Different approaches to identify and assess personal competencies in the admissions process for medical schools have been examined. GPAs and MCAT scores along with letters of evaluation and autobiographical assessment constitute the traditional measures of academic competencies. These measures have limitations and tend to lower the proportion of underrepresented in medicine (URIM) students in the entering class composition. Such limitations have prompted several medical schools to adopt the Multiple Mini Interview (MMI) to increase the reliability and predictive validity of the interview process. This single-institution multiyear cohort study is the only report from a U.S. medical school that shows that, unlike MCAT or GPA, the MMI performance exhibited no statistically significant difference between URIM and non-URIM groups. The findings suggest that increasing use of MMI scores in admission decisions may enhance ethnic diversity among entering medical students. -Sangita Phadtare, Ph.D., Cooper Medical School of Rowan University
EPAs are being used or investigated for use in the transition to independent practice, fellowship, and residency. As the authors write, “Entry into clerkship is just an earlier transition point.” The authors identified EPA content domains in speaking with 19 well-received pre-clerkship faculty members, 8 pre-clerkship students, and 3 clerkship year students. The EPAs were then revised, described, and validated via linkage with previously defined competencies, consultation with an EPA expert, and discussion with convenience samples of local (San Francisco), national, and international educators. The 5 proposed pre-clerkship EPAs focus on the Reporter (gathering, integrating, and communicating information with the care team and the patient) and Educator (providing resources to improve care) competencies. — Laura Willett, MD
Chen HC, McNamara M, Teherani A, Cate OT, O’Sullivan P. Developing Entrustable Professional Activities for Entry Into Clerkship. Acad Med. 2015 Nov 9.
Hard to know for sure, according to this narrative review of the literature. Only 10 RCTs were included here, along with 7 “well-designed controlled trials without randomization”, but overall 72 “high-quality” studies were included, and it is unclear how secular trends in patient safety were accounted for. The most consistent effect was an increase in total cost to the healthcare/educational system (7 of 7 studies). Less consistent data supported improvements in resident quality of life, resident education and performance, and patient complications. Reassuringly, no study reported an increase in patient mortality following duty hours restrictions. — Laura Willett, MD
Lin H, Lin E, Auditore S, Fanning J. A Narrative Review of High-Quality Literature on the Effects of Resident Duty Hours Reforms. Acad Med. 2015 Oct 5.
More and more medical schools are currently using flipped classrooms in their curriculum. These are characterized by substantial pre-class preparation, while in-class time is focused on active student centered learning activities. The success of this method is thus largely dependent on student preparation prior to the session, which is a topic of debate. Typically, watching web lectures as a preparation has been recommended, but more recently, various other approaches are used to serve students’ personal learning preferences. The study describes student preparation in a basic science and a clinical course in which students predominantly used the same study materials. The observation that 40% to 50% of the students chose to combine basic materials with scientific papers, books, and formative test questions does not support the idea that web lectures alone are sufficient to prepare for student-centered in-class activities. It was advised to provide students clear study directions to prevent unfair study load and honor their time commitments. -Sangita Phadtare, Ph.D., Cooper Medical School of Rowan University
Rianne A. M. Bouwmeester & Renske A. M. de Kleijn & Olle Th. J. ten Cate and Harold V. M. van Rijen & Hendrika E. Westerveld, How do medical students prepare for flipped classrooms? Medical Science Educator, 2015 October
Adding to data that checklists may not be the best way to evaluate observed clinical encounters (“Throw Out The Checklists (To Determine OSCE Failure)! A Global Competent/Not Competent Rating Is Better“),researchers looked at internal medicine interns’ evaluations of history and physical examination skills as an external validity check on the US national licensing observed clinical skills test, USMLE 2 CS. After accounting for other USMLE scores, including the USMLE 2 CS data interpretation score based on a written note regarding the encounter, the checklist data-gathering score did not provide any additional predictive information regarding subsequent performance in history and examination during internship. As noted by the authors, the checklists reward exhaustive “rote memorization rather than actual skill”, while educators value “a hypothesis-driven and focused history and physical examination”. — Laura Willett, MD
Cuddy MM, Winward ML, Johnston MM, Lipner RS, Clauser BE. Acad Med. 2015 Sep 21.
Evaluating Validity Evidence for USMLE Step 2 Clinical Skills Data Gathering and Data Interpretation Scores: Does Performance Predict History-Taking and Physical Examination Ratings for First-Year Internal Medicine Residents?
Acad Med. 2015 Sep 21.
A joint task force of clerkship and residency program directors, Vu et al, developed (mostly) non-evidence-based guidelines for internal medicine subinternships, typically taken in the last year of medical school. They recommend a rotation of at least 4 weeks with primary responsibility for 3-5 inpatients, as well as cross-coverage experience. Specific experience with care transitions, order entry, evidence-based medicine, and documentation in electronic health records is recommended. Alignment of subinternship objectives and residency expectations and with the new milestones/entrustable activities is encouraged. It may be useful to require more than one subinternship given the importance of these core skills.
A study published in the same issues (Goren et al) points out how difficult achieving at least one of these aims might be. Overnight subinternship experiences have declined from a near-universal requirement to having a presence in 41% of programs, presumably as a response to progressive duty-hours restrictions. Overnight rotations have traditionally been where students have learned most of their cross-coverage skills
Vu TR, Angus SV, Aronowitz PB, Harrell HE, Levine MA, Carbo A, Whelton S, Ferris A, Appelbaum JS, McNeill DB, Ismail NJ, Elnicki DM; CDIM-APDIM Committee on Transitions to Internship (CACTI) Group. J Gen Intern Med. 2015 Sep;30(9):1369-75.
The Internal Medicine Subinternship-Now More Important than Ever : A Joint CDIM-APDIM Position Paper.
Goren EN, Leizman DS, La Rochelle J, Kogan JR.
Overnight Hospital Experiences for Medical Students: Results of the 2014 Clerkship Directors in Internal Medicine National Survey. J Gen Intern Med. 2015 Sep;30(9):1245-50.
In order to stay current with the continuously changing medical literature doctors need to be life-long, self-regulated learners. The authors of this study propose that medical schools, therefore, need to educate students in effective self-learning skills. This paper examines if the students’ self-regulated learning skills change during medical school, and if there is a correlation between students’ self-learning skills and their grades (GPA).
Using a validated tool, called the Self-Regulation of Learning Self-Report Scale (SRL-SRS), 949 first and third year medical students were surveyed in several self-regulation skills: planning, monitoring, reflection, evaluation, effort, and efficacy. Outcomes were compared between the classes and measured against the students’ GPAs.
Reflection was the only skill that was scored significantly higher in the third year students than the first years. Comparing academic performance (GPAs) with self-regulation skills showed several associations. First year students with a higher GPA reported more skills in reflection, effort, and monitoring than those with lower GPAs. Third year students, likewise, showed a higher GPA correlated with more effort. The authors hypothesize that the highly structured curriculum of medical school does not allow students to develop self-regulation skills even though it is encouraged during medical school and that effective self-learning skills need to be actively taught during the undergraduate medical school years. –Lee Ann Schein, Ph.D.
Lucieer SM, Jonker L, Visscher C, Rikers RM, Themmen AP. Self-regulated learning and academic performance in medical education. Med Teach. 2015 Aug 27:1-9.
No data here. This is a strong plea to reverse the trend for post-medical school training programs to use the score on USMLE Step 1 (the first licensing examination of 4 in the US) as the major screening tool in selecting applicants. This reviewer is old enough to have no recollection of any of my licensing exam scores; at that time, other measures such as clinical clerkship performance and research experience were viewed as more important. The authors express dismay that residency directors are “overweighting a screening test in a manner not supported by strong evidence and for which the test was not specifically designed.” — Laura Willett, MD
Prober CG1, Kolars JC, First LR, Melnick DE. “A Plea to Reassess the Role of United States Medical Licensing Examination Step 1 Scores in Residency Selection.”
Acad Med. 2015 Aug 3.
Several US medical schools are starting small pilot programs which aim to graduate students in 3 years rather than the standard 4 years. The authors cite observational data suggesting that 3 vs. 4 years of training had no effect on commonly measured outcomes such as standardized test results and performance in residency. These “natural experiments” are: multiple US medical schools in the 1970’s, several current US medical schools which block out the fourth year for research or other enrichment activities, 2 current Canadian medical schools (McMaster and Calgary) with many decades of experience with a 3-year curriculum, and several recent “3+3” (3 years of medical school plus 3 years of residency) US programs in family medicine and internal medicine. Advantages of a general shift to a 3-year curriculum could be decreased levels of educational debt and accelerated entry of new physicians into employment. — Laura Willett, MD
Raymond JR Sr, Kerschner JE, Hueston WJ, Maurana CA.”The Merits and Challenges of Three-Year Medical School Curricula: Time for an Evidence-Based Discussion.”
Acad Med. 2015 Aug 11.
In this qualitative study, researchers interviewed 31 EBM instructors from multiple US and Canadian medical schools. Several common challenges and potential solutions were identified. Suboptimal role models were the most common challenge mentioned, as students interact with many faculty members having poor EBM skills and understanding. Other challenges mentioned were intrinsic difficulty of the material, students and faculty having difficulty voicing uncertainty, and a lack of clinical context when teaching EBM in the pre-clinical years. Potential solutions were better integration of EBM over many courses during the four years of medical school, EBM training for clinical faculty, and utilizing “whole-task” exercises that start with real or virtual patients rather than EBM exercises in isolation. — Laura Willett, MD
Maggio LA, Ten Cate O, Chen HC, Irby DM, O’Brien BC. “Challenges to Learning Evidence-Based Medicine and Educational Approaches to Meet These Challenges: A Qualitative Study of Selected EBM Curricula in U.S. and Canadian Medical Schools.” Acad Med. 2015 Jul 21.