Transitioning preclinical students into clerkships amidst curricular disruptions from the COVID-19 pandemic

Figures & data

Table 1. Details of the nine cases and relevant EPAs covered

Clerkship	Chief Complaint	1^ary Diagnosis	EPA 1	EPA 2	EPA 3	EPA 4	EPA 5	EPA 6	EPA 7	EPA 10	Sessions	Communication Skills
Medicine	Dyspnea	Anemia	X	X	X	X	X	X	X	X	5	Specialty consultation
Primary Care	New patient visit	Hypertension	X	X	X	X	X	X	X		3	Telemedicine follow-up
Gynecology	Vaginal bleeding	Uterine cancer	X	X	X	X	X	X	X		3	Virtual follow-up
Pediatrics	Fever and cough	Cystic fibrosis	X	X	X	X	X	X	X		3	Family-centered rounds
Neurology	Seizure	Stroke	X	X	X	X	X	X	X	X	3	Specialty consultation
Obstetrics	Vaginal discharge	Premature labor	X	X	X	X	X	X	X	X	3	Oral presentation
Surgery	Abdominal pain	Cholecystitis	X	X	X	X			X		3	Oral examination
Psychiatry	Failure to thrive	Depression	X	X	X	X	X	X	X		3	Family collateral
Critical Care	Hypotension	Sepsis	X	X	X	X	X	X	X	X	3	Goals of care, consultation

Each clerkship was associated with 1 case. Association of American Medical Colleges (AAMC) Core Entrustable Professional Activities (EPAs). EPA 1 = Gather a History and Perform a Physical Examination, EPA 2 = Prioritize a Differential Diagnosis Following a Clinical Encounter, EPA 3 = Recommend and Interpret Common Diagnostic and Screening Tests, EPA 4 = Enter and Discuss Orders and Prescriptions, EPA 5 = Document a Clinical Encounter in the Patient Record, EPA 6 = Provide an Oral Presentation of a Clinical Encounter, EPA 7 = Form Clinical Questions and Retrieve Evidence to Advance Patient Care, EPA 10 = Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management. Full description of each EPA is available at available at https://www.aamc.org/what-we-do/mission-areas/medical-education/cbme/core-epas/publications.

Figure 1. Example of a self-directed learning case with associated assignments. On day 3 of the medicine case, students also simultaneously started working on the primary care case. Abbreviations used: CC = chief complaint, CXR = chest x-ray, ED = emergency department, EKG = electrocardiogram, FH = family history, GI = gastrointestinal, HPI = history of present illness, Labs = laboratory, Meds/All = medications and allergies, PMH = past medical history, PSH = past surgical history, ROS = review of systems, SH = social history

Table 2. Pre and post-course self-efficacy ratings in performing core competencies

Core competencies & EPAs	Baseline	Week	Week 4	Post-Course
EPA 1: Gather a History and Perform a Physical Examination
Q1. I can gather a patient’s history in a hypothesis-driven fashion.	2.65 ± 0.90	3.12 ± 0.90**	3.69 ± 0.77**	3.88 ± 0.57^†
Q2. I can perform a physical examination on a patient.	2.35 ± 0.78	2.60 ± 0.95**	3.53 ± 0.84**	3.70 ± 0.80
Q10. I can effectively preround on a patient during a subsequent visit.	1.68 ± 0.79	2.61 ± 0.90**	3.24 ± 0.84**	3.68 ± 0.89^δ
EPA 2: Prioritize a Differential Diagnosis Following a Clinical Encounter
Q3. I have a systematic framework for approaching patient’s chief complaints.	2.27 ± 0.93	2.85 ± 0.83**	3.51 ± 0.74**	3.60 ± 0.66
Q4. I can use the history and physical examination to prioritize the differential diagnosis.	2.52 ± 0.93	3.17 ± 0.87**	3.69 ± 0.79**	3.70 ± 0.62
EPA 3: Recommend and Interpret Common Diagnostic and Screening Tests
Q5. I can recommend laboratory tests and other diagnostic studies to help arrive at a diagnosis.	2.18 ± 0.83	2.97 ± 0.87**	3.55 ± 0.79**	3.58 ± 0.65
Q6. I can correctly interpret laboratory tests and diagnostic studies and use them to prioritize the differential diagnosis.	2.20 ± 0.78	3.04 ± 0.84**	3.48 ± 0.77**	3.64 ± 0.64
EPA 4: Enter and Discuss Orders and Prescriptions
Q8. I can offer a diagnostic and therapeutic plan of management during a patient encounter.	1.70 ± 0.77	2.69 ± 0.81**	3.29 ± 0.78**	3.33 ± 0.84
EPA 5: Document a Clinical Encounter in the Patient Record
Q7. I can document an interpretive summary and prioritized assessment of a patient encounter.	2.22 ± 0.94	3.09 ± 0.79**	3.64 ± 0.75**	3.77 ± 0.75
Q11. I can write a progress note or subsequent outpatient clinic note.	2.02 ± 0.88	3.19 ± 0.88**	3.69 ± 0.81**	3.77 ± 0.81
EPA 6: Provide an Oral Presentation of a Clinical Encounter
Q9. I can provide an oral presentation of an initial patient encounter.	2.26 ± 0.97	2.92 ± 0.95**	3.63 ± 0.81**	3.79 ± 0.70
Q12. I can call a specialist team for a consultation.	1.37 ± 0.79	2.76 ± 0.91**	3.34 ± 0.82**	3.20 ± 0.92^†
EPA 7: Form Clinical Questions and Retrieve Evidence to Advance Patient Care
Q13. I can explain the plan of care to a patient after an encounter.	2.17 ± 1.04	3.05 ± 0.93**	3.56 ± 0.84**	3.69 ± 0.87
Q14. I can deliver bad news to a patient.	1.54 ± 0.91	2.24 ± 1.07**	3.31 ± 0.98**	3.13 ± 0.95^δ
Q17. I can acknowledge my knowledge gaps and identify resources to fill them.	3.00 ± 0.88	3.75 ± 0.96**	4.11 ± 0.79**	4.24 ± 0.64
EPA 9: Collaborate as a Member of an Interprofessional Team
Q15. I can work collaboratively with other health care professionals in inpatient and outpatient settings.	2.86 ± 1.12	3.43 ± 0.99**	4.09 ± 0.83**	4.21 ± 0.72
Q16. I can work effectively as a team member to solve problems and learn together.	3.28 ± 1.06	3.78 ± 0.90**	4.18 ± 0.78**	4.34 ± 0.67
EPA 13: Identify System Failures and Contribute to a Culture of Safety and Improvement
Q18. I am able to receive feedback from others and use it as an opportunity for growth.	4.16 ± 0.83	4.24 ± 0.65	4.37 ± 0.67*	4.55 ± 0.52
Q19. I can give feedback to others in order to foster their growth.	3.41 ± 0.96	3.81 ± 0.79**	4.02 ± 0.83**	3.98 ± 0.75
Other
Q20. I have strategies to maintain personal wellness that I can use in the coming year.	3.74 ± 0.86	3.92 ± 0.68*	4.04 ± 0.84**	3.93 ± 0.85

Likert scale of self-efficacy (1 = not at all confident, 2 = slightly confident, 3 = somewhat confident, 4 = fairly confident, 5 = very confident). Paired t-tests comparing weeks 2 and 4 versus baseline: *P < 0.05, **P < 0.01 (N ranged between 100–103) and comparing post-course versus week 4: ^†P < 0.05, ^δP < 0.01 (N ranged between 75 and 79). EPA = Entrustable Professional Activity, Q = question.

Figure 2. Panel A reports content analysis of responses to: ‘What are you most anxious about as you prepare to begin (or now that you are in) your first clerkship.’ Other included adjustment to the new environment, procedural skills, navigating the electronic medical record, grading, etc. Panel B reports content analysis of responses to: ‘What are you most confident about as you prepare to begin (or now that you are in) your first clerkship.’ Other included wellness, general clinical skills and time management. Frequencies indicate % of theme/total number of phrases