Medical Student H&Ps: Do You Have to Observe Them All At Once?

OBJECTIVES: Direct observation of medical students' history and physical examination (H&P) skills by attendings is essential in ensuring trainees' competence. This study compared whether partial observations by multiple pediatric attendings across various clinical encounters versus a full observation by one attending affected students' performance on the pediatric Objective Structured Clinical Examination (OSCE) and the Year 3 Clinical Performance Examination (CPX3). METHODS: For the 2013-2014 and 2014-2015 academic years, 323 medical students submitted either H&P checklists completed by one attending observing an entire H&P (full observations) versus multiple attendings observing portions of the H&P (partial observations). The full and partial observation groups were compared by their pediatric OSCE and CPX3 performance. RESULTS: Students submitting full observations (n = 185) versus partial observations (n = 138) revealed no difference in OSCE (3.10 vs 3.10, P = 0.98) or CPX3 scores (74.49 vs 75.31, P = 0.18). Students submitting checklists by clerkship midpoint performed better on the OSCE (3.11 vs 2.88, P = 0.001) and CPX3 (75.00 vs 72.25, P = 0.03). CONCLUSIONS: Partial versus full observations of students' H&P skills have no effect on standardized clinical examination performance, and clerkships should consider using partial observations of students for efficient assessments. Promptness of checklist submission also may be an indicator of examination performance.

Effect of 80-hour workweek on continuity of care.

Work limitations were mandated (2003) to increase safety and improve resident lifestyle. Is clinic continuity affected? Medical University of South Carolina pediatric residents' records for 6 months of 2002 (before regulation) and 2003 (after regulation) were reviewed. Continuity for physician formula, t tests, and multivariate linear regression were used. Continuity was calculated for 44 residents (2002) and 45 residents (2003). Mean continuity was 54% (2002) and 53% (2003; P = .5); continuity for well-child care visits was 78% (2002) and 73% (2003; P = .047). Continuity decreased most for interns (52% [2002], 47% [2003] for all visits; 76%, 67% for well-child care visits). In the multivariate model, year did not predict continuity. When only well-child care visits were considered, year showed a trend toward significance ( P = .07): 2003 had less continuity. Compared with third-year residents, interns had 8% points less continuity for all visits (6% points less for well-child care visits). Continuity can be maintained despite regulations. Interns are most vulnerable.

Time in continuity clinic as a predictor of continuity of care for pediatric residents.

OBJECTIVE: In 1996, the Residency Review Committee-Pediatrics recommended doubling time in continuity clinic to 2 half days per week. It has yet to be demonstrated that increased time in clinic yields greater continuity of care. The objective of this study was to determine whether increasing the number of half days spent in clinic improves continuity of care for residents. METHODS: We reviewed computerized encounter records for all Medical University of South Carolina pediatric residents from 1982 to 1998. Depending on the year and the resident's training level, house staff spent varying amounts of time in continuity clinic. Time in clinic was estimated from grants and materials generated in the residency program. We calculated continuity of care from the resident's perspective for each individual resident per year using the Continuity for Physician (PHY) formula. RESULTS: Continuity for 488 resident-years (200 residents) was evaluated. Residents spent from 10% to 30% of their time per year in clinic. Mean PHY was 57% (interns), 62% (second-year residents), and 52% (third-year residents). The correlation coefficient (R) between PHY and percentage of time in clinic was .22. In multivariable modeling, percentage of time in clinic, training level, and year predicted continuity. An increase of 1 half day in clinic was associated with an 11% increase in physician continuity. When analyses were limited to sick visits, R improved to .58. The effect size remained 11%. However, training level and academic year were no longer significant. CONCLUSION: Increasing time spent in clinic improves continuity and may indeed enhance the quality of this fundamental experience.

Potential cost savings of decreased emergency department visits through increased continuity in a pediatric medical home.

PURPOSE: To determine the potential cost savings of decreased emergency department (ED) visits resulting from increased continuity of care provided in a pediatric medical home. METHODS: An economic modeling study comparing the cost of ED visits associated with average continuity of care versus the cost of ED visits associated with a 10% point increase in continuity was performed. This model's premise is that increased continuity will decrease care in the ED. Parameters of the model included average continuity of care and expected use of the ED by pediatric patients as well as the relationship between these two variables. Parameters were estimated from the literature. Average continuity, as measured by the Continuity of Care Index by Bice and Boxerman, was determined to be 40%. Average ED use was estimated to be 0.68 visits/child per year. Continuity of care was stratified into low, medium, and high levels. The Medical University of South Carolina's ED charges were used. An average pediatric practice was estimated to contain 2000 patients. RESULTS: Two hypothetical practices of 2000 patients each were created to represent pediatric medical homes: practice 1 received 40% continuity and practice 2 received 50%. The model's outcome was measured in terms of expected ED charges per practice averted over a 1-year period. Increasing continuity of care by 10% points yielded a decline in expected ED visits from 1362 to 1290 per practice: 19,905 US dollars was saved. CONCLUSION: Continuity of care can yield many benefits, including cost savings from decreased charges associated with less frequent ED use.

Risk factors for microalbuminuria in children with sickle cell anemia.

PURPOSE: To determine the prevalence of microalbuminuria and to establish clinical characteristics associated with microalbuminuria in children with sickle cell anemia. PATIENTS AND METHODS: Urine samples of all children (homozygous SS) followed in the Medical College of Georgia's Children's Medical Center Sickle Cell Clinic were screened for microalbuminuria. Random samples were obtained from continent patients at routine office visits between September 1996 and November 1999. A retrospective chart survey was performed to determine clinical correlates for microalbuminuria. Medical records were reviewed for age, sex, hemoglobin, and episodes of pneumonia, pain, aplasia, acute chest syndrome, priapism, and avascular necrosis. Demographic and clinical variables were compared with microalbuminuria by univariate and multivariate logistic regression. RESULTS: One hundred forty-two patients ages 21 months to 20 years made up the study group. The prevalence of microalbuminuria was 19%. Both increasing age and a lower hemoglobin level were found to correlate with microalbuminuria. By multivariate analysis, boys with microalbuminuria were likely to have a lower hemoglobin level and girls with microalbuminuria were likely to be older. None of the following factors were significantly related to microalbuminuria: pain, pneumonia, acute chest syndrome, priapism, avascular necrosis, or aplastic episodes. CONCLUSIONS: Microalbuminuria is strongly and directly related to age and strongly and inversely related to hemoglobin levels. Identification of risk factors for microalbuminuria may allow earlier intervention to prevent renal complications in patients with sickle cell disease.