Do clerkship experiences affect medical students' attitudes toward chronically ill patients?

PURPOSE: To measure changes in medical students' attitudes toward chronically ill patients, and to identify experiences, specifically during clerkships, that contributed to students' attitudes. METHOD: A cohort of students from five U.S. medical schools voluntarily participated in three surveys longitudinally administered before and after required clinical rotations. The first two questionnaires were identical and asked for demographic information and pre-matriculation experiences with chronically ill patients. The third was modified to include questions about clinical experiences with chronically ill patients. Responses from the first and third questionnaires were linked for analysis. RESULTS: A total of 502 of 695 students (69%) completed both the first and the third questionnaires. Many students (36%) had had pre-matriculation experiences with chronic illness. After clinical training, 25% of the respondents stated that they would seek another career specialty if the incidence of chronically ill patients increased in their chosen field, compared with the 9% who responded so before clinical training (p <.001). While 73% of the students had favorable perceptions toward chronically ill patients, and 91% felt involved in care, significantly fewer students (p <.01) had had positive patient care experiences when working with residents (57%) and attendings (59%). Gender, age, prior experiences, and school site were not associated with attitudinal changes. CONCLUSION: Students begin medical school with positive attitudes toward caring for chronically ill patients, but this perception depreciates with clinical experience, which may affect specialty decisions. Contributing factors may include adequate role modeling by residents and attendings and a perceived discrepancy in the quality of care patients receive.

Third-year medical student survey of office preceptorships during the pediatric clerkship.

OBJECTIVE: To assess medical students' interest in a career in pediatrics following their categorical pediatric clerkship. DESIGN: Satisfaction questionnaire to 704 third-year clerks in 5 university medical schools following the pediatric clerkship. METHODS: Analysis of the influence of the community office-based experience compared with the inpatient experience, and examination aspects of the office preceptorship most valued by the medical students. MAIN OUTCOME MEASURE: Satisfaction questionnaire addressing office-based experiences. RESULTS: Third-year pediatric clerks report that the private office setting provides a valuable learning experience, particularly when there is exposure to a wide spectrum of disease and when the preceptor had time to teach. Feelings about pediatrics as career choice rose during the clerkship from neutral to positive, and the frequency of strongly positive feelings rose from 9.2% to 28.6%. In deciding about pediatrics as a career, experiences with patients and residents in the inpatient setting still seem to count more than those experiences in the outpatient setting. CONCLUSION: Categorical pediatric clerkships provide learning environments that influence students positively toward pediatrics as a career choice. This choice is enhanced by encouraging community practitioners with students in their office to expose them to a wide variety of issues and devote time to teaching.

The Interdisciplinary Generalist Project at the University of Nebraska Medical Center.

The Interdisciplinary Generalist Curriculum (IGC) Project at the University of Nebraska College of Medicine (Nebraska) had three goals: (1) to increase first- and second-year students' exposure to primary care practice in the community; (2) to develop specific educational programs introducing these students to the principles and practices of primary care medicine; and (3) to establish a generalist coordinating council to provide leadership and to nurture generalist educational initiatives in the College of MEDICINE: Students at Nebraska were already required to spend three half-days a semester in a longitudinal clinical experience (LCE) and to complete a three-week primary care block experience in the summer between the first and second years. IGC Project funds were used increase the number of required LCE visits to five a semester and to develop curricular enhancements that would maximize the educational potential of community-based clinical experiences for first- and second-year students. Curricular elements developed included a focus on faculty development for preceptors and development of the Primary Care Introduction to Medicine Curriculum, an eight-week, interdisciplinary module scheduled late in the first year to help prepare students for intensive summer rotations. Other developments were the implementation of a pediatric physical examination experience for first-year students and the implementation of instruction in community-oriented primary care in the second year. Lessons learned are related to: (1) the value and power of early clinical experiences; and (2) the enhancing effect of a holistic, longitudinal view of the curriculum on the planning of early clinical experiences.

Pediatric clerkship experience and performance in the Nebraska Education Consortium: a community vs university comparison.

OBJECTIVE: To compare the reported experiences and performance on end-of-course examinations of students completing their pediatric clerkship at the University of Nebraska Medical Center (UNMC), Omaha, with that of students completing their clerkship in a community pediatrician's practice (CPP) outside the Omaha metropolitan area. DESIGN: Cohort study. SETTING: Private and/or institutional practices with both ambulatory and hospital components. PARTICIPANTS: For the academic year 1996-1997, all 113 students completing the 8-week third-year pediatric clerkship returned a questionnaire detailing their opinions of the experience. They also completed written (multiple-choice and essay questions) and oral (standardized parent interview) examinations, locally prepared and based on clerkship curriculum objectives provided to the students at orientation. Prior to student placement in the CPP, the clerkship goals, content, and evaluation methods as well as techniques for teaching in a busy office practice were reviewed with the CPP physicians. Eighty-one students performed their clerkship at UNMC while 31 spent all but the first week of the clerkship in the CPP. MAIN OUTCOME MEASURES: The students' opinions about their experiences and their performances on the end-of-course examinations were compared. Statistical analysis of the questionnaire was done using the Fisher exact test and the Mantel-Haenszel chi2 test while examination performance was compared using the t test and the Wilcoxon rank sum test. RESULTS: The UNMC and CPP groups reported similar opinions of their experiences in the newborn nursery and the inpatient portion of the clerkship, but the CPP students were much more positive about their learning experience in the clinic (P=.001). The CPP students reported more involvement in the patient's overall care (P<.001) and in other aspects of clinic operation (P<.001). The UNMC and CPP students had similar opinions of curriculum content, reading material, and didactic instruction. No group differences were found regarding interest in pediatrics as a career. Most importantly, no group differences were found in performance on any portion of the end-of-course examinations. CONCLUSIONS: Community-based education at the third-year clerkship level can be accomplished without a significant effect on student examination performance if students and faculty are aware of and adhere to a common set of goals. The end result is a much more robust experience for students who spend the clerkship in the practice of a community-based pediatrician.

Teaching newborn medicine to third-year medical students. Use of a checklist.

OBJECTIVE: To determine if use of a checklist during the third-year medical student's newborn medicine rotation within the pediatric clerkship affected grades, end-of-course examination scores, or perceptions of the new-born clinical experience before and after use of this teaching aid. METHODS: The checklist contained 46 newborn medicine-related skills and concepts and required staff review. A postclerkship questionnaire was used to assess the student's perception of all components of the clinical clerkship. A standardized test was used to assess clinical knowledge. The clerkship grade was based on test scores (30%) and clinical performance (70%). RESULTS: All students (N = 321) returned the postclerkship questionnaire from July 1, 1988, to June 30, 1990, and the checklist plus questionnaire (N = 294) from July 1, 1990, to June 30, 1992. During both periods, the curriculum and clinical experience remained unchanged. Although there was no change in grade distribution, mean final examination score (P < .011) and student perception of the nursery portion of the clerkship (P < .01) improved significantly after we began using the checklist. "Poor" ratings of the nursey experience decreased from 12% (1988 to 1989) to 3% (1991 to 1992), and "excellent" ratings increased from 13% to 24%. In addition, examination performance on specific examination questions appeared related to completion of checklist items (r = .68, P < .016). CONCLUSIONS: Use of a readily available checklist, to remind students and faculty of the skills and concepts to be mastered during the nursey portion of the clerkship, did not impact final grades, although information transfer and student perception of the clinical experience improved. We speculate that clear delineation of readily available objectives focuses students and staff, decreases anxiety, and provides a sense of accomplishment.

Heptavax-B in pediatric dialysis patients: effect of systemic lupus erythematosus. Chesapeake Pediatric Nephrology Study Group.

Twenty-three pediatric dialysis patients [6 hemodialysis (HD) and 17 peritoneal dialysis (PD)], with a mean age of 13.9 years, were vaccinated against hepatitis B virus and their seroconversion rates were analyzed. There was no significant difference in the mean duration of dialysis between the HD and PD groups, or between responders and nonresponders to the vaccine. In the HD group, there was a response rate of 83.3% while the PD patients had a response rate of 88.2%. The only patients failing to seroconvert after the three vaccine series all had systemic lupus erythematosus and were taking oral corticosteroids.

Characterization of immune cells in kidneys from patients with Sjogren's syndrome.

The association of interstitial nephritis, the most common renal lesion in Sjogren's syndrome, to the other manifestations of the disease is unclear. To begin to address this issue, the infiltrating cells in frozen kidney tissues from two patients with interstitial nephritis secondary to Sjogren's syndrome were characterized by indirect immunofluorescence. T cells predominated, the majority of which were helper/inducer cells (OKT4+). Both kidneys contained nodules of B cells. The increased proportion of OKT4+ T cells in salivary gland and in interstitial renal lesions of Sjogren's syndrome contrasts with some other forms of interstitial renal disease and suggests that the renal and salivary gland lesions have a similar pathogenesis.

The familial occurrence of focal segmental glomerular sclerosis.

We have observed the occurrence of focal segmental glomerulosclerosis in all three siblings of a single Hispanic family. Each of the children had the onset of significant proteinuria on or before the age of 10. The two oldest children have had progression of their disease to end-stage with subsequent successful transplantation. The youngest sibling continues to have normal renal function. All three patients had renal biopsies prior to the onset of renal insufficiency and each of the biopsies showed the presence of focal segmental glomerulosclerosis with mild diffuse mesangial hypercellularity. Finally, HLA-typing revealed the presence of DRw8 in all three siblings and the father. This report further suggests that genetic factors may be quite important in the development of the lesion of focal segmental glomerulosclerosis.

Imipramine poisoning in a child: lack of efficacy of resin hemoperfusion.

A three-year-old boy ingested up to 1,500 mg of the tricyclic antidepressant imipramine (Tofranil). He entered our facility within two hours of discovery, and multiple resuscitative efforts, which proved unsuccessful, followed. Resin hemoperfusion was used in an effort to remove imipramine from the systemic circulation. Serum concentrations of imipramine and its major metabolite desipramine were determined from serum drawn before, during, and after hemoperfusion. Serum concentrations of imipramine and desipramine did not change appreciably. No improvement in the clinical condition was noted during the hemoperfusion period, which was due in part to the fact that our patient was clinically brain dead upon arrival in our intensive care unit. Our subsequent literature review documents that this case represents the first reported use of hemoperfusion in a pediatric tricyclic antidepressant ingestion, hemoperfusion removes an insignificant portion of the total amount of tricyclic antidepressant ingested, and some pediatric literature misleadingly suggests that hemoperfusion may be useful in such patients. Physicians treating tricyclic antidepressant ingestion cases should avoid using hemoperfusion; standard supportive care remains the essential management response.