ACP Medical Student Health Policy Internship

http://www.acponline.org/medical_students/impact/archives/2010/10/perspect/

Are American Med Students Better than International Med Students?

Kendra Campbell, MD, Psychiatry/Mental Health, 07:56PM Oct 20, 2010
A medical student recently asked me the above question during their rotation with me. He specifically wanted to know if I noticed a difference in the quality of medical students, based on the school they attended. This is a question, which I considered when deciding to attend an international medical school, and is one, which I also pondered during my medical education. As a medical student, I interacted with both "American" medical students and foreign/international ones.

As a resident, I have now interacted with a variety of medical students. I've worked with students who are from U.S. medical schools, and ones who are from international medical schools. While my anecdotal evidence might not hold that much water, I can now say, with complete confidence, that the medical school which a student attends has little correlational value with their performance on clinical rotations. I obviously cannot speak to their board scores, or any other parameters. But when it comes to general knowledge, patient rapport, clinical skills, and overall performance, I've determined that it's more about the student and less about the school.

While this post started out as a discussion about AMGs (American Medical Graduates) versus IMGs (International Medical Graduates), I would like to change gears and give some general tips to medical students from the perspective of a resident. And for the record, while the resident might not be the one to ultimately grade the student (although we do have input), in my experience we are in the unique position of interacting with the students more than the attending. Sometimes we even do more of the teaching. Anyway, here are some tips, which I can provide based on my experience:

1. Be motivated to learn. Even if you are not planning on going into the specialty in which you are rotating, your motivation level speaks volumes about you as a student, and you as a future doctor.

2. Ask many questions. Asking questions shows that you are interested in learning, and will ultimately make you a better physician. (See #1.)

3. Know your patient. Since medical students generally have a lighter patient load, you have the potential to know each patient that you cover even better than the attending or resident might. I promise that nothing impresses the attendings and residents more than a med student who offers a piece of information about the patient, which was unknown to them.

4. Listen, read, and read. If you want to impress your attending and resident (and ultimately be a better prepared doctor), listen to what they teach you. Try to pay attention to what they emphasize as being important, and read up on pertinent subjects in your "free" time. You are in the hospital/clinic/etc. to learn. Take advantage of this opportunity in every way you can, and follow-up on all discussions with researching/reading in your time away from the hospital.

5. Anticipate what needs to be done and do it. Nothing will make your resident (and attending) happier than to find out that you completed the discharge paperwork for them because you knew the patient was going to be discharged that day. Have the consults sheets, CT requests, doctor's orders forms, etc. ready when you anticipate that they are required. Seriously, this is key! And I can't emphasize enough how happy this makes the residents!

So, that's my two cents on how to be an effective medical student, who will ultimately grow into an effective resident, and physician, no matter which med school you attended. But are these strategies and competencies specific to the med school one attends? I'd love to hear what you think.

Top 10 Residency Interview Questions

It’s been one month since ERAS (Electronic Residency Application Service) opened its floodgates and released thousands of potential residents’ applications for residency in the US. There are lots of great resources online for advice and tips with regards to the dreaded residency interviews. But I’ve received emails asking to provide the most common interview questions that I encountered last year, while on the interview trail. So, here is a list that I’ve created, in relative order of frequency:

1. Tell me about yourself.

2. Do you have any questions?

3. Why are you interested in (fill in the blank) as a specialty?

4. What do you like to do for fun?

5. What is your specific interest in this program?

6. What are your future goals, aspirations, beyond residency?

7. What are your weaknesses?

8. Can you see yourself living in this area?

9. Where else have you applied?

10. What area in this speciality interests you most, and do you plan on completing a fellowship?

The above questions are fairly standard. However, for fun, here are some random questions that I was also asked during interviews:

1. If you were a car, what type of car would you be, and why?

2. How do you feel about the philosophical underpinnings of psychiatry?

3. Can a doctor have a pink mohawk?

4. Have you ever had a pink mohawk?

5. If you could paint a mural on the blank wall in front of you, what would you paint, and why?

6. What is the one thing, which is not on your application, which you think would cause us not to accept you into our program?

7. What kind of dogs do you have?

8. If you were a fruit, what kind of fruit would you be, and why?

9. Tell me about the worst patient you’ve encountered.

10. How is your relationship with your family?

I hope this is helpful to a few folks out there. For all of you who have been through the residency interview process, or are currently going through it, please do add either a common question, which I’ve missed, or an “off the wall” one, which you've encountered!

Clerkship Order Linked to Outcomes on Clerkship Exams

September 14, 2010 — Third-year medical student performance is associated with the first clinical clerkship, with students who start with internal medicine showing the highest subject examination performance and overall grades.

However, clerkship order is not associated with clerkship clinical performance or US Medical Licensing Examination Step 2 scores.

The findings, from a retrospective review of medical students attending a single US medical school, are published in the September 15 issue of the Journal of the American Medical Association.

"Studies have demonstrated the importance of clerkship sequence on aspects of performance in select clerkships, and their findings support that students perform better on subject examinations as they progress through the academic year," write Susan M. Kies, EdD, from the University of Illinois College of Medicine, Urbana, and colleagues. "Although research supports that students perform better in clerkship examinations later in the year, we are not aware of any studies that have addressed whether knowledge is gained as a result of a certain clerkship specialty,"

Accordingly, in this study, the authors sought to assess whether the order in which third-year core clerkships are completed affects student performance.

They analyzed the clerkship performance records of 2216 medical students at all 4 campuses of the University of Illinois College of Medicine who completed their third-year core clerkships in internal medicine, family medicine, surgery, pediatrics, psychiatry, and obstetrics/gynecology from July 2000 through June 2008.

They found that first clerkship was significantly associated with mean subject examination scores. For family medicine, it was 71.96 (95% confidence interval [CI], 70.90 - 72.98); internal medicine, 73.86 (95% CI, 73.33 - 74.39); obstetrics/gynecology, 72.36 (95% CI, 71.64 - 73.04); pediatrics, 73.11 (95% CI, 72.38 - 73.84); psychiatry, 72.17 (95% CI, 71.52 - 72.81); and surgery, 72.37 (95% CI, 71.73 - 73.02; P < .001).

Similarly, first clerkship was significantly associated with mean overall clerkship grades. For family medicine, it was 24.20 (95% CI, 23.90 - 24.90); internal medicine, 25.33 (95% CI, 25.07 - 25.60); obstetrics/gynecology, 24.68 (95% CI, 24.32 - 25.05); pediatrics, 24.92 (95% CI, 24.59 - 25.27); psychiatry, 24.61 (95% CI, 24.33 - 25.01); and surgery, 24.97 (95% CI, 24.64 - 25.30; P = .01).

The study also found a significant difference in mean total overall clerkship grades for students taking internal medicine first compared with obstetrics/gynecology (mean difference, 0.65; 95% CI, 0.18 - 1.12), psychiatry (mean difference, 0.66; 95% CI, 0.20-1.12) and family medicine (mean difference, 0.93; 95% CI, 0.37 - 1.50).

The positive association between starting a clerkship with internal medicine and subsequent examination performance throughout the clerkship sequence may be a reflection of a general understanding of internal medicine concepts that provide a basis of medical knowledge that extends to all clinical disciplines, the authors note.

"Having taken the internal medicine clerkship, students may have the basic understanding of these concepts and an advantage in standardized examination performance thereafter," they write.

The University of Illinois may not be representative of a typical medical school because of the diversity of its 4 campuses, the authors note. Other study limitations include the retrospective and observational study design, incomplete randomization to first clerkship, and variation in clerkship experience among the different campuses.

"The success of student clinical performance may be related to factors other than those included within the scope of this study," the authors write in their conclusion. "Additional analyses of student performance in the clinical setting and in other institutions may help provide optimal experiences for students."

The study authors have disclosed no relevant financial relationships.

JAMA. 2010;304:1220-1226.

What To Do When 'Scrubbed In'

Smoking costs U.S. economy billions each year

Expenses directly attributable to death and disease caused by smoking are estimated to be costing the U.S. economy more than $301 billion annually, according to a study released recently by the American Lung Association. In the study, researchers at Penn State University calculate that smoking results in workplace productivity losses of $67.5 billion, costs of premature death totaling $117.1 billion and direct medical expenditures of $116.4 billion (see below).



The study, titled "Smoking cessation: the economic benefits," provides a nationwide cost-benefit analysis that compares the costs to society of smoking with the economic benefits of states providing smoking cessation coverage. The AMA fully supports the report, which provides state governments with compelling economic reasons to help smokers quit.

"Smoking cessation programs have been shown to successfully help smokers quit—lowering the risk for smoking-related diseases and the high costs associated with treating them," AMA Board of Trustees member Barbara McAneny, MD, said. "No other public health measure, including breast cancer or diabetes screening, sees the economic benefits of smoking cessation."

The AMA offers various online tools that physicians can use to help their patients quit smoking, as well as educational resources about the dangers of secondhand smoke. Among them are a webinar to help physicians counsel parents about secondhand and third-hand smoke exposure, a podcast to help physicians incorporate counseling about secondhand smoke into their practices, a self-learning curriculum that explains office-based prevention and intervention strategies regarding secondhand smoke and a module about managing tobacco dependence.

In addition, the AMA’s Healthier Life Steps™ program offers tips and resources to help physicians talk with patients about the dangers of tobacco use. The program provides patient self-assessment questionnaires, action plans, tracking calendars and other resources to help physicians counsel patients who smoke or use other tobacco products.

Learn more about what the AMA is doing to help physicians help their patients quit smoking, stop using other forms of tobacco and avoid exposure to secondhand smoke.

Burnout in Medical Students Linked to Self-Reported Unprofessional Conduct

September 14, 2010 — Burnout in medical students is highly prevalent and is associated with self-reported unprofessional conduct involving patient care, according to the results of a Mayo Clinic study reported in the September 15 issue of the Journal of the American Medical Association.

"Our findings suggest future physicians' altruism, professionalism, and commitment to serve society are eroded by burnout," lead author Liselotte Dyrbye, MD, from the Mayo Clinic in Rochester, Minnesota, said in a news release. "This is concerning since burnout is a pervasive problem among medical students, residents, and physicians in practice."

The goal of this cross-sectional survey was to examine the association between anonymously reported measures of professionalism and burnout among 4400 eligible students from 7 leading medical schools (Mayo Medical School, University of Washington, University of Minnesota, University of Alabama, University of California–San Diego, University of Chicago Pritzker School of Medicine, and the Uniformed Services University of the Health Sciences). The survey included the Maslach Burnout Inventory (MBI), the Primary Care Evaluation of Mental Disorders depression screening tool, and the SF-8 quality of life (QOL) assessment tool. Response rate was 61% (n = 2682).

More than half (52.8%) of the respondents were found to have burnout on the MBI, and those students were more likely to report some form of unprofessional conduct. Although relatively few (<10%) reported academic cheating, up to 43% percent of third- and fourth-year students admitted to some form of unprofessional conduct involving patient care. For example, they may have reported a physical examination finding as normal even though they had not examined that area.

Because the students knew that the reported behavior was inappropriate, the investigators suggest that some elements in the educational process may promote dishonesty.

Burnout was the only aspect of distress independently associated with reporting at least 1 unprofessional behavior, based on multivariable analysis with adjustment for personal and professional characteristics.

For 6 different scenarios, the opinions of only 14% of the students regarding relationships with industry were in line with the American Medical Association policy regarding appropriate interactions between physicians and pharmaceutical companies.

The study authors therefore called on medical schools to "do a better job teaching students about conflict of interest and appropriate relationships with industry."

Altruistic feelings concerning a physician's role in society, such as a desire to provide medical care to the underserved, were less often reported by medical students suffering from burnout.

"As our nation reforms its health care system, it is essential that physicians advocate for patients, promote the public health, and reduce barriers to equitable health care," Dr. Dyrbye said. "Burnout appears to be a threat to this process."

Limitations of this study include response bias, assessment of only a limited number of behaviors and attitudes representing professionalism, reliance on self-reported behavior, and inability to determine causal relationships.

"Future research should investigate whether interventions designed to reduce burnout help students cultivate professional values and behaviour," the study authors conclude.

The Mayo Clinic supported this study. The study authors have disclosed no relevant financial relationships.

JAMA. 2010;304:1173-1180.