Preparing Future Pediatricians: Making Time Count

The fourth year of medical school remains controversial, despite efforts to reform it. A committee from the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine examined transitions from medical school to internship with the goal of better academic advising for students. In 2013 and 2014, the committee examined published literature and the Web sites of 136 Liaison Committee on Medical Education-accredited schools for information on current course offerings for the fourth year of medical school. The authors summarized temporal trends and outcomes when available.Subinternships were required by 122 (90%) of the 136 schools and allow students to experience the intern's role. Capstone courses are increasingly used to fill curricular gaps. Revisiting basic sciences in fourth-year rotations helps to reinforce concepts from earlier years. Many schools require rotations in specific settings, like emergency departments, intensive care units, or ambulatory clinics. A growing number of schools require participation in research, including during the fourth year. Students traditionally take fourth-year clinical electives to improve skills, both within their chosen specialties and in other disciplines. Some students work with underserved populations or seek experiences that will be henceforth unavailable, whereas others use electives to "audition" at desired residency sites. Fourth-year requirements vary considerably among medical schools, reflecting different missions and varied student needs. Few objective outcomes data exist to guide students' choices. Nevertheless, both medical students and educators value the fourth year of medical school and feel it can fill diverse functions in preparing for residency.

The Council of Emergency Medicine Residency Directors (CORD) introduced the standardized letter of recommendation (SLOR) in 1997, and it has become a critical tool for assessing candidates for emergency medicine (EM) training. It has not itself been evaluated since the initial studies associated with its introduction. This study characterizes current SLOR use to evaluate whether it serves its intended purpose of being standardized, concise, and discriminating. This retrospective, multi-institutional study evaluated letters of recommendation from U.S. allopathic applicants to three EM training programs during the 2011-2012 Electronic Residency Application Service (ERAS) application cycle. Distributions of responses to each question on the SLOR were calculated, and the free-text responses were analyzed. Two pilots, performed on five applicants each, assisted in developing a strategy for limiting interrater reliability. Each of the three geographically diverse programs provided a complete list of U.S. allopathic applicants to their program. Upon randomization, each program received a list of coded applicants unique to their program randomly selected for data collection. The number of applicants was selected to reach a goal of approximately 200 SLORs per site (n = 602). Among this group, comprising 278 of 1,498 applicants (18.6%) from U.S. allopathic schools, a total of 1,037 letters of recommendation were written, with 724 (69.8%) written by emergency physicians. SLORs represented 57.9% (602/1037) of all LORs (by any kind of author) and 83.1% (602/724) of letters written by emergency physicians. Three hundred ninety-two of 602 SLORs had a single author (65.1%). For the question on "global assessment," students were scored in the top 10% in 234 of 583 of applications (40.1%; question not answered by some), and 485 of 583 (83.2%) of the applicants were ranked above the level of their peers. Similarly, >95% of all applicants were ranked in the top third compared to peers, for all but one section under "qualifications for emergency medicine." For 405 of 602 of all SLORs (67.2%), one or more questions were left unanswered, while 76 of all SLORs (12.6%) were "customized" or changed from the standard template. Finally, in 291 of 599 of SLORs (48.6%), the word count was greater than the recommended maximum of 200 words. Grade inflation is marked throughout the SLOR, limiting its ability to be discriminating. Furthermore, template customization and skipped questions work against the intention to standardize the SLOR. Finally, it is not uncommon for comments to be longer than guideline recommendations. As an assessment tool, the SLOR could be more discerning, concise, and standardized to serve its intended purpose.

Fostering Collaboration between Undergraduate and Postgraduate Education Directors: An Essential Step to Developing a Continuum of Pediatric Education

To develop future neurologists and translational neuroscientists, we created a neurosciences pathway throughout our medical school curriculum that included early exposure to clinical neurosciences decision-making and added variety to the choices of later clinical neurosciences experiences. Our curricular innovation had 3 parts: (1) integrating basic neurosciences content into an explicit clinical context in a College of Medicine (COM) first year of medical school; (2) expanding pathophysiological principles related to neurosciences in COM second year of medical school; and (3) creating a variety of 3-week clinical neurosciences selectives in COM third year of medical school and 4-week electives/externships for interested learners in COM fourth year of medical school. These new changes were evaluated (1) by comparing national standardized examinations including Neurology Subject examination scores for students choosing clinical neurosciences selectives; (2) by student satisfaction Graduate Questionnaires; and (3) by the total number of our graduates matching in US neurosciences disciplines. Students taking neuroscience selectives demonstrated a nonsignificant trend toward higher Step 2 Clinical Knowledge scores. The students' Neurology Subject examination scores were comparable with those scores reported nationally for other US COM third year of medical school students on 4-week rotations. Student-reported satisfaction in clinical neurology teaching improved from 43.9% (before) to 81.8% (after). The percentage of students matching into clinical neuroscience disciplines rose from 2% (before) to 6% (after). Our neurosciences curricular innovation increased graduating student satisfaction scores, had a mild positive impact on Step 2 Clinical Knowledge scores, and increased the number of students choosing careers in the clinical neurosciences. This model may be a consideration for other medical schools who wish to integrate neurosciences teaching throughout their curriculum.

Background: The neurologic examination is a challenging component of the physical examination for medical students. In response, primarily based on expert consensus, medical schools have supplemented their curricula with standardized patient (SP) sessions that are focused on the neurologic examination. Hypothesis-driven quantitative data are needed to justify the further use of this resource-intensive educational modality, specifically regarding whether using SPs to teach the neurological examination effects a long-term benefit on the application of neurological examination skills.Methods: This study is a cross-sectional analysis of prospectively collected data from medical students at Weill Cornell Medical College. The control group (n=129) received the standard curriculum. The intervention group (n=58) received the standard curriculum and an additional SP session focused on the neurologic examination during the second year of medical school. Student performance on the neurologic examination was assessed in the control and intervention groups via an OSCE administered during the fourth year of medical school. A Neurologic Physical Exam (NPE) score of 0.0 to 6.0 was calculated for each student based on a neurologic examination checklist completed by the SPs during the OSCE. Composite NPE scores in the control and intervention groups were compared with the unpaired t-test.Results: In the fourth year OSCE, composite NPE scores in the intervention group (3.5±1.1) were statistically significantly greater than those in the control group (2.2±1.1) (p<0.0001).Conclusions: SP sessions are an effective tool for teaching the neurologic examination. We determined that a single, structured SP session conducted as an adjunct to our traditional lectures and small groups is associated with a statistically significant improvement in student performance measured 2 years after the session.

This article addresses the problems associated with current undergraduate surgical education and discusses the requirements necessary for its improvement during the third and fourth years of medical school. It asserts that, coincident with the emphasis on faculty research and publication and expanded resident patient care duties, teaching, particularly medical student teaching, has assumed a very low priority. Third-year medical students are attached to surgical teams, where their education is haphazard and disorganized. Furthermore, because any teaching that occurs is teacher oriented rather than student centered, knowledge is accumulated passively and is not well retained. Traditional evaluation using shelf multiple choice examinations and ward ratings by residents and faculty may provide inaccurate assessments of the students' performance. The undergraduate surgical education program should be directed by a faculty member who has been grounded in educational techniques and research and supported by a department chairman committed to bettering the program. In the clerkship, medical students should be assigned to faculty rather than to services and should be presented problems that require solution. Students also should be provided with the resources to solve the problems and should be given sufficient time to solve them. Some operating room experience and bedside teaching should occur during the clerkship. A variety of evaluation and testing methods based on the learning objectives of the clerkship should be used. Third-year students should not be promoted until they have demonstrated their acquisition of appropriate knowledge and skills.(ABSTRACT TRUNCATED AT 250 WORDS)

Obesity is a major health concern in the United States, and its prevalence continues to rise. Although it is a common health issue, many people, including health care professionals, are biased against people with obesity. To determine whether a comprehensive obesity curriculum presented to students in medical school can positively influence their attitudes toward obesity. The study was designed around a comprehensive educational obesity curriculum at Touro University College of Osteopathic Medicine-CA, involving the classes of 2013 through 2018. A survey to assess student attitudes toward obesity was distributed to first-year students before the curriculum, directly after completion, and each year after until graduation (graduating classes of 2015 through 2018). Second- and third-year medical students in 2011 (graduating classes of 2014 and 2013), who did not complete the curriculum, were given an examination to establish baseline values and served as the control group. The obesity curriculum consisted of lectures delivered during the first and second year of medical school and case study simulations during the third year. Knowledge gained from the curriculum was assessed with a multiple-choice examination, and bias was assessed using the Fat Phobia Scale. A total of 718 first- through fourth-year students were included. Students who completed the first year of the obesity curriculum (n=528) showed significantly greater medical knowledge regarding obesity-related epidemiology, pathogenesis, biochemistry, pathophysiology, and metabolic factors; nutrition, diet, physical activity, self-control, and behavior modification; pharmacologic and nonpharmacologic interventions; and associated chronic disorders, based on their multiple-choice examination scores compared with the control group. The examination scores indicated significant increases in medical knowledge compared with the precurriculum cohort after the curriculum (OMS I students: 130 [72.4%]; 133 [92.6%]; 133 [91.1%]; 132 [89.0%]; vs control: 105 [47.2%]; 134 [52.6%], respectively [P<.01]). In all 4 years observed, there was a significant reduction in bias among first-year medical students after obesity curriculum (before: 3.65, 3.76, 3.57, 3.61, and after: 3.47, 3.38, 3.34, 3.37, respectively) (P<.05). The reduction in bias was also significantly sustained throughout the fourth year. A comprehensive obesity curriculum throughout medical school resulted in an improvement in students' attitudes toward and knowledge of obesity.

QS50. Medical Students Have Emotional Intelligence Similar to General Population

To explore medical students' perspective regarding the fourth year of medical school and common educational activities thereof. The authors surveyed students graduating in 2012 with a military service obligation about the importance of common fourth-year activities, the proportion of the fourth year devoted to these activities, and important considerations for the fourth-year curriculum. The authors calculated mean importance scores for educational activities and mean proportions of the fourth year that should be devoted to certain activities. Two reviewers independently coded free-text answers to identify and calculate frequencies for common themes. The response rate was 40% (376/942). Participants rated activities related to improving clinical skills and securing the residency of their choice as more than activities such as learning business skills, conducting research, and studying basic sciences. Participants indicated that electives and direct patient care should comprise the majority of the fourth year and frequently mentioned improving specialty-specific clinical skills, pursuing personal medical interests, and taking time to relax as important fourth-year themes. Students value activities related to securing and succeeding in their chosen residency and the opportunity to pursue electives and take vacation. Faculty should consider the student perspective when reforming curricula.

Carol Brayne: studying dementia in the brain and in populations

Internal medicine (IM) residency graduates consistently report being less prepared for outpatient practice than inpatient medicine. Although an initial study suggested interns arriving for IM residency reported low levels of preparedness for continuity clinic, the impact of education and experience during the undergraduate medical education to graduate medical education transition on ambulatory training is unclear. To describe end of medical school primary care exposure among entering IM interns and its association with self-assessed preparedness for residency continuity clinic. Cross-sectional survey of 161 entering IM interns in 2019. Entering interns at four geographically diverse IM residency programs (University of Chicago, University of North Carolina, University of Pennsylvania, and University of Washington), representing 81 US medical schools. A total of 139 interns (86%) responded to the survey. Surveyed interns reported a median of zero days of general internal medicine (GIM) clinic (interquartile range [IQR]: 0-20days) and 2.5days of multispecialty adult primary care (IQR: 0-26.5days) during fourth year of medical school. The median last exposure to primary care was 13months prior to internship (IQR: 7-18months). Interns who rated themselves as prepared for primary care clinic reported a median of twenty more multispecialty adult primary care days (20 vs. 0days; p < 0.01) and fourteen more GIM clinic days (14 vs. 0days; p < 0.01) than their unprepared counterparts. The experiences were also more recent, with six fewer months between their last multispecialty adult primary care exposure and the start of internship (9 vs. 15months; p < 0.01). The majority of incoming IM interns had no primary care training during the fourth year of medical school. At the start of residency, IM interns who felt more prepared for their primary care clinic reported more recent and more numerous primary care experiences.

The fourth year of medical school is an exciting time for students as it is the culmination of medical school and the time when students prepare for residency. This chapter will focus on the preparation and process of making the year a successful capstone for medical school and a solid foundation for surgical residency.

Objective: To evaluate the prevalence of acne vulgaris among medical students in Saudi Arabia and to assess their knowledge and attitudes about it, as well as the psychosocial impact of acne. Methods: Data was collected from 555 medical students, both males and females, in Saudi Arabia. A cross sectional design was used. Questionnaires were used to collect data. Results: Of the participants 49.5% were male and 50.5% female. More than half of the participants (66.7%) were between 18 and 20 years old. The majority were single (91.4%). The geographical areas where they lived included the north (30.3%), south (13.3 %), central (9.4%), east (17.3%), and west (19.1). About two thirds were in the fourth year of medical school or less. Among the participating medical student, 55% had acne. The most common site affected was the face, and the least affected was the chest. More than half of medical students in the study sample used medical lotions to treat acne (57.0%), with only one third using medication (33.1%). Perceived adverse psychological effects were self-reported by 202 students, 72.1% of the 305 with acne. Most (91.4%) identified hormones as the most important aggravating factor. Other aggravating factors believed by students included change in stress (86.1%), dust and heat (84.9%), cosmetics (69.2%), and lack of care skin and diet (66.8%). Gender were significantly related to the level of knowledge score, with the majority of male students (62.5%) having poor knowledge about acne while 50.9% of the female students had good knowledge. Age, social status, living area, and study year were not significantly associated with knowledge level of participants. Conclusion: Results of this study point out that lack of knowledge about acne is widespread among Saudi medical students, and patients with acne had poor practice and unfavorable attitude.

Pilot: Hematology/Oncology Curriculum for the Internal Medicine and Hematology/Oncology Sub-Internships

A healthy lifestyle is fundamental for the prevention and treatment of cardiovascular disease and other noncommunicable diseases (NCDs). Investment in primary prevention, including modification of health risk behaviors, could result in a 4-fold improvement in health outcomes compared with secondary prevention based on pharmacological treatment. The American Heart Association (AHA) emphasized the importance of lifestyle in its 2020 goals for cardiovascular health promotion and disease reduction. In addition to defining “cardiovascular health” based on criteria for blood pressure and biochemical markers (lipids and glycemia), the AHA Strategic Planning Committee further identified lifestyle characteristics of central importance: nutrition, physical activity, smoking, and maintenance of a healthy body weight.1 The World Health Organization estimated that ≈80% of NCDs could be prevented if 4 key lifestyle practices were followed: a healthy diet, being physically active, avoidance of tobacco, and alcohol intake in moderation.2 To support healthy lifestyle initiatives, major changes are necessary at the societal level to improve population health. Numerous strategies might help to create a culture that promotes and facilitates healthy behaviors, including creating laws and regulations, mounting large-scale public awareness and education campaigns, implementing local community programs, and providing individual counseling.3 Physicians are uniquely positioned to encourage individuals to adopt healthy lifestyle behaviors: Approximately 80% of Americans visit their primary care physician at least once a year. Physicians directly communicate with their patients during clinical encounters across numerous settings, and research indicates that patients highly value recommendations provided by their physicians.4,5 However, data further indicate that lifestyle counseling does not routinely occur in physicians’ offices, thereby representing a lost opportunity. Physicians report that they perform lifestyle counseling during ≈34% of clinic visits.4 Patients, in turn, report an even lower frequency of physician lifestyle counseling. For example, obese patients reported receiving physical activity and …