How did we make the Interdisciplinary Generalist Curriculum Project work? National efforts to facilitate success.

The Interdisciplinary Generalist Curriculum (IGC) Project created curricular changes at the participating schools with very little direct financial support. A reconsideration of the process of this national effort reveals many intangible elements that were as critical to the project's successes as were the direct dollars. Those factors included careful attention to the criteria for school selection, specific project requirements that allowed institutional flexibility in project evolution, national assistance in program implementation, early and ongoing national recognition for project schools, and a highly organized, involved, and goal-oriented national organization. This national initiative provides a successful model for future funding of projects in this era of dwindling financial support for medical education innovation.

The Interdisciplinary Generalist Curriculum Project at the University of Illinois at Chicago College of Medicine.

The Interdisciplinary Generalist Curriculum (IGC) Project was initiated at the University of Illinois at Chicago (UI-Chicago) College of Medicine to link an ongoing longitudinal primary care experience with a didactic curriculum emphasizing generalism. The result of this educational initiative was a more extensive reform of the preclinical curriculum than originally had been planned. The IGC Project catalyzed a critical analysis of the first- and second-year curriculum that continues and that has resulted in the integration of all of the early clinical course work under a single longitudinal curriculum. The IGC Project also established a model for interdisciplinary collaboration in course and curriculum design and expanded the walls of the university to include greater numbers of community-based generalist preceptors. This modestly funded and focused educational initiative had unanticipated and far-reaching implications for educational activities throughout the College of Medicine at UI-Chicago.

Utilization of outpatient diagnostic imaging. Does the physician's gender play a role?

OBJECTIVE: To examine physician and patient characteristics related to the ordering of imaging studies in a general medicine practice and to determine whether physician gender influences ordering patterns. DESIGN: Retrospective cohort study. SETTING: Hospital-based academic general medicine practice of 29 attending physicians. PATIENTS: All 8,203 visits by 5,011 patients during a 6-month period. METHODS: For each visit the following variables were abstracted from the electronic patient record: patient age, patient gender, visit urgency, visit type, and physician seen. All diagnostic imaging studies performed within 30 days of each outpatient visit were identified from the hospital's Radiology Information System. Screening mammography was not included in the analysis. Physician variables included gender and years since medical school graduation. Logistic regression analysis was used to evaluate the effect of various patient, physician, and visit characteristics on the probability of a diagnostic imaging study being ordered. RESULTS: Patient age, urgent visits, visit frequency, and the gender of the physician were all significantly related to the ordering of an imaging study. Correcting for all other factors, the ordering of an imaging study during an outpatient medical visit was 40% more likely if the physician was female (odds ratio = 1.40; 95% confidence interval [CI] 1.01, 1.95). Female physicians were 62% more likely (95% CI 0.99, 2.64) than male physicians to order an imaging study for a male patient and 21% more likely (95% CI 0.87, 1.69) to order an imaging study for a female patient. CONCLUSIONS: Physician gender is a predictor of whether an outpatient medical visit generates an imaging study. Reasons for this observation are unclear, but may be the result of different practice styles of male and female physicians or unmeasured patient characteristics.

Practical approaches to a major educational challenge. Training students in the ambulatory setting.

Medical schools and residency training programs are recognizing the need to expand education in ambulatory medicine. Inpatients wards increasingly provide treatment for only the most critically ill patients and are required only for very specialized procedure-oriented technology. Most diagnostic and management decisions are being made in outpatient settings. This shift in where medical care occurs has led to a reassessment of the educational value of training students and house staff primarily on hospital-based wards. New training initiatives in ambulatory medicine are being developed in medicine, pediatrics, and family medicine, and the principal sites for most of this training are primary care offices, clinics, and health maintenance organizations. Program planners and individual preceptors are confronting numerous obstacles in their efforts to find effective solutions to the dilemmas raised by the need to train large numbers of students in these settings. This article will explore many of these obstacles, including the unique learning requirements of third-year students, the elements of a quality clinical training environment, and the precepting skills needed for this educational task. Finally, we propose for debate a model for ambulatory medical education that focuses on strengthening the ties between academia and the numerous training sites. By taking optimal advantage of academic and community attributes, we are more likely to be assured quality medical education, skilled teaching, and rigorous scholarship in ambulatory medicine.

Detection of bulimia in a primary care setting.

OBJECTIVE: To develop a screening tool for the identification of bulimia in ambulatory practice. DESIGN: Administration of a 112-item questionnaire about eating and weight-control practices to women with known bulimia and to healthy control patients. Questions were compared with DSM-III-R criteria of bulimia as a "gold standard." SETTING: Self-help group for eating disorders and hospital-based primary care practice. SUBJECTS: Thirty of 42 women with known bulimia met DSM-III-R criteria for current bulimia, and 124 of 130 control patients met the criterion of no history of an eating disorder. MAIN RESULTS: Thirteen individual questions discriminated between bulimic subjects and control subjects with a sensitivity and specificity of > 75%. When these questions were entered into a stepwise logistic model, two questions were independently significant. A "no" response to the question "Are you satisfied with your eating patterns?" or a "yes" response to "Do you ever eat in secret?" had a sensitivity of 1.00 and a specificity of 0.90 for bulimia. The positive predictive value, based on a 5% prevalence, was 0.36. CONCLUSIONS: A set of two questions may be as effective as a more extensive questionnaire in identifying women with eating disorders, and could be easily incorporated into the routine medical history obtained from all women.

Strategies to improve teaching in the ambulatory medicine setting.

Expansion of resident training in ambulatory medicine has created new challenges for faculty preceptors. Outpatient teaching is hampered by inadequate time and a reliance on methods of instruction that are more useful for the inpatient setting. Effective outpatient teaching requires an understanding of the objectives of ambulatory medical training and improved facility with teaching methods that accommodate the brief, impromptu nature of ambulatory teaching. In a hypothetical outpatient teaching encounter, the interactions between the patient, resident, and attending physician are dissected to reveal missed opportunities to teach and to explore alternative approaches to the educational process. These approaches include promoting the resident's role as the primary provider, developing a limited teaching agenda for each teaching encounter, focusing on the learner rather than on the diagnostic dilemma posed by the patient, and using questions, role modeling and observation with feedback to promote learning.

Faculty development for ambulatory teaching.

This paper deals with helping faculty members and others learn to teach more effectively in ambulatory settings. First it suggests ways to help clinicians expand and update their knowledge and skills in ambulatory medicine as a foundation for teaching. Next it identifies six skills--establishing mutual expectations, setting limited teaching goals, asking questions, stimulating self-directed learning, giving feedback, and capitalizing on role modeling--that are basic to effective ambulatory teaching. Then it presents strategies for developing and maintaining such skills: assessment of teaching, consultation with experts in education, and participation in programs such as workshops. The paper ends by discussing aspects of institutional support and calling for research on the impact of faculty development efforts on teaching and learning in medicine.

The resident as teacher during work rounds.

The resident is a central figure in the education of medical students and other residents. In order to examine the ways in which residents fulfill their teaching responsibilities, the authors observed 14 first- and second-year internal medicine residents as they reviewed a total of 158 cases during work rounds. Inpatient work rounds were selected for study because in this setting an attending faculty member is not present and the resident bears total responsibility for initiating any teaching that occurs. The results of the study indicated that the most frequently observed teaching behaviors were associated with patient care at the bedside: providing a model of appropriate interaction with patients and verifying clinical findings. Away from the bedside, the residents frequently used brief lectures to teach. The least frequently observed teaching behaviors involved referring to the literature, giving feedback, demonstrating techniques and procedures, and asking questions. Following these observations, the authors initiated a course on clinical teaching for residents.