COMSEP Journal Club
September 2021
Editors: Karen Forbes and Jon Gold
Which medical students choose primary care?
Assessing factors for choosing a primary care specialty in medical students; a longitudinal study. McDonald C, Henderson A, Barlow P, & Keith J. Medical Education Online, 08 April 2021. https://doi.org/10.1080/10872981.2021.1890901
Reviewed by Dana Goplerud
What was the study question?
What factors are associated with medical students matching into a primary care specialty? Do these factors differ between men and women?
How was it done?
Three classes of medical students at the University of Iowa Carver College of Medicine were surveyed annually about individual characteristics and experiences, including demographics, research participation, mentorship, educational debt, and career preferences, with the first survey conducted before matriculation and the final survey after residency match. These results were compared with match rates a primary care specialty, defined as internal medicine, family medicine, or pediatrics. Results were reported for the pooled sample as well as stratified by gender.
What were the results?
Approximately 1 in 3 students (37%) matched into a primary care specialty. Students matching into primary care were more likely to be women (56%) than those not matching into primary care (38%). 1 in 10 students matching into primary care reported that medical debt influenced their choice of specialty, compared to 1 in 4 students not matching into primary care. Men were more likely than women to report that medical school debt influenced their specialty choice (28% vs 10%). In analyses adjusted for pre-matriculation and early medical school factors, women in their M1-M2 years were more likely to match into primary care (aOR 2.06) as well as students with a family member who practices primary care (aOR 3.54). The effect of having a family member in primary care was stronger for women than for men. When adjusting for student characteristics from post-match surveys, gender was no longer a significant predictor of specialty choice. Students after match had lower odds of matching into primary care if they reported quality of life (aOR 0.65) and mastery of technical skills (aOR 0.54) as important features of their career.
What are the implications?
Medical debt is an important factor in choice of specialty, although this association seems to be stronger among men. Other influences like family exposure and lifestyle also influence specialty choice. Medical schools could encourage students to match into primary care specialties by providing information early in medical school about primary care loan forgiveness programs, offering scholarships to students committed to primary care, or enhancing early exposure to primary care careers. Further studies could include qualitative analysis of student attitudes towards primary care as well as analyzing how quantity of education debt relates to specialty choice.
Editor’s Note: Interestingly, there was no reported difference in actual debt between those who chose primary care specialties and those who didn’t—just on whether it influenced specialty choice. The study suggests that men and women perceive the importance of debt (and other values) differently. (JG)
Short-term clerkships, long-term relationships
Building longitudinal relationships into a traditional block clerkship model: a mixed-methods study. Atalay AJ, Osman, NY, Krupa E, Alexander EK. Academic Medicine. 2021; 96(8): 1182-1188. https://dx.doi.org/10.1097/ACM.0000000000003810
Reviewed by Jessica VanNostrand and Molly Rideout
What was the study question?
What are the feasibility and perceived benefits of a longitudinal patient experience for third-year medical students within a block clerkship model?
How was the study done?
54 third-year medical students at one clerkship site for Harvard Medical School participated in a curriculum that involved identifying 2-4 patients within their block clerkships and engaging in four or more additional contacts with at least one patient over the next six months. Following the completion of the clerkship year, students completed electronic surveys recording number and settings of patient encounters. Students were also invited to participate in one confidential individual interview to gather information about the feasibility and perceived value of the program. Quantitative data was reported by frequency of responses while interviews were transcribed and coded into themes.
What were the results?
Survey completion rate was 96% (n=52) and interview participation rate was 78% (n=42). Almost all (94%) of students completed the curriculum requirements and an additional 42% of students were able to maintain continuity with two patients over four medical visits. Most students met their longitudinal patients the first time in the inpatient setting with subsequent meetings in ambulatory settings. Students identified adequate communication and support from faculty in block clerkships as factors promoting the success of the program, while the logistics of completing program requirements and balancing competing priorities from core clerkships were the biggest barriers. They identified an increased understanding of the patient experience as the largest goal and value of the program– this theme became more prevalent in student responses over time. Other perceived values included a greater understanding of the health care system and the progression of disease.
What are the implications?
This study identified a feasible means of increasing patient continuity in medical education through a hybrid experience, incorporating a longitudinal course into a block clerkship model. Although this type of program wouldn’t require complete remodeling of the current clinical teaching structure, there were significant barriers identified by students. Improved methods to manage scheduling logistics as well as a culture shift valuing continuity in education may be needed for successful implementation of similar curricular without increasing student stress and workload. Overall, the program was successful in altering students’ perceptions of health care by increasing their understanding of the patient perspective which may be instrumental in creating
physicians who emphasize patient-centered care. Relationships formed with patients tmay contribute to increased empathy and a decrease in the compassion fatigue that currently plagues the medical education system.
Editor’s Note: This mixed-methods study showed mixed results. As noted above, students appreciated the patient relationships but found the experience hard to integrate within the core clerkship model. Not mentioned in the study is what role the students had within the relationship. I suspect if they thought their presence provided added value to the patient and/or the health care system they would look at it more positively. (JG)
Step scores and medical boards
Exploring the Relationships Between USMLE Performance and Disciplinary Action in Practice: A Validity Study of Score Inferences From a Licensure Examination
Cuddy MM, Young A, Gelman A et al. Academic Medicine. 2017; 92(12):1780-1785. doi:10.1097/ACM.0000000000001747
Reviewed by: Melissa Held, M.D.
What was the study question?
Is there a relationship between scores on Step 1 and Step 2 CK and likelihood of a physician receiving any disciplinary action from a state medical board?
How was it done?
Databases of the NBME and Federation of State Medical Boards (FSMB) were combined, extracting variables on USMLE scores, practice-related information, and disciplinary action data. The overall period of disciplinary actions reported was from 1994-2012 (graduates from 1994-2006). Complete data was available for 164,725 physicians (45% female). For the analyses, the authors used physicians’ first punitive disciplinary action and its associated jurisdiction. The primary independent variables included Step 1 scores and Step 2 CK scores from a physician’s first attempt. Other variables examined included gender and number of years since medical school graduation; specialty area was not accounted for. Using these variables, logistic regression models were used to estimate the chance of receiving a disciplinary action. Of note, when considered separately, both Step 1 scores and Step 2 CK scores each made significant contributions to explaining the odds of receiving a disciplinary action, however when both were included in the model together, the effect of Step 1 scores became nonsignificant.
What were the results?
Physicians who received a disciplinary action had lower mean Step 1 and Step 2 CK scores (205 vs. 214 for Step 1 (SD=21); 202 vs 213 for Step 2CK (SD=23). Twenty eight percent were female with a mean of 14 years of exposure for those with actions and 12 years for those with no action. Physicians with higher Step 2 CK scores had a lower chance of receiving a disciplinary action when controlling for other factors. One percent of physicians in the sample received at least one disciplinary action from a state medical board. Although small, this translates into 2200 physicians, some of whom had multiple actions taken against them.
What are the implications?
Although Step 1 scores did not provide helpful information in this model, Step 2 CK scores seemed to reflect how a physician may behave in practice and those with lower scores may be at risk for future disciplinary action by a state medical board. The study provides some validity evidence to support the suggestion that Step 2 CK reflects skills such as clinical reasoning and judgment. For those students who struggle to study for and pass Step 2 CK, additional support and resources should be made available to these learners to ensure safe clinical practices when they enter the workforce.
Editor’s Comments: While this study examines USMLE exam scores as related to disciplinary actions, another recent paper has explored the same outcome based on the number of attempts at the Step 1, Step 2 CK and Step 3 exams. (Arnhart et al. Academic Medicine 2021; 96:1319-1323). This study has relevance with respect to recent policy changes at the NBME including changing Step 1 results to a pass/fail outcome rather than a raw score and limiting examinees to no more than 4 attempts on each step. Not surprisingly, additional attempts needed to pass each of these 3 exams were also associated with an increased likelihood of receiving disciplinary actions after accounting for other factors. (KFo)
Learning about (and with) telehealth
An outpatient telehealth elective for displaced clinical learners during the COVID-19 pandemic.Weber, A.M., Dua, A., Chang, K. et al. BMC Med Educ 21, 174 (2021). https://doi.org/10.1186/s12909-021-02604-z
Reviewed by Patricia Pichilingue-Reto
What was the study question?
Did an outpatient telehealth elective provide meaningful clinical learning experience to 4th year medical students during the COVID-19 pandemic?
How was it done?
Fourth year medical students were recruited during March and April 2020 to participate in a pilot 4-week service elective. Although the elective was established to improve patient access to outpatient clinic appointments, clear educational objectives were defined. Students attended a training session about teleconsultation flow, use of electronic medical records (EMR) and applications to protect personal information. Attending physicians requested student support. Student roles included calling the patient, who consented to participate in telehealth services, documenting the encounter in the EMR, and transitioning the patients from a regular phone call to a HIPPA-compliant video call system. Students would sometimes join subsequent patient-attending consultation depending on attending physician schedules. Attendings provided the student with feedback and education after the encounter. Students completed surveys to evaluate clinical and educational outcomes, as well as elective evaluations and reflections.
What were the results?
During the pilot 4-week elective period, 64 fourth year medical students completed the training session, but only 29 (45.3%) contributed enough hours to obtain credit and thus submitted an evaluation form. Overall, the evaluations showed that most students considered this a valuable learning experience. Debrief sessions with attendings after the patient encounter were mentioned in only 32.4% of student reflections (11/34). A total of 58 attending physicians from 3 specialties participated in 1411 scheduled appointments. In 81.7% of the initiated visits, the medical students were able to transition patients to the video call system. Barriers encountered in 13.9% of the total of appointments included re-scheduling requests from patients or not answering the phone calls.
What are the implications?
During the COVID-19 pandemic we will continue facing barriers to offer in-person learning clinical experiences to medical students; telehealth opportunities will allow students to remain actively involved in patient care while supporting outpatient services and gaining valuable educational experiences. Telehealth will likely remain as part of our medical schools’ curricula as a valuable and practical method for remote education and efficient patient care.
Editor’s Comments: It is unclear why more than half of the students initially recruited did not complete the elective and/or if there were challenges that limited ongoing participation. After a student’s initial involvement with a patient, they did not always have the opportunity to join the patient-attending consultation; perhaps ensuring this element of the workflow, along with an educational debrief after each patient, would further enhance the educational experience and motivate students to complete the elective (KFo).