Through students' eyes: ethical and professional issues identified by third-year medical students during clerkships.

BACKGROUND: Education in ethics and professionalism should reflect the realities medical students encounter in the hospital and clinic. METHOD: We performed content analyses on Case Observation and Assessments (COAs) written by third-year medical students about ethical and professional issues encountered during their internal medicine and paediatrics clinical clerkships. RESULTS: A cohort of 141 third-year medical students wrote 272 COAs. Content analyses identified 35 subcategories of ethical and professional issues within 7 major domains: decisions regarding treatment (31.4%), communication (21.4%), professional duties (18.4%), justice (9.8%), student-specific issues (5.4%), quality of care (3.8%), and miscellaneous (9.8%). CONCLUSIONS: Students encountered a wide variety of ethical and professional issues that can be used to guide pre-clinical and clinical education. Comparison of our findings with results from similar studies suggests that the wording of an assignment (specifying "ethical" issues, "professional" issues, or both) may influence the kinds of issues students identify in their experience-based clinical narratives.

Using systematically observed clinical encounters (SOCEs) to assess medical students' skills in clinical settings.

INTRODUCTION: The Objective Structured Clinical Examination (OSCE) is widely used to assess the clinical performance of medical students. However, concerns related to cost, availability, and validity, have led educators to investigate alternatives to the OSCE. Some alternatives involve assessing students while they provide care to patients - the mini-CEX (mini-Clinical Evaluation Exercise) and the Long Case are examples. We investigated the psychometrics of systematically observed clinical encounters (SOCEs), in which physicians are supplemented by lay trained observers, as a means of assessing the clinical performances of medical students. METHODS: During the pediatrics clerkship at the University of Iowa, trained lay observers assessed the communication skills of third-year medical students using a communication checklist while the students interviewed and examined pediatric patients. Students then verbally presented their findings to faculty, who assessed students' clinical skills using a standardized form. The reliability of the combined communication and clinical skills scores was calculated using generalizability theory. RESULTS: Fifty-one medical students completed 199 observed patient encounters. The mean combined clinical and communication skills score (out of a maximum 45 points) was 40.8 (standard deviation 3.3). The calculated reliability of the SOCE scores, using generalizability theory, from 10 observed patient encounters was 0.81. Students reported receiving helpful feedback from faculty after 97% of their observed clinical encounters. CONCLUSION: The SOCE can reliably assess the clinical performances of third-year medical students on their pediatrics clerkship. The SOCE is an attractive addition to the other methods utilizing real patient encounters for assessing the skills of learners.

Trained lay observers can reliably assess medical students' communication skills.

CONTEXT: Our project investigated whether trained lay observers can reliably assess the communication skills of medical students by observing their patient encounters in an out-patient clinic. METHODS: During a paediatrics clerkship, trained lay observers (standardised observers [SOs]) assessed the communication skills of Year 3 medical students while the students interviewed patients. These observers accompanied students into examination rooms in an out-patient clinic and completed a 15-item communication skills checklist during the encounter. The reliability of the communication skills scores was calculated using generalisability analysis. Students rated the experience and the validity of the assessment. The communication skills scores recorded by the SOs in the clinic were correlated with communication skills scores on a paediatrics objective structured clinical examination (OSCE). RESULTS: Standardised observers accompanied a total of 51 medical students and watched 199 of their encounters with paediatric patients. The reliability of the communication skills scores from nine observed patient encounters was calculated to be 0.80. There was substantial correlation between the communication skills scores awarded by the clinic observers and students' communication skills scores on their OSCE cases (r = 0.53, P < 0.001). Following 83.8% of the encounters, students strongly agreed that the observer had not interfered with their interaction with the patient. After 95.8% of the encounters, students agreed or strongly agreed that the observers' scoring of their communication skills was valid. CONCLUSIONS: Standardised observers can reliably assess the communication skills of medical students during clinical encounters with patients and are well accepted by students.

Using infant mannequins in objective standardized clinical examinations: are there unintended consequences?

OBJECTIVE: In objective standardized clinical examination (OSCE) of infants, real infants are generally not used. Instead, the standardized patient portrays a parent who answers a student's questions, and there is no physical examination. One way to assess physical examination skills in these encounters is to have students demonstrate the appropriate examination on a mannequin. But before using this approach, we wanted to assess whether having students examine mannequins affects their history-collecting or communication skills. METHODS: Third-year medical students were randomized to 2 versions of an infant OSCE case. During the encounter, controls were handed a printed listing of all physical examination (PE) findings. Students in the mannequin group were told relevant PE findings only after the students had examined a part of the mannequin. Student performances on the OSCE case and perceptions about the case were compared. RESULTS: Thirty-two students were in the control group, and 35 students examined mannequins. No differences were found in total case score (P = .78), or on history-gathering skills (P = .86) and communication skills subscales (P = .78). In addition, questionnaires completed by students after the encounter indicated that the infant mannequins did not affect student perceptions about the realism of the case (P = .91). CONCLUSIONS: Student performances at collecting the clinical history or communicating with the standardized patient were not adversely affected by inclusion of an infant mannequin. This suggests mannequins can be used to assess students' knowledge of the relevant case-specific PE without adverse effect.

The resident view of professionalism behavior frequency in outstanding and "not outstanding" faculty.

BACKGROUND: Professionalism assessment has become necessary for all postgraduate training programs because it is now required for accreditation. To validate the novel items we generated to assess professionalism, we tested whether residents' ratings of faculty they judged as outstanding in professionalism would be distinguishable from those they judged as not outstanding. METHODS: Educators from core clinical disciplines generated 20 items assessing professionalism behaviors on a 7-point frequency scale anchored by "always" and "never." Thirty-five surgical and pediatric residents completed the form twice, anonymously rating 1 faculty member they judged as outstanding and another they judged as not outstanding. RESULTS: The residents produced 69 faculty ratings with means that differed significantly on all items between the outstanding and not-outstanding faculty. The form was highly unidimensional, with the primary factor's eigenvalue being 11.5 and Cronbach's alpha being 0.97. Groups differed most on items, ie, "listens well," "inspires trust," "answers questions directly," and "demonstrates respect for all." CONCLUSION: The behaviors that best distinguished clinical faculty judged by residents as outstanding professionals were listening, trustworthiness, answering directly, and respect.

Multi-institutional development and utilization of a computer-assisted learning program for the pediatrics clerkship: the CLIPP Project.

Computer-assisted instruction (CAI) holds significant promise for meeting the current challenges of medical education by providing consistent and quality teaching materials regardless of training site. The Computer-assisted Learning in Pediatrics Project (CLIPP) was created over three years (2000-2003) to meet this potential through multi-institutional development of interactive Internet-based patient simulations that comprehensively teach the North American core pediatrics clerkship curriculum. Project development adhered to four objectives: (1) comprehensive coverage of the core curriculum; (2) uniform approach to CAI pedagogy; (3) multi-institutional development by educators; and (4) extensive evaluation by users. Pediatrics clerkship directors from 30 institutions worked in teams to develop a series of 31 patient case simulations. An iterative process of case content and pedagogy development, case authoring, peer review, and pilot-testing ensured that the needs of clerkship directors and medical students were met. Fifty medical schools in the United States and Canada are presently using CLIPP. More than 8,000 students have completed over 98,000 case sessions, with an average of 2,000 case sessions completed per week at this time. Each CLIPP case has been completed by more than 3,000 students. The current cost of CLIPP development is approximately $70 per student user, or $6 per case session. The project's success demonstrates that multi-institutional development and implementation of a peer-reviewed comprehensive CAI learning program by medical educators is feasible and provides a useful model for other organizations to develop similar programs. Although CAI development is both time-consuming and costly, the initial investment decreases significantly with broad use over time.

Inevitable iron loss by human adolescents, with calculations of the requirement for absorbed iron.

In growing individuals, the requirement for absorbed iron consists of iron needed for growth and iron needed to replace inevitable iron loss. We were able to estimate inevitable iron loss by adolescents because total body iron of the adolescents had been enriched with the stable isotope, (58)Fe, as the result of earlier studies of iron absorption. During an interval beginning at least 1.56 y after isotope administration (a time sufficient for complete mixing of the isotope with total body iron) and extending for no less than 3.29 y, we determined the isotopic enrichment of circulating iron. On the basis of several assumptions, we calculated total body (58)Fe and total body iron at the beginning and end of the interval. Because of complete mixing of the isotope with total body iron, fractional total (58)Fe loss was the same as fractional loss of total iron. In males, the fractional loss of iron was 9.70%/y and the quantitative loss was 256 mg/y or 0.70 mg/d. In females, the fractional loss of iron was 14.60%/y and the quantitative loss was 306 mg/y or 0.84 mg/d. Using several assumptions, we then calculated that the iron requirement for growth during this interval was 0.76 mg/d for males and 0.31 mg/d for females. Adding the iron loss to the iron requirement for growth, the requirement for absorbed iron was estimated to be 1.46 mg/d for males and 1.15 mg/d for females.