Emergency medicine subinternship: does a standard clinical experience improve performance outcomes?

BACKGROUND: The emergency medicine (EM) subinternship provides a varied experience for senior medical students depending on gender, specialty choice, and interest. A didactic curriculum can be standardized, but the clinical component is difficult to control. Students can be directed to see patients with specific chief complaints.

OBJECTIVES: To assess whether a clinical requirement of 10 predetermined cases improves general knowledge as measured on an objective exam.

METHODS: This was a prospective, nonrandomized, case-controlled study at a public teaching hospital. Students were assigned to the control group (CG) or test group (TG) by alternating block rotations over 6 months. The CG saw emergency department (ED) patients according to interest and faculty direction. The TG was also required to identify ten specific chief complaints. Patient encounters were recorded in computerized logs. A 10-question pretest assessed preexisting knowledge of each chief complaint, and a 40-question final exam tested general EM knowledge. Descriptive statistics measured demographic data. Groups were compared by Fisher's exact test. Difference in means testing was performed to see if pre- to posttest differences varied by group. Multivariate analysis controlled for gender and specialty choice.

RESULTS: Eighteen CG students saw a mean of 57 patients, and 24 TG students saw a mean of 54 patients; 1 CG student (6%) and 7 TG students (31.8%) saw all 10 required cases (Fisher's exact test p = 0.044). Difference in means testing demonstrated a greater relative change in performance (13.4% points) by the TG relative to the CG on a general knowledge exam, compared with their performance on a brief pretest (p = 0.014). The authors performed multivariate regression controlling for pretest score, gender, and EM specialty choice, and neither gender nor intended EM specialty choice was a contributing factor to the improved performance. A greater relative change in performance (7% points) in the TG exam score was found when compared to the CG (p = 0.020).

CONCLUSIONS: Students who participated in the usual didactic curriculum and were required to see ED patients with representative chief complaints performed better on a general EM exam than those who employed common methods of choosing patients.