Grade inflation in internal medicine clerkships: results of a national survey.

BACKGROUND: There has been a discussion among medical educators concerning grade inflation; however, little has been written about it in the medical education literature. PURPOSE: A survey was developed to determine if grade inflation exists by gathering data about grading practices and by gathering the opinions of course directors from Internal Medicine clerkships. METHODS: The survey was administered during the 1996-1997 academic year to all 125 LCME accredited medical school Internal Medicine Clerkship Directors. Grading practices for 3 separate academic years were obtained plus responses to questions about causes of and solutions for grade inflation. RESULTS: Eighty-three surveys were returned for a 66% response rate. There was a trend towards higher grades across the 3 study years, with the 1995-1996 year being statistically significant. Forty-eight percent of the clerkship directors felt that grade inflation existed in their courses, and 43% felt that some students passed who should have failed. CONCLUSION: Statistically significant grade inflation exists in Internal Medicine clerkships. Most disturbingly, 43% feel we are unable appropriately to identify incompetent students.

The impact of the location and structure of an ambulatory rotation on cognitive knowledge and performance.

With the increasing shift to community-based ambulatory education, it is essential to gain a better understanding of the impact of these changes. To assess the impact of the location and structure of an ambulatory internal medicine clerkship rotation on cognitive knowledge and clinical performance, students were assigned to one of the following: (a) a multidisciplinary ambulatory clerkship (MAC), (b) the office of a community-based general internist, or (c) a university-based internal medicine ambulatory clinic. The groups were compared on the internal medicine clerkship examination and preceptor ratings controlling for introduction to clinical medicine course performance via analysis of covariance. MAC students were rated lower than the other two groups by their preceptors. There were no other statistically significant differences. The structure and location of the rotation had little impact on cognitive knowledge. The impact of the structure of the rotation on clinical performance is less clear suggesting that further research is needed.

Creating and evaluating an independent ambulatory internal medicine clerkship.

Patient care is shifting from an inpatient setting to an ambulatory setting. Despite this shift, most internal medicine clerkships provide the majority of medical student training in inpatient settings or in university tertiary care clinics, which are not representative of patient care in a community setting. We created a separate ambulatory clerkship that used volunteer community faculty at local and distant sites. The steps involved are described here, including finding time within the clerkship, reaching consensus within the department, defining the curriculum, identifying sites, and developing preceptors. Various parameters were measured to ensure quality in educational design. Comparisons of the 1-year pilot program, the full implementation program, and the inpatient program revealed that use of community sites does not affect cognitive knowledge acquisition but does influence students' satisfaction level.

Setting standards and defining quality of performance in the validation of a standardized-patient examination format.

PURPOSE: To evaluate whether written standards increase the reproducibility of a physician-facilitated station in an objective structured clinical examination (OSCE) designed to assess history, physical-examination, and communication skills. METHOD: The OSCE examination at the University of Texas Medical Branch-Galveston consists of ten eight-minute stations. Six of these stations consist of three History, Physical-examination, Problem-solving, and Plan (HPPP) station pairs. Each existing clinical-problem HPPP station was given to two content experts to develop standards for faculty rating scales appropriate for the evaluation of third-year medical students. Three pairs of faculty members were used to determine interrater reliability by scoring videotapes of three HPPP stations' presentation and problem-solving components. Faculty pairs scored tapes of 15 students without using standards and tapes of 15 students using the standards developed. Differences between the reliabilities without and with the standards were tested for significance using Fisher's R to Z transformation. The reproducibility and standard error of measurement (SEM) were extrapolated for increasing amounts of testing time. The HPPP component scores were also correlated with the written examination scores and preceptors' ratings. Data were obtained from the three HPPP stations used in the 1995-96 internal medicine clerkship SP examination. RESULTS: In all, 196 students completed the OSCE examination. The standards developed improved interrater reliability and reached statistical significance (p < .01) for one HPPP station. Reproducibility for the presentation and problem-solving components of the HPPP stations were > .80 after five hours of testing. The problem-solving component correlated at .37 and .19 with written examinations and with ward grades, respectively. CONCLUSION: The data from this study suggest that standards increase the reproducibility of presentation and problem-solving components of an OSCE to a level as high as, or higher than, that associated with the history, physical-examination, and communication components of traditional standardized-patient examinations.

The reliability of medical student ratings of clinical teaching.

This study estimated the interrater reliability of medical student evaluations of clinical teaching. Data consisted of 1,570 ratings evaluating 147 faculty over a 4-year period in a 3rd-year internal medicine clerkship. The number of ratings a typical faculty member receives in a year was also calculated and used to extrapolate the standard error of measurement for data typically available to evaluate faculty at different time intervals. The data available to evaluate a faculty member after 1 year was not adequate, but improved substantially at the 5- to 7-year mark, when a faculty member is typically evaluated for promotion and tenure.

HIV risks and risk reduction readiness in hard-to-reach, drug-using African American and Mexican American women: an exploratory study.

In an exploratory study of the HIV risk-taking behaviors and risk reduction readiness of a sample of 74 hard-to-reach, out-of-treatment African American and Mexican American drug-using women who are at high risk for HIV infection, Mexican American women were found to be more likely than African American women to have drug-using sexual partners and to use drugs daily. Cocaine was the drug most commonly used by both groups. Heroin injectors were more likely than nonheroin injectors to use daily and to share needles. Women of both ethnicities expressed considerable readiness for HIV risk reduction. We describe two empirically derived interventions to reduce HIV risks among this population and share our observations regarding collecting data from and intervening with hard-to-reach, drug-using minority women who are at high risk for HIV infection.

Variation among cardiologists in the utilization of right heart catheterization at time of coronary angiography.

To describe how often a right heart catheterization was performed at the time of coronary angiography, the patient characteristics that predicted the use of this procedure, and the variation among cardiologists in the use of this test, we reviewed all cases of coronary angiography (n = 1,282) during the first 2 mo of 1993 at two large community hospitals. Fifty-two percent of the cases received a right heart catheterization at the time of their coronary angiography. The following characteristics were associated with the receipt of a right heart catheterization in a logistic regression analysis: cardiomyopathy (odds ratio = 2.59, 95% CI = 1.01, 6.62), congestive heart failure (odds ratio = 2.07, 95% CI = 1.42, 3.01), valvular heart disease (odds ratio = 2.54, 95% CI = 1.44, 4.49), no coronary angioplasty performed at the procedure (odds ratio = 2.71, 95% CI = 2.12, 3.45), and increased age (odds ratio = 1.13 per decade, 95% CI = 1.03, 1.25). Of 37 cardiologists who performed > 10 coronary angiography procedures, the use of right heart catheterization varied from 10-90%. The cardiologists' practice variation persisted after adjustment for patient clinical characteristics. Because of the high utilization of right heart catheterization at the time of coronary angiography and the variation in use among cardiologists, even when controlling for patient characteristics, the issue of appropriate indications for this procedure needs to be addressed in a rigorous fashion.

Dimensions of clinical competence as conceptualized by medical school faculty.

This study identified dimensions of clinical competence underlying faculty ratings of fourth-year student performance in a standardized patient examination and assessed the impact of these dimensions on faculty pass/fail decisions. Content review coupled with exploratory factor analysis was used to group 17 of 25 specific behavioral rating categories into four homogeneous clusters. Confirmatory factor analysis refined the clusters into four unidimensional scales that included 14 of the original ratings. The dimensions reflected relating to the patient, problem-solving skills, medical history skills, and physical examination skills. The factor structure was cross-validated in a separate data set. Logistic regression indicated problem solving was the only independent predictor of a student passing the exercise.

Age-related differences in the utilization of therapies post acute myocardial infarction.

OBJECTIVE: To describe the effect of age on the care of patients hospitalized with acute myocardial infarction (MI). DESIGN: Retrospective chart review of all cases with a primary or secondary discharge diagnosis of acute MI. SETTING: Two large community hospitals in Milwaukee, Wisconsin, from July 1, 1990 to June 30, 1991. PATIENTS: There were 771 charts reviewed, of which, 149 cases were aged 54 years or younger, 203 were 55 to 64 years, 224 were 65 to 74 years, and 195 were aged 75 years or older. MEASUREMENTS: Hospital charts were examined for use of diagnostic and therapeutic interventions, including medications and procedures, as well as length of stay and in-hospital mortality. RESULTS: Older patients were more likely to be female (18%, 20%, 38%, and 56% for the four age groups, respectively, P < .001 chi-square for linear trend), more likely to present with congestive heart failure (31%, 39%, 51%, and 72%, P < .001), and had a higher in-hospital mortality rate (5%, 7%, 10%, and 18%, P < .001). Older patients had a longer length of stay in the hospital. The use of cardiac catheterization in these post-MI patients was high and did not decrease until after age 75 (85%, 88%, 88%, and 47%, P < .001). The percentage of patients receiving balloon angioplasty decreased with age (51%, 51%, 43%, and 20%, P < .001), whereas the percentage of patients receiving myocardial revascularization did not significantly differ with age (15%, 22%, 25%, and 19%, P = .46). Aspirin was less likely to be prescribed to older patients at discharge (79%, 82%, 70%, and 62%, P < .001). CONCLUSION: A surprisingly high percentage of those older than age 65 received invasive tests and interventions. This high utilization rate coexists with our continued ignorance about the efficacy of these tests and interventions in older adults.

Specialty choice among students entering the fourth year of medical school.

In this article, the authors explore senior medical students' specialty preferences and investigate factors that influence those preferences. The design of the study was a written questionnaire. The setting was a large, state-supported university-based southern medical school. The patients/participants were students entering the fourth year of medical school. One hundred seventy-six students (97% of the class) completed the questionnaire. Of those students, 12.5% were interested only in primary care, 43.2% were interested in both primary and nonprimary care, and 44.3% were interested in nonprimary care careers. Most students considering both primary and nonprimary care careers were interested in general internal medicine or general pediatrics and subspecialties within those fields. Career choice was influenced most strongly by several factors--clerkship experiences, the fact that it fit with skills/abilities, physician role models, the challenge, and intellectual content. Encouragement from family and other students, prestige, and income potential had the least impact on career choice. Students interested in primary care careers valued providing continuity of care much higher than did those interested in nonprimary care specialties. The authors conclude that students' experiences in medical school, particularly during the clerkships, have a significant impact on their specialty choice.

Evaluating problem solving based on the use of history findings in a standardized-patient examination.

PURPOSE: To evaluate a novel item format for assessing clinical problem solving in a standardized-patient examination (SPE). METHOD: In 1992-93 a key-findings item format was included in two versions of three stations in an SPE (given in the style of an objective structured clinical examination) that was taken by 198 third-year students at the end of their three-month internal medicine clerkship at the University of Texas Medical Branch at Galveston. Each of the stations involved an extended matching question that listed ten to 12 findings. The students were told to select as many or as few findings as they wished that were key in leading them to their diagnosis of the standardized patient's (SP's) problem. The findings fell into three categories: (1) key to the diagnosis, (2) provided by the SP but not key to the diagnosis, and (3) not provided by the SP. RESULTS: A total of 169 students (85%) identified at least one of the findings determined to be key in each of the stations. Correctly identifying key findings was related to correctly diagnosing the SP's problem. A total of 145 students (73%) indicated at least one finding across the three cases as key to their diagnosis but not given by the SP. Selecting nonexistent findings as key to diagnosis was not found to be related to performance on the SPE. It was hypothesized that once a diagnosis was made, the students had difficulty differentiating key findings that had led them to the diagnosis from other key features of their cognitive model of illness. CONCLUSION: The students were generally able to obtain and recognize at least some of the key information they needed to formulate appropriate differential diagnoses, and the ability to identify key findings was shown to be related to identifying the most appropriate diagnosis. The key-findings item format has potential both in assessment and for gaining a better understanding of the clinical problem-solving process.

HIV infection treatment costs under Medicaid in Michigan.

The Michigan Medicaid Program payment records generated in the period 1985-89 by 783 persons were analyzed for services related to human immunodeficiency virus (HIV) infection. Other data from death records and the Michigan AIDS Surveillance Registry were available for a subset of those persons. The average monthly payment in 1989 dollars for HIV-related services was $1,302.57. Services determined to be unrelated to HIV infection accounted for 12.5 percent of the total amount for health care received and another 2.5 percent was questionable. The average monthly expenditure for men was roughly twice that for women. The discrepancy did not exist among persons identified in the AIDS Surveillance Registry. Sex differences ceased to exist when Medicaid eligibility (disability versus Aid to Families with Dependent Children) was controlled for by analysis of variance. There were no significant differences between payments to those infected through male-to-male sexual contact and those infected through intravenous drug use. Payments for HIV treatments rose with age to about 40 years, and declined slightly among older adults. The sharpest rise was for those ages 19-25 years and 26-35 years. Large sex differences existed among those who received zidovudine (AZT), 61.4 percent of the men and 19.1 percent of the women. Controlling for Medicaid eligibility moderated those differences, but they remained statistically significant. Differences in zidovudine usage were not found between men and women in the subset identified in the AIDS Surveillance Registry nor among persons infected through male-to-male sexual contact and intravenous drug use.

A pilot study of the relationship between experts' ratings and scores generated by the NBME's Computer-Based Examination System.

This pilot study evaluates the consistency of experts' ratings of students' performances on the National Board of Medical Examiners' Computer Based Examination (CBX) cases and the relationship of those ratings to the CBX's scoring algorithm. The authors were investigating whether an automated scoring algorithm can adequately assess an examinee's management of a computer-simulated patient. In 1989-90, at the Michigan State University College of Human Medicine, eight students, completing a surgery clerkship, each managed eight CBX cases and took a computer-administered, multiple-choice examination. Six clerkship coordinators rated the students' performances in terms of overall management, efficiency, and dangerous actions. The ratings correlated highly with scores produced by the CBX's scoring system.