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Association of Medical Students' Reports of Interactions with the Pharmaceutical and Medical Device Industries and Medical School Policies and Characteristics: A Cross-Sectional Study
Yeh, James S.
Austad, Kirsten E.
Franklin, Jessica M.
Chimonas, Susan
Campbell, Eric G.
Avorn, Jerry
Kesselheim, Aaron S.
PLoS Medicine
Aaron Kesselheim and colleagues compared US medical students' survey responses regarding pharmaceutical company interactions with the schools' AMSA PharmFree scorecard and Institute on Medicine as a Profession's (IMAP) scores.
Please see later in the article for the Editors' Summary
Professional societies use metrics to evaluate medical schools' policies regarding interactions of students and faculty with the pharmaceutical and medical device industries. We compared these metrics and determined which US medical schools' industry interaction policies were associated with student behaviors.
Methods and Findings
Using survey responses from a national sample of 1,610 US medical students, we compared their reported industry interactions with their schools' American Medical Student Association (AMSA) PharmFree Scorecard and average Institute on Medicine as a Profession (IMAP) Conflicts of Interest Policy Database score. We used hierarchical logistic regression models to determine the association between policies and students' gift acceptance, interactions with marketing representatives, and perceived adequacy of faculty–industry separation. We adjusted for year in training, medical school size, and level of US National Institutes of Health (NIH) funding. We used LASSO regression models to identify specific policies associated with the outcomes. We found that IMAP and AMSA scores had similar median values (1.75 [interquartile range 1.50–2.00] versus 1.77 [1.50–2.18], adjusted to compare scores on the same scale). Scores on AMSA and IMAP shared policy dimensions were not closely correlated (gift policies, r = 0.28, 95% CI 0.11–0.44; marketing representative access policies, r = 0.51, 95% CI 0.36–0.63). Students from schools with the most stringent industry interaction policies were less likely to report receiving gifts (AMSA score, odds ratio [OR]: 0.37, 95% CI 0.19–0.72; IMAP score, OR 0.45, 95% CI 0.19–1.04) and less likely to interact with marketing representatives (AMSA score, OR 0.33, 95% CI 0.15–0.69; IMAP score, OR 0.37, 95% CI 0.14–0.95) than students from schools with the lowest ranked policy scores. The association became nonsignificant when fully adjusted for NIH funding level, whereas adjusting for year of education, size of school, and publicly versus privately funded school did not alter the association. Policies limiting gifts, meals, and speaking bureaus were associated with students reporting having not received gifts and having not interacted with marketing representatives. Policy dimensions reflecting the regulation of industry involvement in educational activities (e.g., continuing medical education, travel compensation, and scholarships) were associated with perceived separation between faculty and industry. The study is limited by potential for recall bias and the cross-sectional nature of the survey, as school curricula and industry interaction policies may have changed since the time of the survey administration and study analysis.
As medical schools review policies regulating medical students' industry interactions, limitations on receipt of gifts and meals and participation of faculty in speaking bureaus should be emphasized, and policy makers should pay greater attention to less research-intensive institutions.
Please see later in the article for the Editors' Summary
Editors' Summary
Making and selling prescription drugs and medical devices is big business. To promote their products, pharmaceutical and medical device companies build relationships with physicians by providing information on new drugs, by organizing educational meetings and sponsored events, and by giving gifts. Financial relationships begin early in physicians' careers, with companies providing textbooks and other gifts to first-year medical students. In medical school settings, manufacturers may help to inform trainees and physicians about developments in health care, but they also create the potential for harm to patients and health care systems. These interactions may, for example, reduce trainees' and trained physicians' skepticism about potentially misleading promotional claims and may encourage physicians to prescribe new medications, which are often more expensive than similar unbranded (generic) drugs and more likely to be recalled for safety reasons than older drugs. To address these and other concerns about the potential career-long effects of interactions between medical trainees and industry, many teaching hospitals and medical schools have introduced policies to limit such interactions. The development of these policies has been supported by expert professional groups and medical societies, some of which have created scales to evaluate the strength of the implemented industry interaction policies.
Why Was This Study Done?
The impact of policies designed to limit interactions between students and industry on student behavior is unclear, and it is not known which aspects of the policies are most predictive of student behavior. This information is needed to ensure that the policies are working and to identify ways to improve them. Here, the researchers investigate which medical school characteristics and which aspects of industry interaction policies are most predictive of students' reported behaviors and beliefs by comparing information collected in a national survey of US medical students with the strength of their schools' industry interaction policies measured on two scales—the American Medical Student Association (AMSA) PharmFree Scorecard and the Institute on Medicine as a Profession (IMAP) Conflicts of Interest Policy Database.
What Did the Researchers Do and Find?
The researchers compared information about reported gift acceptance, interactions with marketing representatives, and the perceived adequacy of faculty–industry separation collected from 1,610 medical students at 121 US medical schools with AMSA and IMAP scores for the schools evaluated a year earlier. Students at schools with the highest ranked interaction policies based on the AMSA score were 63% less likely to accept gifts as students at the lowest ranked schools. Students at the highest ranked schools based on the IMAP score were about half as likely to accept gifts as students at the lowest ranked schools, although this finding was not statistically significant (it could be a chance finding). Similarly, students at the highest ranked schools were 70% less likely to interact with sales representatives as students at the lowest ranked schools. These associations became statistically nonsignificant after controlling for the amount of research funding each school received from the US National Institutes of Health (NIH). Policies limiting gifts, meals, and being a part of speaking bureaus (where companies pay speakers to present information about the drugs for dinners and other events) were associated with students' reports of receiving no gifts and of non-interaction with sales representatives. Finally, policies regulating industry involvement in educational activities were associated with the perceived separation between faculty and industry, which was regarded as adequate by most of the students at schools with such policies.
What Do These Findings Mean?
These findings suggest that policies designed to limit industry interactions with medical students need to address multiple aspects of these interactions to achieve changes in the behavior and attitudes of trainees, but that policies limiting gifts, meals, and speaking bureaus may be particularly important. These findings also suggest that the level of NIH funding plays an important role in students' self-reported behaviors and their perceptions of industry, possibly because institutions with greater NIH funding have the resources needed to implement effective policies. The accuracy of these findings may be limited by recall bias (students may have reported their experiences inaccurately), and by the possibility that industry interaction policies may have changed in the year that elapsed between policy grading and the student survey. Nevertheless, these findings suggest that limitations on gifts should be emphasized when academic medical centers refine their policies on interactions between medical students and industry and that particular attention should be paid to the design and implementation of policies that regulate industry interactions in institutions with lower levels of NIH funding.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001743.
The UK General Medical Council provides guidance on financial and commercial arrangements and conflicts of interest as part of its good medical practice document, which describes what is required of all registered doctors in the UK
Information about the American Medical Student Association (AMSA) Just Medicine campaign (formerly the PharmFree campaign) and about the AMSA Scorecard is available
Information about the Institute on Medicine as a Profession (IMAP) and about its Conflicts of Interest Policy Database is also available
"Understanding and Responding to Pharmaceutical Promotion: A Practical Guide" is a manual prepared by Health Action International and the World Health Organization that medical schools can use to train students how to recognize and respond to pharmaceutical promotion
The US Institute of Medicine's report "Conflict of Interest in Medical Research, Education, and Practice" recommends steps to identify, limit, and manage conflicts of interest
The ALOSA Foundation provides evidence-based, non-industry-funded education about treating common conditions and using prescription drugs
Related Articles
Internal Medicine Clerkship Directors' Perceptions About Student Interest in Internal Medicine Careers
Hauer, Karen E.
Fagan, Mark J.
Kernan, Walter
Mintz, Matthew
Durning, Steven J.
Journal of General Internal Medicine
Experienced medical student educators may have insight into the reasons for declining interest in internal medicine (IM) careers, particularly general IM.
To identify factors that, according to IM clerkship directors, influence students' decisions for specialty training in IM.
Cross-sectional national survey.
One hundred ten institutional members of Clerkship Directors in IM.
Frequency counts and percentages were reported for descriptive features of clerkships, residency match results, and clerkship directors' perceptions of factors influencing IM career choice at participating schools. Perceptions were rated on a five-point scale (1 = very much pushes students away from IM careers; 5 = very much attracts students toward IM careers).
Survey response rate was 83/110 (76%); 80 answered IM career-choice questions. Clerkship directors identified three educational items attracting students to IM careers: quality of IM faculty (mean score 4.3, SD = 0.56) and IM rotation (4.1, SD = 0.67), and experiences with IM residents (3.9, SD = 0.94). Items felt most strongly to push students away from IM careers were current practice environment for internists (mean score 2.1, SD = 0.94), income (2.1, SD = 1.08), medical school debt (2.3, SD = 0.89), and work hours in IM (2.4, SD = 1.05). Factor analysis indicated three factors explaining students' career choices: value/prestige of IM, clerkship experience, and exposure to internists.
IM clerkship directors believe that IM clerkship experiences attract students toward IM, whereas the income and lifestyle for practicing internists dissuade them. These results suggest that interventions to enhance the practice environment for IM could increase student interest in the field.
career choice; education, medical, undergraduate; medical students, workforce
Related Articles
"Making the grade:" noncognitive predictors of medical students' clinical clerkship grades.
Lee, Katherine B.
Vaishnavi, Sanjeev N.
Lau, Steven K. M.
Andriole, Dorothy A.
Jeffe, Donna B.
Journal of the National Medical Association
OBJECTIVES: Because clinical clerkship grades are associated with resident selection and performance and are largely based on residents'/attendings' subjective ratings, it is important to identify variables associated with clinical clerkship grades. METHODS: U.S. medical students who completed > or =1 of the following required clinical clerkships--internal medicine, surgery, obstetrics/gynecology, pediatrics, neurology and psychiatry--were invited to participate in an anonymous online survey, which inquired about demographics, degree program, perceived quality of clerkship experiences, assertiveness, reticence and clerkship grades. RESULTS: A total of 2395 medical students (55% women; 57% whites) from 105 schools responded. Multivariable logistic regression models identified factors independently associated with receiving lower clerkship grades (high pass/pass or B/C) compared with the highest grade (honors or A). Students reporting higher quality of clerkship experiences were less likely to report lower grades in all clerkships. Older students more likely reported lower grades in internal medicine (P = 0.02) and neurology (P < 0.001). Underrepresented minorities more likely reported lower grades in all clerkships (P < 0.001); Asians more likely reported lower grades in obstetrics/gynecology (P = 0.007), pediatrics (P = 0.01) and neurology (P = 0.01). Men more likely reported lower grades in obstetrics/gynecology (P < 0.001) and psychiatry (P = 0.004). Students reporting greater reticence more likely reported lower grades in internal medicine (P = 0.02), pediatrics (P = 0.02) and psychiatry (P < 0.05). Students reporting greater assertiveness less likely reported lower grades in all clerkships (P < 0.03) except IM. CONCLUSIONS: The independent associations between lower clerkship grades and nonwhite race, male gender, older age, lower quality of clerkship experiences, and being less assertive and more reticent are concerning and merit further investigation.
Related Articles
Residents as Role Models: The Effect of the Obstetrics and Gynecology Clerkship on Medical Students' Career Interest
Chang, Judy C.
Odrobina, Michele R.
McIntyre-Seltman, Kathleen
Journal of Graduate Medical Education
Medical students' choice of residency specialty is based in part on their clerkship experience. Postclerkship interest in a particular specialty is associated with the students' choice to pursue a career in that field. But, many medical students have a poor perception of their obstetrics and gynecology clerkships.
To determine whether fourth-year medical students' perceptions of teaching quality and quantity and amount of experiential learning during the obstetrics-gynecology clerkship helped determine their interest in obstetrics-gynecology as a career choice.
We distributed an anonymous, self-administered survey to all third-year medical students rotating through their required obstetrics and gynecology clerkship from November 2006 to May 2007. We performed bivariate analysis and used χ2 analysis to explore factors associated with general interest in obstetrics and gynecology and interest in pursuing obstetrics and gynecology as a career.
Eighty-one students (N = 91, 89% response rate) participated. Postclerkship career interest in obstetrics and gynecology was associated with perceptions that the residents behaved professionally (P < .0001) and that the students were treated as part of a team (P = .008). Having clear expectations on labor and delivery procedures (P = .014) was associated with postclerkship career interest. Specific hands-on experiences were not statistically associated with postclerkship career interest. However, performing more speculum examinations in the operating room trended toward having some influence (P = .068). Although more women than men were interested in obstetrics and gynecology as a career both before (P = .027) and after (P = .014) the clerkship, men were more likely to increase their level of career interest during the clerkship (P = .024).
Clerkship factors associated with greater postclerkship interest include higher satisfaction with resident professional behavior and students' sense of inclusion in the clinical team. Obstetrics and gynecology programs need to emphasize to residents their role as educators and professional role models for medical students.
Related Articles
Medical Students' Exposure to and Attitudes about the Pharmaceutical Industry: A Systematic Review
Austad, Kirsten E.
Avorn, Jerry
Kesselheim, Aaron S.
PLoS Medicine
A systematic review of published studies reveals that undergraduate medical students may experience substantial exposure to pharmaceutical marketing, and that this contact may be associated with positive attitudes about marketing.
The relationship between health professionals and the pharmaceutical industry has become a source of controversy. Physicians' attitudes towards the industry can form early in their careers, but little is known about this key stage of development.
Methods and Findings
We performed a systematic review reported according to PRISMA guidelines to determine the frequency and nature of medical students' exposure to the drug industry, as well as students' attitudes concerning pharmaceutical policy issues. We searched MEDLINE, EMBASE, Web of Science, and ERIC from the earliest available dates through May 2010, as well as bibliographies of selected studies. We sought original studies that reported quantitative or qualitative data about medical students' exposure to pharmaceutical marketing, their attitudes about marketing practices, relationships with industry, and related pharmaceutical policy issues. Studies were separated, where possible, into those that addressed preclinical versus clinical training, and were quality rated using a standard methodology. Thirty-two studies met inclusion criteria. We found that 40%–100% of medical students reported interacting with the pharmaceutical industry. A substantial proportion of students (13%–69%) were reported as believing that gifts from industry influence prescribing. Eight studies reported a correlation between frequency of contact and favorable attitudes toward industry interactions. Students were more approving of gifts to physicians or medical students than to government officials. Certain attitudes appeared to change during medical school, though a time trend was not performed; for example, clinical students (53%–71%) were more likely than preclinical students (29%–62%) to report that promotional information helps educate about new drugs.
Undergraduate medical education provides substantial contact with pharmaceutical marketing, and the extent of such contact is associated with positive attitudes about marketing and skepticism about negative implications of these interactions. These results support future research into the association between exposure and attitudes, as well as any modifiable factors that contribute to attitudinal changes during medical education.
Please see later in the article for the Editors' Summary
Editors' Summary
The complex relationship between health professionals and the pharmaceutical industry has long been a subject of discussion among physicians and policymakers. There is a growing body of evidence that suggests that physicians' interactions with pharmaceutical sales representatives may influence clinical decision making in a way that is not always in the best interests of individual patients, for example, encouraging the use of expensive treatments that have no therapeutic advantage over less costly alternatives. The pharmaceutical industry often uses physician education as a marketing tool, as in the case of Continuing Medical Education courses that are designed to drive prescribing practices.
One reason that physicians may be particularly susceptible to pharmaceutical industry marketing messages is that doctors' attitudes towards the pharmaceutical industry may form early in their careers. The socialization effect of professional schooling is strong, and plays a lasting role in shaping views and behaviors.
Why Was This Study Done?
Recently, particularly in the US, some medical schools have limited students' and faculties' contact with industry, but some have argued that these restrictions are detrimental to students' education. Given the controversy over the pharmaceutical industry's role in undergraduate medical training, consolidating current knowledge in this area may be useful for setting priorities for changes to educational practices. In this study, the researchers systematically examined studies of pharmaceutical industry interactions with medical students and whether such interactions influenced students' views on related topics.
What Did the Researchers Do and Find?
The researchers did a comprehensive literature search using appropriate search terms for all relevant quantitative and qualitative studies published before June 2010. Using strict inclusion criteria, the researchers then selected 48 articles (from 1,603 abstracts) for full review and identified 32 eligible for analysis—giving a total of approximately 9,850 medical students studying at 76 medical schools or hospitals.
Most students had some form of interaction with the pharmaceutical industry but contact increased in the clinical years, with up to 90% of all clinical students receiving some form of educational material. The highest level of exposure occurred in the US. In most studies, the majority of students in their clinical training years found it ethically permissible for medical students to accept gifts from drug manufacturers, while a smaller percentage of preclinical students reported such attitudes. Students justified their entitlement to gifts by citing financial hardship or by asserting that most other students accepted gifts. In addition, although most students believed that education from industry sources is biased, students variably reported that information obtained from industry sources was useful and a valuable part of their education.
Almost two-thirds of students reported that they were immune to bias induced by promotion, gifts, or interactions with sales representatives but also reported that fellow medical students or doctors are influenced by such encounters. Eight studies reported a relationship between exposure to the pharmaceutical industry and positive attitudes about industry interactions and marketing strategies (although not all included supportive statistical data). Finally, student opinions were split on whether physician–industry interactions should be regulated by medical schools or the government.
What Do These Findings Mean?
This analysis shows that students are frequently exposed to pharmaceutical marketing, even in the preclinical years, and that the extent of students' contact with industry is generally associated with positive attitudes about marketing and skepticism towards any negative implications of interactions with industry. Therefore, strategies to educate students about interactions with the pharmaceutical industry should directly address widely held misconceptions about the effects of marketing and other biases that can emerge from industry interactions. But education alone may be insufficient. Institutional policies, such as rules regulating industry interactions, can play an important role in shaping students' attitudes, and interventions that decrease students' contact with industry and eliminate gifts may have a positive effect on building the skills that evidence-based medical practice requires. These changes can help cultivate strong professional values and instill in students a respect for scientific principles and critical evidence review that will later inform clinical decision-making and prescribing practices.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001037.
Further information about the influence of the pharmaceutical industry on doctors and medical students can be found at the American Medical Students Association PharmFree campaign and PharmFree Scorecard, Medsin-UKs PharmAware campaign, the nonprofit organization Healthy Skepticism, and the Web site of No Free Lunch.
Related Articles
The effect of medical students' gender, ethnicity and attitude towards poetry-reading on the evaluation of a required, clinically-integrated poetry- based educational intervention
Muszkat, Mordechai
Barak, Orly
Lalazar, Gadi
Mazal, Bracha
Schneider, Ronen
Levi, Irit Mor-Yosef
Cohen, Matan J
Canetti, Laura
Yehuda, Arie Ben
Naparstek, Yaakov
BMC Medical Education
Art -based interventions are widely used in medical education. However, data on the potential effects of art-based interventions on medical students have been limited to small qualitative studies on students' evaluation of elective programs, and thus their findings may be difficult to generalize. The goal of this study is to examine, in an unselected students' population, the effect of students' gender, ethnicity and attitude towards poetry on their evaluation of a clinically-integrated poetry-based educational intervention.
A required Clinically- Oriented Poetry-reading Experience (COPE) is integrated into the 4th year internal medicine clerkship. We constructed a questionnaire regarding the program's effects on students. Students completed the questionnaire at the end of the clerkship. We performed a Confirmatory Factor Analysis, and examined the relationship between students' evaluation of the program and students' ethnicity, gender, attitude towards poetry-reading, and the timing of the program (early/late) during the fourth year.
144 students participated in the program, of which 112 completed the questionnaires. We identified two effect factors: "student-patient" and "self and colleagues". The average score for "student-patient" factor was significantly higher as compared to the "self and colleagues" factor.
Evaluation the "student- patient" effect factor was higher among Arab and Druze as compared to Jewish students. Students' attitude towards poetry-reading did not correlate with the "student-patient" effect, but correlated with the "self and colleagues" effect. The evaluation of the "self and colleagues" effect was higher among students who participated in the program during their second as compared with the first clerkship. Students' gender was not associated with any of the effects identified. Students favored obligatory participation in COPE as compared with elective course format.
According to students' evaluation, a format of integrated, obligatory poetry-based intervention may be suitable for enhancing "student-patient" aims in heterogeneous student populations. The higher evaluation of the "patient-student" effect among Arab and Druze as compared to Jewish students may be related to cultural differences in the perception of this component of medical professionalism. Further research can provide insight into the effect of cultural and ethnic differences on actual empathy of medical students in patient encounters.
Art-based intervention; Poetry; Medical humanities; Medical education
Related Articles
Influence of Assigned Reading on Senior Medical Student Clinical Performance
Hoffman, Lance
Bott, Kristine
Puumala, Susan
Shostrom, Valerie
Western Journal of Emergency Medicine
This Institutional Review Board-approved, prospective, observational study compared the clinical performance of senior medical students in an emergency medicine (EM) clerkship using a clinical behavioral evaluation tool in which one group had mandatory, topic specific readings and the other did not.
The study took place in an urban, tertiary referral center emergency department treating 43,000 patients annually and supporting medical student clerkships and an EM residency. The grades of two groups of senior medical students participating in an elective EM clerkship were compared. Those students during the 2002–2004 academic years were not assigned mandatory, topic-specific reading for the clerkship, while those during the 2004–2007 academic years were. The groups were compared on baseline demographic information, prior academic performance, and EM clerkship grade distributions using appropriate statistical techniques, including multinomial logistic regression, chi-square tests, and Fisher's Exact tests.
The control and experimental groups each had 83 subjects and were similar in baseline characteristics, except for the control group performing better than the experimental group during the basic science training of medical school (years 1–2; p=0.01). The experimental group had statistically significant more members in the EM Interest Group (EMIG; p=0.0001) and more members who went on to match in an EM residency (p=0.0007). The difference in grade distributions between the control group and experimental group was not statistically significant (p=0.40). Of note, those student members of the EMIG (p=0.0005) and those later matching to an emergency medicine residency (p<0.0001) were more likely to earn a grade of "honors" for the clerkship.
The addition of uniform, topic-specific reading assignments to an EM senior medical student curriculum does not improve the overall clinical performance of those students as measured using a clinical behavioral evaluation tool.
Related Articles
Evaluating team-based, lecture-based, and hybrid learning methods for neurology clerkship in China: a method-comparison study
Yang, Lian-Hong
Jiang, Long-Yuan
Xu, Bing
Liu, Shu-Qiong
Liang, Yan-Ran
Ye, Jin-Hao
Tao, En-Xiang
BMC Medical Education
Neurology is complex, abstract, and difficult for students to learn. However, a good learning method for neurology clerkship training is required to help students quickly develop strong clinical thinking as well as problem-solving skills. Both the traditional lecture-based learning (LBL) and the relatively new team-based learning (TBL) methods have inherent strengths and weaknesses when applied to neurology clerkship education. However, the strengths of each method may complement the weaknesses of the other. Combining TBL with LBL may produce better learning outcomes than TBL or LBL alone. We propose a hybrid method (TBL + LBL) and designed an experiment to compare the learning outcomes with those of pure LBL and pure TBL.
One hundred twenty-seven fourth-year medical students attended a two-week neurology clerkship program organized by the Department of Neurology, Sun Yat-Sen Memorial Hospital. All of the students were from Grade 2007, Department of Clinical Medicine, Zhongshan School of Medicine, Sun Yat-Sen University. These students were assigned to one of three groups randomly: Group A (TBL + LBL, with 41 students), Group B (LBL, with 43 students), and Group C (TBL, with 43 students). The learning outcomes were evaluated by a questionnaire and two tests covering basic knowledge of neurology and clinical practice.
The practice test scores of Group A were similar to those of Group B, but significantly higher than those of Group C. The theoretical test scores and the total scores of Group A were significantly higher than those of Groups B and C. In addition, 100% of the students in Group A were satisfied with the combination of TBL + LBL.
Our results support our proposal that the combination of TBL + LBL is acceptable to students and produces better learning outcomes than either method alone in neurology clerkships. In addition, the proposed hybrid method may also be suited for other medical clerkships that require students to absorb a large amount of abstract and complex course materials in a short period, such as pediatrics and internal medicine clerkships.
Lecture-based learning; Team-based learning; Neurology; Clerkship; Hybrid learning method
Related Articles
Improving the National Board of Medical Examiners Internal Medicine Subject Exam for Use in Clerkship Evaluation
Elnicki, D Michael
Lescisin, Dianne A
Case, Susan
Journal of General Internal Medicine
To provide a consensus opinion on modifying the National Board of Medical Examiners (NBME) Medicine Subject Exam (Shelf) to: 1) reflect the internal medicine clerkship curriculum, developed by the Society of General Internal Medicine (SGIM) and the Clerkship Directors in Internal Medicine (CDIM); 2) emphasize knowledge important for a clerkship student; and 3) obtain feedback about students' performances on the Shelf.
Two-round Delphi technique.
The CDIM Research and Evaluation Committee and CDIM members on NBME Step 2 Committees.
Using 1–5 Likert scales (5 = highest ratings), the group rated test question content for relevance to the SGIM–CDIM Curriculum Guide and importance for clerkship students' knowledge. The Shelf content is organized into 4 physician tasks and into 11 sections that are generally organ system based. Each iteration of the Shelf has 100 questions. Participants indicated a desired distribution of questions by physician task and section, topics critical for inclusion on each exam, and new topics to include. They specified the types of feedback clerkship directors desired on students' performances. Following the first round, participants viewed pooled results prior to submitting their second-round responses.
Of 15 individuals contacted, 12 (80%) participated in each round. The desired distribution by physician task was: diagnosis (43), treatment (23), mechanism of disease (20), and health maintenance (15). The sections with the most questions requested were the cardiovascular (17), respiratory (15), and gastroenterology (12) sections. The fewest were requested in aging/ethics (4) and neurology, dermatology, and immunology (5 each). Examples of low-rated content were Wilson's Disease, chancroid and tracheal rupture (all <2.0). Health maintenance in type 2 diabetes, hypertension, and cardiovascular disease all received 5.0 ratings. Participants desired feedback by: section (4.6) and physician task (3.9), on performances of the entire class (4.0), and for individual students (3.8).
Clerkship directors identified test content that was relevant to the curricular content and important for clerkship students to know, and they indicated a desired question distribution. They would most like feedback on their students' performance by organ system–based sections for the complete academic year. This collaborative effort could serve as a model for aligning national exams with course goals.
clinical clerkship; clinical competance; student evaluation; undergraduate education
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Improving the Physical Diagnosis Skills of Third-year Medical Students
Fagan, Mark J
Griffith, Rebecca A
Obbard, Laura
O'Connor, Carolyn J
Journal of General Internal Medicine
To determine if a literature-based physical diagnosis curriculum could improve student knowledge, skill, and self-confidence in physical diagnosis.
Prospective controlled trial of an educational intervention.
Required internal medicine clerkship for third-year medical students at Brown Medical School.
Third-year medical students who completed the internal medicine clerkship during the academic year 1999–2000: 32 students at 1 clerkship site received the intervention; a total of 50 students at 3 other clerkship sites served as controls.
Physical diagnosis curriculum based on 8 articles from the Journal of the American Medical Association's Rational Clinical Examination series. Intervention students met weekly for 1 hour with a preceptor to review each article, discuss the sensitivity and specificity of the maneuvers and findings, and practice the techniques with an inpatient who agreed to be visited and examined.
Physical diagnosis knowledge for the 8 topics was evaluated using a 22-item multiple choice question quiz, skill was evaluated using trained evaluators, and self-confidence was assessed using an end-of-clerkship survey. Intervention students scored significantly higher than the control group on the knowledge quiz (mean correct score 70% vs 63%, P = .002), skills assessment (mean correct score 90% vs 54%, P < .001), and self-confidence score (mean total score 40 vs 35, P = .003), and they expressed greater satisfaction with the physical diagnosis teaching they received in the clerkship.
This physical diagnosis curriculum was successful in improving students' knowledge, skill, and self-confidence in physical diagnosis.
physical diagnosis; medical education; clinical examination
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Are students ready for meaningful use?
Ferenchick, Gary S.
Solomon, David
Mohmand, Asad
Towfiq, Basim
Kavanaugh, Kevin
Warbasse, Larry
Addison, James
Chames, Frances
Medical Education Online
The meaningful use (MU) of electronic medical records (EMRs) is being implemented in three stages. Key objectives of stage one include electronic analysis of data entered into structured fields, using decision-support tools (e.g., checking drug–drug interactions [DDI]) and electronic information exchange.
The authors assessed the performance of medical students on 10 stage-one MU tasks and measured the correlation between students' MU performance and subsequent end-of-clerkship professionalism assessments and their grades on an end-of-year objective structured clinical examination.
Two-hundred and twenty-two third-year medical students on the internal medicine (IM) clerkship.
Design/main measures
From July 2010 to February 2012, all students viewed 15 online tutorials covering MU competencies. The authors measured student MU documentation and performance in the chart of a virtual patient using a fully functional training EMR. Specific MU measurements included, adding: a new problem, a new medication, an advanced directive, smoking status, the results of screening tests; and performing a DDI (in which a major interaction was probable), and communicating a plan for this interaction.
Key results
A total of 130 MU errors were identified. Sixty-eight (30.6%) students had at least one error, and 30 (13.5%) had more than one (range 2–6). Of the 130 errors, 90 (69.2%) were errors in structured data entry. Errors occurred in medication dosing and instructions (18%), DDI identification (12%), documenting smoking status (15%), and colonoscopy results (23%). Students with MU errors demonstrated poorer performance on end-of-clerkship professionalism assessments (r =−0.112, p=0.048) and lower observed structured clinical examination (OSCE) history-taking skills (r =−0.165, p=0.008) and communication scores (r= − 0.173, p=0.006).
MU errors among medical students are common and correlate with subsequent poor performance in multiple educational domains. These results indicate that without assessment and feedback, a substantial minority of students may not be ready to progress to more advanced MU tasks.
documentation/methods; electronic health records; professional competence; students; medical; curriculum
Related Articles
A Cross-sectional Measurement of Medical Student Empathy
Chen, Daniel
Lew, Robert
Hershman, Warren
Orlander, Jay
Journal of General Internal Medicine
Empathy is important in the physician–patient relationship. Prior studies have suggested that physician empathy may decline with clinical training.
To measure and examine student empathy across medical school years.
Design and Participants
A cross-sectional study of students at Boston University School of Medicine in 2006. Incoming students plus each class near the end of the academic year were surveyed.
The Jefferson Scale of Physician Empathy–Student Version (JSPE-S), a validated 20-item self-administered questionnaire with a total score ranging from 20 to 140. JSPE-S scores were controlled for potential confounders such as gender, age, anticipated financial debt upon graduation, and future career interest.
658 students participated in the study (81.4% of the school population). The first-year medical student class had the highest empathy scores (118.5), whereas the fourth-year class had the lowest empathy scores (106.6). Measured empathy differed between second- and third-year classes (118.2 vs 112.7, P < .001), corresponding to the first year of clinical training. Empathy appears to increase from the incoming to the first-year class (115.5 vs 118.5, P = .02). Students preferring people-oriented specialties had higher empathy scores than students preferring technology-oriented specialties (114.6 vs 111.4, P = .002). Female students were more likely than male students to choose people-oriented specialties (51.5 vs 26.9%, P < .001). Females had higher JSPE-S scores than males (116.5 vs 112.1, P < .001). Age and debt did not affect empathy scores.
Empathy scores of students in the preclinical years were higher than in the clinical years. Efforts are needed to determine whether differences in empathy scores among the classes are cohort effects or represent changes occurring in the course of medical education. Future research is needed to confirm whether clinical training impacts empathy negatively, and, if so, whether interventions can be designed to mitigate this impact.
empathy; medical student education; physician attitudes
Related Articles
The Association of Student Examination Performance with Faculty and Resident Ratings Using a Modified RIME Process
Griffith III, Charles H.
Wilson, John F.
Journal of General Internal Medicine
RIME is a descriptive framework in which students and their teachers can gauge progress throughout a clerkship from R (reporter) to I (interpreter) to M (manager) to E (educator). RIME, as described in the literature, is complemented by residents and attending physicians meeting with a clerkship director to discuss individual student progress, with group discussion resulting in assignment of a RIME stage.
1) to determine whether a student's RIME rating is associated with end-of-clerkship examination performance; and 2) to determine whose independent RIME rating is most predictive of a student's examination performance: attendings, residents, or interns.
Prospective cohort study.
Third year medical students from academic years 2004–2005 and early 2005–2006 at 1 medical school.
Measurements and Main Results
Each attending, resident, and intern independently assessed the student's final RIME stage attained. For the purpose of analysis, R stage=1, I=2, M=3, and E=4. Regression analyses were performed with examination scores as dependent variables (National Board of Medical Examiners [NBME] medicine subject examination and a clinical performance examination [CPE]), with independent variables of mean attending RIME score, mean resident score, and mean intern score. For the 122 students, significant predictors of NBME subject exam score were resident RIME rating (p = .008) and intern RIME rating (p = .02). Significant predictor of CPE performance was resident RIME rating (p = .01).
House staff RIME ratings of students are associated with student performance on written and clinical skills examinations.
medical education; clinical evaluation; medical students
Related Articles
Effect of the Inpatient General Medicine Rotation on Student Pursuit of a Generalist Career
Arora, Vineet
Wetterneck, Tosha B
Schnipper, Jeffrey L
Auerbach, Andrew D
Kaboli, Peter
Wachter, Robert M
Levinson, Wendy
Humphrey, Holly J
Meltzer, David
Journal of General Internal Medicine
Entry into general internal medicine (GIM) has declined. The effect of the inpatient general medicine rotation on medical student career choices is uncertain.
To assess the effect of student satisfaction with the inpatient general medicine rotation on pursuit of a career in GIM.
Multicenter cohort study.
Third-year medical students between July 2001 and June 2003.
End-of-internal medicine clerkship survey assessed satisfaction with the rotation using a 5-point Likert scale. Pursuit of a career in GIM defined as: (1) response of "Very Likely" or "Certain" to the question "How likely are you to pursue a career in GIM?"; and (2) entry into an internal medicine residency using institutional match data.
Four hundred and two of 751 (54%) students responded. Of the student respondents, 307 (75%) matched in the 2 years following their rotations. Twenty-eight percent (87) of those that matched chose an internal medicine residency. Of these, 8% (25/307) were pursuing a career in GIM. Adjusting for site and preclerkship interest, overall satisfaction with the rotation predicted pursuit of a career in GIM (odds ratio [OR] 3.91, P<.001). Although satisfaction with individual items did not predict pursuit of a generalist career, factor analysis revealed 3 components of satisfaction (attending, resident, and teaching). Adjusting for preclerkship interest, 2 factors (attending and teaching) were associated with student pursuit of a career in GIM (P<.01).
Increased satisfaction with the inpatient general medicine rotation promotes pursuit of a career in GIM.
medical student; career interest; general internal medicine
Related Articles
How an ethics workshop for preceptors affects medical students.
Hennen, B. K.
Morrissy, J.
Grindrod, A.
Canadian Family Physician
OBJECTIVE: To determine whether a workshop on medical ethics attended by family medicine preceptors would affect their students' learning of ethics, and what educational and experiential factors affected the students' learning about ethics. DESIGN: A 3-hour workshop planned by a group of family physicians and ethicists and taught by a faculty member and an ethicist was offered to family physician preceptors. Students entering the clerkship were invited by letter to complete written answers to two clinical papers. Their answers were compared with "ideal" answers based on a weighted composite of the responses of 12 family physicians with a particular interest in ethics. The scores of students assigned to preceptors who had been offered the workshop were compared with those of students assigned to a control group of preceptors. Clerks were also asked about influences on their answers. PARTICIPANTS: The 86 preceptors participating in the family medicine programs at the University of Western Ontario, divided by random selection within geographic clustering into an experimental group of 50 and a control group of 36. Preceptors offered the workshop were considered to be in the experimental group whether or not they attended. The student questionnaire was sent to all students entering the family medicine clerkship program in the academic year 1989-1990 and some in the following year, until sufficient responses were received. Responses were analyzed from 32 clerks in the experimental group and 36 in the control group. MAIN OUTCOME MEASURE: Performance of students whose preceptors were invited to the workshop against performance of students whose preceptors were not invited to the workshop. RESULTS: No significant differences were noted between the performance of students whose preceptors were offered the workshop and those whose preceptors were not. CONCLUSION: The single outcome measure and the volunteer bias make conclusions difficult to draw. Further studies varying interventions and outcome measures are warranted.
Related Articles
Intercalated degrees, learning styles, and career preferences: prospective longitudinal study of UK medical students
McManus, I C
Richards, P
Winder, B C
BMJ : British Medical Journal
To assess the effects of taking an intercalated degree (BSc) on the study habits and learning styles of medical students and on their interest in a career in medical research.
Longitudinal questionnaire study of medical students at application to medical school and in their final year.
All UK medical schools.
6901 medical school applicants for admission in 1991 were studied in the autumn of 1990. 3333 entered medical school in 1991 or 1992, and 2695 who were due to qualify in 1996 or 1997 were studied 3 months before the end of their clinical course. Response rates were 92% for applicants and 56% for final year students.
Main outcome measures
Study habits (surface, deep, and strategic learning style) and interest in different medical careers, including medical research. Identical questions were used at time of application and in final year.
Students who had taken an intercalated degree had higher deep and strategic learning scores than at application to medical school. Those with highest degree classes had higher strategic and deep learning scores and lower surface learning scores. Students taking intercalated degrees showed greater interest in careers in medical research and laboratory medicine and less interest in general practice than their peers. The effects of the course on interest in medical research and learning styles were independent. The effect of the intercalated degree was greatest in schools where relatively few students took intercalated degrees.
Intercalated degrees result in a greater interest in research careers and higher deep and strategic learning scores. However, the effects are much reduced in schools where most students intercalate a degree. Introduction of intercalated degrees for all medical students without sufficient resources may not therefore achieve its expected effects.
Key messagesAlthough intercalated degrees are well established, little is known about their effect on medical studentsIn this longitudinal study final year students who had taken intercalated degree were more interested in medical research, and had higher deep and strategic learning style scores than other studentsThe effects of the intercalated degree were dose dependent, being greatest in those gaining a first class degreeThe effects of the intercalated degree were greatest in medical schools where a relatively small proportion of medical students took the degree.Differences between medical schools are most easily explained by resource dilution
Related Articles
Exposure to Death is Associated with Positive Attitudes and Higher Knowledge About End-of-Life Care in Graduating Medical Students
Anderson, Wendy G.
Williams, Jillian E.
Bost, James E.
Barnard, David
Journal of Palliative Medicine
To examine the relationship between exposure to death and attitudes and knowledge about end-of-life care in graduating medical students.
Participants and methods
Survey of students graduating from the University of Pittsburgh School of Medicine between 2001 and 2006. Students reported their personal experience with death and their exposure to death and dying patients during medical school. They rated their agreement, on a 4-point Likert scale, with 8 attitude items that were previously used in a national survey. Knowledge about end-of-life care was assessed with a 15-item test about pain and symptom management, ethics, treatment appropriateness, and hospice.
Three hundred and eighty students completed the survey; the response rate was 47%. Seventy-six percent of students reported personal experience with death, and 73% reported caring for dying patients or witnessing a patient's death during their third-year clerkships. Students had positive attitudes about physicians' responsibility and ability to help dying patients and their families, but reported negative emotional reactions to end-of-life care. Students who reported personal or professional experience with death had more positive attitudes and higher knowledge scores than those who did not, p < 0.05.
Educational initiatives should maximize the time medical students spend caring for dying patients. Teaching students end-of-life care during the course of their clinical clerkships is an effective way to improve attitudes about end-of-life care. Schools should focus on developing emotionally supportive settings in which to teach students about death and dying.
Related Articles
Impact of a Pre-Clinical Clinical Skills Curriculum on Student Performance in Third-Year Clerkships
Jackson, Molly Blackley
Keen, Misbah
Wenrich, Marjorie D.
Schaad, Doug C.
Robins, Lynne
Goldstein, Erika A.
Journal of General Internal Medicine
Research on the outcomes of pre-clinical curricula for clinical skills development is needed to assess their influence on medical student performance in clerkships.
To better understand the impact of a clinical-skills curriculum in the pre-clinical setting on student performance.
We conducted a non-randomized, retrospective, pre-post review of student performance evaluations from 3rd-year clerkships, before and after implementation of a clinical-skills curriculum, the Colleges (2001–2007).
Comparisons of clerkship performance data revealed statistically significant differences favoring the post-Colleges group in the Internal Medicine clerkship for 9 of 12 clinical-skills domains, including Technical Communication Skills (p < 0.023, effect size 0.16), Procedural Skills (p < 0.031, effect size 0.17), Communication Skills (p < 0.003, effect size 0.21), Patient Relationships (p < 0.003, effect size 0.21), Professional Relationships (p < 0.021, effect size 0.17), Educational Attitudes (p < 0.001, effect size 0.24), Initiative and Interest (p < 0.032, effect size 0.15), Attendance and Participation (p < 0.007, effect size 0.19), and Dependability (p < 0.008, effect size 0.19). Statistically significant differences were identified favoring the post-Colleges group in technical communication skills for three of six basic clerkships (Internal Medicine, Surgery, and Pediatrics).
Implementation of a pre-clinical fundamental skills curriculum appears to be associated with improved clerkship performance in the 3rd year of medical school, particularly in the Internal Medicine clerkship. Similar curricula, focused on teaching clinical skills in small groups at the bedside with personalized mentoring from faculty members, may improve student performance. Continued efforts are needed to understand how to best prepare students for clinical clerkships and how to evaluate outcomes of similar pre-clinical skills programs.
medical education; clinical skills; medical students; pre-clinical; curriculum
Related Articles
Using a formative simulated patient exercise for curriculum evaluation
Solomon, David J
Laird-Fick, Heather S
Keefe, Carole W
Thompson, Margaret E
Noel, Mary Margaret
BMC Medical Education
It is not clear that teaching specific history taking, physical examination and patient teaching techniques to medical students results in durable behavioural changes. We used a quasi-experimental design that approximated a randomized double blinded trial to examine whether a Participatory Decision-Making (PDM) educational module taught in a clerkship improves performance on a Simulated Patient Exercise (SPE) in another clerkship, and how this is influenced by the time between training and assessment.
Third year medical students in an internal medicine clerkship were assessed on their use of PDM skills in an SPE conducted in the second week of the clerkship. The rotational structure of the third year clerkships formed a pseudo-randomized design where students had 1) completed the family practice clerkship containing a training module on PDM skills approximately four weeks prior to the SPE, 2) completed the family medicine clerkship and the training module approximately 12 weeks prior to the SPE or 3) had not completed the family medicine clerkship and the PDM training module at the time they were assessed via the SPE.
Based on limited pilot data there were statistically significant differences between students who received PDM training approximately four weeks prior to the SPE and students who received training approximately 12 weeks prior to the SPE. Students who received training 12 weeks prior to the SPE performed better than those who received training four weeks prior to the SPE. In a second comparison students who received training four weeks prior to the SPE performed better than those who did not receive training but the differences narrowly missed statistical significance (P < 0.05).
This pilot study demonstrated the feasibility of a methodology for conducting rigorous curricular evaluations using natural experiments based on the structure of clinical rotations. In addition, it provided preliminary data suggesting targeted educational interventions can result in marked improvements in the clinical skills spontaneously exhibited by physician trainees in a setting different from which the skills were taught.
Related Articles
Prolonged Delays for Research Training in Medical School are Associated with Poorer Subsequent Clinical Knowledge
Dyrbye, Liselotte N.
Thomas, Matthew R.
Natt, Neena
Rohren, Charles H.
Journal of General Internal Medicine
Complementary degree programs and research training are important alternative tracks in medical school that typically interrupt the traditional MD curriculum.
Examine effects of such a break on clinical knowledge after reentry into the MD curriculum.
Retrospective cohort study.
Three hundred and two graduates of Mayo Medical School.
Main Measurements
Compared years of delay between the second and third years of medical school with third year clerkship grades, National Board of Medical Examiner's (NBME) Subject Examinations, and United States Medical License Exam (USMLE) Step 2.
Main Results
258, 13, and 31 students spent 0, 1, or ≥3 years pursing research between the second and third year. Baseline measures of knowledge before matriculation and before the third year were similar between groups. Whereas a 1-year delay had no significant effect, a ≥3-year delay was associated with fewer clerkship honors and lower NBME Medicine, Pediatrics, and Psychiatry percentiles compared to no delay (all p < .05). Students with a ≥3-year delay had a 77% reduction in the odds of honors in Medicine. For each year of delay beyond 3, students' third-year NBME Medicine, Neurology, Obstetrics and Gynecology, and Psychiatry scores decreased as did USMLE Step 2 scores (r = −.38 to −.50, p < .05).
Delays of ≥3 years between the second and third years of medical school are associated with lower grades and scores on clinical knowledge tests. Further research is needed to determine the optimal timing of research training and develop effective interventions to facilitate reentry into the medical school curriculum.
students; medical; education; undergraduate; research; USMLE; NBME subject examination; clerkship grade; clerkship honors
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The Effect of Student Gender on the Obstetrics and Gynecology Clerkship Experience
Chang, Judy C.
Odrobina, Michele R.
McIntyre-Seltman, Kathleen
Journal of Women's Health
To explore the effects of the students' gender on their perception of quality and quantity of teaching, the amount of experiential learning, and their interest in obstetrics and gynecology.
Anonymous, self-administered surveys to third-year medical students rotating on the obstetrics and gynecology clerkship.
Eighty-one of 91 students participated (89% response rate): 33 men, 46 women, 2 declined to reveal their gender. No significant gender differences existed regarding number of interactions with residents and faculty; number of deliveries, surgeries, or examinations performed; perceived quality of teaching; or feeling included as part of the clinical team. Male students were more likely to report performing specific surgical procedures, such as operating the bovie cautery during gynecological surgeries (p = 0.005). More men experienced patients refusing to allow them to participate in the clinical interview (p < 0.0001) and physical examination (p < 0.0001). Male students were also more likely to report feeling that their gender negatively impacted their clerkship experience (p < 0.0001). Although less likely to report preclerkship and postclerkship career interest in obstetrics and gynecology, male students were more likely to report that their interest increased at the end of the clerkship.
Male students were more likely to experience gender bias from patients on the obstetrics and gynecology service. Male students also described feeling socially excluded from female-dominated clinical teams. Obstetrics and gynecology educators need to consider methods of encouraging patients to accept medical student participation regardless of gender. Obstetrics and gynecology faculty and residents need to be sensitive to subtle forms of gender bias and ensure equal inclusion for both male and female medical students.
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A new method for the assessment of patient safety competencies during a medical school clerkship using an objective structured clinical examination
Daud-Gallotti, Renata Mahfuz
Morinaga, Christian Valle
Arlindo-Rodrigues, Marcelo
Velasco, Irineu Tadeu
Arruda Martins, Milton
Tiberio, Iolanda Calvo
Patient safety is seldom assessed using objective evaluations during undergraduate medical education.
To evaluate the performance of fifth-year medical students using an objective structured clinical examination focused on patient safety after implementation of an interactive program based on adverse events recognition and disclosure.
In 2007, a patient safety program was implemented in the internal medicine clerkship of our hospital. The program focused on human error theory, epidemiology of incidents, adverse events, and disclosure. Upon completion of the program, students completed an objective structured clinical examination with five stations and standardized patients. One station focused on patient safety issues, including medical error recognition/disclosure, the patient-physician relationship and humanism issues. A standardized checklist was completed by each standardized patient to assess the performance of each student. The student's global performance at each station and performance in the domains of medical error, the patient-physician relationship and humanism were determined. The correlations between the student performances in these three domains were calculated.
A total of 95 students participated in the objective structured clinical examination. The mean global score at the patient safety station was 87.59±1.24 points. Students' performance in the medical error domain was significantly lower than their performance on patient-physician relationship and humanistic issues. Less than 60% of students (n = 54) offered the simulated patient an apology after a medical error occurred. A significant correlation was found between scores obtained in the medical error domains and scores related to both the patient-physician relationship and humanistic domains.
An objective structured clinical examination is a useful tool to evaluate patient safety competencies during the medical student clerkship.
Organized Structured Clinical Examination; Patient Safety; Medical Education; Assessment; Clerkship
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Development and Evaluation of a Palliative Medicine Curriculum for Third-Year Medical Students
von Gunten, Charles F.
Mullan, Patricia
Nelesen, Richard A.
Soskins, Matt
Savoia, Maria
Buckholz, Gary
Weissman, David E.
Journal of Palliative Medicine
To assess the impact, retention, and magnitude of effect of a required didactic and experiential palliative care curriculum on third-year medical students' knowledge, confidence, and concerns about end-of-life care, over time and in comparison to benchmark data from a national study of internal medicine residents and faculty.
Prospective study of third-year medical students prior to and immediately after course completion, with a follow-up assessment in the fourth year, and in comparison to benchmark data from a large national study.
Internal Medicine Clerkship in a public accredited medical school.
Five hundred ninety-three third-year medical students, from July 2002 to December 2007.
Main outcome measures
Pre- and postinstruction performance on: knowledge, confidence (self-assessed competence), and concerns (attitudes) about end-of-life care measures, validated in a national study of internal medicine residents and faculty. Medical student's reflective written comments were qualitatively assessed.
Required 32-hour didactic and experiential curriculum, including home hospice visits and inpatient hospice care, with content drawn from the AMA-sponsored Education for Physicians on End-of-life Care (EPEC) Project.
Analysis of 487 paired t tests shows significant improvements, with 23% improvement in knowledge (F1,486=881, p<0.001), 56% improvement in self-reported competence (F1,486=2,804, p<0.001), and 29% decrease in self-reported concern (F1,486=208, p<0.001). Retesting medical students in the fourth year showed a further 5% increase in confidence (p<0.0002), 13% increase in allaying concerns (p<0.0001), but a 6% drop in knowledge. The curriculum's effect size on M3 students' knowledge (0.56) exceeded that of a national cross-sectional study comparing residents at progressive training levels (0.18) Themes identified in students' reflective comments included perceived relevance, humanism, and effectiveness of methods used to teach and assess palliative care education.
We conclude that required structured didactic and experiential palliative care during the clinical clerkship year of medical student education shows significant and largely sustained effects indicating students are better prepared than a national sample of residents and attending physicians.
Related Articles
Teaching medical students a clinical approach to altered mental status: simulation enhances traditional curriculum
Sperling, Jeremy D.
Clark, Sunday
Kang, Yoon
Medical Education Online
Simulation-based medical education (SBME) is increasingly being utilized for teaching clinical skills in undergraduate medical education. Studies have evaluated the impact of adding SBME to third- and fourth-year curriculum; however, very little research has assessed its efficacy for teaching clinical skills in pre-clerkship coursework. To measure the impact of a simulation exercise during a pre-clinical curriculum, a simulation session was added to a pre-clerkship course at our medical school where the clinical approach to altered mental status (AMS) is traditionally taught using a lecture and an interactive case-based session in a small group format. The objective was to measure simulation's impact on students' knowledge acquisition, comfort, and perceived competence with regards to the AMS patient.
AMS simulation exercises were added to the lecture and small group case sessions in June 2010 and 2011. Simulation sessions consisted of two clinical cases using a high-fidelity full-body simulator followed by a faculty debriefing after each case. Student participation in a simulation session was voluntary. Students who did and did not participate in a simulation session completed a post-test to assess knowledge and a survey to understand comfort and perceived competence in their approach to AMS.
A total of 154 students completed the post-test and survey and 65 (42%) attended a simulation session. Post-test scores were higher in students who attended a simulation session compared to those who did not (p<0.001). Students who participated in a simulation session were more comfortable in their overall approach to treating AMS patients (p=0.05). They were also more likely to state that they could articulate a differential diagnosis (p=0.03), know what initial diagnostic tests are needed (p=0.01), and understand what interventions are useful in the first few minutes (p=0.003). Students who participated in a simulation session were more likely to find the overall AMS curriculum useful (p<0.001).
Students who participated in a simulation exercise performed better on a knowledge-based test and reported increased comfort and perceived competence in their clinical approach to AMS. SBME shows significant promise for teaching clinical skills to medical students during pre-clinical curriculum.
mental status change; simulation; pre-clinical medical students
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Introduction to Evidence-Based Medicine: a student-selected component at the Faculty of Medicine, King Abdulaziz University
Hassanien, Mohammed Ahmed
Advances in Medical Education and Practice
Evidence-based medicine (EBM) involves approaching a clinical problem using a four-step method: (1) formulate a clear clinical question from a patient's problem, (2) search the literature for relevant clinical articles, (3) evaluate (critically appraise) the evidence for its validity and usefulness, (4) implement useful findings into clinical practice. EBM has now been incorporated as an integral part of the medical curriculum in many faculties of medicine around the world. The Faculty of Medicine, King Abdulaziz University, started its process of curriculum reform and introduction of the new curriculum 4 years ago. One of the most characteristic aspects of this curriculum is the introduction of special study modules and electives as a student-selected component in the fourth year of study; the Introduction to Evidence-Based Medicine course was included as one of these special study modules. The purpose of this article is to evaluate the EBM skills of medical students after completing the course and their perceptions of the faculty member delivering the course and organization of the course.
Materials and methods
The EBM course was held for the first time as a special study module for fourth-year medical students in the first semester of the academic year 2009–2010. Fifteen students were enrolled in this course. At the end of the course, students anonymously evaluated aspects of the course regarding their EBM skills and course organization using a five- point Likert scale in response to an online course evaluation questionnaire. In addition, students' achievement was evaluated with regard to the skills and competencies taught in the course.
Medical students generally gave high scores to all aspects of the EBM course, including course organization, course delivery, methods of assessment, and overall. Scores were also high for students' self-evaluation of skill level and EBM experience. The results of a faculty member's evaluation of the students' achievement showed an average total percentage (92.2%) for all EBM steps.
The EBM course at the Faculty of Medicine, King Abdulaziz University, is useful for familiarizing medical students with the basic principles of EBM and to help them in answering routine questions of clinical interest in a systematic way. In light of the results obtained from implementing this course with a small number of students, and as a student-selected component, the author believes integrating EBM longitudinally throughout the curriculum would be beneficial for King Abdulaziz University medical students. It would provide a foundation of knowledge, offer easy access to resources, promote point-of-care and team learning, help students to develop applicable skills for lifelong learning, and help the faculty to achieve its goals of becoming more student-centered and encouraging students to employ more self-directed learning strategies.
student-selected component; evidence-based medicine; learning; curriculum
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text:
No political dialogue has occurred during the 17-year ceasefire period and the KIO were intimidated to remove weapons and transform into the Burmese Army-controlled Border Guard Force (BGF) before the November 7 election in 2010.
The KIO cast off the BGF plan, saying it cannot accept transformation of its armed wing.
Talks between the KIO and the Burmese government were also aborted in 1963, 1972, and 1980 respectively; though, they all failed to get to the bottom of the political standoff between the two sides.
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Definición de lachrymatory en inglés:
(also lacrimatory)
adjetivotechnical or literary
Relating to, tending to cause, or containing tears: a lachrymatory secretion
Más ejemplos en oraciones
- Preferably, the explosive slug is placed between the compartment containing the lacrimatory substance and the compartment containing the pyrogenic substance.
- The lachrymatory factor from an onion activates the nerve endings of pain fibres in the top layer of the cornea, leading to increased production and release of tears.
- The effect of the lacrimatory factor can be sharply diminished by freezing the onion or submerging the onion in water (diluting the chemical, which is soluble in water) before cutting.
sustantivo (plural lachrymatories)
A vial of a kind found in ancient Roman tombs and thought to be a lachrymal vase.
Oraciones de ejemplo
- Glass, including lachrymatories, is mentioned as occurring sometimes, but apparently only in small quantities.
- Ancient Greeks buried their dead with lacrimatories, vials full of mourners' tears.
- Ancient Greeks, Romans and Hebrews would cry into small vials, or lachrymatories, that would then be sealed and buried with the dead.
Mid 17th century (as a noun denoting a vial): from Latin lacrima, on the pattern of chrismatory.
For editors and proofreaders
División en sílabas: lach·ry·ma·to·ry
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Now closed.
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12 miles NE
Neath, SWANSEA
13 miles ENE
Neath, GWENT
20 miles ENE
Bridgend, SOUTH GLAMORGAN
Now closed.
22 miles E
Carmarthen, CARMARTHENSHIRE
23 miles NW
Carmarthen, CARMARTHENSHIRE
23 miles NW
Pencoed CF35 6UW, BRIDGEND
24 miles E
Ilfracombe, DEVON
24 miles S
LLandow, Cowbridge, BRIDGEND
26 miles ESE
porth, RHONDDA CYNON TAFF
28 miles E
Llangadog, CARMARTHENSHIRE
29 miles NNE
Pontyclun, CARDIFF
29 miles E
Pontypridd, RHONDDA CYNON TAFF
Now closed.
31 miles E
Merthyr Tydfil, MERTHYR TYDFIL
32 miles ENE
Merthyr Tydfil, MID GLAMORGAN
32 miles E
Barnstaple, DEVON
33 miles S
Cardiff, SOUTH GLAMORGAN
33 miles E
Narberth, PEMBROKESHIRE
33 miles WNW
« none | Page 1 | next »
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urban planner jobs
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Zoning Administrator
Town of Herndon, VA - Herndon, VA
Master of Urban Planning preferred. Certification by the American Institute of Certified Planners (AICP) required....
Senior Urban Planner
Bolton & Menk Inc - Burnsville, MN
Bolton & Menk has an exciting opportunity for a Senior Urban Planner to join our well-established and growing team....
CEQA NEPA Environmental Planner
CoreTechsDirect - Oakland, CA
CEQA NEPA Environmental Planner - 1111*. Responsibilities of the CEQA NEPA Environmental Planner*. Bachelor's degree or equivalent experience in environmental...
Sr Planner - Energy
County of San Luis Obispo - San Luis Obispo, CA
Sr Planner - Energy. The San Luis Obispo County Department of Planning & Building is offering an exciting career opportunity for Senior Planner in the Energy...
Zoning Administrator
Town of Herndon, Virginia - Herndon, VA
Certification by the American Institute of Certified Planners (AICP) required. Master of Urban Planning and a minimum of six (6) years of professional planning...
Associate Planner / Assistant Planner - San Diego
Cameron Craig Group - San Diego, CA
Associate Planner / Assistant Planner – San Diego. Degree in urban planning or similar, Master's Degree preferred....
Urban Planning Manager
CyberCoders - Cleburne, TX
Urban Planning Manager Do you have your AICP with 3+ years of urban planning experience in Texas?If so.....
City Engineer/ Planning Director
City of Alma - Alma, AR
As a sole Planner, this position offers an opportunity for the successful candidate to build skills in a wide variety of areas, including long range planning,...
Senior Planner
San Mateo County Transit District - San Carlos, CA
BS/BA degree in Urban Planning, Transportation Planning or a closely related field. The Senior Planner will report to the Manager, Operations Planning for San...
Discharge Planner/Medical Social Worker Job
PeaceHealth - Florence, OR
PeaceHealth has approximately 16,000 caregivers, a multi-specialty medical group practice with more than 800 physicians and providers, a comprehensive...


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No worries, we are the walk-in clinic. No appointment necessary
New patients welcome.
We bulk bill everyone who has a valid Medicare card
All basic and urgent medical cares (non life threatening)
See the doctor anytime!
You can now queue up online for doctor's appointment, and check the current queue at the clinic with our
Real Time Queue
Now open all weekend at Claremont clinic:
Sat 8 am to 6 pm
Sun 9 am to 5 pm


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Spicy Mini Pork Kabobs
Total Time
Prep 15 mins
Cook 4 hrs 30 mins
This is out of my "C'mon Over!" Pillsbury cookbook...enjoy! You can Assemble the kabobs in advance; cover and refrigerate them for up to three hours.
Ingredients Nutrition
- 1 large garlic clove, finely chopped
- 3 teaspoons chili powder
- 1 teaspoon ground coriander
- 3 tablespoons olive oil
- 1⁄8 teaspoon red pepper sauce
- 1 1⁄2 lbs pork tenderloin, cut into 1-inch cubes
- 12 wooden skewers (6 inch)
- In medium nonmetal bowl or 1-gallon resealable food-storage plastic bag, mix all ingredients except pork and skewers. Add pork; turn to coat. Cover dish or seal bag: refrigerate at least 4 hours to marinate. Soak wooden skewers in water 30 minutes.
- Heat gas or charcoal grill. Thread pork evenly onto skewers: discard marinade.
- Place kabobs on grill over medium-high heat. Cook 12 to 15 minutes, turning once, until pork is no longer pink in center.
Most Helpful
Yum! These were super simple and really tasty. Loved the flavors in the marinade. I let mine marinate overnight and they were delish. Thanks for sharing, Teresa. Made for FYC tag.
We enjoyed these delicious mini kebabs very much. They were so flavorful. The meat was tender and juicy. Crunchy on the outside just the way we like our BBQ. These little babies were ready in no time. Thank you for sharing this recipe that was quick and easy to make with terrific results. Served with a drizzle of Homemade Pomegranate Reduction Sauce and coconut cashew rice for a memorable meal. Made FYC Tag Game.
These are very tasty and simple to make. Perfect for weekday grilling since they grill up quickly. I think if I were entertaining and served these, something like a yogurt chipotle dip would be very nice and set them over the top. Reviewed for the "For your consideration" tag game.


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Synonyms of profitable in English:
1 a profitable company
moneymaking, profit-making, commercial, successful, solvent, in the black, gainful, remunerative, financially rewarding, paying, lucrative, bankable
[Antonyms] loss-making
2 profitable study
rewarding, fruitful, illuminating, informative, well spent
[Antonyms] fruitless, useless
Definition of profitable in:
What do you find interesting about this word or phrase?
Comments that don't adhere to our Community Guidelines may be moderated or removed.
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Welcome to Cambridge Open Studios
Cambridge Open Studios is a flourishing community of around 470 artists, craftspeople and designer-makers working throughout Cambridgeshire. Our aim is to help bring artists and local people together. Browse our Member pages and FAQs to find out more about us.
July Open Studios
Each July we invite the public to visit our workshops and studios as part of the annual Open Studios event. This provides an opportunity for you to see our work and find out about the techniques we use and the passions that inspire us. Browse the 2016 Open Studios pages to see who is taking part this year or download a copy of the 2016 Open Studios Guide.


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Top Definition
A great guy many people can look up too. A great person to hang out with all the time. Has many friends but always keeps his priorities in check. Will stick up for you no matter what. He will always make sure your feeling good. Usually people with the name Dakwon are Free-spirited. Try not to get on the bad-side unless you like being ignored!
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Atlanta, GAUSA
July 17, 2014
I've made a 2-cycle engine propel a bicycle (almost), carvings in clay for casting/molding processes, and generally whatever interests me otherwise.
Just recently moved to Atlanta from Huntsville/Chattanooga. I enjoy making new things and breaking perfectly fine things even more.
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Sorry! The position you're looking for is no longer available. Check out other Market Research internships in San Diego, CA below.
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Junior Marketing Manager
ZoCo Marketing Solutions, Inc. — San Diego, CA
July 30 2016
... Market Research & Lead Generation for client support in the commercial area. Job Description: · ... internships considered!) · Ideally 1 or 2 years experience in marketing, sa…
Application Deadline: Available Year-round
Business Development Associate
Bainbridge, Inc. — San Diego, CA
July 30 2016
Conduct research of prospective targets, industries, markets, and competitionDemonstrated ... Our best client solutions come from all levels of the firm from interns to directors. Reflecting…
Application Deadline: Available Year-round


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3 of 3 people found the following review helpful
A strong female character copes with crime and family,
Verified Purchase(What's this?)
This review is from: The Hunter (Hardcover)
Takako Otomichi is a female cop in a man's Japan. When a murder victim dies in a fire started by an incendiary device hidden in his belt, Takako is among the detectives assigned to the case. She's partnered with a male detective sergeant who views her as an ornament. The investigation seems to be running out of steam when a second gruesome death occurs, this one apparently caused by a wild dog or a domesticated wolf. The relationship between the killings is the mystery that occupies Takako professionally. Divorced and living alone until her annoying sister shows up, Takako's personal life frustrates her as much as her job.
Takako's perseverance makes her a sympathetic character, but she is also easy to like: she's smart, she's tenacious, and she has a biting sense of humor (although, for the most part, she keeps her sarcasm to herself). She thinks of her partner as "the emperor penguin." Her partner fits the stereotype of the career cop who has sacrificed his family to his job, who drinks too much and doesn't trust women. Although most of the story is presented from Takako's point of view, we sometimes see the novel's events through her male partner's eyes. The differing perspectives offer insight into the failure of the partners to communicate -- the two characters make assumptions about each other that, left unspoken, make it impossible for them to work as a team.
The subordinate role of women in Japanese society is a recurring theme in Japanese crime fiction (it appears in Out and The Cage among other novels); in The Hunter, Takako does her best to ignore the persistent sexism she encounters, even when it hobbles her investigation. She also tries to ignore her domineering mother and hapless sister, but doing so only adds to her stress. She feels best about herself when she's riding her motorcycle. Her connection to the mysterious animal she ends up tracking (as well as her love of riding) suggests her desire for freedom, a desire that is only a dream given the relentless demands of her job and family.
Readers looking for a strong female character should enjoy The Hunter. The novel isn't a whodunit -- there isn't much in the way of clues for the reader to piece together -- but the story moves quickly and in unexpected directions. The connection between the crimes is a bit farfetched, but that's common enough in thrillers. It's interesting to compare issues of gender equality across cultural lines, but it's even more interesting to read about Takako battling the kind of personal demons that afflict people in every culture. The prose in The Hunter flows more naturally than it does in some other novels translated from Japanese that I've read. For its intriguing central character and enjoyable story, I would give The Hunter 4 1/2 stars (if that option were available).
Review Details
(6 customer reviews)
2 star
Location: Tzer Island
Top Reviewer Ranking: 121


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What does "500 Internal Server Error" mean?
What does "500 Internal Server Error" mean?
This is a common problem with those who are hosting with 1&1. Try adding this to the top of your .htaccess file and try again:
AddType x-mapp-php5 .php
500 Internal Server Error means that something in your site settings is causing the server to not want to serve your site
It could be in the htaqccess file, or it could be something as simple as a white space after a ?> closing tag in a php file, or it could be something far more deep-rooted.
Start by looking at the last change you made, or the htaccess file is a usual culprit.
Internal server errors are usually described in more detail in the server error log. If you have access to your server error log, generate the error again, note the date and time, then immediately check your server error log for anything useful. If you don't have access to your server error log, ask your hosting provider to look for you.
This topic has been closed to new replies.


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Theo Muse
Hello internet friends! Here is the third and regrettably the final episode of the Yes I Do series for the season. SUMMER-Y: Sponsor This? team affiliates charge off a street ledge set up and then everyone gets together for one last hoorah at Park City. Our plan was to film a lot more backcountry expeditions and street features however the snow season was less that desirable....Mahwell. Keep a look out for more content dropping in hot from NZ this summer/winter, whatever you call it. Hope everyone in the world enjoys this one :)
PLUG: Like SponsorThis? on facebook and check out the new garments oozing style here: facebook.com/pages/Sponsor-This/129330237110758
Riders include: Ryan Anderson, Brett Wilson, Ozzy Henning, Hamish Martin, Steph Feld, Sam Christie, and some banger frontflip cameos from Ray Stone and Fillip Payne..Waaaapow.
Track One: King Of Spain by Tallest Man On Earth
Track Two: That's What's Up by Edward Sharp and the Magnetic Zeros.
and as always FIlmed and Edited by me! theo muse.


text:
Ephrata News
Local news for Ephrata, WA continually updated from thousands of sources on the web.
When Does Anti-Immigration Go Too Far?
29 Shocking Celebrities Who Did Porn Before Becoming Re...
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Updated: Sat Jul 23, 2016 05:33 pm
Copyright © 2016 Topix LLC


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worked for same bank for 7 years without complaint. a couple of months ago I had the opportunity to speak with a superior about a few problems. shortly after that I was written up....then I was written up again...and now within two and a half months time i have been terminated. I was not written up this last time just verbally let go the reason was for breach of privacy..which did not happen since no other customers saw the information - only bank employees
Business Attorney
No case....you are presumably an at-will employee......listener did not like you which is not illegal.
My answer is not intended to be giving legal advice and this topic can be a complex area where the advice of a licensed attorney in your State should be obtained. Please click "helpful" or "best answer" if my answer added any value or add a "comment" if you have more info for me to help you get a better answer.
Immigration Attorney
You have no cause of action to sue for wrongful termination under the facts as cited here. All employment is considered "at will", unless you were made to leave your prior job or made to move in order to accept the job, none of which is the case in this instance. Sorry.
Behar Intl. Counsel 619.234.5962 Kindly be advised that the answer above is only general in nature cannot be construed as legal advice, given that not enough facts are known. It is your responsibility to retain a lawyer to analyze the facts specific to your particular situation in order to give you specific advice. Specific answers will require cognizance of all pertinent facts about your case. Any answers offered on Avvo are of a general nature only, and are not meant to create an attorney-client relationship.
Employment / Labor Attorney
With all due respect to the other attorneys who have answered, I do not believe we know enough to make a blanket statement that you have no case.
The question turns on what "problems" you discussed with your superior. If you were complaining about treatment you were receiving based on race, gender, religion, disability, or national origin (and possibly sexual orientation, as you say your are in KCMO), then this could be a case for retaliation and/or discrimination.
However, if the "problems" were garden variety workplace complaints, then the other attorneys are correct.
If the situation is more the former than the latter, call a local employment attorney--most will do free consultations. You can find a list of specialists at www.nela.org. Good luck.
This answer is solely for assistance via the AVVO network. My answer to this question does not create an attorney-client relationship. I would appreciate your marking my answer as helpful if you find that to be the case.
Child Support Lawyer
The only cause of action for "wrongful termination" in Missouri is for whistleblower wrongful termination. And whistleblower wrongful termination is only a cause of action if you told someone other than the supervisor engaging in the activity. Depending on what problems you were bringing to the supervisor you could have a claim. If it was just a complaint about how they run the business, they probably had a legal reason to terminate you.
Post a free question on our public forum.Ask a Question
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Help make the music happen! Play a special role in providing quality music programming in our community with your gift to NISOM.
Funds Are Needed For:
Annual Fund
Student Scholarships
Endowment Fund
Program Sponsorships
The Northeast Iowa School of Music is 501(c)3 organization. All donations are tax-deductible. Learn More
Get Involved: Volunteer Today!
NISOM does not schedule volunteers on a daily or weekly basis, but extra hands are extremely helpful at times. Contact us to be added to our volunteer call list.
Show Off Your Love Of Music
with NISOM shirts and merchandise. Opt for a fun T-shirt, a more subltle polo, or a variety of goodies like mini messenger bags, insluated lunch bags, and keychain flashlights. Available at the NISOM office while supplies last. Proceeds support music education.
The Northeast Iowa School of Music (NISOM) is a non-profit community music school that welcomes students of all ages and abilities in instructional programs. NISOM also offers concerts and outreach programs to a wide-range of audiences.
Private Lessons: Begin one-on-one lessons at any time for the summer session
Group Classes: Small groups for kids and adults
Browse All Programming by Age Group: Kids age 3-9 | Tween & Teens | College | Adults
July 18: Registration began for current (summer) students
July 25: Registration opens to former students
Aug 1: Registration opens to new students
School year begins August 22
Lessons | Registration | Tuition | Policies
May 2016 Student Newsletter
NISOM in the News - Again!
From Flute to Frozen: L&MOP Spring 2016