June 2019

posted in: 2019 Journal Clubs | 0

Medical Students and QI

Teaching Students How to Improve Safety and Quality in Two Children' Hospitals: Building a Pediatric Clerkship Patient Safety and Quality Experience. Genuardi, Frank J. et al. Academic Pediatrics, 2019. In press.



Reviewed by Patricia Mcburney



What was the study question?

To improve medical student understanding of systems-based practice and patient safety. is it feasible for medical students to identify patient vulnerabilities/safety issues and to propose interventions during a 4-week pediatric inpatient rotation?

How was the study done?

An 8-semester curriculum introducing medical students to quality improvement and patient safety efforts was integrated into pre-existing courses for medical students at the University of Florida. At 2 major clinical sites within that system, pediatric clerkship students were required to present on 1 identified adverse or “near miss” event and the potential intervention(s). The presentations were made to peers and hospital stakeholders (faculty, housestaff, quality officer, and hospital staff). The presentations were scored for level of intervention (risk reduction strategies) using a rubric adapted from the Institute for Safe Medication Practices (ISMP). The proposed interventions were scored from low to high:1, informal education; 2, formal education;  3, rules and policies; 4, checklists; 5, standardization and protocols; 6, automation and computerization; 7, forcing functions and constraints. The proposed interventions were also scored for feasibility (how likely to be implemented), again on a 7-point scale.

What were the results?

51 of 52 (98%) of student presentations were evaluated. Presentations proposed an average of 1.9 interventions for each safety concern. Safety issues included security of pediatric floors, infection control, error reporting, environmental health issues, communication, and hand-offs.  The proposed interventions were distributed across all 7 levels of intervention.  In regard to feasibility, 57.7% of the proposals scored at least 5 (higher likelihood of being implemented) on the feasibility scale.  26.9% scored 3 or less (lower likelihood of being implemented).

What are the implications of these findings?

Third-year students can contribute to the culture of safety! Their role may be underutilized in keeping hospitalized children safe.


Editor’s note: We have all felt pressure to teach about and to involve students in QI efforts. It is nice to have guidance regarding how to do that and to see that it can be useful and effective. (RR)

Parents know best

Using a flipped classroom and the perspective of families to teach medical students about children with disabilities and special education.

Sheppard, ME, Vitalone-Raccaro, N, Kaari, JM, & Ajumobi, TT.  Disability and Health Journal (2017), 10(4), 552-558. https://doi.org/10.1016/j.dhjo.2017.03.012

Reviewed by: Marisa de Souza

What were the study questions?

What do medical students know about special education laws and practices? What bearing do an on-line presentation, parent presentation and an online group discussion have on knowledge of special education laws and practices and working with families of children with disabilities? How does the curricular addition impact students’ perceptions of the physician’s role in supporting children with disabilities?

How was the study done?

A class of 160 second year medical students participated in a three-part learning curriculum, which included (a) a mandatory online module about the Individuals with Disabilities Education Act and the role of the physician, (b) an interactive classroom panel of parents of children with disabilities, and (c) submission of an online reflective narrative. 112 students completed a pre-test and 118 completed the post-test using an online platform, with 91 total matched pairs. The questionnaire included demographic questions, as well as questions about perceived and actual knowledge about special education. Multiple choice questions included options for a correct response, an incorrect response and “do not know” to avoid guessing. Students’ reflections of the online discussion were anonymously compiled and analyzed using thematic analysis.

What were the results?

There was a significant increase in the number of students choosing correct answers on the post-test, demonstrating an increased understanding of special education laws. Major themes from the qualitative component established that students understood the value of learning about special education to better support patients and families. Students also expressed that they anticipated this knowledge would impact their practice and relationships with families.

What are the implications?

A flipped classroom approach along with a parent panel and a narrative reflection helped to increase students’ knowledge of special education law. This combined didactic and interactive experiential learning method also enabled the students to appreciate the value of the content by connecting information with patient and parent stories. There may be limited opportunities during medical school to work with children with disabilities and their families. Early exposure and training could empower medical students to provide and advocate for well-rounded support to children with disabilities.

Editor’s note: The thematic analysis of these students’ reflections was of particular interest; students described the importance of this information and its impact on not only what physicians do, but the impact on the relationship between physicians, children with disabilities and their families. From their own reflections, students generated the ideas of (a) view the child first as a child, (b) have empathy, (c) accommodate the needs of families during visits, and (d) understand the unique demands on families – demonstrating the immense value in experiential learning (KFo).

Can palpation skills be assessed objectively?

“Princess and the pea”- an assessment tool for palpation skills in postgraduate education

Kamp R, Moltner A, Harendz S. BMC Medical Education 2019. 19:177. Published Ahead of Print.



Reviewed by Randy Rockney

What was the study question?

Can a palpation assessment tool be developed for use in undergraduate medical education?

How was the study done?

The study authors from a medical school in Hamburg, Germany modified and standardized a previously developed tool where a coin, a European cent, was hidden under layers of copy paper ranging from 50 to 500 sheets per stack. Three groups of participants-22 physicians with no osteopathic training, (control group); 25 participants before and after an osteopathic palpation training program; and 31 physicians with at least 700 hours of osteopathic skills training (expert group), were asked to locate the hidden coin by palpation. In some instances no coin had been hidden.

What were the results?

The authors found good test-retest reliabilities for different paper layers up to 300 sheets. The control group detected a coin significantly better than the pre-training group; the training group showed significantly more correct coin localizations after the training and did better than the expert group as well unless there was no hidden coin.

What are the implications of these findings?

According to the glossary of osteopathic terminology “palpation is the application of the fingers to the surface of the skin or other tissues, using varying amounts of pressure, to selectively determine the condition of the parts beneath.” The authors also note that palpation is a complex skill that depends on individual factors. For example, between the ages of 20 and 80, the somatosensory ability decreases physiologically by an average of 1% per year, but this natural decrease is slowed in practicing physiotherapists and osteopaths by the demands placed on the haptic system. Hence, the use of experienced osteopaths in the expert group. Medical education would benefit tremendously from novel approaches like the one demonstrated in this study to teach and assess physical diagnosis skills.

Editor’s note: With so many demands for what needs to be “taught” to students, the focus on observing and more importantly assessing students’ clinical skills in physical examination is often left to the wayside. While sheets of paper may not represent the texture of living tissue, this novel approach provides an assessment opportunity to help learners hone their palpation skills (KFo).


What makes a good oral case presentation?

What Skills Do Clinical Evaluators Value Most In Oral Case Presentations?

Lancaster I, Basson M.  Teaching and Learning in Medicine, 31:2, 129-135.


Reviewed by Suzanne Friedman

What was the study question?

What specific oral presentation skills are most important to clinical faculty and how do they compare with learner expectations?

How was the study done?

Third year students participated in ‘Professor Rounds’ where they presented cases and received feedback via the Patient Presentation Rating (PPR) tool. The PRR is a validated 18 item, competency-based formative evaluation that has been shown to provide better feedback than unstructured feedback. Students were evaluated by clerkship directors who had been trained on using the tool. In addition, pre-clinical students were surveyed about which of the skills addressed on the PPR they thought were most important for an oral presentation.

What were the results?

513 PPR evaluations of 137 students were performed over 2 years. Analyses were performed to assess the correlation of the subscores of the PPR with the overall assessment. Only the vital signs, the overall organization and whether the evaluator had a clear idea of the patient’s situation were found to significantly correlate with the overall score. 68/156 preclinical students responded to the survey.  These students felt the most critical elements of the presentation were having a clear idea of the patient’s situation, chief complaint and history of present illness.

What are the implications?

The PPR tool has been shown to help improve formative feedback but this study focuses on the disjunction between faculty expectations and learners’. As oral case presentations are an essential part of all clerkships and all evaluations, this disconnect between evaluators and students offers an area for training.  Given that much of the faculty’s expectations focus around clinical reasoning skills, there is a needed area of skill development for students during their clerkship year.

Editor’s Note: The authors may not have been entirely fair in comparing faculty expectations of clerkship students to preclinical students’ expectations of themselves.  Nonetheless, it is very likely true that the oral presentations of an early student will look different from that of a clerkship student or a resident and a developmental approach is reasonable.  Milestones, anyone? (JG)