March 2019

posted in: 2019 Journal Clubs | 0

How do we teach physical examination skills?

Approaches to Teaching the Physical Exam to Preclerkship Medical Students: Results of a National Survey   Uchida T, ParkYS, Ovitsh RK, Hojsak J, Gowda D, Farnan JM, Boyle M, Blood AD, Achike FI, and Silvestri RC  Academic Medicine Jan 2019 94(1) 129-134


Reviewed by Suzanne Friedman



What was the study question?

In view of the USMLE Skills exam, shortened pre-clerkship curricula and other pedagogic approaches.  what are the current approaches to physical examination (PE)  teaching for pre-clerkship students?

How was the study done?

A cross sectional survey was created by members of the Directors of Clinical Skills Courses.  The study assessed curricular design, methods and assessment related to the timing and integration of the teaching of the PE. Surveys were sent to institutional representatives from 141 medical schools.

What were the results?

75% of schools completed the survey.  On average, schools spent 82 hours teaching the PE, with most beginning within the first 2 months of school.  In the majority of schools, the PE is taught via integration with history taking, anatomy or physiology. 87% of schools taught a comprehensive approach to the PE and 68% a clinical reasoning approach, with 56% teaching both. Almost all schools used online learning including videos and simulators.  Schools had an average of 7 formative and 4 summative assessments. Curricula are evaluated via student satisfaction, OSCE results and USMLE scores.

What are the implications?

Ensuring comprehensive and coordinated delivery and assessment of this content is crucial both for those involved in preclinical and clinical GME and for competency based education. Given that there is little data on the optimal methods for teaching the PE, this provides both best practices and areas for further research.  Some pedagogical approaches that are evidence based, such as a clinical reasoning approach to PE, criterion based standard setting and inter-professional education, have still not been adopted at many institutions.

Editor’s note: Having had medical experience in several developing countries I am always impressed by both the reliance on physical examination skills in the absence of the cornucopia of diagnostic technology we enjoy in our society as well as the expertise with physical diagnosis demonstrated by clinicians in those countries.  While I am not suggesting that every medical student should or needs to work in a developing country to learn physical examination skills it would be interesting to determine what we might learn and employ in our teaching of PE skills from those sources. (RR)



Students and Family-Centered Rounds

Medical Student Participation in Patient- and Family- Centered Rounding: A National Survey of Pediatric Clerkships.

Trost MJ,  Potisek NM, Seltz LB, Rudnick M,  Mamey MR, Long M, Quigley PD

Academic Pediatrics 2019, In Press.

Reviewed by Miriam Schechter

What was the study question?

With patient- and family- centered rounds (PFCR) becoming routine what are the prevalence of, orientation practices for, and potential challenges of student participation in PFCR?

How was the study done?

The 2017 COMSEP annual survey queried members about students and PFCR. Five questions, including 1 open-ended, focused on challenges students face. Chi-square and t-test analyses to were used to compare responses across institutions.  A qualitative content analysis was completed on the open-ended question.

What were the results?

60% (94/156) of medical schools representing 98 unique training sites responded to the PFCR questions. Eighty five percent of sites reported medical student participation in PFCR.

Half of the sites had informal PFCR student orientations, 20% had formal structure, and only 2 sites used a published curriculum.  While the most common format was didactic lecture, handouts, videos, and role-play were used to a much lesser degree. Orientation was conducted at the start of the clerkship in 49% of programs, and on the first day of the students’ inpatient block in 29%. Most orientations were led by the clerkship director (30%), inpatient attendings (27%) or residents (20%).

Clerkship directors sensed challenges for medical students in 4 domains: 1) communication, 2) anxiety, 3) expectations, and 4) systems. Students may struggle with “translating back” medical information to families and knowing how to disclose sensitive information. Lack of familiarity with the structure of PFCR, presenting to a large, mixed group, and variable attending expectations may lead to performance anxiety. Finally, limited time and space, may place constraints on student participation and teaching.


What are the implications of these findings? 

Since student participation in PFCR is widespread in pediatric clerkships, but orientation practices are diverse, development of a standardized orientation to prepare students for their role is needed. An engaging, effective, uniform orientation format would be beneficial to clerkship directors. Using orientation to address potential challenges students will face could help with their successful integration into PFCR.

Editor’s note: Family centered rounds can be a remarkable challenge for medical students and performance anxiety is rampant. I ask each clerkship student to write a medical narrative describing a notable experience on the pediatric clerkship and a student's experience on family-entered rounds ranks right up there with first confrontation with child abuse or the medical student role in regard to themes addressed. The more orientation to common pitfalls like disclosure of sensitive information or difficulty keeping discussions in lay terms the better. (RR)


Exploring the Lack of Diversity in Competitive Residencies—Starting at the Roots

How Small Differences in Assessed Clinical Performance Amplify to Large Differences in Grades and Awards: A Cascade With Serious Consequences for Students Underrepresented in Medicine.

Teherani A, Hauer KE, Fernandez A, King TE, Lucey C.  Acad Med.  2018 Sep;93(9):1286-1292.

Reviewed by Fatima Aly

What was the study question?

What are the differences in clerkship assessments between students who are underrepresented in medicine (UIM) and those who are not, why do those differences occur, and how can we mitigate them?

How was the study done?

The authors describe a quality improvement effort related to improving disparities in student performance between UIM and non-UIM students.  .670 medical students’ data from graduating classes of 2013–2016 at a single institutionwere analyzed with respect to three outcomes: high-stakes standardized exams (eg MCAT, USMLE 1, USMLE 2 CK), number of honors grades earned in medical school clerkships, and membership in the Alpha Omega Alpha Honor medical society (AOA)..  at matriculation.Performance on these outcomes was compared between UIM students and non-UIM students.  A fishbone diagram was created to explore the root causes of differential performance between the two groups.  The authors then describe the efforts they have made to mitigate these differences.

What were the results?

Comparison between UIM and non UIM groups showed mean test score results were lower for UIM students (differences were larger in MCAT scores and medium in USMLE step 1 and step 2 CK); UIM students received slightly lower clerkship director ratings (one-tenth of a point in the clerkship assessment scale).  Cumulative effect resulted in less honor grades across all clerkships.  As a result, UIM students were 3 times less likely to be selected for AOA membership.

Root cause analysis suggested a number of potential factors contributing to the differences.  These included student factors (eg social isolation, susceptibility to stereotype threat and microagressions) faculty factors (eg unconscious bias, colorblind ideology, commission of microaggressions),  and cultural/structural factors (eg normative vs criterion-based grading, overemphasis on exam scores in grade determination).

Countermeasures taken including changes in curriculum, the assessment system, faculty development and program evaluation are described.

What are the implications of these findings?

These data suggests that small differences in early career high stakes exams have large consequences in later eligibility and selection to competitive residency programs and lifelong careers especially in academic medicine.

Editor’s Note: When recently surveyed about USMLE numeric scoring, COMSEP members expressed a concern that numeric reports disadvantage underrepresented students.  This study supports that concern, but suggests that there are other factors at work as well.  The good news is that differences in standardized test scores seem to narrow over time.  The bad news is that gaps in performance assessments still exist.  As with other forms of bias, bias in student assessment requires awareness, planning and cultural change to address. (JG)



Medical Student Depression—Who’s at Risk?

A Prognostic Index to Identify the Risk of Developing Depression Symptoms Among U.S. Medical Students Derived From a National, Four-Year Longitudinal Study.

Dyrbye et al. Academic Medicine. 2019; 94:217- 226.

Review by Antoinette C. Spoto-Cannons

What was the study question?

What individual and school-related factors increase the risk of developing depression symptoms by the fourth year of medical school and can we predict who is at greatest risk?

How was the study done?

The authors invited students entering 49 U.S. medical schools in 2010 to participate in a longitudinal study in which they were asked to complete validated surveys during their first and fourth years. 4,732 of 5,823 (81%) of invited first year students completed surveys to identify individual demographics, depression, coping skills, and social support. Seventy percent (3,743/4,732) completed the follow up surveys in fourth year. Additionally, public data characteristics of medical schools including class size, research ranking, MCAT scores, and in-state tuition were ascertained. The authors randomly divided the participants in to discovery (n=2,455) and replication (n=1,288) cohorts.

What were the results?

The authors confirmed a high prevalence of depression symptoms (31.2%; 1,167/3,743) in fourth-year medical students.  Eight risk factors determined to independently increase the risk medical student depression during training include age > 24 years, non-white race, non-Hispanic/non-Latino ethnicity; middle-tertile tuition cost; baseline depression symptoms at year one, high perceived stress, high negative coping behaviors, and low social support.  Utilizing these risk factors and their risk scores (0-10), students were categorized into low risk (0–1), intermediate risk (2–3), high risk (4–5), and very high risk (6 or higher) of developing depressive symptoms by their fourth year.  Depression-PI score of intermediate risk, high risk, and very high risk correlated with odds ratios of 1.75, 3.98, and 9.19 in the discovery cohort and 1.82, 4.58, and 10.25 in the replication cohort for developing depression in their fourth year.

What are the implications?

This study supports the need for wellness programs for all medical students as mandated by the LCME and should include initiatives promoting positive coping behaviours, teaching stress reduction strategies, and fostering social support among medical students. By risk stratifying medical students, medical schools may be able to provide additional support to those at risk and actively screen those at high risk in order to provide early intervention if indicated.


Editor’s Comments: This large study confirms the high prevalence of depression of graduating medical students (approximately 1/3) which has significant consequences both personally and professionally. There is no doubt that efforts to promote student wellness for all students are needed. By being able to risk-stratify a student’s risk of developing depression, medical schools may look to developing approaches for additional support to those at higher risk, while considering the challenges of preventing stigmatizing individual students and protecting confidentiality (KFo).