feedback is given face-to-face, limiting its value. PURPOSE: We expected that standardized patients (SPs) would also be more lenient in scoring when they gave immediate feedback to the students. METHODS: Data from 6 clinical skills assessments of students in Years 1 to 4 of medical school were used. Comparisons in scoring were made for the cases on which students received feedback and those where they did not. Analysis was done using a hierarchical linear regression model to test for significant differences. RESULTS: The results indicated no significant difference in scoring for the history and physical exam checklists. There was a small but significant difference on the measure of interpersonal and interviewing skills. CONCLUSIONS: The SPs were trained to avoid stringency, leniency, and restricted range in scoring students. These training methods may be useful for training faculty to give face-to-face feedback.