By Glenn Laffel, MD, PhD
Senior Vice President, Clinical Affairs
Practice Fusion

Not too long ago, it seemed safe and reasonable to define health information technology (HIT) narrowly as the management of health information and its secure exchange between patients, providers, and insurers.[1]

For many, the definition effectively compartmentalized HIT. It was for someone else, not me.

That began to change when quality initiatives started forcing physicians to deal with performance data and patients began showing up with reprints of journal articles they hadn’t read themselves.

But nothing could have prepared physicians to handle the flood of HIT that inundates them today, a flood that threatens to sweep away established codes of professional conduct and disrupt the very processes by which care is rendered and doctors communicate with patients.

Consider these examples:

1) Dr. Jain, a medical intern[2] receives a friend request on Facebook from Erica Baxter. As a medical student, Jain helped deliver Baxter’s baby. Is Baxter simply a grateful patient interested in sharing news about her child, or does she have other motives? Jain clicks “confirm,” granting Baxter access to his network of friends, his personal photographs and blog, and the scrawls of others on his wall.

2) Dr. Margolis, a middle-aged pulmonologist, receives 120 emails per day. The assortment reflects her busy life. There’s one from her child who needs a lift at 6:30. Her dentist has an opening for her prophylaxis, and her secretary just added a patient to her afternoon schedule.

And then there are emails from her patients, some of which require immediate attention.

Problem is, Dr. Margolis can’t read all her emails. She has a thousand unread messages in her inbox. She worries that some contain time-sensitive information from patients.

3) Dr. Tapscott, nearing the end of his career in family practice, is convinced by office personnel to adopt an electronic health record (EHR).

But the implementation goes poorly. He can’t get the hang of it and believes it puts a barrier between himself and his patients. Five months and $20,000 later, he ditches the system.

Physicians have faced emerging ethical challenges before. Their struggle to develop professional identities is as old as the profession itself. And this isn’t the first time they’ve have had to incorporate new innovations, but the HIT Deluge multiplies these challenges several fold, and creates myriad new ones, many of which remain vexing even to deep thinkers in the field.

The Impact of EHRs on Medical Education

EHRs are a prime example of this. They have begun an inevitable march into the lives of all physicians, stimulated by the American Recovery and Reinvestment Act, which allocated $21 billion to encourage “meaningful use” of such systems[3].

The Fed’s largesse is based on the premise that EHRs will improve quality and reduce the costs of care, but the move will impact the health care system in other ways as well. One such area is medical education.

What kind of impact can we expect? In some ways, EHRs appear to enhance medical education, but in others, the impact appears to be negative.

Benefits
Two studies suggest that EHRs improve documentation[4] by medical students. In the first, Morrow and Dobbie found that first-year students who used an EHR to document a history recorded more features of pain [5]than those using paper charts.

In another survey of third-year students, Rouf and Chumley showed that 72% reported asking more history questions when prompted by an EHR.

These authors also assert that EHRs make it easier for faculty to give feedback to students[6], track the procedures they perform and store records of interesting cases for future use.

Beyond this, EHR speeds access to the medical literature which should facilitate learning and encourage students to rely on medical evidence.

Risks
EHRs have some negative impact as well, particularly relating to the learning environment and patient-physician communication.

EHRs can disrupt the learning environment by creating shortcuts that threaten the time-honored process by which trainees synthesize patient’s symptoms, signs, and lab results into a coherent story and present them to senior clinicians for feedback and discussion.

One example of this is the process by which trainees copy and paste chart notes and other information created by others, and send them to supervisors for feedback. This discourages critical thinking by the trainee[7].

The potential negative impact of EHRs on physician-patient communication is particularly acute for medical students who are just finding their voices as professionals. Inserting a terminal into the middle of a student’s session with a patient adds complexity to the interaction, might reduce eye contact and stilt the conversation, and prevent her from seeing how her words and body language affect her patients.

Tweaking Medical Education to Leverage EHR Benefits

As these issues show, the quality-improving, cost-reducing benefits of EHRs can only be realized by aligning multiple systems and user-based factors. Educators can begin the alignment in three ways:

Begin EHR Education Early
The process should begin in Year 1. Non-science oriented courses like “Introduction to the Patient,” present ideal opportunities to introduce the medium.

If students master EHR skills before their clinical rotations, they can focus the latter time on traditional learning exercises, such as clinical reasoning, diagnosis and so on.

What to Teach
Students should be taught how to use basic EHR functions like order entry, lab look-up, messaging and charting. This exposure should occur away from patients so students can focus on the EHR itself.

They should also be exposed to the nuances of physician–patient communication in the presence of an EHR. Specific communication techniques include:

-        adjusting the spacing between patient, physician and computer so the patient can see what the physician is doing on the computer,

-        encouraging the physician to walk-through data on the screen with patients,

-        spending no more than 30 seconds at a time typing into the computer,

-        making eye contact with the patient; assessing the patient’s emotional status and understanding of the information provided

Don’t Forget Faculty
Most medical school faculty have received no EHR training, yet until they become facile, they can’t be good role models for students. This topic is beyond the scope of this article.

Social Media: Disruptive Force in Medicine

In medicine, social media including Facebook, Twitter, YouTube, blogs and virtual physician communities has grown explosively.

Enterprising providers have deployed sophisticated social media strategies to extend their brand around the world. The Mayo Clinic, for example, maintains several blogs[8], a Facebook fan page[9] (which has 8,800 fans), a library of YouTube videos and a Twitter stream[10] (7,120 followers)[11].

Many physicians also leverage social media to help patients access support networks, a heretofore difficult undertaking for homebound or geographically isolated patients, or those with rare diseases.[12]

But social media also creates challenges for physicians.

In some ways, the challenges are most acute for the youngest physicians, who grew up with Facebook. Unlike their counterparts, they are familiar with social media, but some have become ensnared by it.

Thousands of young physicians have created personal social histories and exposed them on Facebook. Their challenge is to manage this archive while forging identities as professionals.

A study by Thompson and colleagues the University of Florida sheds light on the challenge. They found that of the 44% of students at the UF Medical School who maintained Facebook profiles, only 37% made their entries private. More than half shared information regarding their sexual orientation, while 58% shared their relationship status and half shared political opinions.

A closer inspection of the profiles of 10 randomly-selected medical students revealed that 7 included photos showing them drinking alcohol. Five of these implied excessive drinking. Three students had joined groups that were flagrantly sexist (“Physicians looking for trophy wives in training”) or racially charged (“I should have gone to a blacker college”).[13]

The boundary-blurring effects of social media extend in every direction since medical students, nurses, housestaff, fellows and faculty are linked[14], and the chain is only as strong as its weakest link.

What has been done to mitigate risks associated with social media?

Many have issued warnings. “Caution is recommended,” wrote Jules Dienstag in an email to Harvard medical students. The Dean for Medical Education explained that when “using social networking sites such as Facebook…items that represent unprofessional behavior that are posted by you reflect poorly on you and the medical profession. Such items may become public and could subject you to unintended consequences.”

Similarly, Drexel University College of Medicine warned students that information on social-networking sites can impact decision making regarding their applications to residency programs[15].

Warnings like these are analogous to a “Dangerous Rip-Currents” sign at the beach. By the time people read it, they have arrived in wet suits, having driven an hour to get there.

Some believe the challenges posed by social media are large enough to warrant promulgation of guidelines for its use in health care, modeled after AMIA’s “Guidelines for the Use of Electronic Mail with Patients” which were published just as providers began relying on that medium.[16]

Such an approach begs questions like who has the authority to issue such guidelines, or whether they could impact behavior without an associated means for enforcement. And since no one believes that social media utilization in healthcare should be regulated, the alternative is to modify medical school curricula and beef-up CME.

With social media, the genie is out of the bottle.

Innovations That Make a Difference

Even though EHRs and social media have had a large impact on medicine, it does not necessarily follow that medical education should be modified to account for them.

After all, thousands of technologies have disseminated into the mainstream; medicine accommodates them organically.

To some extent, this is happening with social media. In the Florida study of Facebook utilization for example[17], 64% of medical students were found to have fully public Facebook accounts, whereas only 12% of residents did.

It’s also true that finding space to teach HIT in a packed medical school curriculum means subtracting time from something else.

Still, we argue that the HIT Deluge presents unprecedented challenges to patient-physician communication and while blurring social boundaries in ways that generate ethical challenges and legal risks that cannot be ignored.

Medical schools including Harvard, Stanford, Vanderbilt and UCSF approach the conundrum by offering elective courses in HIT, often in conjunction with other graduate schools.

HST.921, “Information Technology in the Health Care System of the Future,”[18] is an example. The course is open to all graduate students at Harvard and MIT, including those at Harvard Medical School.

In it, students learn how HIT improves health care quality and provides new options for patient education and self-care.

Florida State University College of Medicine, one of the nation’s newest medical schools, has taken a more aggressive approach. Bypassing the above-mentioned incremental approach, its  Internet-age curriculum has HIT woven into its fabric.

FSU students receive laptops upon arrival. Their textbooks are on line. During orientation and first semester, they learn to access library resources on line and gain exposure to decision support tools.

In the second semester, they receive PDAs and learn how to carry out literature reviews and manage bibliographies on line.

In their fourth semester, FSU students learn to use SOAPware, a laptop-supportable EHR. During their third year, they use SOAPWare during supervised patient encounters and receive feedback from supervising physicians.

And what about all the physicians who graduated medical school years ago and have had no HIT education whatsoever? That’s where Russ Cucina, an associate medical director of IT at UCSF plays a vital role. Cucina, you see, teaches a CME class called, “Blogs, Tweets, and Facebook: What the Hospital and Medical Administrator Needs to Know.”

We hear it’s filling up fast.

[2] http://content.nejm.org/cgi/content/full/361/7/649?ijkey=Tarf0DE9052Gc&keytype=ref&siteid=nejm

[3] http://www.ehrbloggers.com/2009/07/meaningful-use-take-ii.html

[4] http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000069

[5] http://www.stfm.org/fmhub/fm2008/July/Heidi462.pdf

[6] http://www.biomedcentral.com/bmcmededuc/

[7] http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000069

[8] http://www.mayoclinic.org/blogs/index.html

[9] http://www.facebook.com/pages/Mayo-Clinic/7673082516

[10] http://twitter.com/mayoclinic

[11] http://www.informationweek.com/news/healthcare/patient/showArticle.jhtml?articleID=219200127

[12] http://www.nytimes.com/2009/06/11/health/11chen.html?_r=1

[13] http://news.ufl.edu/2008/07/10/facebook/

[14] http://content.nejm.org/cgi/content/full/361/7/649?ijkey=Tarf0DE9052Gc&keytype=ref&siteid=nejm

[15] ibid

[16] http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=9452989

[17] http://news.ufl.edu/2008/07/10/facebook/

[18] http://www.hst921.org/home/

Glenn Laffel is Senior Vice President of Clinical Affairs for Practice Fusion.  Practice Fusion addresses the complexities and critical needs of today’s healthcare environment by providing a free, web-based Electronic Health Record (EHR) application to physicians.

Authors of The Successful Match: 200 Rules to Succeed in the Residency Match and 250 Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them

“I saw his drunk photos on MySpace, and he just strikes me as immature. Do you think that matters?” “I don’t know, but we have 30 other great applicants here to choose from.”

“She’s a member of the Facebook group, ‘Medical Students Behaving Badly.’  I don’t think that’s someone we should bring in as a resident.”

Applying for residency, as every applicant knows, is a long, complex process, and understandably so. Residency selection committees use every tool at their disposal to compare applicants. Would programs use internet search engines and social networking sites, such as Facebook and MySpace, to screen applicants?

No studies examining this issue as it pertains to the residency application process have been published. However, there is data available from other fields. In the business world, employers are increasingly using social networking sites to learn more about potential hires:

• In a recent CareerBuilder.com survey of 3,169 hiring managers, 22% used social networking profiles to screen potential hires.¹
• Α Vault.com survey found that 44% of employers reported looking up potential hires on social networking sites.²
• According to the executive search firm ExecuNet, 77% of recruiters surveyed used the Web to screen applicants.³

How did the information discovered affect hiring decisions?  In the CareerBuilder.com survey, 34% of managers who used these sites in the screening process reported dropping candidates from consideration based on the content found.  Most concerning for these hiring managers were candidates posting information about alcohol or drug use, followed closely by posting of inappropriate photographs or information.  Less commonly cited, but still areas of concern, were poor communication skills and discriminatory comments related to race, religion, or gender.  Even an unprofessional screen name, while seemingly much more innocuous, raised concern for some managers.

In a recent study published in the Journal of General Internal Medicine, researchers at a major medical school in the Southeastern U.S. evaluated the Facebook profiles of all students at their institution.⁴ Of the 501 medical student participants in the study, 64.3% had Facebook accounts.  In an analysis of these profiles, the authors found the following:

•    Forty percent joined online groups.  While most groups were benign in nature, some groups raised concern, including those with the names “Party of important male physicians,” “Keep your f***ing hand down in lecture and shut the f*** up,” and “I should have gone to a blacker college.”
•    When a random subset of students was examined more closely, 70% were found to have photographs with alcohol, with a substantial number showing excessive drinking.
•    Some profiles contained unprofessional comments, involving foul language, overt sexuality, and patient privacy violations.

While students maintain that their personal profiles were never meant to be viewed by anyone other than their friends, the reality is that anything placed in a publicly available profile may be viewed by programs and used in the selection process.  As stated by the Student Affairs Office at the Drexel University College of Medicine, “programs/employers are increasingly gaining access to social networking sites such as Facebook and MySpace to see what they can learn about candidates…”⁵

Social networking sites often allow users to restrict access to their profiles.  While students often realize this, many users fail to activate these privacy features.  In the aforementioned study of medical students, 62.7% kept their Facebook account public.  Even when a profile is restricted, however, there are ways around privacy guards.  For example, a member of the residency selection committee who is a graduate of your college or medical school, can create a profile using an alumni email address.  In doing so, he can acquire access to current students at that institution.  In this way, he can circumvent the privacy guards in place at social networking sites such as Facebook.

Some students argue that their online personality is different from their professional personality.  Therefore, no conclusions or assumptions should be drawn from the content posted.  It is currently true that research examining the predictive value of posted content on social networking sites as it relates to on-the-job behavior or performance is not available. However, that’s not likely to stop a program director from making judgments about you based on your personal profile.

In selecting candidates, programs are searching for those who will succeed as residents and, later, as practicing physicians.  They also seek to avoid problem residents, defined as “trainees who demonstrate a significant enough problem that requires intervention by someone of authority, usually the program director or chief resident.”⁶ When Yao looked at reasons why certain residents were considered “problem residents,” among the deficiencies reported were inappropriate interaction with colleagues or staff, unsatisfactory humanistic behavior with patients, and unacceptable moral or unethical behaviors.⁷

Studies have shown that behavioral and noncognitive traits and skills have significant value in predicting resident performance.  However, programs are limited in how they can assess these skills.  The use of social networking sites may provide additional information about potential residents not found in traditional application components (i.e., curriculum vitae, letters of recommendation, MSPE, personal statement, transcript, interview).

In justifying their actions for use of this information, programs may maintain that unprofessionalism displayed at social networking sites may be a harbinger of future unprofessionalism during or after residency.  In a retrospective study done by Dr. Papadakis, associate dean of student affairs at the UCSF School of Medicine, researchers searched for warning signs during medical school associated with an increased risk for disciplinary action later as a physician.⁸ They found that “disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school.”

Since programs are free to use whatever tools are at their disposal for the evaluation of residency applicants, we recommend that you view social networking sites as yet another tool.  Even with privacy guards in place, there are ways to circumvent restrictions.  Therefore, we recommend a preemptive stance or approach to keep your online persona clean.  We recommend the following:

•    Google yourself regularly to ensure that troublesome or offensive material does not appear online.
•    Employ whatever privacy guards or blocking tools are offered by your social networking site.
•    Closely review your posted materials (i.e., comments, photos, membership in groups) to ensure you are displaying the professionalism expected in a future resident and doctor.
•    As you examine your online persona, consider your audience.  You and your friends may feel that the content is relatively normal or harmless, but faculty members and program directors may have a completely different viewpoint.
•    Remove any material, including photographs and text, that may be considered inappropriate.
•    If you cannot remove the information, politely contact the company or person who owns the site and request its removal.
•    If the information cannot be removed, be prepared to discuss it should the issue be raised during an interview.
•    Consider creating profiles at professional networking sites such as LinkedIn.  Such sites tend to be ranked highly by internet search engines and profiles placed at these sites may be displayed first on an internet search of your name.

Finally, we agree with the recommendations of Brittany Warwick, in her SDN article “Keep Your Online Persona Clean.”⁹ She recommends using “your online presence to advertise your good qualities.  You can post information about your leadership, maturity, growth, and potential.”  An online persona conveying a professional image may solidify a program’s decision to interview or even rank you favorably.

References

1. Available at www.CareerBuilder.com
2. Available at www.Vault.com
3. Available at www.ExecuNet.com
4. Thompson, LA, Dawson K, Ferdig R, Black EW, Boyer J, CouttsJ, Black NP.  The intersection of online social networking with medical professionalism.  J Gen Intern Med 2008; 23 (7): 954 – 957.
5. http://webcampus.drexelmed.edu/osa/careeradvising/interview.asp
6. American Board of Internal Medicine.  In:  Materials from Association of Program Directors in Internal Medicine (APDIM)’s Chief Residents’ Workshop on Problem Residents; April 19, 1999; New Orleans, LA.
7. Yao DC, Wright SM.  National survey of internal medicine residency program directors regarding problem residents.  JAMA 2000; 284 (9): 1099 – 1104.
8. Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND.  Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board.  Teach Learn Med 2007; 79 (3): 244 – 249.
9. Warwick, B.  Keep your online persona clean.  Available at www.studentdoctor.net.

Authors of The Successful Match: 200 Rules to Succeed in the Residency Match and 250 Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them

In researching our book, we asked applicants what they found most difficult about the residency application process. A number of applicants commented on the same issue. “There’s so much conflicting information out there. How do you know what to believe? Who should you listen to?”

Applicants with mentors have a decided advantage. A joint committee of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine described a mentor as “someone who takes a special interest in helping another person develop into a successful professional.”¹ In defining the term, the committee described a fundamental difference between mentoring and advising. “Mentoring is a personal, as well as, professional relationship. An adviser might or might not be a mentor, depending on the quality of the relationship.” While the two terms are not synonymous, for the purposes of this column, we will use them interchangeably.

Mentoring relationships are invaluable. Students benefit greatly when the wisdom, experience, and perspective of a knowledgeable faculty member are used to help them achieve a successful match. Having a mentor to guide you through the complex residency application process is recognized by students as an important factor in boosting the strength of their application. In a survey of third- and fourth-year medical students at UCSF, 96% of all participants rated mentors as important or very important.² Unfortunately, recognizing the value of a mentoring relationship is a far cry from developing such a relationship. Although 96% of the participants rated mentors as important, only 36% actually reported having a mentor.

The value of mentoring is recognized in all fields. The literature in the fields of business, education, and medicine all support its value. Comments made by medical school faculty emphasize the value of a mentoring relationship:

“I had a difficult time learning the rules of the game.”³

“Without a mentor…I had no idea really what to expect from academic medicine. I have been feeling my way through the tunnels because I don’t know where the roadblocks are. I just kind of deal with them when I get there.”³

These words resonated with us, as they mirror the type of comments we hear from applicants. It’s tough to learn the rules of the game when they’re not actually written down anywhere. “I didn’t know you could customize your personal statements for different programs.” “I didn’t know I should have sent an email thank you immediately after the interview, especially since I was planning to send a note later.” Particularly difficult is when you learn the rules of the game too late to make a difference. “I didn’t know that 93% of matched applicants to radiation oncology in the NRMP data from 2007 had reported one or more abstracts, publications, or presentations. I’m in my fourth year now, and it’s probably too late.”⁴

Medical schools have recognized the importance of mentoring and advising students, and have responded with the development of mentoring programs. As would be expected, these programs have differed widely in structure and scope. At schools such as Johns Hopkins and Columbia, highly organized programs have been developed.

At other schools, the mentoring process is much more informal. Students may be given a list of faculty members willing to serve as advisors, and then encouraged to cultivate relationships. As one student in a survey of UCSF students stated, “I create the relationship, and then I follow it. I sort of take the risk.”⁵ Not all students find it so easy. Some have blamed themselves for not being assertive enough to find a mentor. “I just didn’t know how to go about setting myself up for a good thing to happen.”⁵ Others maintained that the problem lies with the system, citing the short duration of courses and clerkships as impediments to developing relationships with faculty.

Finding a potential mentor and developing an effective relationship can be very difficult. Understandably, students often hesitate to burden faculty members who are already clearly very busy. However, while faculty members have many demands placed on their time, there are faculty at every medical school who find mentoring and advising students enjoyable and rewarding. While these individuals are sometimes recognized publicly for their work, it is more typical that they go about their work diligently but quietly. You should make every effort to identify these types of motivated, dedicated individuals. In one study, 28% of students met their mentors during inpatient clerkships, 19% through research activities, and 9% during outpatient clerkships.²

Some students won’t find a mentor through their randomly assigned clerkships and courses. Persistence, courage, and some degree of assertiveness may be necessary. The process may be very informal. You may hear from the residents or your colleagues that Drs. A, B, and C have helped advise many students applying to your field in past years. You may then request that faculty member for a clerkship assignment or research elective. Some may be open to meeting with you. On the other hand, you may be advised to start the process by setting up a meeting with the clerkship director, program director or chairman of the department. The intent of this meeting would be to state that you’re planning to apply to the field of …. From there, the meeting can go in several directions. You can ask for recommendations on potential advisors. You can ask for recommendations on the application process, given the strength of your credentials. You can seek opportunities to work on a case report, to work on a research project, or to arrange a research elective.

Some schools lack residency programs in certain specialties. That poses obvious difficulties for students applying to that specialty. One option would be to seek advisors elsewhere, such as during an audition elective. In addition, local or national organizations may provide assistance. The Society of Academic Emergency Medicine (SAEM) has a medical student virtual advisor program open to students at all institutions. Through this program, students can query experienced individuals about a variety of issues, including the EM residency application process. Recognizing the importance of mentorship, SDN has launched an innovative mentorship program as well.

Finding the right mentor can be difficult. Even when a formal system for assigning mentors exists, this doesn’t necessarily mean that the mentor will be the right fit for the student. Should this happen, you should seek guidance from other faculty members. Few mentors have the answers to every question, and it is often to your advantage to have several opinions on certain issues.

As you consider possible mentors, you should be aware of problems that can occur in the advisor-advisee relationship. Chief among these is the potential conflict of interest that can occur with a mentor who advises a student and also serves on the residency selection committee at a program affiliated with the student’s medical school. In a survey of 740 graduating medical students from 10 U.S. medical schools, Miller found that nearly half met with their advisors during or following the interview season.6 The results indicated that:

· 31.8% were encouraged to rank the advisor’s program highly.
· 10.3% were asked which programs they planned to rank highly.
· 4% were asked how they planned to rank the advisor’s program.

Not surprisingly, students reported varying degrees of discomfort from these queries. One respondent stated that “it felt very uncomfortable to talk to him about my own strengths and weaknesses and about which programs I preferred knowing that he would later be evaluating me in comparison with many other applicants and deciding whether or not to advocate for me to be accepted.” Faced with such dilemmas, some students felt pressured to make misleading statements. Miller went on to raise some important questions. “What is safe for applicants to tell their advisors? Can applicants be sure that their advisors will put their interests first in these situations?” You need to consider how you would respond to these types of queries, since you may be placed in a similar situation.

Studies on medical students, mentoring, and the match are sparse. However, our experience has clearly demonstrated that having an effective advisor is invaluable. Mentors can help students with career decisions, evaluate potential residency programs, review curriculum vitas and personal statements, write letters of recommendation, and conduct mock interviews. Since faculty members often sit on residency selection committees, many can offer the type of insight into the selection process that is not available elsewhere. By analyzing and comparing your credentials with previous years’ students who have matched, specialty-specific advisors can identify specific ways in which you can strengthen your application. They can work with you to develop an overall strategy for success. Applicants should work hard to identify potential mentors, since these relationships can be invaluable in ensuring a successful match.

References

¹Adviser, teacher, role model, friend. (http://stills.nap.edu/readingroom/books/mentor). Accessed 3/13/08. Washington, DC: National Academy Press; 1997.

²Aagaard EM, Hauer KE. A cross-sectional descriptive study of mentoring relationships formed by medical students. J Gen Intern Med 2003; 18: 298-302.

³Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui, T. “Having the right chemistry”: a qualitative study of mentoring in academic medicine. Acad Med 2003; 78(3): 328-334.

⁴Charting outcomes in the match: characteristics of applicants who matched to their preferred specialty in the 2007 NRMP main residency match. (www.nrmp.org/data/chartingoutcomes2007.pdf ). Accessed 3/20/08. Washington, DC: National Resident Matching Program; 2007.

⁵Hauer KE, Teherani A, Dechet A, Aagaard EM. Medical students’ perceptions of mentoring: a focus-group analysis. Med Teach 2005; 27(8): 732-734.

⁶Miller JB, Schaad DC, Crittenden RA, Oriol NE. The departmental advisor’s effect on medical students’ confidence when the advisor evaluates or recruits for their own program during the match. Teach Learn Med 2004; 16(3): 290-295.

Authors of The Successful Match: 200 Rules to Succeed in the Residency Match and 250 Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them

Every aspiring physician knows the importance of memorization, especially in the basic science years. As you advance in your career, however, communication skills come to the forefront. Physicians with poor communication skills are more likely to be sued. (Virshup) They are more likely to be disciplined by the medical board. They may not receive as many professional referrals from colleagues or word-of-mouth referrals from patients.

Successful communication requires establishing a connection and imparting a message. Successful patient care does not end with gathering data from your patient. It revolves around imparting that information to the entire team that is involved in patient care: your team members, the consulting physicians, the nurses, the patient and family members, and even the cafeteria, among others. (“The patient’s allergies include a history of anaphylaxis to shrimp.”)

Third year students, in the midst of early clinical rotations, quickly recognize the importance of communication. Memorization may be a crucial skill for those taking exams and receiving grades based on an objective test score. However, when receiving a subjective grade based on your ability to take care of patients, one’s ability to communicate with patients, to establish rapport with colleagues, and to impart medical information, become important indicators of communication skills.

How exactly do medical schools determine a student’s ability to provide excellent patient care? A student’s grade in core clinical rotations is determined by several factors, including subjective ratings and objective test scores. One study examined the evaluation techniques of 97 US medical schools. (Kassebaum) Faculty and resident ratings accounted for 50-70% of a student’s grade in core clinical rotations.

How do faculty and residents arrive at their subjective rating of a student’s abilities? Clerkship evaluation forms ask faculty to rate students on specific skills, such as a student’s ability to take a history and perform a physical examination. However, attending physicians rarely or infrequently observe students in these areas. In fact, in a survey of 322 University of Virginia medical students at the end of their third year, 51% reported never having a faculty member observe them while taking a history; 81% had never been observed performing a complete physical exam. (Howley) Therefore, many faculty draw conclusions about a student’s ability in these areas from the quality of the oral case presentation.

In a study of surgical faculty, Pulito found that it was rare for faculty members to directly observe a student taking a history or doing a physical examination. (Pulito) In fact, only one of nine faculty members surveyed had done so. Despite this, five of the nine faculty participants rated students in this area. They inferred the rating of this characteristic from other factors, particularly the oral case presentation. Pulito wrote that “in the clinic setting, for example, if a student presents a patient to an attending and is verbally facile, succinctly describing a focused history and physical examination, the inference may be drawn that the student expeditiously obtained the relevant history and performed an appropriate examination.”

In one study focusing on communication apprehension among medical students starting a surgery rotation, Lang wrote that “much of a student or resident’s evaluation is based on oral presentations.” (Lang) In another study assessing student performance on a pediatrics clerkship, Greenberg found “a highly significant relationship between students receiving a final grade of honors and an ‘A’ on their case grade.” (Greenberg)

In oral case presentations, students aim to effectively transfer important clinical information between team members. When done well, these presentations facilitate patient care, improve team efficiency, and become a valuable learning experience. Since they also serve an evaluative function, students hope to deliver high-quality presentations to prove their competence. While some students are inherently gifted in the area of making presentations, all would benefit from practice and the following suggestions:

• Expectations for the oral case presentation vary from clerkship to clerkship, attending to attending, and resident to resident. For this reason, always meet with your attending and resident on the first day or two of the clerkship to ascertain their expectations.

• Your goal is to leave this discussion knowing the attending or resident’s personal preferences (preferably before your first presentation). Ask specific questions about time limits, the order in which to present information, and so on. “Do you want me to report the entire physical exam or just pertinent positives?” “Which labs would you like to hear, or would you prefer to hear all of them?”

• What worked well with one attending or resident may not work well with another. You may have internalized a certain set of “presentation rules.” With the start of a new clerkship or arrival of a new attending, recognize that these rules may not meet their needs.

• Be aware of the context in which you are presenting. Your presentation to a resident with whom you evaluated the patient should be different than the presentation given to an attending who is hearing about the patient for the first time.

• Make your presentation flow like a story. Your goal, many times, is to make an argument for a particular condition. Put the details of the case together in such a way as to lead the listener to a diagnosis.

• As a novice clinician, your inexperience makes it difficult to decide what to include and what to leave out. The easy way out, and the route that many students take, is to simply read the written H & P word for word. However, the oral case presentation should be a carefully edited version of the written record. The key is to communicate only what’s relevant. For a new clerk, that can be very difficult. Don’t be afraid to ask for help in this area.

• Use residents as a resource. Residents are often familiar with attending preferences and can help polish your presentation before you have to deliver it to the attending.

• Seek feedback after each and every one of your presentations. The best feedback is that which is explicit and timely. Many attendings won’t automatically provide feedback; you may have to specifically ask for it. “Dr. So, do you have any suggestions on how I can improve my presentation?”

• Uncertainty is normal with oral case presentations. Because of the evaluative function of these presentations, it can be tempting to bluff or lie in an effort to look good. As hard as it can be to say “I don’t know,” honesty and accuracy in the transfer of clinical information is vital to patient care. In a survey of Johns Hopkins medical students, 13% to 24% admitted to cheating during the clinical years of medical school. (Dans) Examples included “recording tasks not performed” and “lying about having ordered tests.”

• Projecting confidence is important. Your choice of words, the manner in which you speak, and your body language are all factors that will be used to judge the quality of your presentation.

• It is rare to present a patient without any interruptions. In one study of emergency medicine faculty and students, the mean number of interruptions was 2.49 per oral case presentation. (Yang) Although students often view interruptions as a sign that their presentation is lacking, this is often not the case. Attendings find it difficult to balance the need to teach with the need to care for a service full of sick patients. In addition to interruptions due to time constraints, you may be asked to repeat information or clarify a certain point. Unfortunately, many students let interruptions derail their presentation, and find they can’t recover.

• Many students stop short of offering an assessment and plan, especially novice clinicians who don’t feel qualified to do so. Always offer your own assessment and plan. Attending physicians are impressed with students who take the initiative to do so.

• Read extensively about your patients’ problems using a variety of resources, including handbooks, specialty textbooks, and the recent literature. As you read, make it a habit to ask “why?” Why did we order this test? Why did we choose this particular antibiotic? Such questions further your understanding of the disease – not to mention prepare you for the attending questions that are sure to come during or following your presentation.

Because of the complexity of the oral case presentation and the varied needs and expectations of residents and attendings, delivering high-quality presentations can be difficult. Is it worth the effort? Absolutely. First, presentation quality is a major factor used in the evaluation of students. Second, the development and acquisition of communication skills is important for your future career as a physician. That’s precisely why, in recent years, organizations such as the Association of American Medical Colleges (AAMC), Clerkship Directors of Internal Medicine (CDIM), and the Accreditation Council for Graduate Medical Education (ACGME) have emphasized its importance. In fact, the AAMC considers the development and acquisition of communication skills a core learning objective for medical students.

Communication skills remain important at every stage of your career. For fourth year students, currently in the process of submitting applications and awaiting invitations to interview, communication skills take on renewed importance. A successful interview requires establishing a connection with the interviewer and imparting a message about your strengths and abilities, a topic we will review in our next column.

REFERENCES

Virshup BB, Oppenberg AA, Coleman MM. Strategic risk management: reducing malpractice claims through more effective patient-doctor communication. Am J Med Qual 1999; 14(4): 153-9.

Kassebaum DG, Eaglen RH. Shortcomings in the evaluation of students’ clinical skills and behaviors in medical school. Acad Med 1999; 74(7): 942-9.

Howley LD, Wilson LG. Direct observation of students during clerkship rotations: a multiyear descriptive study. Acad Med 2004; 79 (3): 276-280.

Pulito AR, Donnelly MB, Plymale M, Mentzer RM Jr. What do faculty observe of medical students’ clinical performance. Teach Learn Med 2006; 18(2): 99-104.

Lang NP, Rowland-Morin PA, Coe N. Identification of communication apprehension in medical students starting a surgery rotation. Am J Surg 1998; 176 (1): 41-45.

Greenberg LW, Getson PR. Assessing student performance on a pediatric clerkship. Arch Pediatr Adolesc Med 1996; 150 (11): 1209-1212.

Dans P. Self-reported cheating by students at one medical school. Acad Med 1996; 71 (1 Suppl): 70-72.

Yang G, Chin R. Assessment of teacher interruptions on learners during oral case presentations. Acad Emerg Med 2007; 14 (6): 521-525.

Authors of The Successful Match: 200 Rules to Succeed in the Residency Match and 250 Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them

Which of the following is the most important academic criterion used by program directors to select residents?

A) USMLE step 1 score
B) USMLE step 2 CK score
C) Pre-clinical course grades
D) Third-year clerkship grades
E) Membership in Alpha Omega Alpha (AOA)

In our own surveys, we have found that students almost always answer this question incorrectly. Students generally base their answer on information gathered from classmates, upperclassmen, residents, and discussion forums, among others. These are all useful sources of information. The ideal way to answer this question, though, would be to discuss it with those individuals directly involved in the residency selection process—in particular, program directors in your chosen field. Ideally, this should be done early in your medical school education. With this knowledge in hand, you can make the most of your opportunities, placing yourself in a position to succeed and match with the specialty or program of your choice.

Fortunately, others have done this work and published their findings. A survey of approximately 800 program directors was performed by Dr. Wagoner, the former dean of students at the University of Chicago Pritzker School of Medicine. These program directors represented 14 specialties, and were surveyed about the importance of various academic criteria used in the selection of residents.¹ Dr. Wagoner and her colleagues learned that grades in required clerkships are the most important academic criteria used to select residents.

At most schools, required or core clerkships include internal medicine, pediatrics, psychiatry, surgery, obstetrics/gynecology, and family medicine.Most medical students are surprised to learn that grades in required clerkships are ranked higher in importance than USMLE scores. In our inaugural column, we presented data from a survey showing that 44% of students from three U.S. medical schools perceived required third-year clerkship grades as moderately, mildly, or not at all important in the residency selection process.²

While many reasons exist for this disconnect between the perceived and actual importance of clerkship grades, we know that this can impact students’ efforts and attitudes during rotations.

As this article goes to press, we recognize that thousands of students across the country have begun, or are about to begin, their third year of medical school. Put simply, your performance this academic year can make or break your chances of a successful match.

• Grades in required clerkships are the most important academic criteria used to select residents.
• “Number of honors clerkship grades” was the second most important academic criteria used to select residents in the most competitive specialties.
• Clerkship grades are the major determinant of class rank. The most competitive specialties rate class rank among the three most important selection criteria.
• Clerkship grades are a major factor used by schools in electing students to the Alpha Omega Alpha Honor Medical Society (AOA). Election to AOA is highly valued by many competitive specialties. In some programs, and in some specialties such as dermatology, membership in AOA is used as a screening tool to determine which applicants are even considered for interviews.
• Comments made by attending physicians on the clerkship evaluation form find their way, often verbatim, into the Medical Student Performance Evaluation (MSPE). The MSPE, formerly known as the Dean’s letter, is often scrutinized closely by residency programs.
• Clerkship performance and grades are important in securing strong letters of recommendation. In competitive residencies where many applicants have excelled academically, letters of recommendation take on additional importance.

We present one final question: Which of the following is the most important academic criterion used by ophthalmology program directors to select residents?

A) USMLE step 1 score
B) Alpha Omega Alpha
C) USMLE step 2 CK score
D) Grades in required third-year clerkships
E) Grades in the ophthalmology clerkship

If you selected choice D, congratulations. The correct answer is indeed “grades in required third-year clerkships.” In the Wagoner study, 46 ophthalmology program directors were surveyed. Grades in required clerkships and the number of honors grades were ranked higher in importance than grades from ophthalmology electives.

Is this finding surprising? In our experience, all students recognize the importance of grades in their chosen specialty. However, fewer understand the overall importance of grades in required clerkships. A review of various discussion forums reinforces this finding.

In our next column, we’ll discuss the transition between the basic science and clinical years of medical school: what makes the transition such a challenge, and can be done to excel?

References

1. Wagoner NE, Suriano JR. Program directors’ responses to a survey on variables used to select residents in a time of change. Acad Med 1999; 74(1):51-8.

2. Brandenburg S, Kruzick T, Lin CT, Robinson A, and Adams LJ. Residency selection criteria: what medical students perceive as important. Med Educ Online 2005; 10:17.

The discussion thread for this article may be found here: http://forums.studentdoctor.net/showthread.php?p=5328043

Authors of The Successful Match: 200 Rules to Succeed in the Residency Match and 250 Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them

“Where was the career guidance I needed for the past three years? No one sat me down in my first year and told me what it would take to get the career of my choice. Had I been handed a residency application form in my first year, I would have made many decisions differently. I cannot help thinking that my medical school has let me down. I am not going to shine on my residency application, as I had hoped.”

- S. Ellen Morch (Morch SE. Students unprepared for residency applications. CMAJ 1994; 151(9): 1237-8)

Thirteen years have passed since these words were written by a fourth-year medical student, and yet we continue to counsel students who find themselves in the same position. “If only I knew then what I know now” is sadly a common refrain among residency applicants.

As faculty advisors, we have had the opportunity to advise students through all facets of the residency application process. Unfortunately, misperceptions about the criteria involved in this process are shockingly common among students. Conversations with students confirm this fact. Conversations with faculty highlight this issue. Even a review of posted comments on message boards confirms the confusion among students as to what it takes to have a successful match.

This fact was highlighted several years ago when researchers surveyed medical students at the University of Colorado, University of Utah, and Vanderbilt University (Brandenburg S, Kruzick T, Lin CT, Robinson A, and Adams LJ. Residency selection criteria: what medical students perceive as important. Med Educ Online 2005; 10: 17). The aim of the survey was to discern which criteria students felt were important in the residency selection process. Students were asked to rate the importance of various criteria, including clerkship grades, USMLE scores, AOA membership, class rank, letters of recommendation, and published research.

• Although 55.9% of students considered grades in required 3rd year clerkships to be extremely important, 44% felt that these grades were moderately, mildly, or not important at all. In a recent survey of program directors representing the most competitive specialties, grades in required clerkships consistently received the top ranking (Wagoner NE, Suriano JR. Program directors’ responses to a survey on variables used to select residents in a time of change. Acad Med 1999; 74(1): 51-8).
• Only 14.7% of students rated the number of honors grades as extremely important. Program directors considered the total number of honors grades to be one of the three most important factors in considering a candidate.
• 49.3% of students felt that class rank was mildly important or not important at all. However, program directors rated class rank high in importance, following only clerkship grades and the total number of honors grades.

Clearly, there are significant differences in the degree of importance students and program directors attach to these different criteria. These misperceptions have the potential to affect a student’s chances of matching into a particular specialty or residency program.

From our own experiences as students, and in the process of counseling students, we know how difficult, anxiety-provoking, and mysterious the residency selection process is. Combining evidence-based advice from our review of the literature on medical education, along with our own years of experience and discussions with hundreds of students, residents, and faculty colleagues, we hope to clear up these misperceptions. Our goal is to make you a well-informed applicant. A better understanding of the residency selection process can help you develop an approach that maximizes your chances of a successful match into the specialty or residency program of your choice.

We invite you to join us regularly here at sdn for our column – The Successful Match. In our next column, we address the importance of the third year of medical school, specifically clerkship grades.

Samir P. Desai, M.D.

Dr. Samir Desai is a faculty member in the Department of Medicine at the Baylor College of Medicine. He has educated and mentored medical students and residents, work for which he has received teaching awards. As a member of several committees, including the internal medicine residency selection committee and the medical school admissions committee, he has gained considerable insight into the obstacles that prevent students from reaching their academic and professional goals.

His experience and insight led him to write a series of books to help students tackle the challenges of medical school. He is now the author and editor of ten books that together have sold over 80,000 copies worldwide. Most recently, he coauthored the 250 Biggest Mistakes 3rd Year Medical Students Make, a book developed to help students successfully transition into and excel during the third year. Among the other titles he has written are the popular The Residency Match: 101 Biggest Mistakes and the Clinician’s Guide to Laboratory Medicine.

In 2002, he founded md2b.net, a website committed to helping today’s medical student become tomorrow’s doctor. At the site, a variety of resources, including survival guides for each core clerkship, are available to help students tackle the challenges of these rotations.

After completing his residency training in internal medicine at Northwestern University in Chicago, Dr. Desai had the opportunity of serving as chief resident. He received his M.D. degree from Wayne State University School of Medicine in Detroit, graduating first in his class.

Rajani Katta, M.D.

Dr. Rajani Katta is an Associate Professor in the Department of Dermatology at Baylor College of Medicine. She has authored over thirty articles published in scientific journals, and lectured extensively both nationally and locally on dermatology and contact dermatitis to students, residents, and physicians.

She serves as the course director for dermatology in the basic science years, and has served as the clerkship director for the dermatology rotation. She has seen firsthand the difficulties of matching into a competitive specialty such as dermatology, and has witnessed over the past nine years the increasingly difficult match process for dermatology applicants. Most recently, she coauthored the 250 Biggest Mistakes 3rd Year Medical Students Make, a book developed to help students successfully transition into and excel during the third year.

After graduating with honors from Baylor College of Medicine and completing her internship in internal medicine, she completed her dermatology residency at the Northwestern University School of Medicine.

Authors of: 250 Biggest Mistakes 3rd Year Medical Students Make And How to Avoid Them