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Background and Objectives: Many medical student-patient encounters occur in the outpatient setting. Conference room staffing (CRS) of student presentations has been the norm in the United States in recent decades. However, this method may not be suitable for outpatient precepting, being inefficient and reducing valuable direct face time between physician and patient. Precepting in the Presence of the Patient (PIPP) has previously been found to be an effective educational model in the outpatient setting but has never been studied in family medicine clinics, nor with non-English speaking patients, nor patients from lower socioeconomic backgrounds with low literacy.Methods: We used a randomized controlled trial of educational models comparing time spent using PIPP with CRS in two family medicine clinics. Patient, student, and physician satisfaction were also measured using a 5-point Likert scale; total encounter time and time spent precepting were also recorded.Results: PIPP is strongly preferred by attending physicians while patients and students were equally satisfied with either precepting method. PIPP provides an additional 3 minutes of physician-patient face time (17.39 versus 14.08 minutes) in an encounter that is overall shortened by 2 minutes (17.39 versus 19.71 minutes).Conclusions: PIPP is an effective method for precepting medical students in family medicine clinics, even with non-English speaking patients and those with low literacy. Given the time constraints of family physicians, PIPP should be considered as a preferred, time-efficient method for training medical students that is well received by patients, students, and particularly by physicians. [ABSTRACT FROM AUTHOR]

Background: How multiple forms of psychological distress coexist in individual medical students has not been formally studied. Aim: To explore the prevalence of various forms of distress in medical students and their relationship to recent suicidal ideation or serious thoughts of dropping out of school. Methods: All medical students at seven US schools were surveyed with standardized instruments to evaluate burnout, depression, stress, mental quality of life (QOL), physical QOL, and fatigue. Additional items explored recent suicidal ideation and serious thoughts of dropping out of medical school. Results: Nearly all (1846/2246, 82%) of medical students had at least one form of distress with 1066 (58%%) having ≥3 forms of distress. A dose-response relationship was found between the number of manifestations of distress and recent suicidal ideation or serious thoughts of dropping out. For example, students with 2, 4, or 6 forms of distress were 5, 15, and 24 fold, respectively, more likely to have suicidal ideation than students with no forms of distress assessed. All forms of distress were independently associated with suicidal ideation or serious thoughts of dropping out on multivariable analysis. Conclusions: Most medical students experience ≥1 manifestation of distress with many experiencing multiple forms of distress simultaneously. The more forms of distress experienced the greater the risk for suicidal ideation and thoughts of dropping out of medical school. [ABSTRACT FROM AUTHOR]

This study provides empirical evidence in relation to a growing body of literature concerned with the 'socialisation' effects of accounting and business education. A prevalent criticism within this literature is that accounting and business education in the United Kingdom and the United States, by assuming a 'value-neutral' appearance, ignores the implicit ethical and moral assumptions by which it is underpinned. In particular, it has been noted that accounting and business education tends to prioritise the interests of shareholders above all other stakeholder groups. This paper reports on the results of a set of focus group interviews with both undergraduate accounting students and students commencing their training with a professional accounting body. The research explores their perceptions about the purpose of accounting and the objectives of business. The findings suggest that both university and professional students' views on these issues tend to be informed by an Anglo-American shareholder discourse, whereby the needs of shareholders are prioritised. Moreover, this shareholder orientation appeared to be more pronounced for professional accounting students. [ABSTRACT FROM AUTHOR]

CONTEXT Burnout is prevalent amongmedical students and is a predictor of subsequent serious consideration of dropping out of medical school and suicide ideation. Understanding of the factors that protect against burnout is needed to guide student wellness programmes. METHODS A total of 1321 medical students attending five institutions were studied longitudinally (2006-2007). The surveys included standardised instruments to evaluate burnout, quality of life, fatigue and stress. Additional items explored social support, learning climate, life events, employment status and demographics. Students who did not have burnout at either time-point (resilient students) were compared with those who indicated burnout at one or both time-points (vulnerable students) using a Wilcoxon-Mann-Whitney test or Fisher's exact test. Similarly, the differences between those who recovered and those who were chronically burned out were also compared in students with burnout at the first time-point. Logistic regression modelling was employed to evaluate associations between the independent variables and resiliency to and recovery from burnout. RESULTS Overall, 792 (60.0%) students completed the burnout inventory at both timepoints. No differences in demographic characteristics were observed between resilient (290 /792 [36.6%]) and vulnerable (502 / 792 [63.4%]) students. Resilient students were less likely to experience depression, had a higher quality of life, were less likely to be employed, had experienced fewer stressful life events, reported higher levels of social support, perceived their learning climate more positively and experienced less stress and fatigue (all p < 0.05) than vulnerable students. On multivariable analysis, perceiving student education as a priority for faculty staff, experiencing less stress, not being employed and being a minority were factors independently associated with recovery from burnout. CONCLUSIONS Modifiable individual factors and learning climate characteristics including employment status, stress level and perceptions of the prioritising of student education by faculty members relate to medical students' vulnerability to burnout. [ABSTRACT FROM AUTHOR]

Background: Little is known about the prevalence of suicidal ideation among U.S. medical students or how it relates to burnout. Objective: To assess the frequency of suicidal ideation among medical students and explore its relationship with burnout. Design: Cross-sectional 2007 and longitudinal 2006 to 2007 cohort study. Setting: 7 medical schools in the United States. Participants: 4287 medical students at 7 medical schools, with students at 5 institutions studied longitudinally. Measurements: Prevalence of suicidal ideation in the past year and its relationship to burnout, demographic characteristics, and quality of life. Results: Burnout was reported by 49.6% (95% CI, 47.5% to 51.8%) of students, and 11.2% (CI, 9.9% to 12.6%) reported suicidal ideation within the past year. In a sensitivity analysis that assumed all nonresponders did not have suicidal ideation, the prevalence of suicidal ideation in the past 12 months would be 5.8%. In the longitudinal cohort, burnout (P < 0.001 for all domains), quality of life (P < 0.002 for each domain), and depressive symptoms (P < 0.001) at baseline predicted suicidal ideation over the following year. In multivariable analysis, burnout and low mental quality of life at baseline were independent predictors of suicidal ideation over the following year. Of the 370 students who met criteria for burnout in 2006, 99 (26.8%) recovered. Recovery from burnout was associated with markedly less suicidal ideation, which suggests that recovery from burnout decreased suicide risk. Limitation: Although response rates (52% for the cross-sectional study and 65% for the longitudinal cohort study) are typical of physician surveys, nonresponse by some students reduces the precision of the estimated frequency of suicidal ideation and burnout. Conclusion: Approximately 50% of students experience burnout and 10% experience suicidal ideation during medical school. Burnout seems to be associated with increased likelihood of subsequent suicidal ideation, whereas recovery from burnout is associated with less suicidal ideation. [ABSTRACT FROM AUTHOR]

Background: Some medical schools have replaced all student practice peer physical examinations in the curriculum with examinations of standardized patients (SPs). Purpose: To assess attitudes of medical students toward practicing physical examinations with classmates, including genital, rectal, or female breast components. Methods: Survey administered to all 235 Year-4 students at University of Minnesota Medical School (69% response rate). Results: Ninety-five percent believed that limited peer practice exams are valuable. Six percent of students were uncomfortable with these exams: This was strongly associated with having had an uncomfortable experience. Conclusions: Although most students value practicing limited exams with classmates, a small, consistent number of students are very uncomfortable with these. Explicit guidelines for faculty and classmate behavior may minimize their discomfort, but alternatives to peer exam, such as SP exams, need to be provided this small group. There is no role for peer genital, rectal, or female breast exams in the curriculum. [ABSTRACT FROM AUTHOR]

Background: Distress is prevalent among residents and often attributed to rigors of training. Aims: To explore the prevalence of burnout and depression and measured mental quality of life (QOL) among graduating medical students shortly before they began residency. Method: Pooled analysis of data from 1428 fourth year medical students who responded to 1 of 3 multi-institutional studies. Students completed the Maslach Burnout Inventory, PRIME MD, and SF-8 to measure burnout, depression, and low mental QOL (defined as mean mental SF-8 scores ½ a standard deviation below the population norm) and answered demographic items. Results: Shortly before beginning residency, 49%% of responding medical students had burnout, 38%% endorsed depressive symptoms, and 34%% had low mental QOL. While no differences in the prevalence of distress was observed by residency specialty area, there were subtle differences in the manifestation of burnout by specialty. Medical students entering surgical fields had lower mean emotional scores, students entering primary care fields had lower mean depersonalization scores, and students entering non-primary care/non-surgical fields reported the lowest mean personal accomplishment scores (all p ≤ 0.03). Conclusion: Our results indicate a high prevalence of distress among graduating medical students across all specialty disciplines before they even begin residency training. [ABSTRACT FROM AUTHOR]

Background: Although electronic cigarette (e-cigarette) use has rapidly increased, there is little data about what United States medical students know or are taught about them. This study examined medical students’ experiences, knowledge, and attitudes regarding e-cigarettes, as well as their evaluation of their education on e-cigarettes. Methods: A cross-sectional online survey of medical students currently enrolled at the University of Minnesota Medical School (n = 984) was conducted over a three-week period in August and September 2015. Primary outcomes included students’ personal experiences with e-cigarettes, knowledge and attitudes about e-cigarettes, and students’ assessment of their education on e-cigarettes. Results: 66.9% medical students completed the survey. 58% (n = 382) of participants identified as female. 35.8% (n = 235) were “not sure” whether e-cigarettes were approved by the FDA for smoking cessation, while 4.1% (n = 27) falsely believed they were. While 82.9% (n = 543) agreed or strongly agreed that they felt confident in their ability to discuss traditional cigarette use with patients, only 12.4% (n = 81) agreed or strongly agreed that they felt confident in their ability to discuss e-cigarettes with patients. 94.8% (n = 619) of participants believed that they had not received adequate education about e-cigarettes in medical school. A higher proportion of males reported ever using an e-cigarette. Conclusions: The gaps in medical student knowledge and wide variances in attitudes about e-cigarettes at one medical school together with their report of inadequate education in an environment of increasing use of e-cigarette use in the U.S. speaks to a need for the development of medical school curriculum on e-cigarettes. [ABSTRACT FROM AUTHOR]

Background: Although medical student specialty choices shape the future of the healthcare workforce, factors influencing changes in specialty preference during training remain poorly understood. Aim: To explore if medical student distress and empathy predicts changes in students' specialty preference. Methods: A total of 858/1321 medical students attending five medical schools responded to surveys in 2006 and 2007. The survey included questions about specialty choice, burnout, depression, quality of life, and empathy. Results: A total of 26%% (205/799) changed their specialty preference over 1 year. Depersonalization - an aspect of burnout - was the only distress variable associated with change in specialty preference (OR, odds ratio 0.962 for each 1-point increase in score, p == 0.03). Empathy at baseline and changes in empathy over the course of 1 year did not predict change in specialty preference (all p > 0.05). On multi-variable analysis, being a third year (OR 1.92), being male (OR 1.48), and depersonalization score (OR 0.962 for each point increase) independently predicted a change in specialty preference. Distress and empathy did not independently predict students' losing interest in primary care whereas being a fourth-year student (OR 1.83) and being female (OR 1.83) did. Conclusion: Among those who did have a major change in their specialty preference, distress and empathy did not play a major role. [ABSTRACT FROM AUTHOR]

Background and Objectives: Proficiency in procedural care achieved during residency is a major driver of family physician scope of practice. To date, no inventory exists of the advanced procedures and clinical skills performed by teaching family physicians. This study comprises the first such survey and assesses the attitude of respondents toward the importance of family physicians performing procedures., Methods: We sent a clinical skills inventory to a convenience sample of teaching family physicians employed at 18 medical school-affiliated, community, and military residency programs across the United States., Results: The overall response rate was 46% (N=337). Respondents performed a median of 12 advanced procedures and clinical skills (IQR: 8-18). Endorsed procedures ranged from skin biopsy (n=316, 93.8%) and joint injection (n=279, 82.8%) to colonoscopy (n=21, 6.2%) and cesarean delivery (n=23, 6.8%), and reported skills ranged from medication-assisted treatment (n=181, 53.7%) to highly active antiretrovial therapy (n=35, 10.4%). Gender and career stage were associated with statistically significant differences in endorsement of specific procedures. For example, fracture management was more likely to be performed by late- versus early-career faculty (54.1% vs 24.2%, P&lt;.001) and by male versus female respondents (54.9% vs 24.2%, P&lt;.001). Most respondents (84.3%) agreed that future family physicians should learn procedures and advanced clinical skills., Conclusions: Family medicine teaching faculty perform a wide array of procedures and advanced skills. Apparent differences by career stage and gender identity in the performance of some of the procedural and skill areas may portend a shift in the procedural training of future family physicians.

Background: The risk of stent thrombosis (ST) or target lesion revascularization (TLR) is increased with smaller stent diameters (SD). Whether SD has a deleterious effect in women treated with early- vs. new-generation drug-eluting stents (DES) is unknown., Methods: We pooled patient-level data from 26 randomized control trials of DES. Only women treated with DES were included. Subjects were stratified according to SD: small, SD ≤ 2.75 mm; intermediate, 2.75 mm < SD ≤ 3.25 mm; and large, SD ≥ 3.25 mm. Endpoints of interest were 3-year definite ST, TLR, major adverse cardiac events (MACE: the composite of death, myocardial infarction or TLR) and death., Results: Of 6413 women, 2274 (35.0%) had a small SD, 2448 (38.0%) had an intermediate SD, and 1691 (26.0%) had a large SD. By multivariable analysis, stent diameter (per 0.25 mm decrease) was associated with an increased risk of TLR and ST, which was uniform in terms of magnitude and direction between early- and new-generation DES. There were no differences in MACE or death across groups., Conclusion: Small SD in women undergoing PCI is associated with an increased risk of definite ST and TLR, consistently with both early- and new-generation DES., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Phenomenon : Pairing medical students with community-based preceptors has provided unique medical education advantages. However, due to an increase in the number of M.D.-granting medical schools and medical school class sizes, academic medical institutions have struggled to recruit community preceptors to teach their students. This task has been made more difficult due to rising pressures upon institutions and clinicians-for example, increased productivity demands, greater volume and oversight of electronic health record documentation, and competition for community preceptors from both D.O. and non-U.S.-based medical schools. Although academic institutions have historically relied largely on altruistic motives and intrinsic rewards to actively engage and retain community-based preceptors, alternative models have arisen, chiefly those in which community-based preceptors are explicitly compensated for teaching. Approach : To study this phenomenon, representatives of the Alliance for Clinical Education developed and deployed a 31-item survey accompanied with a subset of free text questions to the collective membership of its 8-member constituent organizations. Survey questions explored if community preceptors were compensated indirectly or directly and what types of compensation were provided, if any. There were 188 surveys analyzed, with an estimated response rate of 18.2%. Findings : Twenty-six percent of respondents indicated they compensate community preceptors directly and/or indirectly. Respondents discussed their motivations for payment (or nonpayment), mechanisms for paying, aspirations to pay, and expectations of the recipient. No statistically significant association was found when comparing responses of paid versus not paid by region. Free text responses provided additional insight regarding payment considerations, institutional competition, recruitment/retention, recognition, and education issues. Insights : Increasingly, medical schools are finding it necessary to provide funding for community preceptors in order to retain them. New creative forms of compensation to community preceptors may prove important in the future for this vital aspect of medical student education.

As U.S. medical educators know, it has been exceedingly difficult over the past decade to train medical students to document in the electronic health record (EHR) yet remain compliant with Centers for Medicare and Medicaid Services (CMS) guidelines. Indeed, some institutions have interpreted the guidelines to prohibit all medical student documentation in the EHR. This has been particularly challenging since the Association of American Medical Colleges has recommended that all medical school graduates be entrusted with 13 specific professional activities, two of which directly require student use of the EHR. Furthermore, critical efforts by clerkship directors to recruit community physicians as preceptors of medical students have been significantly hampered by the medical students' inability to document encounters. Therefore, the CMS policy transmittal Pub 100-04 Medicare Claims Processing Manual, released on February 2, 2018, which now explicitly allows appropriately supervised student documentation to be submitted for billing, is a welcome policy change. U.S. medical educators need to seize this opportunity, encourage their health systems to revise their internal precepting practices, and widely advertise to community preceptors that students can now add value in the clinical setting by assisting with documentation in the EHR.

Purpose: Although burnout is associated with erosion of professionalism and serious personal consequences, whether positive mental health can enhance professionalism and how it shapes personal experience remain poorly understood. The study simultaneously explores the relationship between positive mental health and burnout with professionalism and personal experience., Method: The authors surveyed 4,400 medical students at seven U.S. medical schools in 2009 to assess mental health (categorized as languishing, moderate, and flourishing) and burnout. Additional items explored professional behaviors, beliefs, suicidal ideation, and serious thoughts of dropping out., Results: A total of 2,682/4,400 (61%) responded. Prevalence of suicidal ideation (55/114 [48.2%], 281/1,128 [24.9%], and 127/1,409 [9.1%]) and serious thoughts of dropping out (15/114 [13.2%], 30/1,128 [2.7%], and 14/1,409 [1.0%]) decreased as mental health improved from languishing, moderate, and flourishing, respectively (all P < .0001); this relationship between personal experience and mental health persisted independent of burnout (all P < .001). As mental health improved, the prevalence of unprofessional behaviors (i.e., cheating and dishonest behaviors) also declined, whereas students' altruistic beliefs regarding physicians' responsibility toward society improved. For example, 33/113 (29.2%), 426/1,120 (38.0%), and 718/1,391 (51.6%) of students with languishing, moderate, and flourishing mental health endorsed all five altruistic professional beliefs (P < .0001). The relationship between professional beliefs and mental health persisted among students with burnout, whereas fewer relationships were found among students without burnout., Conclusions: Findings suggest that positive mental health attenuates some adverse consequences of burnout. Medical student wellness programs should aspire to prevent burnout and promote mental health.

Purpose: Psychological distress is common among medical students. Curriculum structure and grading scales are modifiable learning environment factors that may influence student well-being. The authors sought to examine relationships among curriculum structures, grading scales, and student well-being., Method: The authors surveyed 2,056 first- and second-year medical students at seven U.S. medical schools in 2007. They used the Perceived Stress Scale, Maslach Burnout Inventory, and Medical Outcomes Study Short Form (SF-8) to measure stress, burnout, and quality of life, respectively. They measured curriculum structure using hours spent in didactic, clinical, and testing experiences. Grading scales were categorized as two categories (pass/fail) versus three or more categories (e.g., honors/pass/fail)., Results: Of the 2,056 students, 1,192 (58%) responded. In multivariate analyses, students in schools using grading scales with three or more categories had higher levels of stress (beta 2.65; 95% CI 1.54-3.76, P<.0001), emotional exhaustion (beta 5.35; 95% CI 3.34-7.37, P<.0001), and depersonalization (beta 1.36; 95% CI 0.53-2.19, P=.001) and were more likely to have burnout (OR 2.17; 95% CI 1.41-3.35, P=.0005) and to have seriously considered dropping out of school (OR 2.24; 95% CI 1.54-3.27, P<.0001) compared with students in schools using pass/fail grading. There were no relationships between time spent in didactic and clinical experiences and well-being., Conclusions: How students are evaluated has a greater impact than other aspects of curriculum structure on their well-being. Curricular reform intended to enhance student well-being should incorporate pass/fail grading.

Context: The relationship between professionalism and distress among medical students is unknown., Objective: To determine the relationship between measures of professionalism and burnout among US medical students., Design, Setting, and Participants: Cross-sectional survey of all medical students attending 7 US medical schools (overall response rate, 2682/4400 [61%]) in the spring of 2009. The survey included the Maslach Burnout Inventory (MBI), the PRIME-MD depression screening instrument, and the SF-8 quality of life (QOL) assessment tool, as well as items exploring students' personal engagement in unprofessional conduct, understanding of appropriate relationships with industry, and attitudes regarding physicians' responsibility to society., Main Outcome Measures: Frequency of self-reported cheating/dishonest behaviors, understanding of appropriate relationships with industry as defined by American Medical Association policy, attitudes about physicians' responsibility to society, and the relationship of these dimensions of professionalism to burnout, symptoms of depression, and QOL., Results: Of the students who responded to all the MBI items, 1354 of 2566 (52.8%) had burnout. Cheating/dishonest academic behaviors were rare (endorsed by <10%) in comparison to unprofessional conduct related to patient care (endorsed by up to 43%). Only 14% (362/2531) of students had opinions on relationships with industry consistent with guidelines for 6 scenarios. Students with burnout were more likely to report engaging in 1 or more unprofessional behaviors than those without burnout (35.0% vs 21.9%; odds ratio [OR], 1.89; 95% confidence interval [CI], 1.59-2.24). Students with burnout were also less likely to report holding altruistic views regarding physicians' responsibility to society. For example, students with burnout were less likely to want to provide care for the medically underserved than those without burnout (79.3% vs 85.0%; OR, 0.68; 95% CI, 0.55-0.83). After multivariable analysis adjusting for personal and professional characteristics, burnout was the only aspect of distress independently associated with reporting 1 or more unprofessional behaviors (OR, 1.76; 95% CI, 1.45-2.13) or holding at least 1 less altruistic view regarding physicians' responsibility to society (OR, 1.65; 95% CI, 1.35-2.01)., Conclusion: Burnout was associated with self-reported unprofessional conduct and less altruistic professional values among medical students at 7 US schools.

Background: Little is known about the training experience of minority medical students. We explore differences in the prevalence of burnout, depressive symptoms, and quality of life (QOL) among minority and nonminority medical students as well as the role race/ethnicity plays in students' experiences., Methods: Medical students (N = 3080) at 5 medical schools were surveyed in 2006 using validated instruments to assess burnout, depression, and QOL. Students were also asked about the impact of race/ethnicity on their training experience., Results: The response rate was 55%. Nearly half of students reported burnout (47%) and depressive symptoms (49%). Mental QOL scores were lower among students than among the age-matched general population (43.1 vs 47.2; P < .001). Prevalence of depressive symptoms was similar regardless of minority status, but more nonminority students had burnout (39% vs 33%; P < .03). Minority students were more likely to report that their race/ethnicity had adversely affected their medical school experience (11% vs 2%; P < .001) and cited racial discrimination, racial prejudice, feelings of isolation, and different cultural expectations as causes. Minority students reporting such experiences were more likely to have burnout, depressive symptoms, and low mental QOL scores than were minority students without such experiences (all P < .05)., Conclusions: Symptoms of distress are prevalent among medical students. While minorities appear to be at lower risk for burnout than nonminority students, race does contribute to the distress minority students do experience. Additional studies are needed to define the causes of these perceptions and to improve the learning climate for all students.

Purpose: To compare how different institutional review boards (IRBs) process and evaluate the same multiinstitutional educational research proposal of medical students' quality of life., Method: Prospective collection in 2005 of key variables regarding the IRB submission and review process of the same educational research proposal involving medical students, which was submitted to six IRBs, each associated with a different medical school., Results: Four IRBs determined the protocol was appropriate for expedited review, and the remaining two required full review. Substantial variation existed in the time to review the protocol by an IRB administrator/IRB member (range 1-101 days) and by the IRB committee (range 6-115 days). One IRB committee approved the study as written. The remaining five IRB committees had a median of 13 requests for additional information/changes to the protocol. Sixty-eight percent of requests (36 of 53) pertained to the informed consent letter; one third (12 of 36) of these requests were unique modifications requested by one IRB but not the others. Although five IRB committees approved the survey after a median of 47 days (range 6-73), one committee had not responded six months after submission (164 days), preventing that school from participating., Conclusions: The findings suggest variability in the timeliness and consistency of IRB review of medical education research across institutions that may hinder multi-institutional research and slow evidence-based medical education reform. The findings demonstrate the difficulties of having medical education research reviewed by IRBs, which are typically designed to review clinical trials, and suggest that the review process for medical education research needs reform.