Context Shortfalls in the US physician workforce are anticipated as the population ages and medical students' interest in careers in internal medicine (IM) has declined (particularly general IM, the primary specialty serving older adults). The factors influencing current students' career choices regarding IM are unclear. Objectives To describe medical students' career decision making regarding IM and to identify modifiable factors related to this decision making. Design, Setting, and Participants Web-based cross-sectional survey of 1177 fourth-year medical students (82% response rate) at 11 US medical schools in spring 2007. Main Outcome Measures Demographics, debt, educational experiences, and number who chose or considered IM careers were measured. Factor analysis was performed to assess influences on career chosen. Logistic regression analysis was conducted to assess independent association of variables with IM career choice. Results Of 1177 respondents, 274 (23.2%) planned careers in IM, including 24 (2.0%) in general IM. Only 228 (19.4%) responded that their core IM clerkship made a career in general IM seem more attractive, whereas 574 (48.8%) responded that it made a career in subspecialty IM more attractive. Three factors influenced career choice regarding IM: educational experiences in IM, the nature of patient care in IM, and lifestyle. Students were more likely to pursue careers in IM if they were male (odds ratio [OR] 1.75; 95% confidence interval [CI], 1.20-2.56), were attending a private school (OR, 1.88; 95% CI, 1.26-2.83), were favorably impressed with their educational experience in IM (OR, 4.57; 95% CI, 3.01-6.93), reported favorable feelings about caring for IM patients (OR, 8.72; 95% CI, 6.03-12.62), or reported a favorable impression of internists' lifestyle (OR, 2.00; 95% CI, 1.39-2.87). Conclusions Medical students valued the teaching during IM clerkships but expressed serious reservations about IM as a career. Students who reported more favorable impressions of the patients cared for by internists, the IM practice environment, and internists' lifestyle were more likely to pursue a career in IM.

Robust response rates are essential for effective survey-based strategies. Researchers can improve survey validity by addressing both response rates and nonresponse bias. In this AMEE Guide, we explain response rate calculations and discuss methods for improving response rates to surveys as a whole (unit nonresponse) and to questions within a survey (item nonresponse). Finally, we introduce the concept of nonresponse bias and provide simple methods to measure it.

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AIM:The Observed Simulated Hand-off Experience (OSHE) was created to evaluate medical students' sign-out skills using a real-time assessment tool, the Hand-off CEX.SETTING: Thirty-two 4th year medical students participated as part of an elective course.PROGRAM DESCRIPTION: One week following an interactive workshop where students learned effective hand-off strategies, students participated in an experience in which they performed a hand-off of a mock patient using simulated history and physical examination data and a brief video. PROGRAM EVALUATION:Internal medicine residents served as standardized hand-off receivers and were trained on expectations. Students were provided feedback using a newly developed Hand-off CEX, based on the "Mini-CEX," which rates overall hand-off performance and its components on a 9-point Likert-type scale. Outcomes included performance ratings and pre-and poststudent self-assessments of hand-off preparedness. Data were analyzed using Wilcoxon signed-rank tests and descriptive statistics. Resident receivers rated overall student performance with a mean score of 6.75 (range 4-9, maximum 9). Statistically significant improvement was observed in self-perceived preparedness for performing an effective hand-off (67% post-vs. 27% prereporting 'well-prepared,' p<0.009).DISCUSSION: This brief, standardized hand-off training exercise improved students' confidence and was rated highly by trained observers. Future work focuses on formal validation of the Hand-off CEX instrument. 129 SETTINGThe OSHE was a module in a month-long skills-based "Transitions to Internship" elective course offered to graduating students in April of their final year of medical school. Thirty-four students who had matched into nine different specialties participated in the course. This elective focuses specifically on "orphan" topics not addressed elsewhere in the curriculum. Topics include procedural skills, preparedness for life as a resident, advanced communication skills (e.g., obtaining informed consent and disclosing medical error) and personal life preparedness (e.g., debt management and maintaining work/life balance). PROGRAM DESCRIPTIONStudents participated in a 90-min interactive workshop on communication skills necessary to perform effective handoffs (see online Appendix A). This module, delivered by one of the authors (VA), discussed communication theory as it relates to effective hand-off communication. Key points communicated during this workshop included: the importance of face-to-face communication, encouraging questions from the hand-off receiver, providing detailed "to-do" lists with rationale and anticipatory guidance. The instructor included case-based examples on the importance of effective hand-offs both in medicine and other industries 20 .The components of a written hand-off were discussed during the 90-min hand-off training, and students were given a representative example of a high-quality written sign-out 21 .Finally, students were provided with electronic access to the workshop materials and a...

Background Despite the importance of feedback, the literature suggests that there is inadequate feedback in graduate medical education. Objective We explored barriers and facilitators that residents in anesthesiology, emergency medicine, obstetrics and gynecology, and surgery experience with giving and receiving feedback during their clinical training. Methods Residents from 3 geographically diverse teaching institutions were recruited to participate in focus groups in 2012. Open-ended questions prompted residents to describe their experiences with giving and receiving feedback, and discuss facilitators and barriers. Data were transcribed and analyzed using the constant comparative method associated with a grounded theory approach. Results A total of 19 residents participated in 1 of 3 focus groups. Five major themes related to feedback were identified: teacher factors, learner factors, feedback process, feedback content, and educational context. Unapproachable attendings, time pressures due to clinical work, and discomfort with giving negative feedback were cited as major barriers in the feedback process. Learner engagement in the process was a major facilitator in the feedback process. Conclusions Residents provided insights for improving the feedback process based on their dual roles as teachers and learners. Time pressures in the learning environment may be mitigated by efforts to improve the quality of teacher-learner relationships. Forms for collecting written feedback should be augmented by faculty development to ensure meaningful use. Efforts to improve residents' comfort with giving feedback and encouraging learners to engage in the feedback process may foster an environment conducive to increasing feedback.

Student observation and participation in unprofessional behaviors increased during clerkships. Participation in unprofessional behaviors is associated with perceiving these behaviors as acceptable.

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Personal exposure to role models in medical school is an important predictor of residency training in that role model's specialty.