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To the Editor: Incoming residents are expected to be competent in managing transitions of care, 1 but medical students report knowledge gaps related to the hospital discharge process.2 Although some schools offer curricula on discharge skills, education on this topic is not universal.3-7 The current study sought to determine the frequency of participation, learning, and independence in managing hospital discharge by third-and fourth-year medical students. METHODSThis was an anonymous, cross-sectional survey of thirdand fourth-year medical students who completed their Medicine clerkship at four medical schools in the mid-Atlantic region in 2012-13. A convenience sample of private, public, and federal schools was assembled. None of the schools had formal discharge skills curricula. Institutional review board approval was obtained at all institutions. Students were e-mailed four times to request participation.Domains included frequency of participation, perceived independence, teaching, and additional training desired in seven critical discharge tasks (Online Appendix 1).8 Independent variables included year in school and subinternships completed. The survey was pilot-tested for face and content validity.Data were analyzed descriptively using Stata 11 IC (Stata Corp., College Station, TX). It was decided a priori to compare frequency of participation of fewer than half of patients with more frequent participation and for independence comparing "can do independently" with all other. T-tests assessed differences in means of frequency and independence using independent variables. Upon request from participating institutions, data were not analyzed according to school. RESULTSThree hundred seventy-eight students who had finished their medicine clerkship completed the survey and were included. Response rate was 44%. Thirty-one percent were third-year students, 69% were fourth-year students, and 70% had completed a subinternship.Most students reported participating in discharge tasks during the medicine clerkship with at least half of patients (Table 1). Fewer students reported reviewing discharge instructions with patients (56%) and communicating with primary care physicians (PCPs) (29%). Fourthyear students were more likely than third-year students to report identifying barriers to discharge (mean 3.5 vs 3.1 on 0-4 scale), educating patients at discharge (3.9 vs 3.6), communicating with PCPs (2.3 vs 1.7), and collaborating with the multidisciplinary team (3.6 vs 2.9, all P < .01).Ninety-six percent of students reported that residents taught them discharge skills, 48% that they taught themselves, and 30% that they learned these skills from attending physicians. Half reported independence in reconciling medications, collaborating with the multidisciplinary team, and reviewing discharge instructions, but fewer than half reported independence in the remaining discharge skills.Students who completed at least one subinternship reported higher levels of independence in all skills except Seventeen students who reported not havi...

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This case outlines the process of using quality improvement tools during the instructional systems design process. The clerkship curriculum of the third year of medical school was undergoing a complete reform in terms of time and content. An instructional designer was utilized to complete a needs analysis and participate in the instructional systems design process. A need for a common understanding of the language of medical education and instructional design drove the team to utilize the Institute for Healthcare Improvement (IHI) Quality Improvement tools. The reform took 11 months, involved six clerkship directors, multiple administrators, and resulted in consensus among the clerkship directors regarding the knowledge, skills, and attitudes appropriate for a third-year medical student curriculum.

Medical students face professional experiences of death and loss during their formative training years. Personal experiences of death and loss are unique to each individual student. Surprisingly little is known about how medical students conceptualize loss or death. We sought to explore the responses of third year medical students to a selfreflection exercise focused on loss. We conducted a qualitative analysis of 127 third year medical school students responses to identify common and uncommon themes and language used by medical students to discuss and conceptualize loss. These findings may allow educators to tailor education programs on end of life care and mindfulness in a real and relevant manner. In addition, the wide breadth of student perspectives will inform appropriate support and resources required as physicians-in-training face loss during their training.