Teaching Clinical Reasoning Early

Clinical reasoning is either not explicitly taught or taught to more experienced learners.  In this study, educators at Weill Cornell medical school assessed the impact of a theory-informed clinical reasoning curriculum for first year medical students before they’ve had much clinical experience. The curriculum consisted of a lecture on concepts of dual process theory, script theory and cognitive biases, and 3 days of clinical reasoning exams where students reviewed History and Physical write ups (without the assessment and plan) and generated problem lists, summary statements, and leading and alternative diagnoses with rationale and illness scripts.  The study found that 80% of students had a complete problem representation, 63% of problem representations were concise, and 92% of problem representations included semantic qualifiers, suggesting that clinical reasoning can be successfully taught to inexperienced learners. Whether this translates into improved performance during clerkships remains to be seen. — Sarang Kim, MD

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Justin J. Choi, Jeanie Gribben, Myriam Lin, Erika L. Abramson & Juliet Aizer (2023) Using an experiential learning model to teach clinical reasoning theory and cognitive bias: an evaluation of a first-year medical student curriculum, Medical Education Online, 28:1, DOI: 10.1080/10872981.2022.2153782

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Unmatched and Unwanted?

A study of 206 comments on the online discussion forum Reddit reveals that between 2021 and 2022 US and Canadian medical students who did not match into residency programs showed signs of regret for having attended (and paid for!) medical school, thinking of themselves as failures and considering alternate careers.  These outcomes occurred even though medical schools likely provided (to varying degrees) mental health support, feedback on residency applications, and de-stigmatization of being unmatched.  — The Editorial Team

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Morrissette, Anita MD1; Morrissette, Matthew MD2. “The Feeling of Failure Is Immense”: A Qualitative Analysis of the Experiences of Unmatched Residency Applicants Using Reddit. Academic Medicine ():10.1097/ACM.0000000000005120, December 12, 2022. | DOI: 10.1097/ACM.0000000000005120

Are the Increasing Numbers of Out-of-State Students at State-“Supported” Medical Schools a Good Thing?

This nationwide study of US MD-granting schools reports two concerning and possibly related trends.  Over the past 15 years or so, the number of out-of-state applicants and matriculants to state-sponsored schools has gone up substantially.  This is generally helpful to the schools’ financial status, as out-of-state students usually pay a lot more tuition than in-state students.  Over the same time period, mean medical student debt has gone up by about 75%, to eye-popping levels.  The authors surmise that in-state applicants displaced by accepted out-of-state students may attend schools which are either private or out-of-state for them, markedly increasing their cost of med school attendance. — Laura Willett, MD

Kraus, Molly B. MD1; Hasan, Shaina H. MD2; Buckner-Petty, Skye A.3; Files, Julia A. MD4; Hayes, Sharonne N. MD5; Habermann, Elizabeth B. PhD6; LeMond, Lisa M. MD7. Out-of-State Students at State Medical Schools and Increasing Medical Debt. Academic Medicine: November 08, 2022 – Volume – Issue – 10.1097/ACM.0000000000005079
doi: 10.1097/ACM.0000000000005079

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What Do Teaching Evaluations Evaluate?

In this readable commentary about the value of teaching evaluations(TEs) by students, the authors summarize a lot of evidence suggesting that TEs measure a lot of things other than teaching, for example attractiveness and charisma, and that they should not be used as the sole or main arbiter of faculty personnel decisions.  The authors do not suggest getting rid of student-generated TEs, as students are often the only observers who can give input on items such as the learning environment and TEs may serve as a valuable source of formative feedback for faculty.  However, many weaknesses are summarized here:  TEs correlate poorly or not at all with other measures of learning;  TE ratings may be biased against female or minority race faculty;  student anonymity protects the occasional seriously unprofessional comments received by faculty; and TE ratings are adversely affected by poor grades received by students, providing a disincentive for faculty to give students negative feedback.  Overall advice on TEs:  handle with care, and develop/validate more competency-based assessments of faculty. — Laura Willett, MD

Ginsburg, Shiphra MD, MEd, PhD1; Stroud, Lynfa MD, MEd2. Necessary But Insufficient and Possibly Counterproductive: The Complex Problem of Teaching Evaluations. Academic Medicine: October 04, 2022.

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It’s A DIY World for Medical Education Researchers

Medical education research lab is an emerging model for conducting medical education research. Defined as a distinct research team led by single or multiple PIs to study specific problems, medical education research lab is a strategic attempt at overcoming the well-recognized challenges in medical education research, such as lack of support and funding. Guided by the vision, passion, and political will of well-established investigator(s), a med ed research lab can catalyze research by developing an infrastructure for research, collaborative support, and competing for extramural funding. Using case examples, the authors of this study describe various medical education research lab models, highlighting advantages, disadvantages, and challenges, and also include a well-organized start up guide for those seeking to start a research lab. A notable shared phenotype among medical education research labs: the primary mission of the PI is research rather than teaching. The authors believe that this is a critical difference that distinguishes research labs from educational centers or teaching collaboratives. Given the typical underfunded and under-supported landscape of med ed research that is often driven by faculty who are primarily educators and not researchers, this reviewer feels that this model, however innovative and promising, is unlikely to take off in most institutions. — Sarang Kim, MD

Gisondi Michael A. MD; Michael Sarah DO, MS,; Li-Sauerwine Simiao MD, MSCR; Brazil Victoria MD, MBA; Caretta-Weyer Holly A. MD, MHPE; Issenberg Barry MD; Giordano Jonathan DO, MEd; Lineberry Matthew PhD; Olson Adriana Segura MD, MAEd; Burkhardt John C. MD, PhD; Chan Teresa M. MD, MHPE, The Purpose, Design, and Promise of Medical Education Research Labs, Academic Medicine, June 2022. 

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MCAT, Grades Are Predictive Of Important Outcomes After All!

The investigators examined Medical College Admission Test (MCAT) scores and undergraduate grade point averages (UGPAs) from a large representative sample of students in US and Canadian MD-granting schools, and looked for correlations to multiple educational outcomes.  These outcomes included:  numeric grade in pre-clerkship courses, first attempt USMLE Step 1 grade, clerkship examination scores, clerkship GPAs, and first attempt USMLE Step 2 CK grade.  Probably the most important outcome, from the standpoint of the student, was “progress in medical school” which was defined as “completion of coursework on time or within one extra year; passing relevant licensure exams on the first attempt; and experiencing no withdrawal or dismissal from medical school for academic reasons.”  MCAT scores were a moderate-to-strong predictor of all measured outcomes, including those occurring during clerkship year or after.  For most outcomes, MCAT scores were a slightly stronger predictor than UGPA, and the combination of MCAT and UGPA was more predictive than either measure alone.  Importantly, MCAT scores were quite predictive of medical student outcome across a range of student demographics, including gender, race, and parental education. — Laura Willett, MD

Hanson JT, Busche K, Elks ML, Jackson-Williams LE, Liotta RA, Miller C, Morris CA, Thiessen B, Yuan K. The Validity of MCAT Scores in Predicting Students’ Performance and Progress in Medical School: Results from a Multisite Study. Acad Med. 2022 May 24. doi: 10.1097/ACM.0000000000004754. Epub ahead of print. PMID: 35612915.

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Who Are Our Medical Students (By Family Income)?

Students from high-income households are very over-represented in US medical schools.  This is a conclusion from a comparison of US Census subjects to matriculating US allopathic medical students who reported race/ethnicity and parental income on the 2017-19 AAMC Matriculating Student Questionnaires (response rates 65-71%).  A representation index (RI) was calculated for subgroups of medical students defined by race/ethnicity and family income as compared to the representation of these subgroups in the general US population.  About half of medical students come from the top 20^th percentile of family income.  Twenty-four percent of medical students come from the top 5^th percentile of family income, for a RI of 4.8.  Taken on its face, this means that young people from the top 5^th percentile of family income have approximately a 5 times higher chance of matriculating into medical school than the average US resident.  At the other end of the financial spectrum, only 25% of our students come from the lowest 60^th percentile of family income.  This under-representation was most marked for non-Hispanic white students: in this group, only 18% of students come from the lowest 60^th percentile of family income — Laura Willet, MD.

Shahriar AA, Puram VV, Miller JM, Sagi V, Castañón-Gonzalez LA, Prasad S, Crichlow R. Socioeconomic Diversity of the Matriculating US Medical Student Body by Race, Ethnicity, and Sex, 2017-2019. JAMA Netw Open. 2022 Mar 1;5(3):e222621. doi: 10.1001/jamanetworkopen.2022.2621. PMID: 35289863.

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Widespread But Mostly Mild – Internal Residents Report Mistreatment

In this survey study of 21,931 US internal medicine residents (81% response rate), 48% reported experiencing and 62% reported witnessing “inappropriate comments or actions based on identity markers” at any time during their residency.  Fortunately, most of these incidents were reported as occurring “infrequently” or “sometimes”.  Reports were made more frequently by residents who were female, US medical grads, or native English-speakers.  The most common sources of these comments or actions were patients and their families, followed by nurses, faculty, and other residents.  These results are similar to those from prior studies of surgical residents. — Laura Willett, MD

Finn KM, O’Connor AB, McGarry K, Harris L, Zaas A. Prevalence and Sources of Mistreatment Experienced by Internal Medicine Residents. JAMA Intern Med. 2022 Feb 28:e220051. doi: 10.1001/jamainternmed.2022.0051. Epub ahead of print. PMID: 35226048; PMCID: PMC8886451.

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Measuring Clinical Reasoning in Admission Notes?

This study examined the use of a revised assessment tool (IDEA–(I)interpretive summary, (D) differential diagnosis with commitment to most likely diagnosis, (E) explanation of reasoning for most likely diagnosis, (A) alternative diagnosis with explanation of reasoning, plus descriptive anchors) to evaluate clinical reasoning in admission notes written by internal medicine residents and fellows at a large academic medical center in New York City.  A panel of clinician educators reviewed 252 randomly selected, de-identified admission notes written by 30 different trainees.  They found that only 53% of the notes were considered high quality (score of 6 or higher on a scale of 0-10).  Intraclass correlation was high (0.84). The use of a relatively straight forward rating tool with a high reliability to assess clinical reasoning (something educators are all struggling to measure) with clinical notes that are already being generated as part of existing workflow makes this study’s findings noteworthy. The major downside would be the amount of faculty time and effort required to grade each note, as well as the fact that clinical notes were not really designed to measure clinical skills. In fact, with the transition to EHR, many have lamented the perceived deterioration of clinical notes driven by ease of copy and pasted text without much thought given to accuracy, relevance, or internal consistency, let alone documentation of clinical reasoning. Until we get buy-in from our trainees that clinical notes should reflect accurate data and sound clinical reasoning, the effort required to evaluate notes may seem to outweigh possible benefits, especially if adapted widely and routinely across a whole program. However, this study’s findings may lend support to selected use, such as facilitation of feedback for individual trainees requiring targeted remediation for clinical reasoning. — Sarang Kim, MD

Schaye, V., Miller, L., Kudlowitz, D. et al. Development of a Clinical Reasoning Documentation Assessment Tool for Resident and Fellow Admission Notes: a Shared Mental Model for Feedback. J GEN INTERN MED 37, 507–512 (2022). https://doi.org/10.1007/s11606-021-06805-6

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Point-Of-Care Ultrasound: Progress And Problems

Ultrasound: The good news is ultrasound usage in the medical school curriculum has experienced a two-fold increase since 2014, according to a recent survey of clinical directors and curricular deans at 154 medical schools.  The bad news is there is no standardized approach to integrating POCUS into the curriculum with only 57% of schools reporting an approved POCUS curriculum and 10% a longitudinal 4-year curriculum.  Despite improvements in ultrasound technology and demonstrated benefits from its use in the clinical setting, barriers identified in previous surveys are stubbornly persistent today: lack of curriculum time, lack of funds to purchase equipment, and lack of faculty time to deliver the content. — The Editorial Staff

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Frances M. Russell, MD, Bita Zakeri, PhD, Audrey Herbert, MD, Robinson M. Ferre, MD, Abraham Leiser, and Paul M. Wallach, MD, The State of Point-of-Care Ultrasound Training in Undergraduate Medical Education: Findings From a National Survey, Academic Medicine, 2021.