Stress and value: the student perspective on utilizing real vs. actor patients in objective structured clinical examinations.

BACKGROUND: Studies have shown objective structured clinical examinations (OSCEs) to be one of the most reliable tools in assessing clinical performance; however in Pediatrics they primarily use manikins, simulators or parent actors which limits the comprehensiveness of the assessment. In our Pediatric Clerkship, medical students are evaluated using a standardized rubric during a clinical evaluation exercise (CEX) with real patients. This study assessed medical students' perceived stress levels and the educational value of the CEX compared an OSCE. We hypothesized there would be equal stress and value for students with the CEX experience compared to the OSCE. METHODS: Third year students anonymously completed questionnaires after required Pediatric CEX and Internal Medicine OSCE evaluations from July 2016-June 2017. The questionnaire included questions from the Intrinsic Motivation Inventory, a validated tool used to assess feelings of stress and perceived value of an exercise. RESULTS: A total of 147 and 145 questionnaires were completed after the CEX and OSCE. There were no differences between groups regarding levels of "nervousness" (p = 0.543) and "relaxation" (p = 0.055); students felt more "at ease" (p = 0.002) and less "pressure" (p < 0.001) during the CEX. Students perceived the CEX to be more useful and important to improve skills compared to the OSCE for the history taking, physical exam and interpersonal skills. CONCLUSIONS: Our results indicate that the CEX was associated with lower stress levels and had higher perceived value when compared to the OSCE. This study supports the usefulness of incorporating real patients into the clinical evaluation of medical students.

Improving Medical Student Inpatient Documentation Through Feedback Using a Note Assessment Tool.

Introduction Documentation within the Electronic Health Record (EHR) is an essential skill for medical students to succeed in residency and post-residency training. The increased use of medical student progress notes for billable services raises the need for the education and assessment of quality note writing. We hypothesized that structured note feedback using a note assessment tool would improve the quality of medical student inpatient progress notes. Methods We conducted a retrospective study to review the quality of student inpatient progress notes written before and after structured feedback using the Responsible Electronic Documentation (RED) checklist throughout a third-year internal medicine clerkship. The first intervention group received feedback from clerkship directors in the 2017-2018 academic year and the second intervention group received feedback from ward residents/attendings in the 2018-2019 academic year. Within each intervention group, the total note scores from pre and post-intervention were compared. Results Feedback from clerkship directors yielded a greater increase in students' total note score from pre to post-intervention compared to ward resident/attending feedback (F(1,255) = 12.84, p < 0.001). Cohen's d effect size value was greater for the clerkship director feedback arm (d=0.71) compared to the ward resident/attending feedback arm (d=0.24). Post-hoc analyses using dependent sample t-tests revealed that there were significant increases in total note scores from pre to post-intervention for both the clerkship director arm (t(123) = 8.26, p < 0.001, d = 0.71) and the ward resident/attending arm (t(132) = 2.85, p = 0.005, d = 0.24). Conclusion Clerkship director feedback led to a greater increase in medical student documentation compared to ward attending/resident feedback. Nonetheless, structured feedback with a note assessment tool, whether from clerkship directors or ward attendings/residents, leads to a significant improvement in medical student documentation. Though there are various methods for providing feedback, educators can use the RED checklist to provide clear guidelines that will facilitate note-writing feedback.

Teaching Medical Students to Reflect More Deeply.

PROBLEM: Although many studies have examined the importance of reflective writing in medical education, there is a scarcity of evidence for any particular intervention to improve the quality of reflection among medical students. Historically, students on our Internal Medicine clerkship were given a written reflection assignment without explanation of critical reflection. To facilitate the development of deeper reflection, a new curriculum was introduced. INTERVENTION: A 90-minute workshop on critical reflection was introduced at the start of the Internal Medicine rotation. Key components included a video clip stimulating reflection, small- and large-group exercises, and a faculty member's personal reflection. Students were then asked to write two reflection papers. To minimize bias, the names and dates were removed from each reflection paper and combined with reflection papers from a historical control group. Four faculty used a previously validated tool, the REFLECT rubric, to independently grade the written reflection papers as nonreflective (as a 1), thoughtful action (2), reflection (3), or critical reflection (4). The final grade of each paper was determined by consensus among the graders. CONTEXT: The 90-minute workshop was given once at the beginning of each 10-week requisite Internal Medicine clerkship to 3rd-year medical students. OUTCOME: One hundred fifty-five papers written after the workshop were compared to 155 papers from a preworkshop historical control group. The primary analysis showed the number of students writing "critical reflection" papers increased after the educational intervention, from 14% to 47% (p = .0002). The effect size using Cohen's d was 0.62. The kappa statistic used to measure interrater reliability among the four graders was 0.37. LESSONS LEARNED: Through a 90-minute reflection workshop more 3rd-year students were able to demonstrate the potential for "critical reflection" compared to previous students not exposed to this teaching. Strengths include the large sample size of written reflection papers submitted throughout an entire academic year and blinded grading of papers that minimized bias. The low interrater reliability is a limitation. We believe this curriculum could readily be adapted to a clerkship seeking to enhance learner reflection.