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PURPOSE: Clinical performance evaluations play a critical role in determining medical school clerkship grades. This study aimed to provide clarification from clerkship directors in internal medicine on what constitutes an effective and informative narrative description of student performance. METHODS: In September 2016, the Clerkship Directors in Internal Medicine (CDIM) electronically administered its annual, voluntary, and confidential cross-sectional survey of its US membership. One section of the survey asked six questions regarding the helpful components of an effective narrative evaluation. Respondents were asked to rate the effectiveness of elements contained within narrative evaluations of students. RESULTS: Ninety-five CDIM members responded to the survey with an overall response rate of 74.2%. Descriptions of skills and behaviors were felt to be the most important, followed by a description of the overall synthetic or global assessment level of the student. Descriptions of personality and attitude were the next highest rated feature followed by adjectives describing performance. Length was felt to be the least important component. In free-text comments, several respondents indicated that direct observation of performance and specific examples of skills and behaviors are also desirable. CONCLUSIONS: Narrative evaluations of students that explicitly comment on skills, behaviors, and an overarching performance level of the learner are strongly preferred by clerkship directors. Direct observation of clinical performance and giving specific examples of such behaviors give evaluations even more importance. Faculty development on evaluation and assessment should include instruction on these narrative assessment characteristics.

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INTRODUCTION: Clinical encounters are often assessed using a checklist. However, without direct faculty observation, the timing and sequence of questions are not captured. We theorized that the sequence of questions can be captured and measured using coherence scores that may distinguish between low and high performing candidates. METHODS: A logical sequence of key features was determined using the standard case checklist for an observed structured clinical exam (OSCE). An independent clinician educator reviewed each encounter to provide a global rating. Coherence scores were calculated based on question sequence. These scores were compared with global ratings and checklist scores. RESULTS: Coherence scores were positively correlated to checklist scores and to global ratings, and these correlations increased as global ratings improved. Coherence scores explained more of the variance in student performance as global ratings improved. DISCUSSION: Logically structured question sequences may indicate a higher performing student, and this information is often lost when using only overall checklist scores. CONCLUSIONS: The sequence test takers ask questions can be accurately recorded, and is correlated to checklist scores and to global ratings. The sequence of questions during a clinical encounter is not captured by traditional checklist scoring, and may represent an important dimension of performance.

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OBJECTIVE: This study describes and categorizes the cultural frictions and conflicts within a successfully implemented Internal Medicine Patient-Centered Medical Home (PCMH) clinic at the National Naval Medical Center, and provides lessons learned for combating these concerns. METHODS: A semistructured interview protocol was developed, focusing on unique tenets of the PCMH, benefits of the model, and perceived obstacles to practicing medicine within this delivery system. The interviews included questions regarding efforts to foster team cohesion and impediments within the PCMH, as well as unique influences of the larger organization and the patient population, and lingering concerns about threats to the PCMH's viability. KEY RESULTS: Cultural tensions were revealed in four areas: perceived competing values within PCMH, individual resistance to PCMH values, within-team conflicts threatening the acculturation of PCMH values, and threats to the culture from external stakeholders. CONCLUSIONS: Recommendations for addressing these areas include values clarification and empowerment, training for socialization, realistic job previews, selective personnel retention, team building and conflict resolution mechanisms, and increased senior managerial support.

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BACKGROUND AND OBJECTIVES: While medical student interest groups (IGs, also known as student clubs) are widely offered, their actual use and effectiveness to affect students' specialty choice (eg, increase selection of family medicine) are poorly understood. We performed this study to describe student participation in IGs, association with specialty selection, and perceived benefit of participation. METHODS: An electronic, cross-sectional, quantitative survey of all fourth-year US medical students in 2009 with a Department of Defense service obligation was conducted. Each participant indicated which of 18 listed IGs they attended with a yes or no response. Each participant also rated the overall benefit of IGs on a 9-point scale and provided their top choice for the residency Match. RESULTS: The response rate was 53% (419/797). Students attended an average of 3.5 specialty IGs. For all 18 specialties queried, IG attendance was associated with selection in the Match, and 77% of students attended the IG of their selected specialty. However, IG participation was perceived as having a small effect on specialty choice, as the mean response was 3.6 (standard deviation=2.4) on a 1 to 9 scale. CONCLUSIONS: IG participation is common and is strongly associated with specialty choice, but the benefit appears to be small.

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OBJECTIVE: • To review experience with nephrectomy/thrombectomy for a renal cell carcimoma (RCC) with a level IV tumour thrombus and to evaluate the benefit of deep hypothermic circulatory arrest (DHCA) with cardiopulmonary bypass (CPBP). PATIENTS AND METHODS: • A multi-institutional retrospective database was created to assess the outcomes of surgery for RCC and associated level IV tumour thrombus from 1983 to 2007. Patients were identified based on radiographic records/operative findings. • Only cases using CPBP were analysed. Clinicopathological and operative characteristics including use of DHCA were recorded. • Overall survival (OS) for all patients and by use of DHCA was assessed. Comparisons of clinical and operative characteristics by use of DHCA were performed. • A Cox regression model determined predictors of perioperative/in-hospital mortality. RESULTS: • In all, 63 patients underwent resection with CPBP; overall perioperative mortality was 22.2%. • There were no significant differences in clinicopathological characteristics, operative duration, estimated blood loss, transfusions, and hospital stay by use of DHCA. • Perioperative mortality rate was lower in patients undergoing DHCA (8.3% vs 37.5%, P = 0.006). • The median OS was longer for the patients undergoing DHCA (15.8 vs 7.7 months); however, this failed to reach statistical significance (P = 0.357). • On multivariate analysis, age of > 60 years (hazard ratio [HR] 6.7, 95% confidence interval [CI] 1.5-31.1, P = 0.015) and the use of DHCA (HR 0.13, 95% CI 0.036-0.51, P = 0.003) were independent predictors of perioperative mortality. CONCLUSIONS: • Radical nephrectomy and level IV tumour thrombectomy is associated with significant mortality. • The use of DHCA does not appear to adversely affect operative characteristics and may limit perioperative mortality. • Further prospective studies should be performed to confirm the benefit of DHCA.

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OBJECTIVE: To evaluate our early experience with neoadjuvant therapy (sunitinib or sorafenib) in advanced renal cell carcinoma (RCC), to explore the effect on both tumour biology and potential for downstaging advanced tumours, as systemic therapy for RCC has historically resulted in little if any primary tumour response, but recent experience with targeted therapy suggests otherwise. PATIENTS AND METHODS: The preliminary experience with neoadjuvant therapy for the surgical management of RCC was reviewed at two large referral centres. Several unique patients were identified who had a novel response to systemic therapy that altered the surgical strategy. RESULTS: Four patients who had targeted therapy before surgery are described and in whom there were effects on tumour biology not seen previously with chemotherapy and cytokine therapy. The selected patients who had neoadjuvant targeted therapy had shrinkage of a tumour thrombus in the inferior vena cava, nodal involvement, renal fossa recurrence and tumour within a solitary kidney. CONCLUSIONS: The introduction of new molecular agents has revolutionized the treatment of patients with metastatic RCC. Responses to targeted therapy within the primary tumour, tumour thrombus, renal fossa recurrence, and lymph node metastases are novel findings not seen during treatment with immunotherapeutic-based strategies. This might be a signal for urological surgeons to re-evaluate the paradigm for the surgical management of advanced RCC. Potential applications are presented to encourage further investigations with targeted therapy in the neoadjuvant setting.

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