Bridging the Gap Between the Classroom and the Clerkship: A Clinical Reasoning Curriculum for Third-Year Medical Students.
ABSTRACT: Introduction:Clinical reasoning is the complex cognitive process that drives the diagnosis of disease and treatment of patients. There is a national call for medical educators to develop clinical reasoning curricula in undergraduate medical education. To address this need, we developed a longitudinal clinical reasoning curriculum for internal medicine clerkship students. Methods:We delivered six 1-hour sessions to approximately 40 students over the 15-week combined medicine-surgery clerkship at Penn State College of Medicine. We developed the content using previous work in clinical reasoning, including the American College of Physicians' Teaching Medicine Series book Teaching Clinical Reasoning. Students applied a clinical reasoning diagnostic framework to written cases during each workshop. Each session followed a scaffold approach and built upon previously learned clinical reasoning skills. We administered a pre- and postsurvey to assess students' baseline knowledge of clinical reasoning concepts and perceived confidence in performing clinical reasoning skills. Students also provided open-ended responses regarding the effectiveness of the curriculum. Results:The curriculum was well received by students and led to increased perceived knowledge of clinical reasoning concepts and increased confidence in applying clinical reasoning skills. Students commented on the usefulness of practicing clinical reasoning in a controlled environment while utilizing a framework that could be deliberately applied to patient care. Discussion:The longitudinal clinical reasoning curriculum was effective in reinforcing key concepts of clinical reasoning and allowed for deliberate practice in a controlled environment. The curriculum is generalizable to students in both the preclinical and clinical years.
Project description:BACKGROUND:Recent reports, including the Institute of Medicine's Improving Diagnosis in Health Care, highlight the pervasiveness and underappreciated harm of diagnostic error, and recommend enhancing health care professional education in diagnostic reasoning. However, little is known about clinical reasoning curricula at US medical schools. OBJECTIVE:To describe clinical reasoning curricula at US medical schools and to determine the attitudes of internal medicine clerkship directors toward teaching of clinical reasoning. DESIGN:Cross-sectional multicenter study. PARTICIPANTS:US institutional members of the Clerkship Directors in Internal Medicine (CDIM). MAIN MEASURES:Examined responses to a survey that was emailed in May 2015 to CDIM institutional representatives, who reported on their medical school's clinical reasoning curriculum. KEY RESULTS:The response rate was 74% (91/123). Most respondents reported that a structured curriculum in clinical reasoning should be taught in all phases of medical education, including the preclinical years (64/85; 75%), clinical clerkships (76/87; 87%), and the fourth year (75/88; 85%), and that more curricular time should be devoted to the topic. Respondents indicated that most students enter the clerkship with only poor (25/85; 29%) to fair (47/85; 55%) knowledge of key clinical reasoning concepts. Most institutions (52/91; 57%) surveyed lacked sessions dedicated to these topics. Lack of curricular time (59/67, 88%) and faculty expertise in teaching these concepts (53/76, 69%) were identified as barriers. CONCLUSIONS:Internal medicine clerkship directors believe that clinical reasoning should be taught throughout the 4 years of medical school, with the greatest emphasis in the clinical years. However, only a minority reported having teaching sessions devoted to clinical reasoning, citing a lack of curricular time and faculty expertise as the largest barriers. Our findings suggest that additional institutional and national resources should be dedicated to developing clinical reasoning curricula to improve diagnostic accuracy and reduce diagnostic error.
Project description:<h4>Introduction</h4>Despite high obesity rates nationwide, many medical schools provide insufficient nutrition education. It has been difficult to deliver nutrition education in the Columbia University College of Physicians and Surgeons primary care clerkship given its numerous clinical sites offering varied expertise. We supplemented the clerkship curriculum with an interactive e-learning module designed to provide medical students with knowledge and skills in nutrition and weight management, as well as an understanding of registered dietitians' role. The module was created using Articulate Storyline 2 software and emphasizes active learning and simulated clinical decision-making.<h4>Methods</h4>Learning objectives and a curriculum were developed based on a literature review, a student focus group, and the guidance of a multidisciplinary committee. The module integrates narrated content with interactive exercises and utilizes multiple teaching styles. Participants were third-year medical students in the primary care clerkship during January-May 2016 (<i>n</i> = 64). Students completed a web-based evaluation survey after the module.<h4>Results</h4>Ninety-two percent of students completed the module in 2 hours or less. Ninety-seven percent agreed that the module was easy to navigate, and 93% agreed that it contributed to their understanding of the topic. Qualitatively, students generally responded positively to the module's active learning component and its use of multiple teaching styles.<h4>Discussion</h4>This web-based interactive learning module is an accessible tool that allows educators to simultaneously deliver information and target clinical reasoning skills. Active learning facilitates students' engagement with the content. This module is easily adaptable for other learners, including physicians and patients, and other areas of the curriculum.
Project description:Background:While the term "information literacy" is not often used, the skills associated with that concept are now central to the mission and accreditation process of medical schools. The simultaneous emphasis on critical thinking skills, knowledge acquisition, active learning, and development and acceptance of technology perfectly positions libraries to be central to and integrated into the curriculum. Case Presentation:This case study discusses how one medical school and health sciences library leveraged accreditation to develop a sustainable and efficient flipped classroom model for teaching information literacy skills to first-year medical students. The model provides first-year medical students with the opportunity to learn information literacy skills, critical thinking skills, and teamwork, and then practice these skills throughout the pre-clerkship years. Conclusions:The curriculum was deemed a success and will be included in next year's first-year curriculum. Faculty have reported substantial improvements in the information sources that first-year medical students are using in subsequent clinical reasoning conferences and in other parts of the curriculum. The effectiveness of the curriculum model was assessed using a rubric.
Project description:Introduction:Patient handoffs, the communications required for the safe transfer of patient care, are known to be a common source of medical errors. Simulation exercises are effective techniques for teaching the procedures and patient interaction skills involved in a handoff. We developed a teaching tool that allows students to individually interact with a simulated patient, develop a treatment plan, and practice a handoff to another provider. Methods:The curriculum is a flexible instructional tool to teach patient handoffs in the context of a simulated obstetric emergency for learners at the clerkship through first-year obstetrics and gynecology resident levels. The curriculum secondarily teaches management of first-trimester bleeding with acute blood loss and can be adapted to allow advanced learners to practice obtaining informed consent. To evaluate this simulation for educational effectiveness, we developed a faculty observation assessment tool. Results:The simulation assessments for history taking, fund of knowledge, and interpersonal skills were predictive of subsequent clerkship clinical grades. Eighty percent of students agreed the exercise was realistic, 95% agreed it was relevant to the clinical curriculum, 90% agreed the simulation taught handoff skills, and 73% agreed the simulation increased confidence in handoff skills. Students uniformly found the curriculum to be relevant, realistic, and effective at teaching handoff skills. Discussion:Use of this curriculum has the potential to improve students' communication skills, handoff performance, and confidence during an obstetrics and gynecology clerkship. The assessment tool may allow early identification of students in need of improvement in communication skills.
Project description:INTRODUCTION:Despite the extraordinary amount of time physicians spend communicating with patients, dedicated education strategies on this topic are lacking. The objective of this study was to develop a multimodal curriculum including direct patient feedback and assess whether it improves communication skills as measured by the Communication Assessment Tool (CAT) in fourth-year medical students during an emergency medicine (EM) clerkship. METHODS:This was a prospective, randomized trial of fourth-year students in an EM clerkship at an academic medical center from 2016-2017. We developed a multimodal curriculum to teach communication skills consisting of 1) an asynchronous video on communication skills, and 2) direct patient feedback from the CAT, a 15-question tool with validity evidence in the emergency department setting. The intervention group received the curriculum at the clerkship midpoint. The control group received the curriculum at the clerkship's end. We calculated proportions and odds ratios (OR) of students achieving maximum CAT score in the first and second half of the clerkship. RESULTS:A total of 64 students were enrolled: 37 in the control group and 27 in the intervention group. The percentage of students achieving the maximum CAT score was similar between groups during the first half (OR 0.70, p = 0.15). Following the intervention, students in the intervention group achieved a maximum score more often than the control group (OR 1.65, p = 0.008). CONCLUSION:Students exposed to the curriculum early had higher patient ratings on communication compared to the control group. A multimodal curriculum involving direct patient feedback may be an effective means of teaching communication skills.
Project description:Purpose:To design, implement, and launch courses that integrate foundational science learning and clinical application in a post-clerkship undergraduate medical school curriculum. Method:In Academic Year (AY) 15-16, as part of a comprehensive curricular revision, Vanderbilt University School of Medicine (VUSM) formally implemented "Integrated Science Courses" (ISCs) that combined rigorous training in the foundational sciences with meaningful clinical experiences. These courses integrated foundational sciences that could be leveraged in the clinical environment, utilized a variety of instructional modalities, and included quantitative and qualitative (competency-based milestones) student assessments. Each ISC underwent a rigorous quality improvement process that required input on foundational science content, student experience, and student performance assessment. Results:Eleven ISCs were delivered to 173 students in AY15-16, with some students taking more than one ISC. Immediately after completing each course, 93% (n=222) of ISC enrollees completed a course evaluation. Students (91%; n=201) 'agreed' or 'strongly agreed' that foundational science learning informed and enriched the clinical experiences. Furthermore, 94% (n=209) of students thought that the clinical experiences informed and enriched the foundational science learning. Ninety-four percent of the students anticipated using the foundational science knowledge acquired in future clinical training and practice. Conclusion:The teaching of foundational sciences in the clinical workplace in the post-clerkship medical curriculum is challenging and resource-intensive, yet feasible. Additional experience with the model will inform the mix of courses as well as the breadth and depth of foundational science instruction that is necessary to foster scientifically-based clinical reasoning skills in each student.
Project description:Physicians have an important role addressing the obesity epidemic. Lack of adequate teaching to provide weight management counseling (WMC) is cited as a reason for limited treatment. National guidelines have not been translated into an evidence-supported, competency-based curriculum in medical schools. Weight Management Counseling in Medical Schools: A Randomized Controlled Trial (MSWeight) is designed to determine if a multi-modal theoretically-guided WMC educational intervention improves observed counseling skills and secondarily improve perceived skills and self-efficacy among medical students compared to traditional education (TE). Eight U.S. medical schools were pair-matched and randomized in a group randomized controlled trial to evaluate whether a multi-modal education (MME) intervention compared to traditional education (TE) improves observed WMC skills. The MME intervention includes innovative components in years 1-3: a structured web-course; a role play exercise, WebPatientEncounter, and an enhanced outpatient internal medicine or family medicine clerkship. This evidence-supported curriculum uses the 5As framework to guide treatment and incorporates patient-centered counseling to engage the patient. The primary outcome is a comparison of scores on an Objective Structured Clinical Examination (OSCE) WMC case among third year medical students. The secondary outcome compares changes in scores of medical students from their first to third year on an assessment of perceived WMC skills and self-efficacy. MSWeight is the first RCT in medical schools to evaluate whether interventions integrated into the curriculum improve medical students' WMC skills. If this educational approach for teaching WMC is effective, feasible and acceptable it can affect how medical schools integrate WMC teaching into their curriculum.
Project description:Emergency departments (EDs) offer a variety of learning opportunities for undergraduate medical students. It is however, difficult to evaluate whether they are receiving recommended training during their emergency medicine (EM) clerkship without identifying their clinical activities. We aimed to evaluate the clinical exposure of the final year medical students at our College during their EM clerkship.This is a retrospective analysis of prospectively collected student logbooks. 75 students rotated in a 4-week EM clerkship during 2015-2016. The students rotated in EDs of two hospitals. Each ED treats more than 120,000 cases annually. The students completed 12 eight-hours shifts. Presentations and procedures seen were compared with EM curriculum recommendations.Five thousand one hundred twenty-two patient presentations and 3246 procedures were recorded in the logbooks, an average (SD) of 68.3 (17.6) patients and 46.1 (14.0) procedures. None of the students encountered all ten recommended presentations. Two students (2.6%) logged all nine procedure categories of the EM curriculum.Recommended presentations and procedures of the EM clerkship were not fully encountered by all our students. Different settings vary in the availability and type of patients and procedures. Each clinical clerkship should tailor their teaching methods based on the available learning opportunities.
Project description:Introduction:Many medical schools provide opportunities for students to learn about health disparities, social determinants of health, and the role physicians play in promoting health equity. The family medicine clerkship exposes medical students to these topics to help them understand the health status of patients. A multielement curriculum was incorporated into the core family medicine clerkship to provide the full medical school class exposure to community medicine and was updated in 2014 to increase the emphasis on clinical correlation of community medicine concepts. Methods:This curriculum consists of a community medicine orientation, a community-based experience, a didactic session, and a reflection paper. The orientation serves as an introduction to the course, and the community-based experience provides hands-on understanding of community medicine. The didactic session encompasses a half-day session of preparatory work, team-based exercises, an interactive lecture, individual reflection, and a seminar-style discussion. Students share their experience with the curriculum in their reflection papers. Results:Since 2014, 286 have students completed the updated curriculum, and reactions have been highly favorable. Most students have agreed or strongly agreed that the sessions met the learning objectives. Student preparation was demonstrated by individual quiz scores (average: 87%, n = 93). Learning and behavior change were evaluated using structured rubric scoring of reflection papers (average: 94%, n = 67). Discussion:Overall, this community medicine curriculum includes a variety of learning experiences for medical students to gain knowledge, attitudes, and skills that are applicable to care in all specialties and may be easily adapted to use in other settings.
Project description:<h4>Introduction</h4>As emergency medicine (EM) has become a more prominent feature in the clinical years of medical school training, national EM clerkship curricula have been published to address the need to standardize students' experiences in the field. However, current national student curricula in EM do not include core pediatric emergency medicine (PEM) concepts.<h4>Methods</h4>A workgroup was formed by the Clerkship Directors in Emergency Medicine and the Pediatric Interest Group of the Society of Academic Emergency Medicine to develop a consensus on the content to be covered in EM and PEM student courses.<h4>Results</h4>The consensus is presented with the goal of outlining principles of pediatric emergency care and prioritizing students' exposure to the most common and life-threatening illnesses and injuries.<h4>Conclusion</h4>This consensus curriculum can serve as a guide to directors of PEM and EM courses to optimize PEM knowledge and skills education.