Unintended Consequences? Assessing the Impact of Curricular Change on Medical Student Participation in a Student-Run Free Clinic.

INTRODUCTION: In a prior qualitative study of the impact of a new (ACE) medical school curriculum, students and faculty reported decreased participation in the student-run free clinic (SRFC) attributed to more intensive scheduling and more frequent testing compared to the previous (Legacy) curriculum. MATERIALS AND METHODS: To verify and understand this perception formed during curriculum reform, we conducted a mixed method study to measure student participation in the SRFC before and after curricular change and assessed student beliefs and motivations about SRFC participation using focus groups. RESULTS: Overall SRFC participation did not decrease among students in the ACE cohort following curriculum change. Additionally, both Legacy and ACE groups showed lower participation during test weeks, but the decrease was not significantly different between the ACE and Legacy cohorts. Focus groups confirmed the pervasive misbelief that SRFC participation was indeed lower among ACE students and attributed to reduced student discretionary time plus increased preparation time for frequent testing. Focus groups also revealed several "values" about volunteering at the SRFC which should be endorsed and promoted by schools considering curricular change. Participants valued the SRFC for educational items that were most effectively taught in the SRFC, notably social determinants of health, interprofessional practice, and interviewing with medical interpreters. They also valued the SRFC for professional validation, opportunities to apply course content, practice clinical skills, form important professional relationships, and provide community service. CONCLUSIONS: Our findings validate the value of SRFC experience as reported by students and demonstrate that, contrary to misbeliefs, participation was not negatively impacted by curricular reform.

Burnout and Other Types of Emotional Distress Among Medical Students.

BACKGROUND: The medical literature reports that many medical trainees experience burnout. The primary goal of this study was to determine how the prevalence of burnout and other forms of emotional distress among the University of Kansas School of Medicine (KUSM) medical students compared to the previously published data. METHODS: We conducted a cross-sectional survey of 379 medical students. Between July and September 2018, we surveyed 872 KUSM medical students on the three campuses (Kansas City, Salina, and Wichita) of KUSM. The survey included items on demographic information, burnout, symptoms of depression, fatigue, quality of life, and self-reported general health. The authors used standard descriptive summary statistics, Kruskal-Wallis test/one-way analysis of variance, chi-square test, correlation, and multivariate logistic regression model to analyze the data. RESULTS: The overall response rate was 43.5% with 48% of the students reporting manifestations of burnout. Burnout, depression, and fatigue were lowest during the first year of training and increased as year in training progressed. In multivariate models, only year in training was associated with increased odds of burnout, symptoms of depression, and fatigue. Nearly 46% of the students screened positive for depression, and 44.6% reported high levels of fatigue in the past week. CONCLUSION: Even though KUSM students have a lower prevalence of burnout than the national rate (48% vs. 55.9%), this prevalence is high enough to warrant new interventions. Because burnout and other emotional distress increase over the course of medical school no matter what campus the students attend, interventions should be both longitudinal and global across all campuses.

Exploring the Impact of Group Size on Medical Students' Perception of Learning and Professional Development During Clinical Rotations.

INTRODUCTION: Research assessing the size of learning groups in medical education and how that affects the learner's experience is limited. The main goals of the study were to (1) assess the effect of varying group size on medical students' subjective experiences during clinical years. We hypothesized that students in smaller groups were more likely to have better experiences during clinical rotation than those in larger groups, and (2) determine if medical students have desirable experiences working with other medical learners (fellows, residents, osteopathic students, physician assistants, and nurse practitioners) during clinical rotations. METHODS: The study utilized a mixed method approach where 153 medical students in their clinical years were asked to complete a 10-item survey. A linear-by-linear association test of trend and Mann-Whitney U test were used to evaluate the students' quantitative data. A multidisciplinary team used an immersion-crystallization approach to analyze the content of the students' qualitative data. RESULTS: There was a 90% (137/153) response rate. Most students (80%) reported desirable experiences during clinical rotations because of supportive learning environments, engaging preceptors, willingness of residents to teach, as well as the opportunity to participate in patient care. There were significant differences in students' perceived clinical experiences as a function of group size, where groups of two students were preferable over groups of four or more. CONCLUSIONS: Varying group size appears to affect students' clinical experiences.

Improving Interrater Reliability of Medical Student Assessment by Clinical Supervisors.

INTRODUCTION: Clinical clerkships that rely on community preceptors as faculty and assessors are challenged by the variability in their assessments of student performance. This workshop was designed to improve the interrater reliability of preceptors' assessment of student performance. METHODS: This workshop uses a series of videos showing standardized student interactions with standardized patients and a preceptor. The videos feature a borderline satisfactory student-patient encounter and a superior student encounter. For each case, there is a video of the student providing an oral presentation of the encounter to a preceptor. The concept of a plus/delta card is also presented. Participants are asked to note positive elements of the interactions and elements needing improvement on the plus/delta card while watching the videos. Next, participants share their assessment of the students with the group using an audience response system. Group discussion allows for consensus and leads to decreased variation in preceptor assessments of each student's performance. This workshop has been delivered to preceptors in our institution as a 1-hour workshop. Additionally, a version has been presented twice at national medical teaching conferences as a faculty development workshop, instructing faculty how to facilitate the workshop. RESULTS: Participant evaluations from the workshop show an increase in preceptors' awareness of specific student behaviors to observe as well as increased confidence with assessing more consistently across various student performances. DISCUSSION: Using videos with standardized patients, students, and preceptors demonstrating various qualities of performance is effective in improving precision in preceptors' assessment of students in clinical settings.

Does a Vacation Break Impact the Outcomes of Required Clinical Clerkships?

BACKGROUND AND OBJECTIVES: Our objective was to assess the impact of disruption by a new 2-week vacation break on outcomes of required third-year clerkships. METHODS: Mean scores on National Board of Medical Examiners (NBME) clerkship specific clinical science subject ("subject") examinations and overall student evaluations were compared for clerkships with the break and those over the previous 3 years without the break. Students were surveyed about the impact of the break on learning and the time spent studying during the break. RESULTS: No significant differences were found in examination scores between clerkships with the break and those without. Overall student clerkship evaluations were significantly different only for the surgery clerkship. The break was regarded more favorably by students on the 8-week than the 6-week clerkships, but student perspectives varied significantly by specialty. The time reported studying varied significantly by specialty and campus. Student comments were predominantly supportive of the break and focused on the advantages of opportunity to relax, spend time with family, and to study. Concerns included forgetting content knowledge, losing skills, and having difficulty regaining momentum on return to the clerkship. CONCLUSIONS: Interruption of clerkships by a 2-week break was not associated with any significant change in subject examination scores or overall student evaluation of the clerkship, despite predominantly positive comments. Significant differences were reported by specialty in student perception of benefit and reported time studying during the break.

Laryngeal problems.

Laryngeal complaints are common reasons for patients to seek care. There is considerable overlap between patient symptoms and final diagnosis. This article begins with a general approach to laryngeal symptoms followed by individual consideration of both the common and serious conditions of the larynx. Early diagnosis and treatment are important for improving outcomes in patients with laryngeal complaints.

Nasolaryngoscopy.

Nasolaryngoscopy is a low-risk, quick means of making a specific diagnosis for voice complaints; it should be performed before empiric treatment based on history and general examination alone. The most common indications for nasolaryngoscopy are hoarseness, globus sensation, and chronic cough. The most common findings in a primary care setting include laryngopharyngeal reflux (43%), chronic rhinitis (32%), and vocal cord lesions (13%).

Silicon photomultiplier (SPM) detection of low-level bioluminescence for the development of deployable whole-cell biosensors: possibilities and limitations.

Whole-cell bacterial bioreporters await miniaturized photon counting modules with high sensitivity and robust compatible hardware to fulfill their promise of versatile, on-site biosensor functionality. In this study, we explore the photon counting readout properties of the silicon photomultiplier (SPM) with a thermoelectric cooler and the possibilities of detecting low-level bioluminescent signals. Detection performance was evaluated through a simulated LED light source and the bioluminescence produced by the genetically engineered Pseudomonas fluorescens bacterial bioreporter 5RL. Compared with the conventional photomultiplier tube (PMT), the results revealed that the cooled SPM exhibits a wider linear response to inducible substrate concentrations (salicylate) ranging from 250 to 5000 ppb. Although cooling of the SPM lowered dark count rates and improved the minimum detectable signal, and the application of a digital filter enhanced the signal-to-noise ratio, the detection of very low light signals is still limited and remains a challenge in the design of compact photon counting systems.

Are students less likely to report pertinent negatives in post-encounter notes?

BACKGROUND AND OBJECTIVES: In completing post-encounter notes (PENs), students are believed to under-report about 30% of the important information obtained in the medical history. The resulting incomplete clinical notes can contribute to adverse patient care and medicolegal outcomes. We hypothesized that pertinent negative items would be more likely to be under-reported than positive items. We compared reporting rates for pertinent positive and negative items on two cases in a clinical skills assessment (CSA) taken by all 55 third-year students. Based on standardized patient (SP) checklists, students obtained 87% of both positive and negative items. Scoring of PENs found significant differences in the reporting rates for positive (75%) and negative (52%) items. These results were consistent for each case. Students appear to be able to elicit pertinent negative information from patients but, although these items may be crucial in the medical history, they are significantly more likely than positive items to be omitted from the clinical note.

Complete genome sequence of Thauera aminoaromatica strain MZ1T.

Thauera aminoaromatica strain MZ1T, an isolate belonging to genus Thauera, of the family Rhodocyclaceae and the class the Betaproteobacteria, has been characterized for its ability to produce abundant exopolysaccharide and degrade various aromatic compounds with nitrate as an electron acceptor. These properties, if fully understood at the genome-sequence level, can aid in environmental processing of organic matter in anaerobic cycles by short-circuiting a central anaerobic metabolite, acetate, from microbiological conversion to methane, a critical greenhouse gas. Strain MZ1T is the first strain from the genus Thauera with a completely sequenced genome. The 4,496,212 bp chromosome and 78,374 bp plasmid contain 4,071 protein-coding and 71 RNA genes, and were sequenced as part of the DOE Community Sequencing Program CSP_776774.

Do students falsify information in clinical notes?

BACKGROUND: If students report information in a post-encounter note that was allegedly not obtained from the patient, they may be suspected of serious professional misconduct, ie, deliberate falsification of patient data. Over-reporting during a clinical assessment may result in accusations of cheating and even lead to failure of a high-stakes examination. Despite these serious implications, the prevalence and reasons for over-reporting are not clear. We investigated every detected incident of false reporting during our high-stakes clinical skills assessment (CSA) at the end of the third year. Of 73 alleged incidents, 69 were attributed to errors in standardized patient (SP) performance, note scoring, data management, or the design of cases or scoring instruments. The four instances of over-reporting by students were more compatible with mistakes and lack of specificity than deliberate falsification. We conclude that all potential sources of error must be excluded before over-reporting incidents are attributed to deliberate falsification of data by students.

Student treatment on clerkships based on their specialty interests.

BACKGROUND: Student clerkship experiences may suffer if teachers are not sympathetic to students' clinical interests. PURPOSE: In this study, we quantified these experiences, compared reports of primary care and focused specialty students, and identified clerkships and teachers that posed special problems. METHODS: Students starting their 4th year at 6 schools completed a survey. RESULTS: The response rate was 75%. Students reported that these experiences, which were provoked by their clinical interests, were common: hearing deprecating comments about their interests, being denied learning opportunities, receiving lower evaluations, being discouraged from pursing their interests, and needing to be evasive for self-protection. Primary care students reported less mistreatment than focused specialty students. Students identified some clerkships and types of teachers as special problem sources. Students reported mistreatment triggered by clinical interests at twice the national rates for mistreatment triggered by race or sex. CONCLUSIONS: Such mistreatment is common and challenges medical schools to ensure that students are treated well regardless of their career aspirations.

Which patients are most challenging for second-year medical students?

BACKGROUND AND OBJECTIVES: Fostering appropriate attitudes toward patients begins with recognition of the physician's personal biases and preferences about patients. We sought to assist second-year medical students to identify those patient attributes that may influence their clinical behavior, especially in difficult patient encounters. This study's objectives were (1) to identify the principal patient characteristics reported by students to evoke negative or positive affective reactions sufficient to compromise the quality of patient care and (2) to examine differences between male and female students on these patient characteristics. METHODS: An anonymous survey was made of all second-year medical students attending a seminar on medical errors. Students recorded the three principal patient characteristics that might evoke in them a negative personal reaction sufficient to compromise the quality of clinical care. Students then recorded three principal patient characteristics that might evoke a positive reaction sufficient to compromise the quality of clinical care. The data were analyzed to identify the primary concerns of the entire group of students and any significant differences between male and female students. RESULTS: Information on negative attitudes was provided by 67 of 71 (94%) students and on positive attitudes by 70 of 71 (99%). Content analysis identified four general categories of patient characteristics associated with negative attitudes (patients who are rude, contributed to medical problem, are abusive to others, and other attributes). Five general categories (patients with whom students have personal connection or patients who have physical and/or social attractiveness, vulnerability, power/influence, and other) were associated with positive attitudes by the students. The leading patient attributes reported as likely to influence clinical behavior were the positive attributes of "personal connection" and "attractiveness." These were reported by 60% and 53% of the class, respectively, compared to the leading negative attributes of "rudeness" and "contributed to own condition," each reported by 51% of students. Significant differences between male and female students only occurred in the categories of "rude" and "attractive." CONCLUSIONS: Students are willing to disclose specific, personal attitudes toward patients that they perceive as sufficiently serious to influence the quality of clinical care. More than half of the students anticipated difficulty in providing optimal care to patients who exhibit certain characteristics. More students reported concerns about positive affective reactions to patients than about negative reactions. Medical education should address these issues in strategies to adequately prepare students for practice.

The RAFT approach to academic detailing with preceptors.

We have adapted "academic detailing" as a method to deliver real-time faculty development to nearly all community preceptors, both rural and urban, using the RAFT technique (Rapport-building, Assessment, Focused preceptor development, Thanks/Trinkets). The method is expensive in terms of faculty time and can be difficult to schedule. However, it has proven to be a valuable, learner-centered method that reaches preceptors missed by traditional faculty development workshops. Preceptors experience support, both student and preceptor problems are identified and addressed early, and academic faculty gain a better understanding of the preceptor environment.