[Show abstract][Hide abstract] ABSTRACT: Few studies have compared the effect of Web-based eLearning versus small-group learning on medical student outcomes. Palliative and end-of-life (PEOL) education is ideal for this comparison, given uneven access to PEOL experts and content nationally.
In 2010, the authors enrolled all third-year medical students at the University of California, Davis School of Medicine into a quasi-randomized controlled trial of Web-based interactive education (eDoctoring) compared with small-group education (Doctoring) on PEOL clinical content over two months. Students participated in three 3-hour PEOL sessions with similar content. Outcomes included a 24-item PEOL-specific self-efficacy scale with three domains (diagnosis/treatment [Cronbach alpha = 0.92; CI: 0.91-0.93], communication/prognosis [alpha = 0.95; CI: 0.93-0.96], and social impact/self-care [alpha = 0.91; CI: 0.88-0.92]); 8 knowledge items; 10 curricular advantage/disadvantages; and curricular satisfaction (both students and faculty).
Students were randomly assigned to Web-based eDoctoring (n = 48) or small-group Doctoring (n = 71) curricula. Self-efficacy and knowledge improved equivalently between groups (e.g., prognosis self-efficacy, 19%; knowledge, 10%-42%). Student and faculty ratings of the Web-based eDoctoring curriculum and the small-group Doctoring curriculum were equivalent for most goals, and overall satisfaction was equivalent for each, with a trend toward decreased eDoctoring student satisfaction.
Findings showed equivalent gains in self-efficacy and knowledge between students participating in a Web-based PEOL curriculum in comparison with students learning similar content in a small-group format. Web-based curricula can standardize content presentation when local teaching expertise is limited, but it may lead to decreased user satisfaction.
Academic medicine: journal of the Association of American Medical Colleges 12/2014; 90(3). DOI:10.1097/ACM.0000000000000607 · 2.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND Many primary care physicians (PCPs) are ill-equipped to provide screening and counseling for inherited breast cancer. OBJECTIVE To evaluate the outcomes of an interactive web-based genetics curriculum versus text curriculum for primary care physicians. DESIGN Randomized two-group design. PARTICIPANTS 121 California and Pennsylvania community physicians. INTERVENTION Web-based interactive genetics curriculum, evaluated against a control group of physicians who studied genetics review articles. After education, physicians interacted with an announced standardized patient (SP) at risk for inherited breast cancer. MAIN MEASURES Transcripts of visit discussions were coded for presence or absence of 69 topics relevant to inherited breast cancer. KEY RESULTS Across all physicians, history-taking, discussions of test result implications, and exploration of ethical and legal issues were incomplete. Approximately half of physicians offered a genetic counseling referral (54.6 %), and fewer (43.8 %) recommended testing. Intervention physicians were more likely than controls to explore genetic counseling benefits (78.3 % versus 60.7 %, P = 0.048), encourage genetic counseling before testing (38.3 % versus 21.3 %, P = 0.048), ask about a family history of prostate cancer (25.0 % versus 6.6 %, P = 0.006), and report that a positive result indicated an increased risk of prostate cancer for male relatives (20.0 % versus 1.6 %, P = 0.001). Intervention-group physicians were less likely than controls to ask about Ashkenazi heritage (13.3 % versus 34.4 %, P = 0.01) or to reply that they would get tested when asked, “What would you do?” (33.3 % versus 54.1 %, P = 0.03). CONCLUSIONS Physicians infrequently performed key counseling behaviors, and this was true regardless of whether they had completed the web-based interactive training or read clinical reviews.
Journal of General Internal Medicine 12/2014; 30(3). DOI:10.1007/s11606-014-3113-5 · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract This study evaluates whether medical and veterinary students' attitudes toward "One Health" and interprofessional education changed after participating in a joint small group learning exercise focused on risk factors associated with zoonotic disease. A survey was distributed to third-year medical students (n = 98) and second-year veterinary students (n = 140), each with a 95% response rate. Overall, 92% of veterinary students and 73% of medical students agreed or strongly agreed that "One Health" was relevant to their desired specialty. Students from both schools largely agreed that interprofessional education should be a goal of the curriculum for their school, and that interprofessional approaches strengthen their overall education. Students reported increased confidence in their communication skills and improved ability to contribute to One Health collaborative teams. This educational intervention, built around a patient case, focused on a variety of learning objectives including skills (such as communication), knowledge (of zoonotic toxoplasmosis) and attitudes (toward collaborative learning and practice). By sparking an interest in One Health during their early professional education, we sought to encourage a new generation of physicians and veterinarians to adopt a more collaborative spirit to their clinical practice, which will ultimately benefit human, animal and environmental health.
Journal of Interprofessional Care 07/2014; 29(1):1-6. DOI:10.3109/13561820.2014.940039 · 1.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract This article presents the findings of a scoping review designed to identify the extent, nature and range of literature on interprofessional education (IPE) initiatives between the human health professions and veterinary medical students, which is particularly important to advance One Health education and research. Nine published articles were identified. The websites of six universities were searched in order to collect further information. Interventions vary widely with regards to their structure and delivery, their objectives, the participants involved, and outcome measures. Healthcare professional programmes focus upon interprofessional collaborative practice in the human healthcare setting. By contrast, postgraduate programmes focus upon topics under the One Health paradigm but make little mention of interprofessional collaboration. Evidence of the impact of interventions on team processes at the human, animal, and environmental interface is extremely limited. In order to enhance our understanding of what constitutes effective IPE between veterinary medical students and the human health professions, guide intervention development, and the development of outcome measures, there is a need to further explore, define, differentiate and validate some of the terms and concepts used to describe interprofessional interventions.
Journal of Interprofessional Care 03/2014; 28(4). DOI:10.3109/13561820.2014.895979 · 1.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
With the growing need to train medical professionals how to engage their patients in advance care planning, this study examines medical students' experience using an interactive, online decision aid to help consenting adults complete an advance directive.
Third-year medical students at the University of California, Davis (UC Davis) used an online, multimedia decision aid to help an adult discuss his or her wishes for medical treatment and create a formal advance directive for health care. Students then wrote essays about their experiences, and an iterative analysis was used for thematic categorization.
Four distinct thematic categories emerged from students' essays: 1) students' personal experiences with advance care planning; 2) participants' experiences; 3) recommendations for practice regarding advance care planning; and 4) feedback about the online decision aid.
An interactive, online decision aid can play a meaningful role in educating medical professionals about advance care planning.
Journal of palliative medicine 10/2013; 16(12). DOI:10.1089/jpm.2013.0039 · 1.91 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose:
Prostate cancer screening with prostate-specific antigen (PSA) is a controversial issue. The present study aimed to explore physician behaviors during an unannounced standardized patient encounter that was part of a randomized controlled trial to educate physicians using a prostate cancer screening, interactive, Web-based module.
Participants included 118 internal medicine and family medicine physicians from 5 health systems in California, in 2007-2008. Control physicians received usual education about prostate cancer screening (brochures from the Center for Disease Control and Prevention). Intervention physicians participated in the prostate cancer screening module. Within 3 months, all physicians saw unannounced standardized patients who prompted prostate cancer screening discussions in clinic. The encounter was audio-recorded, and the recordings were transcribed. Authors analyzed physician behaviors around screening: (1) engagement after prompting, (2) degree of shared decision making, and (3) final recommendations for prostate cancer screening.
After prompting, 90% of physicians discussed prostate cancer screening. In comparison with control physicians, intervention physicians showed somewhat more shared decision making behaviors (intervention 14 items vs control 11 items, P <.05), were more likely to mention no screening as an option (intervention 63% vs control 26%, P <.05), to encourage patients to consider different screening options (intervention 62% vs control 39%, P <.05) and seeking input from others (intervention 25% vs control 7%, P<.05).
A brief Web-based interactive educational intervention can improve shared decision making, neutrality in recommendation, and reduce PSA test ordering. Engaging patients in discussion of the uses and limitations of tests with uncertain value can decrease utilization of the tests.
The Annals of Family Medicine 07/2013; 11(4):315-23. DOI:10.1370/afm.1509 · 5.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Most expert groups recommend shared decision making for prostate cancer screening. Most primary care physicians, however, routinely order a prostate-specific antigen (PSA) test with little or no discussion about whether they believe the potential benefits justify the risk of harm. We sought to assess whether educating primary care physicians and activating their patients to ask about prostate cancer screening had a synergistic effect on shared decision making, rates and types of discussions about prostate cancer screening, and the physician's final recommendations.
Our study was a cluster randomized controlled trial among primary care physicians and their patients, comparing usual education (control), with physician education alone (MD-Ed), and with physician education and patient activation (MD-Ed+A). Participants included 120 physicians in 5 group practices, and 712 male patients aged 50 to 75 years. The interventions comprised a Web-based educational program for all intervention physicians and MD-Ed+A patients compared with usual education (brochures from the Centers for Disease Control and Prevention). The primary outcome measure was patients' reported postvisit shared decision making regarding prostate cancer screening; secondary measures included unannounced standardized patients' reported shared decision making and the physician's recommendation for prostate cancer screening.
Patients' ratings of shared decision making were moderate and did not differ between groups. MD-Ed+A patients reported that physicians had higher prostate cancer screening discussion rates (MD-Ed+A = 65%, MD-Ed = 41%, control=38%; P <.01). Standardized patients reported that physicians seeing MD-Ed+A patients were more neutral during prostate cancer screening recommendations (MD-Ed+A=50%, MD-Ed=33%, control=15%; P <.05). Of the male patients, 80% had had previous PSA tests.
Although activating physicians and patients did not lead to significant changes in all aspects of physician attitudes and behaviors that we studied, interventions that involved physicians did have a large effect on their attitudes toward screening and in the discussions they had with patients, including their being more likely than control physicians to engage in prostate cancer screening discussions and more likely to be neutral in their final recommendations.
The Annals of Family Medicine 07/2013; 11(4):324-34. DOI:10.1370/afm.1550 · 5.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Shared decision making improves value-concordant decision-making around prostate cancer screening (PrCS). Yet, PrCS discussions remain complex, challenging and often emotional for physicians and average-risk men. OBJECTIVE: In July 2011, the Centers for Disease Control and Prevention convened a multidisciplinary expert panel to identify priorities for funding agencies and development groups to promote evidence-based, value-concordant decisions between men at average risk for prostate cancer and their physicians. DESIGN: Two-day multidisciplinary expert panel in Atlanta, Georgia, with structured discussions and formal consensus processes. PARTICIPANTS: Sixteen panelists represented diverse specialties (primary care, medical oncology, urology), disciplines (sociology, communication, medical education, clinical epidemiology) and market sectors (patient advocacy groups, Federal funding agencies, guideline-development organizations). MAIN MEASURES: Panelists used guiding interactional and evaluation models to identify and rate strategies that might improve PrCS discussions and decisions for physicians, patients and health systems/society. Efficacy was defined as the likelihood of each strategy to impact outcomes. Effort was defined as the relative amount of effort to develop, implement and sustain the strategy. Each strategy was rated (1-7 scale; 7 = maximum) using group process software (ThinkTank(TM)). For each group, intervention strategies were grouped as financial/regulatory, educational, communication or attitudinal levers. For each strategy, barriers were identified. KEY RESULTS: Highly ranked strategies to improve value-concordant shared decision-making (SDM) included: changing outpatient clinic visit reimbursement to reward SDM; development of evidence-based, technology-assisted, point-of-service tools for physicians and patients; reframing confusing prostate cancer screening messages; providing pre-visit decision support interventions; utilizing electronic health records to promote benchmarking/best practices; providing additional training for physicians around value-concordant decision-making; and using re-accreditation to promote training. CONCLUSIONS: Conference outcomes present an expert consensus of strategies likely to improve value-concordant prostate cancer screening decisions. In addition, the methodology used to obtain agreement provides a model of successful collaboration around this and future controversial cancer screening issues, which may be of interest to funding agencies, educators and policy makers.
Journal of General Internal Medicine 05/2013; 28(11). DOI:10.1007/s11606-013-2419-z · 3.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction:
The information provided by pharmaceutical sales representatives has been shown to influence prescribing. To enable safe prescribing, medicines information must include harm as well as benefits. Regulation supports this aim, but relative effectiveness of different approaches is not known. The United States (US) and France directly regulate drug promotion; Canada relies on industry self-regulation. France has the strictest information standards.
This is a prospective cohort study in Montreal, Vancouver, Sacramento and Toulouse. We recruited random samples of primary care physicians from May 2009 to June 2010 to report on consecutive sales visits. The primary outcome measure was "minimally adequate safety information" (mention of at least one indication, serious adverse event, common adverse event, and contraindication, and no unqualified safety claims or unapproved indications).
Two hundred and fifty-five physicians reported on 1,692 drug-specific promotions. "Minimally adequate safety information" did not differ: 1.7 % of promotions; range 0.9-3.0 % per site. Sales representatives provided some vs. no information on harm more often in Toulouse than in Montreal and Vancouver: 61 % vs. 34 %, OR = 4.0; 95 % CI 2.8-5.6, or Sacramento (39 %), OR = 2.4; 95 % CI 1.7-3.6. Serious adverse events were rarely mentioned (5-6 % of promotions in all four sites), although 45 % of promotions were for drugs with US Food and Drug Administration (FDA) "black box" warnings of serious risks. Nevertheless, physicians judged the quality of scientific information to be good or excellent in 901 (54 %) of promotions, and indicated readiness to prescribe 64 % of the time.
"Minimally adequate safety information" did not differ in the US and Canadian sites, despite regulatory differences. In Toulouse, consistent with stricter standards, more harm information was provided. However, in all sites, physicians were rarely informed about serious adverse events, raising questions about whether current approaches to regulation of sales representatives adequately protect patient health.
Journal of General Internal Medicine 04/2013; 28(10). DOI:10.1007/s11606-013-2411-7 · 3.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The authors reflect on the creation of the Doctoring program at the UCLA School of Medicine two decades ago. Although Doctoring-at UCLA and other institutions where it has been implemented-has successfully taught large numbers of students psychosocial content and communications skills that are often overlooked in traditional medical school curricula and has had an impact on the larger culture of medical education, the authors believe that its full promise remains unfulfilled. Of the many practical difficulties they encountered in creating and implementing this comprehensive program, the greatest barriers, by far, were cultural. The authors argue that the impact of programs like Doctoring-programs that attempt not only to change the content of what students learn but also to encourage students to think critically and to question fundamental aspects of the way medicine is taught, learned, and practiced-cannot grow unless and until the larger culture of medicine also changes. They offer recommendations for overcoming barriers to improve the next generation of Doctoring and similar programs; these include changing the philosophy behind the selection of medical students, providing far greater resources and support for course faculty, and altering incentives for medical school faculty. They conclude that until major cultural and structural barriers are overcome and the values that Doctoring and like programs attempt to engender become the primary values of the larger culture they seek to change, these programs will continue in fundamental ways to function outside the dominant culture of medicine.
Academic medicine: journal of the Association of American Medical Colleges 04/2013; 88(4):438-441. DOI:10.1097/ACM.0b013e318285b019 · 2.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Over the past decade there has been an enormous increase in the availability of and demand for genetic tests. The appropriateuse ofgenetic tests has the potentialtoenhance both the quality and length of human life. Not surprisingly, numerous stakeholder groups have emerged seeking to influence the medical profession and the public in an attempt to guide genetic test use. Some of these groups offer advice based on their expertise and scientific evidence; others are driven by profit. When ordering genetic tests, we need to remember that the screening tests are similar to other screening tests we often order, same basic principles should apply as to other screening tests (PSA, colonoscopy, etc.). Clear criteria are already established for appropriate use of screening tests. 1 Readers of JGIM need only a reminder that genetic testing is most useful when 1) a person has a personal or family history that increases their risk for a genetic syndrome; 2) the results of the test can be interpreted, and 3) the testing will influence medical management. Certainly issues unique to genetic testing include ethical dilemmas involving families, discrimination, and stigma. The public often is confused by genetics, and some people hold beliefs that are not consistent with accepted medical understanding. As a result, our patients may make clinical choices based on erroneous assumptions. All of this suggests a vital role for patient education and makes the case for careful shared decision-making between physicians and patients. Haga 2 and colleagues present a cross sectional study of 356 primary care physicians with a 44% response rate. The study examines several issues related to genetic profiling (a statistical process of looking for “risk patterns” of complex diseases such as obesity and diabetes). It is important to understand that genetic profiling is not susceptibility testing (e.g., BRCA testing) which is intended to look for specific gene mutations associated with specific diseases. Instead, genetic profiling looks at single nucleotide polymorphisms (SNPs) in an attempt to identify potential risk information only by statistical association. In theory, the benefit of genetic profiling (as opposed to susceptibility testing) is to encourage disease prevention by encouraging healthy behavior change. However, to date there have been no proven direct benefits from genetic profiling. Haga’s research design was to survey a national practice group of primary care physicians (MDVIP) that started offering genomic risk profiling as a part of their routine practice. This national practice group had recently announced a “collaboration” with the for-profit company Navigenics which heavily markets genetic tests to physicians and the public. Part of this “collaboration” involved an offer by Navigenics to provide as a gift, a personalized genetic profile to all MDVIP physicians. 2 Is it possible that this offer of free genetic testing to doctors had as the primary goal of helping to promote the test and increase company profits? One important finding from Haga’s study was that one third of physicians offered a free genetic profile (cost=$999) accepted the offer. Not surprisingly, those who accepted the free offer were eight times more likely to order the genetic test on their patients compared to those who did not accept the free offer. The low response rate in Haga’s study precludes us from making any broad assumptions of physician behavior; although, hidden in her study are two important social issues that deserve comment. Our patients trust us, and need to trust us, to provide them advice based on what we believe is in their best interest and not influenced by other considerations such as gifts or perks that the doctor receives. Did the MDVIP leadership not consider a $999 offer of a free laboratory test a gift intended to influence the doctor’s practice behaviors? Did they naively believe that Navigenics was offering this free testing based on an altruistic concern over the health of MDVIP doctors? Could it be that Navigenetics knew that an offer of free tests to doctors would increase test ordering for patients? Could it be that this was the basis of their promotional campaign—getting doctors to agree to genetic testing by offering it to them for free?” An offer of an incentive (in this case a free genetic test) from a
Journal of General Internal Medicine 06/2011; 26(8):824-5. DOI:10.1007/s11606-011-1756-z · 3.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Medical genetics lends itself to disseminated teaching methods because of mismatches between numbers of physicians having patients with genetic disorders and availability of genetic specialists.
During 3 years, we implemented an interactive, web-based curriculum on ethical, legal, and social implications in medical genetics for primary care residents in three specialties at three institutions. Residents took five (of 10) cases and three (of five) tutorials that varied by specialty. We assessed changes in self-efficacy (primary outcome), knowledge, application, and viewpoints.
Overall enrollment was 69% (279/403). One institution did not complete implementation and was dropped from pre-post comparisons. We developed a six-factor ethical, legal, and social implications self-efficacy scale (Cronbach α = 0.95). Baseline self-efficacy was moderate (71/115; range: 23-115) and increased 15% after participation. Pre-post knowledge scores were high and unchanged. Residents reported that this curriculum covered ethical, legal, and social implications/genetics better than their usual curricula. Most (68-91%) identified advantages, especially in providing flexibility and stimulating self-directed learning. After participation, residents reported creating learning goals (66%) and acting on those goals (62%).
Ethical, legal, and social implications genetics curricular participation led to modest self-efficacy gains. Residents reported that the curriculum covered unique content areas, had advantages over traditional curriculum, and that they applied ethical, legal, and social implications content clinically. We share lessons from developing and implementing this complex web-based curriculum across multiple institutions.
Genetics in medicine: official journal of the American College of Medical Genetics 06/2011; 13(6):553-62. DOI:10.1097/GIM.0b013e31820e279a · 7.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Worldwide, health care providers use strikes and job actions to influence policy. For health care providers, especially physicians, strikes create an ethical tension between an obligation to care for current patients (e.g., to provide care and avoid abandonment) and an obligation to better care for future patients by seeking system improvements (e.g., improvements in safety, to access, and in the composition and strength of the health care workforce). This tension is further intensified when the potential benefit of a strike involves professional self-interest and the potential risk involves patient harm or death. By definition, trainees are still forming their professional identities and values, including their opinions on fair wages, health policy, employee benefits, professionalism, and strikes. In this article, the authors explore these ethical tensions, beginning with a discussion of reactions to a potential 2005 nursing strike at the University of California, Davis, Medical Center. The authors then propose a conceptual model describing factors that may influence health care providers' decisions to strike (including personal ethics, personal agency, and strike-related context). In particular, the authors explore the relationship between training level and attitudes toward taking a job action, such as going on strike. Because trainees' attitudes toward strikes continue to evolve during training, the authors maintain that open discussion around the ethics of health care professionals' strikes and other methods of conflict resolution should be included in medical education to enhance professionalism and systems-based practice training. The authors include sample case vignettes to help initiate these important discussions.
Academic medicine: journal of the Association of American Medical Colleges 03/2011; 86(5):580-5. DOI:10.1097/ACM.0b013e318212b551 · 2.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In today's world health events in one nation or geographic area often have repercussions for the health and well-being of populations beyond that region; sometimes even globally. In recent years many factors, most notably concern about emerging infectious diseases, have contributed to an increasing appreciation of the interdependency of human, animal and ecosystem health worldwide. Integrated global approaches to improve the health of humans, animals and their shared environments are proving to be in the best interest of many countries. A special symposium and award were established in memoriam to the internationally renowned epidemiologist, Dr. Calvin W. Schwabe, who (while at the University of California, Davis) was a significant advocate of the “One Medicine” approach to public health, calling upon all health professionals, including veterinarians, to work collaboratively and comparatively to improve human health. This paper discusses the evolution of the “One Medicine” concept into a global “One Health” approach to research, training capacity and service infrastructure, focused not only on disease, but also on health at the individual, population, and ecosystem levels. Projects involving UCD faculty which attempt to integrate a One Health approach include the Health for Animals and Livelihood Improvement (HALI) Project in Tanzania, Envirovet Summer Institute, Avian Flu School and Newcastle Immunization Program in Africa, a web-based virtual global health training program, and the Calvin Schwabe One Health Project.
Preventive Veterinary Medicine 12/2009; 92(4-92):268-274. DOI:10.1016/j.prevetmed.2009.09.002 · 2.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The authors describe in detail the 3-year model of the Doctoring curriculum plus an elective fourth-year Doctoring course at University of California, Davis School of Medicine (UCDSOM) and University of California, Los Angeles (UCLA) School of Medicine and the critical role for psychiatry faculty leadership and participation.
The authors present a review of curricular materials and course operations for the different Doctoring courses for first-, second-, third-, and fourth-year curriculum. The authors describe the role of psychiatry faculty in both leadership and in group facilitation.
The Doctoring curriculum offers case-based, small-group learning that relies heavily on standardized patients to teach core content around doctor-patient communication, ethics, behavioral medicine, and counseling approaches. There are frequent psychosocial issues woven in to these encounters. Psychiatry faculty members and other mental health professionals are well-prepared by virtue of their training to lead small group discussions and facilitate the supportive elements of the small groups in medical education.
The Doctoring curriculum is both a biopsychosocial educational endeavor and a high-visibility leadership opportunity for the Department of Psychiatry. Other medical schools and departments of psychiatry may wish to pursue similar roles in their didactic programs.