The July transition from medical student to internship brings potential risk for poor patient outcomes, including worsened mortality, known as the July effect.1 Graded responsibilities based on competencies has been suggested as tool to mitigate the July effect.1 A national survey of internal medicine residency program directors found their highest and second highest-ranked competency priorities for new interns were “knowing when to seek assistance” and “communication with nurses/nurse triage,” with 95.7% and 89% respectively assigning each of these competencies a high priority.2 Further, 67% of incoming interns reported no formal training in cross coverage.3 Prior single-center experiences with simulated calls have demonstrated improved medical student confidence in their future internship performance.4 We utilized simulated nurse calls for mock emergency cases as a tool to build fourth-year medical student skills in communication with nurse team members, triaging patient scenarios for further evaluation, and escalation of care and to enhance student skills in the management of emergencies prior to internship.
Mock Call Structure
Thirty-seven students who had intentions to apply for an internal medicine internship were enrolled in a two-week internship preparedness course. As part of this course, they were provided didactic education on patient handoff, communication with physicians and nurses, and management of common medical emergencies. Sixteen preceptors (faculty and senior residents in internal medicine) were trained to simulate progressively challenging emergencies from a scripted case on a telephone call with a fourth-year medical student. The calls were to be made at a pre-scheduled window of time and each were to last between 15 to 20 minutes. During these mock calls, the student would be presented with a chief concern and a brief relevant history. The student could request appropriate vitals, physical exam findings, labs, and other information the nurse, simulated by preceptors, could provide from the script. If a student would ask for data that was not scripted, preceptors were asked to improvise a response based on the contents of the case, including responding that the data requested was either unavailable or unable to be obtained. The cases would involve dynamic changes in patient status based on the student’s management. For example, if a student correctly initiated insulin and dextrose in the management of hyperkalemia, a follow up electrocardiogram may show resolution of the signs of hyperkalemia that were present on initial evaluation. The students’ receipt of lab or imaging would also be based on simulated times for those tests. For example, an electrocardiogram would be provided relatively soon after the student requested it, but computed tomography of the abdomen may be delayed or not be available during the mock call. Preceptors were asked to simulate providing emergency treatment and initiate management the fourth-year medical student communicated they wanted.
During these mock calls, the fourth-year medical students were expected to do the following:
- Utilize closed loop communication in receiving a concern from the mock call nurse;
- Triage scenarios that required further testing, bedside evaluation and discussion with senior resident, consulting or attending physician;
- Recognize scenarios that required escalations of care, such as transfers to intensive care units;
- Initiate management of common emergencies; and
- Advise the mock call nurse on next steps utilizing closed loop communication.
The mock cases were limited to nine chief concerns we felt interns commonly must respond to, including separate calls for hyperkalemia, tachycardia, gastrointestinal bleeding, chest pain, fever, dyspnea, alcohol withdrawal, abdominal pain, and a transfusion reaction. The cases varied in complexity and acuity, and preceptors were advised to start with simpler cases with lower acuity of illness and gradually introduce more challenging cases with improved student performance. At the end of each mock call, the student was provided formative feedback on their performance in the case, specifically in their expected competencies in communication, triage, escalation of care, and initiation of management based a rubric of what the student must do, should do, could do, and should not do. A total of four mock calls were completed with each student.
Mock Call Outcomes
All thirty-seven students participated in this mock call experience through an end of year preparedness course. Students were asked to self-rate themselves prior to and after the mock call experience on a 1 to 5 Likert scale, with 1 being able to observe an emergency call to 5 being able to complete the emergency call with distant supervision, but with an attending or senior resident available. Prior to the mock calls the students self-rating on their fulfillment of the competencies of recognizing, triaging and initiation of management during an emergency nurse call was as a mean of 3.3 (range 1 to 5). After the mock calls, students self-rated themselves at a mean of 4.0 (range 3 to 5).
Preceptors subjectively noted student’s performance improved on formative feedback on each mock call, with more “must dos’’ and “should dos” being completed on each subsequent call. Preceptor evaluators also noted 100% of students could utilize closed loop communication in advising the nurse in next steps with either direct or indirect supervision. Further, 88% of students could initiate initial management under either direct supervision or indirect supervision. Preceptor stated 83% of students could recognize scenarios that required escalation of care, bedside evaluation or discussion with a senior resident or attending physician with either direct or indirect supervision.
Our preceptor evaluations were limited by a completion rate of 65% and by recall bias of the last mock call performance which was often stronger. Our preceptor evaluation data were also limited by not assessing the evaluation of patients and escalation of care separately. There was also heterogeneity in both the mock calls and the evaluations due to preceptors coming from different levels of training from senior residents to junior faculty. Training sessions for preceptors to prepare for the mock calls and evaluations were available in both live online and recorded formats, which may have resulted in variable levels of preceptor training as some preceptors may not have completed recorded training. This is turn may have resulted in heterogeneity in evaluations and preceptor administered mock calls which these training sessions were designed to standardize. Recruitment of preceptors may have affected student performance and engagement, as the preceptors were recruited from a select group of internal medicine residents and faculty who were already participating in a medical student coaching program for the students in the course.
We found students enjoyed the experience of mock calls, as a unique and valuable experience. They self-rated an improved ability to recognize and manage emergency scenarios. Preceptors measured improved student communication, management, triage in evaluation, and escalation of care on each mock call. Mock calls on emergency scenarios provided fourth-year medical students a valuable simulated experience of handling emergencies in intern year. In the future, we plan on making our mock calls a longitudinal experience across the academic year to facilitate year-long learning, and to allow more student experience in mock calls. Additionally, we hope to survey past students on the impact of mock calls on their experiences and readiness in intern year.
- Young JQ, Ranji SR, Wachter RM, et al. “July effect”: Impact of the academic year-end changeover on patient outcomes. Ann Intern Med. 2011 Sep 6;155(5):309-15. doi:10.7326/0003-4819-155-5-201109060-00354. Epub 2011 Jul 11.
- Angus S, Vu TR, Halvorsen AJ, et al. What skills should new internal medicine interns have in July? A national survey of Internal Medicine Residency Program directors. Acad Med. 2014;89(3):432-435. doi:10.1097/acm.0000000000000133.
- Sterkenburg A, Barach P, Kalkman C, et al. When do supervising physicians decide to entrust residents with unsupervised tasks? Acad Med. 2010;85(9):1408-1417. doi:10.1097/acm.0b013e3181eab0ec.
- Schwind CJ, Boehler ML, Markwell SJ, et al. Use of simulated pages to prepare medical students for internship and improve patient safety. Acad Med. 2011;86(1):77-84. doi:10.1097/acm.0b013e3181ff9893.
Clinical Practice, Leadership, Administration, & Career Planning, Medical Education, Research, SGIM
Dr. Kapadia (firstname.lastname@example.org) is an assistant professor in the department of medicine at the University of South Florida Morsani College of Medicine. Dr. Gupta (email@example.com) is an associate professor in the department of medicine at the University of South Florida Morsani College of Medicine.
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