[Show abstract][Hide abstract] ABSTRACT: Web-based cases are well accepted by medical students and enable faculty to deliver equivalent educational experiences to all students. A 2009 literature search revealed no study investigating student use patterns of Web-based case libraries for self-directed learning. We investigated third-year students' use of a Web-based case program for self-directed learning in a family medicine clerkship.
We analyzed Design A Case usage patterns of 210 medical students during academic year 2008--2009. We compared board score differences between these students and those from the previous 5 years who did not use Design A Case. We analyzed data from a 13-item survey, administered to a subgroup of 85 students, about the strengths, weaknesses, and acceptability of the program.
Students completed, on average, four cases, which was beyond the requirement of three. They reported that the content was highly relevant to cases they saw in clinic. Almost 75% preferred the self-directed Web-based learning over didactics, and most (64%) felt they learned more electronically. Use of the cases was associated with equivalent Board scores versus didactic lectures.
In our setting, self-directed learning using a Web-based case program was highly acceptable to students. Web-based cases may provide an option for family medicine educators who wish to deliver equivalent educational experiences across sites.
Family medicine 11/2009; 42(7):496-500. · 1.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A 2006 national survey of pediatric clerkship directors revealed that only 25% taught cultural competence, but 81% expressed interest in a validated cultural competence curriculum. The authors designed and evaluated a multi-modality cultural competence curriculum for pediatric clerkships including a validated cultural knowledge test.
Curriculum content included two interactive workshops, multimedia web cases, and a Cultural and Linguistic Competence Pocket Guide. Evaluation included a student satisfaction survey, a Nominal Technique Focus Group, and a validated knowledge test. The knowledge test comprised 6 case studies with 49 multiple choice items covering the curricular content.
Of 149/160 (93%) students who completed satisfaction surveys using a 5-point Likert scale, >82% strongly agreed or agreed that the curricular intervention was a meaningful experience (93%), increased their understanding of the culture of medicine (91%), increased their knowledge of racial and ethnic disparities (89%) and core cultural issues (91%), and improved their skills in working with interpreters (90%) and cross-cultural communication (82%). Top strengths identified by a focus group (34 students) included learning about interpreters, examples of cultural practices, and raised cultural awareness. Pre- and post-knowledge test scores improved by 17% (p<.0001). After six administrations, the test achieved the target reliability of .7.
The authors successfully designed and validated a practical cultural competence curriculum for pediatric clerkships that meets the need demonstrated in the 2006 national survey.
This curriculum will enable pediatric clerkship directors to equip more graduates to provide culturally sensitive pediatric care to an increasingly diverse US population.
[Show abstract][Hide abstract] ABSTRACT: Background to the Debate
Background to the debate: Many countries worldwide are digitizing patients' medical records. In the United States, the recent economic stimulus package (“the American Recovery and Reinvestment Act of 2009”), signed into law by President Obama, includes $US17 billion in incentives for health providers to switch to electronic health records (EHRs). The package also includes $US2 billion for the development of EHR standards and best-practice guidelines. What impact will the rise of EHRs have upon medical education? This debate examines both the threats and opportunities.
PLoS Medicine 06/2009; 6(5):e1000069. DOI:10.1371/journal.pmed.1000069 · 14.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Graduating medical students will universally use electronic health records (EHRs), yet a June 2007 literature search revealed no descriptions of EHR-specific communication skills curricula in US medical schools. We designed and tested methods to teach first-year medical students to optimally integrate EHRs into physician-patient communication in ambulatory encounters.
We randomly assigned 17 volunteer students to control (n=8) and intervention (n=9) groups. Both groups learned the mechanics of documenting patient histories using the EHR. Additionally, we taught the intervention group EHR-specific communications skills using guided discovery, brief didactics, and practice role plays. We compared both groups' general and EHR-specific communications skills using a standardized patient (SP) case.
Students receiving EHR communication skills training performed significantly better than controls in six of 10 EHR communication skills. In 10 of 11 general communication skills, there were no significant differences between groups.
First-year medical students can demonstrate EHR communication skills early in their medical training. However, in our setting, students did not spontaneously demonstrate EHR skills without instruction, and such skills did not correlate with general communication skills.
Family medicine 02/2009; 41(1):28-33. · 1.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Communication skills, including patient-centered interviewing (PCI), have become a major priority for educational and licensing organizations in the United States. While patient-centered interviewing is associated with positive patient outcomes and improved diagnostic accuracy, it is unknown if an association exists between patient-centered interviewing and student performance in high-stakes clinical skills assessment (CSA) examinations. The purpose of this study was to determine if generic communication skills and patient-centered interviewing skills were associated with students' overall student performance on a multi-station clinical skills assessment (CSA) examination.
This was a cross-sectional study to assess student performance with standardized patients (SPs). We conducted a retrospective review of 30 videotaped SP encounters of Third year medical students (class of 2006) at the University of Kansas School of Medicine. We measured correlations between observed PCI scores, overall CSA scores and CSA interpersonal and communication (ICS) skills scores of student-SP encounters.
PCI scores, as measured with the Four Habits Coding Scheme, a measurement tool of patient-centered communication, were not correlated with either overall CSA scores or ICS scores. Students' PCI scores were lower than the ICS scores (57% vs. 85% of correct items). The students performed poorly (30% mean score of correct items) in eliciting patient perspectives, compared to three other domains (Invest in the beginning, Demonstrate empathy, and Invest in end) of patient-centered interviewing.
Our study failed to demonstrate any association between student performance and patient-centered interviewing skills (PCI) in the setting of a comprehensive in-house CSA examination. Third-year medical students in our study did not practice some elements of patient-centered interviewing.
Given the increasing importance of patient-centered communication, the high-stakes in-house clinical skills examinations may consider assessing patient-centered interviewing using a more comprehensive and valid checklist.
[Show abstract][Hide abstract] ABSTRACT: United States academic medical centers are increasingly incorporating electronic health records (EHR) into teaching settings. We report third year medical students' attitudes towards clinical learning using the electronic health record in ambulatory primary care clinics.
In academic year 2005-06, 60 third year students were invited to complete a questionnaire after finishing the required Ambulatory Medicine/Family Medicine clerkship. The authors elicited themes for the questionnaire by asking a focus group of third year students how using the EHR had impacted their learning. Five themes emerged: organization of information, access to online resources, prompts from the EHR, personal performance (charting and presenting), and communication with patients and preceptors. The authors added a sixth theme: impact on student and patient follow-up. The authors created a 21-item questionnaire, based on these themes that used a 5-point Likert scale from "Strongly Agree" to "Strongly Disagree". The authors emailed an electronic survey link to each consenting student immediately following their clerkship experience in Ambulatory Medicine/Family Medicine.
33 of 53 consenting students (62%) returned completed questionnaires. Most students liked the EHR's ability to organize information, with 70% of students responding that essential information was easier to find electronically. Only 36% and 33% of students reported accessing online patient information or clinical guidelines more often when using the EHR than when using paper charts. Most students (72%) reported asking more history questions due to EHR prompts, and 39% ordered more clinical preventive services. Most students (69%) reported that the EHR improved their documentation. 39% of students responded that they received more feedback on their EHR notes compared to paper chart notes. Only 64% of students were satisfied with the doctor-patient communication with the EHR, and 48% stated they spent less time looking at the patient.
Third year medical students reported generally positive attitudes towards using the EHR in the ambulatory setting. They reported receiving more feedback on their electronic charts than on paper charts. However, students reported significant concerns about the potential impact of the EHR on their ability to conduct the doctor-patient encounter.
BMC Medical Education 02/2008; 8(1):13. DOI:10.1186/1472-6920-8-13 · 1.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cultural sensitivity may be especially important in the care of children, and national pediatric associations have issued policy statements promoting cultural competence in medical education. The authors conducted a national survey to investigate the current state of cultural competence teaching and learning within U.S. pediatric clerkships.
The authors surveyed 125 U.S. pediatric clerkship directors concerning the presence or absence of cultural curricula, content, teaching methods, and evaluation. Question types were multiple-choice single/best answer, checklists, five-point Likert-type scales, and free-text responses.
Of 100 respondents (80% response rate), most agreed or strongly agreed that teaching culturally competent care is important (91%), enhances the physician/patient/family relationship (99%), and improves patient outcomes (90%). Twenty four of 98 respondents (25%) reported cultural competence teaching. The most common teaching methods were lectures (63%), experiential learning through community activities (58%), and small-group discussions (54%). Only 14 respondents reported any curricular evaluation, the commonest methods being student surveys, clinical case presentations, and standardized patient experiences. Top factors facilitating curriculum development were culturally diverse populations of patients, students, faculty, and hospital staff, and faculty interest and expertise. Top challenges included lack of protected time for program development, funding, and faculty expertise.
Few U.S. pediatric clerkships currently provide cultural competence curricula. The authors' suggestions to promote cultural competence teaching include providing faculty development opportunities and developing and disseminating teaching materials and evaluation tools. Such dissemination is important to graduate physicians, who can provide culturally sensitive pediatric care to the changing U.S. population.
Academic Medicine 07/2007; 82(6):558-62. DOI:10.1097/ACM.0b013e3180555ace · 2.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A systematic approach advocated by the World Health Organization can help minimize poor-quality and erroneous prescribing. This six-step approach to prescribing suggests that the physician should (1) evaluate and dearly define the patient's problem; (2) specify the therapeutic objective; (3) select the appropriate drug therapy; (4) initiate therapy with appropriate details and consider nonpharmacologic therapies; (5) give information, instructions, and warnings; and (6) evaluate therapy regularly (e.g., monitor treatment results, consider discontinuation of the drug). The authors add two additional steps: (7) consider drug cost when prescribing; and (8) use computers and other tools to reduce prescribing errors. These eight steps, along with ongoing self-directed learning, compose a systematic approach to prescribing that is efficient and practical for the family physician. Using prescribing software and having access to electronic drug references on a desktop or handheld computer can also improve the legibility and accuracy of prescriptions and help physicians avoid errors.
American family physician 02/2007; 75(2):231-6. · 2.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We conducted a review of the evaluation literature and outcomes from community-oriented primary care (COPC) programs in US family medicine residencies since 1969.
We used a Medline and ERIC search for "community-oriented primary care" in English from 1969-2005.
Twenty-two articles were found that concerned US family medicine residency COPC. Six surveys over 25 years reported stable rates of COPC teaching (approximately 40%). Eight descriptive and eight evaluative papers described 14 residency COPC programs. Teaching and learning methods included block and longitudinal rotations and COPC projects. Evaluation methodologies included one quasi-experimental control group study, pretests and posttests of knowledge and attitudes, focus groups, and semi-structured interviews. Reported outcomes included changes in residents' knowledge, attitudes, and behaviors; effect on graduates' career choice and future practice; and impact on patient care and community health.
Few studies have evaluated residency COPC programs. Evaluation has been less than rigorous, with variable results, but at least one study indicates positive outcomes at each evaluation level. More residency programs must evaluate and disseminate outcomes from their COPC projects to determine the value of COPC to residents, colleagues, community partners, and funding agencies.
Family medicine 07/2006; 38(6):399-407. · 1.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Teaching physical examination skills effectively, consistently, and cost-effectively is challenging. Faculty time is the most expensive resource. One solution is to train medical students using lay physical examination teaching associates. In this study, we investigated the feasibility, acceptability, and cost-effectiveness of training medical students using teaching associates trained by a lay expert instead of a clinician.
We used teaching associates to instruct students about techniques of physical examination. We measured students' satisfaction with this teaching approach. We also monitored the financial cost of this approach compared to the previously used approach in which faculty physicians taught physical examination skills.
Our program proved practical to accomplish and acceptable to students. Students rated the program highly, and we saved approximately $9,100, compared with our previous faculty-intensive teaching program.
We believe that our program is popular with students, cost-effective, and generalizable to other institutions.
Family medicine 06/2006; 38(5):326-9. · 1.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Tomorrow's physicians must learn to access, retrieve, integrate and apply current information into ambulatory patient encounters, yet few medical schools teach 'real time' information management.
We compared two groups of clerkship students' information management skills using a standardized patient case. The intervention group participated in case-based discussions including exercises that required them to manage new information. The control group completed the same case discussions without information management exercises.
After five weeks, there was no significant difference between the control and intervention groups' scores on the standardized patient case. However, third rotation students significantly outperformed first rotation students.
Case-based exercises to teach information management failed to improve students' performance on a standardized patient case. Increased number of clinical rotations was associated with improved performance.
BMC Medical Education 02/2006; 6:14. DOI:10.1186/1472-6920-6-14 · 1.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Clinicians cannot provide all recommended preventive services in a single office visit and must learn to prioritize. This skill is not overtly addressed in medical school.
We designed a workshop to teach third-year medical students to prioritize preventive services during an office visit. In a prospective controlled trial, we compared performance on a standardized patient case.
Students performed well, but there was no significant difference between intervention and control groups' mean scores on the standardized patient encounter.
Our brief intervention failed to increase students' scores on a standardized patient case requiring preventive services prioritization.
Family medicine 01/2006; 38(10):696-9. · 1.17 Impact Factor