Enter and Discuss Orders and Prescriptions (EPA 4): A Curriculum for Fourth-Year Medical Students.

Introduction: Order entry, entrustable professional activity (EPA) 4, is one of several EPAs that residency program directors identify as a weakness for PGY 1 residents. A multispecialty survey of program directors indicated that only 69% of interns could be trusted to enter and discuss orders and prescriptions without supervision. To address this gap, we developed a formative workshop for fourth-year medical students. Methods: Prior to the start of their subinternships, 366 fourth-year medical students engaged in an order entry workshop. Students performed chart reviews on electronic standardized patients within an educational electronic health record (EHR), placed admission orders, customized order sets, responded to safety alerts, utilized decision support tools, and incorporated high-value care considerations. Students used expert-validated rubrics to assess the quality of their admission orders and participated in a facilitated group discussion on key learning points. Finally, students participated in order entry, with all orders requiring cosignature by a supervising physician, during their clinical rotations. Students reported their confidence with order entry before and after the workshop and after the clinical rotation. Results: One hundred seventeen students completed the pre- and postworkshop surveys, and 99 went on to complete the postcourse evaluation. Students showed a statistically significant increase in their confidence level following the workshop. Discussion: Order entry is a critical, complex skill that requires deliberate instruction. This curriculum, which leverages the features of an educational EHR, can facilitate instruction, practice, and confidence gains regarding order entry prior to further application of these skills in the clinical environment.

Post-Clerkship Curricular Reform: Specialty-Specific Tracks and Entrustable Professional Activities to Guide the Transition to Residency.

The development of core entrustable professional activities (EPA) for entering residency and Accreditation Council for Graduate Medical Education's milestones have spurred thinking about the fourth year of medical school as a transition to residency. In this monograph, we lay out our specialty focused post-clerkship curriculum and report learner and residency director perceptions over the first three years of implementation. Ongoing curricular monitoring has reinforced core principles but has also informed actionable quality improvement efforts. EPA-focused learning experiences, integration of specialty-specific milestones, addition of the feedforward process, and accessible mentorships have been key curricular elements to guide the transition to residency.

The effect of supplemental high Fidelity simulation training in medical students.

BACKGROUND: Simulation-based education (SBE) with high-fidelity simulation (HFS) offers medical students early exposure to the clinical environment, allowing development of clinical scenarios and management. We hypothesized that supplementation of standard pulmonary physiology curriculum with HFS would improve the performance of first-year medical students on written tests of pulmonary physiology. METHODS: This observational pilot study included SBE with three HFS scenarios of patient care that highlighted basic pulmonary physiology. First-year medical students' test scores of their cardio-pulmonary curriculum were compared between students who participated in SBE versus only lecture-based education (LBE). A survey was administered to the SBE group to assess their perception of the HFS. RESULTS: From a class of 188 first-year medical students, 89 (47%) participated in the SBE and the remaining 99 were considered as the LBE group. On their cardio-pulmonary curriculum test, the SBE group had a median score of 106 [IQR: 97,110] and LBE group of 99 [IQR: 89,105] (p < 0.001). For the pulmonary physiology subsection, scores were also significantly different between groups (p < 0.001). CONCLUSIONS: Implementation of supplemental SBE could be an adequate technique to improve learning enhancement and overall satisfaction in preclinical medical students.

Development of an Assessment for Entrustable Professional Activity (EPA) 10: Emergent Patient Management.

INTRODUCTION: Medical schools in the United States are encouraged to prepare and certify the entrustment of medical students to perform 13 core entrustable professional activities (EPAs) prior to graduation. Entrustment is defined as the informed belief that the learner is qualified to autonomously perform specific patient-care activities. Core EPA-10 is the entrustment of a graduate to care for the emergent patient. The purpose of this project was to design a realistic performance assessment method for evaluating fourth-year medical students on EPA-10. METHODS: First, we wrote five emergent patient case-scenarios that a medical trainee would likely confront in an acute care setting. Furthermore, we developed high-fidelity simulations to realistically portray these patient case scenarios. Finally, we designed a performance assessment instrument to evaluate the medical student's performance on executing critical actions related to EPA-10 competencies. Critical actions included the following: triage skills, mustering the medical team, identifying causes of patient decompensation, and initiating care. Up to four students were involved with each case scenario; however, only the team leader was evaluated using the assessment instruments developed for each case. RESULTS: A total of 114 students participated in the EPA-10 assessment during their final year of medical school. Most students demonstrated competence in recognizing unstable vital signs (97%), engaging the team (93%), and making appropriate dispositions (92%). Almost 87% of the students were rated as having reached entrustment to manage the care of an emergent patient (99 of 114). Inter-rater reliability varied by case scenario, ranging from moderate to near-perfect agreement. Three of five case-scenario assessment instruments contained items that were internally consistent at measuring student performance. Additionally, the individual item scores for these case scenarios were highly correlated with the global entrustment decision. CONCLUSION: High-fidelity simulation showed good potential for effective assessment of medical student entrustment of caring for the emergent patient. Preliminary evidence from this pilot project suggests content validity of most cases and associated checklist items. The assessments also demonstrated moderately strong faculty inter-rater reliability.

Educational Handoffs from Medical School to Residency: an Emerging Opportunity.

This article was migrated. The article was marked as recommended. In this Personal View article we discuss the limitations of the summative medical student data currently received by residencies pre-match (such as transcripts, the Dean's Letter and letters of recommendation) to adequately communicate a student's strengths, weaknesses, and learning needs as they begin internship. We briefly summarize the evolution of medical student and resident performance evaluation, and discuss the role that educational handoffs may play in the future as students transition to internship. We then consider emerging questions about the feasibility and mechanics of educational handoffs and discuss possible steps forward.

Sleep-associated movement disorders and heart failure.

Sleep-associated movement disorders are a broad group of sleep disorders characterized by involuntary movements that may disrupt sleep. Relatively little is known about the clinical consequences of sleep-associated movement disorders on cardiovascular health. Because these disorders manifest mostly during sleep, recognizing a movement disorder can be particularly difficult. Nevertheless, patients can have frequent arousals and suffer from similar sleep deprivation, fragmentation, and autonomic disruption as occurs in sleep-disordered breathing. Subsequently, these disorders may have a serious impact on daytime function and perception of health in patients with chronic heart failure.