Assessment of Medical Students' Ability to Integrate Point-of-Care Cardiac Ultrasound Into a Case-Based Simulation After a Short Intervention.

INTRODUCTION: While a large amount of point-of-care ultrasound (POCUS) undergraduate medical education research exists, very little assesses the effectiveness of teaching on the student's ability to utilize POCUS within a clinical context. We set out to assess the ability of pre-clinical (second year) medical students to perform and interpret a parasternal long axis (PSLA) cardiac ultrasound view, and to diagnose a pericardial effusion on POCUS in a simulated patient with hypotension. METHODS: This was a prospective study assessing second-year medical students before and after focused cardiac POCUS instruction. Pre-instruction, students completed a pre-assessment and test. They then watched a short video on cardiac ultrasound technique, anatomy, and pathology. Students then participated in 10 minutes of one-on-one hands-on instruction using a simulated patient. Immediately after didactics and hands-on instruction, students in groups of two to four completed a case simulation where they performed a PSLA view, identified pathology, and made a diagnosis. Differences between pre- and post-workshop responses were analyzed using the Chi-square test. RESULTS: We analyzed data on 132 pre-clinical second-year medical students; 126 (95%) had limited to no POCUS experience prior to the workshop. Comparing pre- to post-workshop responses, we found significant improvement in students' ability to identify a pericardial effusion (46% to 69%) (p=0.002) on a PSLA cardiac view. Of the 57 student groups (132 students), 41 (72%) groups were able to adequately obtain a PSLA view on a mannequin using an ultrasound simulator without needing guidance with probe placement or maneuvering. Thirty-five (61%) student groups were able to identify a pericardial effusion and diagnose cardiac tamponade in a simulated patient with hypotension. CONCLUSION: After short, structured training, pre-clinical medical students, novice to cardiac POCUS, showed improved knowledge with identifying a pericardial effusion on an ultrasound image. The majority of students were able to obtain a PSLA view and diagnose cardiac tamponade in a hypotensive patient during a during a case-based simulation.

Piloting a Graduate Medical Education Point-of-Care Ultrasound Curriculum.

Objective As point-of-care ultrasound (POCUS) use grows, training in graduate medical education (GME) is increasingly needed. We piloted a multispecialty GME POCUS curriculum and assessed feasibility, knowledge, and comfort with performing POCUS exams. Methods Residents were selected from the following residency programs: internal medicine, family medicine, emergency medicine, and a combined internal medicine/pediatrics program. Didactics occurred through an online curriculum that consisted of five modules: physics and machine operation, cardiac, lung, soft tissue, and extended focused sonography in trauma applications. Residents completed a pre- and post-curriculum questionnaire, as well as knowledge assessments before and after each module. One-hour hands-on training sessions were held for each module. Differences between pre- and post-participation questionnaire responses were analyzed using the Wilcoxon rank sum. Results Of the 24 residents selected, 21 (86%) were post-graduate year two or three, and 16 (65%) were from the internal medicine program. Eighteen (67%) residents reported limited prior POCUS experience. All pre- to post-knowledge assessment scores increased (p<0.05). Statistically significant increases pre- to post-curriculum were found for frequency of POCUS use (p = 0.003), comfort in using POCUS for assessing for abdominal aortic aneurysm, soft tissue abscess detection, undifferentiated hypotension and dyspnea, cardiac arrest and heart failure (p<0.025); and competency in machine use, acquiring and interpreting images and incorporating POCUS into clinical practice (p<0.001). All participants felt the skills learned during this curriculum were essential to their future practice. Conclusions In this pilot, we found using a combination of online and hands-on training to be feasible, with improvement in residents' knowledge, comfort, and use of POCUS.

Medical School Without Walls: 50 Years of Regional Campuses at Indiana University School of Medicine.

The history of Indiana University School of Medicine (IUSM) dates to 1871, when Indiana Medical College entered into an affiliation with Indiana University in Bloomington to offer medical education. In 1971, the Indiana General Assembly passed a bill to create and fund a distributed model for medical education for which IUSM was responsible, an innovative approach to implementing a statewide medical education program. IUSM became one of the first U.S. medical schools to implement what is today known as a regional medical campus model. This regional medical campus system has permitted IUSM to expand enrollment based on national and local concerns about physician shortages, increase access to care locally, support expansion of graduate medical education, and provide opportunities for research and scholarship by faculty and students statewide. This effort was made possible by partnerships with other universities and health care systems across the state and the support of local community and state leaders. The model is a forward-thinking and cost-effective way to educate physicians for service in the state of Indiana and is applicable to others. This article highlights milestones in IUSM's 50-year history of regional medical education, describes the development of the regional medical campus model, recognizes significant achievements over the years, shares lessons learned, and discusses considerations for the future of medical education.

Point-of-Care Ultrasound Education During a Pandemic: From Webinar to Progressive Dinner-Style Bedside Learning.

OBJECTIVE: Point-of-care ultrasound (POCUS), traditionally, requires the proximity of learners and educators, making POCUS education challenging during the COVID-19 pandemic. We set out to evaluate three alternate approaches to teaching POCUS in UME. Sessions progressed from an online seminar to a remote, interactive simulation to a "progressive dinner" style session, as precautions evolved throughout the pandemic. METHODS: This prospective study details a series of three POCUS workshops that were designed to align with prevailing social distancing precautions during the COVID-19 pandemic. Overall, 656 medical students were included. The first and second workshops used web-based conferencing technology with real-time ultrasound imaging, with the second workshop focusing on clinical integration through simulation. As distancing precautions were updated, a novel "progressive dinner" technique was used for the third workshop. Surveys were conducted after each session to obtain feedback on students' attitudes toward alternative teaching techniques and quantitative and qualitative analyses were used. RESULTS: The initial, remote POCUS workshop was performed for 180 medical students. Ninety-nine (177) percent of students felt the session was "intellectually challenging" and "stimulating." Ninety-nine percent of students (340/344), after the second workshop, indicated the session was intellectually challenging, stimulating, and a positive learning experience. Students' ability to correctly identify pathologic images increased post-session evaluation from in-session polling. For workshop three, 99% (107/108) of students indicated that the session was "informative." There was a significant improvement in pre- to post-workshop knowledge regarding image acquisition, interpretation, and clinical integration. CONCLUSION: While image acquisition skills are best conveyed at the bedside, these modified POCUS teaching techniques developed and delivered in alignment with COVID-19 pandemic restrictions during a series of three workshops were shown to be effective surrogates for traditional teaching approaches when social distancing requirements, a large learner pool, or lack of local expertise exist.

Resilience matters: Student perceptions of the impact of COVID-19 on medical education.

INTRODUCTION: We assessed students' perception of the impact of the pandemic on their well-being, education, academic achievement, and whether grit and resilience alter students' ability to mitigate the stress associated with disruptions in education. We hypothesized that students would report a negative impact, and those with higher grit and resilience scores would be less impacted. METHODS: A multidisciplinary team of educators created and distributed a survey to medical students. Survey results were analyzed using descriptive statistics, ANOVA, and multivariate linear regressions. A p-value <.05 was considered statistically significant. RESULTS: A total of 195 students were included in the study. Approximately 92% reported that clinical education was negatively affected, including participants with higher grit scores. Students with higher resilience scores were more optimistic about clinical education. Those with higher resilience scores were less likely to report anxiety, insomnia, and tiredness. CONCLUSION: More resilient students were able to manage the stress associated with the disruption in their education. Resiliency training should be year-specific, and integrated into the UME curriculum due to the different demands each year presents.

Medical Student Experiences With Electronic Health Records Nationally: A Longitudinal Analysis Including School-Level Effects.

PURPOSE: Increasingly, medical school graduates have been expected to be competent in the knowledge and skills associated with effective electronic health record (EHR) use. Yet little is known about how student experiences with EHRs have changed over time or how these trends vary by medical school. This study examined shifts in U.S. medical student interactions with EHRs during their clinical education, 2012-2016, and how these interactions varied by clerkship within and across medical schools. METHOD: Data came from an online survey about EHR use administered to medical students after completing the Step 2 Clinical Knowledge portion of the United States Medical Licensing Examination. For a sample of 17,202 medical students from 140 U.S.-based Liaison Committee on Medical Education accredited medical school campuses, multilevel modeling techniques were used to estimate overall and school-specific trends in student access to and entry of information into EHRs for 7 core inpatient clerkships. RESULTS: Results showed upward trajectories in likelihood of student EHR experiences, with smaller increases found for information entry compared with access. These trends varied by inpatient clerkship rotation, with some disciplines exhibiting more rapid increases than others. For both access and information entry, estimated clerkship-specific trajectories differed by medical school in terms of size and direction. For all clerkships, greater school-to-school variation in the likelihood of student entry, compared with student access, remained at the end of the study period. CONCLUSIONS: Increases in medical student interactions with EHRs suggest a growing commitment to educating students on safe and effective EHR use. Nonetheless, at some schools and in some clerkships, students may receive inadequate educational opportunities to practice using EHRs. In turn, medical students may be differentially prepared to effectively engage with EHRs upon entering residency, particularly with the knowledge and skills needed to effectively document and transmit information in EHRs.

The State of Point-of-Care Ultrasound Training in Undergraduate Medical Education: Findings From a National Survey.

PURPOSE: The primary aim of this study was to evaluate the current state of point-of-care ultrasound (POCUS) integration in undergraduate medical education (UME) at MD-granting medical schools in the United States. METHOD: In 2020, 154 clinical ultrasound directors and curricular deans at MD-granting medical schools were surveyed. The 25-question survey collected data about school characteristics, barriers to POCUS training implementation, and POCUS curriculum details. Descriptive analysis was conducted using frequency and percentage distributions. RESULTS: One hundred twenty-two (79%) of 154 schools responded to the survey, of which 36 were multicampus. Sixty-nine (57%) schools had an approved POCUS curriculum, with 10 (8%) offering a longitudinal 4-year curriculum. For a majority of schools, POCUS instruction was required during the first year (86%) and second year (68%). Forty-two (61%) schools were teaching fundamentals, diagnostic, and procedural ultrasound. One hundred fifteen (94%) schools identified barriers to implementing POCUS training in UME, which included lack of trained faculty (63%), lack of time in current curricula (54%), and lack of equipment (44%). Seven (6%) schools identified no barriers. CONCLUSIONS: Over half of the responding medical schools in the United States had integrated POCUS instruction into their UME curricula. Despite this, a very small portion had a longitudinal curriculum and multiple barriers existed for implementation, with the most common being lack of trained faculty. The data from this study can be used by schools planning to add or expand POCUS instruction within their current curricula.

Assessing medical students' knowledge in differentiating the diagnosis and treatment of unipolar vs bipolar depression.

BACKGROUND: Depression is one of the leading causes of premature death and disability. However, both unipolar and bipolar depression are underdiagnosed and undertreated. The aims of this study were to assess medical students' level of confidence in and knowledge of diagnosing and treating depression before and after completing a psychiatry clerkship, and their knowledge of differentiating unipolar vs bipolar depression. METHODS: Third-year medical students at Augusta University (Georgia, USA) completed an online questionnaire to assess confidence in and knowledge of diagnosing and treating unipolar and bipolar depression. RESULTS: Students who completed a psychiatry clerkship were statistically significantly more comfortable/confident with diagnosing (P < .0001) and treating (P < .0001) unipolar depression. Regarding bipolar depression, 73% of students who completed a psychiatry clerkship correctly diagnosed bipolar disorder, vs 59% of students who did not complete a psychiatry clerkship. This difference was not statistically significant (P = .181). CONCLUSIONS: Students who completed a psychiatry clerkship were more confident in diagnosing and treating unipolar depression compared with those who did not complete a psychiatry clerkship. However, there was no statistically significant difference between students who had completed a psychiatry clerkship and those who had not completed a psychiatry clerkship in making the correct diagnosis of bipolar depression. Neither group had a very high rate of correct diagnosis.

Development and implementation of a point of care ultrasound curriculum at a multi-site institution.

In 2014, over 60% of medical schools were incorporating point of care ultrasound (POCUS) into their curriculum. Today, over 6 years later, many more schools are teaching POCUS or are in the planning stages of implementing a POCUS curriculum. In 2019, the AAMC reported that 53 schools or over one-third of US medical schools have multi-site campuses for undergraduate medical education. Implementation of a POCUS educational initiative at a multi-site campus presents unique challenges for teaching a uniform curriculum statewide. This article will discuss the POCUS curriculum and implementation process at a large multi-site institution.

Incidence of resident mistreatment in the learning environment across three institutions.

INTRODUCTION: Mistreatment in the learning environment is associated with negative outcomes for trainees. While the Association of American Medical Colleges (AAMC) annual Graduation Questionnaire (GQ) has collected medical student reports of mistreatment for a decade, there is not a similar nationally benchmarked survey for residents. The objective of this study is to explore the prevalence of resident experiences with mistreatment. METHODS: Residents at three academic institutions were surveyed using questions similar to the GQ in 2018. Quantitative data were analyzed based on frequency and Mann-Whitney U tests to detect gender differences. RESULTS: Nine hundred ninety-six of 2682 residents (37.1%) responded to the survey. Thirty-nine percent of residents reported experiencing at least one incident of mistreatment. The highest reported incidents were public humiliation (23.7%) and subject to offensive sexist remarks/comments (16.0%). Female residents indicated experiencing significantly more incidents of public embarrassment, public humiliation, offensive sexist remarks, lower evaluations based on gender, denied opportunities for training or rewards, and unwanted sexual advances. Faculty were the most frequent instigators of mistreatment (66.4%). Of trainees who reported experiencing mistreatment, less than one-quarter reported the behavior. CONCLUSION: Mistreatment in the academic learning environment is a concern in residency programs. There is increased frequency among female residents.

Medical student experiences with accessing and entering patient information in electronic health records during the obstetrics-gynecology clerkship.

BACKGROUND: Medical school graduates should be able to enter information from patient encounters and to write orders and prescriptions in the electronic health record. Studies have shown that, although students often can access electronic health records, some students may receive inadequate preparation for these skills. Greater understanding of student exposure to electronic health records during their obstetrics and gynecology clerkships can help to determine the extent to which students receive the educational experiences that may best prepare them for their future training and practice. OBJECTIVE: The purpose of this study was to examine medical student reporting of electronic health record use during the obstetrics and gynecology clerkship. STUDY DESIGN: A Step 2 Clinical Knowledge End-of-Examination Survey about electronic health record use was administered to medical students after they completed the Step 2 Clinical Knowledge component of the United States Medical Licensing Examination. For inpatient and outpatient rotations, students were asked if they accessed a record and if they entered notes or orders into it. Descriptive statistics for a sample of 16,366 medical students who graduated from Liaison Committee on Medical Education-accredited schools from 2012-2016 summarize student interactions with electronic health records by rotation type and graduation year. Chi-square techniques were used to examine mean differences in access and entry. RESULTS: The survey had an overall response rate of 70%. In 2016, most survey respondents (94%) accessed electronic health records during their obstetrics and gynecology clerkship, but 26% of them reported "read-only" access. On the inpatient service, <10% of students reported any order entry; 58% of them reported entering progress notes, and 47% of them reported entering an admitting history and physical. CONCLUSION: Medical school graduates who are entering obstetrics and gynecology residencies are expected to be competent in documenting clinical encounters and entering orders, including those that are unique to obstetrics and gynecology. This study shows that some students may receive less experience with entering information into electronic health records during their obstetrics and gynecology clerkships than others, which could result in unequal levels of preparedness for graduate medical education.

Training the Trainer: Faculty From Across Multiple Specialties Show Improved Confidence, Knowledge and Skill in Point of Care Ultrasound After a Short Intervention.

Objectives  Lack of faculty skill and confidence in performing and teaching point-of-care ultrasound (POCUS) remains a significant barrier to implementation of a longitudinal ultrasound curriculum in undergraduate medical education. Our objective was to assess faculty comfort, knowledge and skill with performing and teaching POCUS before and after a focused workshop. Methods  This was a prospective study assessing faculty from multiple specialties. Faculty completed a pre- and post-workshop survey and ultrasound knowledge assessment, and a post-workshop objective structured clinical examination (OSCE) to assess ability to perform POCUS. Differences between pre- and post-workshop responses were analyzed using Fisher's Exact and Wilcoxon tests, and statistical significance was accepted for p<0.05. Results We analyzed data on 78 faculty from multiple disciplines. Faculty had a median of 7.5 years of experience with medical student teaching. Sixty-eight percent of faculty had performed <25 prior ultrasound (US) examinations. Comparing pre- to post-workshop responses, we found significant reductions in barriers to using US, and improved confidence with using, obtaining and interpreting POCUS (p<0.01). Faculty felt significantly more comfortable with the idea of teaching medical students POCUS (p<0.01). POCUS knowledge improved from 50% to 86% (p<0.01). On the post-workshop OSCE, 90% of anatomic structures were correctly identified with a median image quality of 4 out of 5. Conclusion After attending a six-hour workshop, faculty across multiple specialties had increased confidence with using and teaching POCUS, showed improved knowledge, and were able to correctly identify pertinent anatomic structures with ultrasound while obtaining good image quality.

Electronic Health Record Use in Internal Medicine Clerkships and Sub-internships for Medical Students Graduating from 2012 to 2016.

BACKGROUND: As electronic health records (EHRs) became broadly available in medical practice, effective use of EHRs by medical students emerged as an essential aspect of medical education. While new federal clinical documentation guidelines have the potential to encourage greater medical student EHR use and enhance student learning experiences with respect to EHRs, little is known nationally about how students have engaged with EHRs in the past. OBJECTIVE: This study examines medical student accounts of EHR use during their internal medicine (IM) clerkships and sub-internships during a 5-year time period prior to the new clinical documentation guidelines. DESIGN: An online survey about EHR use was administered to medical students immediately after they completed USMLE Step 2 CK. PARTICIPANTS: The sample included 16,602 medical students planning to graduate from US medical schools from 2012 to 2016. MAIN MEASURES: Descriptive statistics were computed to determine the average percentage of students engaged in various health record activities during their IM educational experiences by graduation year. KEY RESULTS: The vast majority (99%) of medical students used EHRs during IM clerkships or sub-internships. Most students reported that they entered information into EHRs during the inpatient component of the IM clerkship (84%), outpatient component of the IM clerkship (70%), and the IM sub-internship (92%). Yet, 43% of the students who graduated in 2016 never entered admission orders and 35% of them never entered post-admission orders. CONCLUSIONS: Medical school graduates ought to be able to effectively document clinical encounters and enter orders into EHR systems. Although most students used and entered information into EHRs during their IM clinical training, many students appear to have received inadequate opportunities to enter notes or orders, in particular. Implications for graduate medical education preparedness are considered. Future research should address similar questions using comparable national data collected after the recent guideline changes.

Ultrasound Curriculum Implementation into a State-Wide Family Medicine Clerkship.

INTRODUCTION: While point of care ultrasound (POCUS) integration into clinical clerkships provides unique educational experiences for students, there are barriers to implementation, particularly in a distributed campus medical school model in clerkships where the faculty do not often perform POCUS, like family medicine (FM). The objective of this paper is to describe the implementation and evaluation of a POCUS curriculum in an FM core clinical clerkship in a state-wide medical school campus model. METHODS: Seventeen Philips Lumify Ultrasound Systems were used in 20 clerkship sites with the requirement that students obtain abdominal aortic and inferior vena cava (IVC) images on patients evaluated during their rotation. Images were de-identified, transmitted to a university cloud-based storage account, and scored by medical school ultrasound faculty. RESULTS: Students were able to obtain adequate images of the aorta and IVC without direct ultrasound-trained faculty at the performance site. Of the 183 students, 119 (65%) were able to successfully submit images for scoring with failure to upload to the cloud-based storage account as the most common reason students were unsuccessful (42%). The majority of students (62%) scored in the top quartile of image quality scoring with the percentage of those scoring in the top quartile improving during the academic year from 57% in the first four rotations to 67% in the last four rotations. CONCLUSION: Barriers to implementation of a POCUS curriculum into a FM clerkship in a distributed campus medical school model can be challenging due to equipment availability and issues around the successful transmission of images. These challenges can be overcome however with sufficient attention to implementation design that includes equipment sharing protocols and technical options that enhance the ease of image transmission.

Differences in Medical Students' Academic Performance between a Pass/Fail and Tiered Grading System.

OBJECTIVES: Medical school implementation of a pass/fail grading system offers the opportunity for a reduction in student stress and anxiety and the creation of a less competitive environment, leading to an improvement in overall well-being. Some critics of a pass/fail system have raised concerns of a decrement in academic performance. The purpose of this research project was to determine whether medical students at the Medical College of Georgia experienced a significant change in academic performance when graded using a pass/fail grading system rather than a tiered grading system in the year 1 curriculum. METHODS: This retrospective cohort study included a convenience sample of two cohorts of students: the first had tiered grading in the first year of medical school (classes of 2015 and 2016; n = 389) and the second cohort had pass/fail grading in the first year of medical school (classes of 2017 and 2018; n=385). Students' undergraduate grade point average and Medical College Admission Test scores in the two cohorts were compared. The first- and second-year averages and comprehensive finals, and the US Medical Licensing Examination step 1 scores were compared. Mann-Whitney U tests were calculated to compare the cohorts' grades. RESULTS: Overall, both cohorts performed similarly in the first and second year of medical school and on US Medical Licensing Examination step 1; however, there were a few unimportant but statistically significant differences of 1 to 2 points on a 100-point scale. In a few instances, the pass/fail cohort performed slightly better and in others, slightly worse. CONCLUSIONS: Overall academic performance was similar. The potential for an enhanced learning environment associated with pass/fail grading does not create an important decrement in academic performance.

Medical Student Use of Electronic and Paper Health Records During Inpatient Clinical Clerkships: Results of a National Longitudinal Study.

PURPOSE: An important goal of medical education is to teach students to use an electronic health record (EHR) safely and effectively. The purpose of this study is to examine medical student accounts of EHR use during their core inpatient clinical clerkships using a national sample. Paper health records (PHRs) are similarly examined. METHOD: An online survey about health record use within the inpatient component of six core clerkships was administered to medical students after they completed Step 2 Clinical Knowledge of the United States Medical Licensing Examination. The sample included 17,202 U.S. medical students graduating between 2012 and 2016. Mean percentages of clerkships in which students engaged in various health record activities were computed, and analysis of variance was used to examine differences. RESULTS: The mean percentages of clerkships in which a student accessed or entered information into an EHR increased from 78% to 93% and 59% to 72%, respectively. For students who used an EHR, the mean percentage of clerkships in which they entered information remained constant at 76%. Students entered notes during the majority of their clerkships, with increases over time. However, students entered orders in less than a quarter of their clerkships, with decreases over time. The percentage of clerkships in which students used PHRs was lower and declining. CONCLUSIONS: Although students used an EHR in the majority of their inpatient core clerkships, they received limited educational experiences related to order and note writing, which could translate into a lack of preparedness for future training and practice.

The impact of an Emergency Medical Technician basic course prior to medical school on medical students.

BACKGROUND: Previous research on Emergency Medical Technician (EMT) programs as an early clinical experience indicates that medical students' confidence in patient care and team-building skills increases with participation. However, very little is known about the unplanned, long-term effects of EMT courses on medical students once they enter medical school. OBJECTIVES: This study examined the immediate outcomes produced by the month-long summer EMT course and the unplanned outcomes that students reported 1 year later. METHODS: Pre/postsurveys were collected on all 25 students who graduated from the EMT course offered before their first year. These survey data were analyzed using a paired-samples t test. A subset of students (N = 14) consented to taking a survey and be interviewed on the lasting impact of their EMT experience. Interviews were conducted 10 months after the 2016 cohort completed the EMT course and at 22 months for the 2015 cohort. They were audio-recorded, transcribed, and analyzed using inductive content analysis. RESULTS: Survey results indicated that students' confidence in patient care and team-building skills increased significantly for all identified skills at the P < 0.05 level. Overall confidence in patient care increased 1.5 points (P = 0.001) on 1-4 Likert-type scale. Overall confidence in team-building skills increased at 0.7 points (P = 0.01). Qualitative analysis of interviews discovered four themes, including the retention and transferability of practical skills, a developed understanding of team communication, comfort with patient interactions, and the development of a framework for assessing patients' needs. Students applied the EMT skills in various extracurricular volunteering experiences and in clinical skills courses. CONCLUSIONS: This study concludes that EMT programs have both immediate and lasting effects that seem to assist students with making sense of and navigating other learning opportunities. Specifically, EMT courses offered to students prior to their entry into medical school may help orient them to team-based health care and triaging patient care.