Using standardized patient encounters to teach longitudinal continuity of care in a family medicine clerkship.

BACKGROUND: Despite demonstrated benefits of continuity of care, longitudinal care experiences are difficult to provide to medical students. A series of standardized patient encounters was developed as an innovative curricular element to address this gap in training for medical students in a family medicine clerkship. The objective of this paper is to describe the development and implementation of the curriculum, evaluate the effectiveness of the curriculum for increasing student confidence around continuity of care and chronic disease management, and explore student opinions of the value of the experience. METHODS: The encounters simulate continuity of care in typical family medicine practice over four standardized patient visits, providing students with experience in longitudinal relationships, ongoing management of chronic and acute conditions, lifestyle counseling, and the use of an electronic medical record. Perceptions of the curriculum were obtained using a pre-post survey asking students to self-rate experience and confidence in continuity relationships, chronic disease management, and lifestyle counseling. Students were also asked about the overall effectiveness of the encounters for simulating family practice and continuity of care. Open-ended comments were gathered through weekly reflection papers submitted by the students. RESULTS: Of 138 third-year medical students, 137 completed the pre-survey, 126 completed the post-survey, and 125 (91%) completed both the pre- and the post-survey. Evaluation results demonstrated that students highly valued the experience. Complete confidence data for 116 students demonstrated increased confidence pre-post (t(115) = 14.92, p < .001) in managing chronic disease and establishing relationships. Open-ended comments reflected how the experience fostered appreciation for the significance of patient-doctor relationships and continuity of care. CONCLUSIONS: This curriculum offers a promising approach to providing students with continuity of care experience. The model addresses a general lack of training in continuity of care in medical schools and provides a standardized method for teaching chronic disease management and continuity relationships.

A curriculum on care for people with disabilities: effects on medical student self-reported attitudes and comfort level.

BACKGROUND: Early, frequent encounters with people with disabilities may improve medical students' knowledge, attitudes and skills regarding their care. We developed and implemented a longitudinal four-year curriculum addressing caring for people with disabilities. OBJECTIVES/HYPOTHESIS: To test differences in mean scores between intervention and control groups on individual post-survey items regarding attitudes toward people with disabilities, and to conduct exploratory procedures to examine individual factors that may account for group differences. METHODS: Students at two U.S. medical schools, one with the new curriculum, and one with no specific disabilities curriculum, were surveyed in Year 1 of medical school, prior to curriculum introduction, and again at the end of Year 3, using a validated 30-item instrument measuring medical students' self-reported attitudes and comfort toward people with disabilities. We compared mean item ratings between the two groups using χ(2) and ANOVA. Principal components analysis was then used to construct linear composite variables that were then regressed on potential predictors of attitudes and comfort level. RESULTS: The intervention led to significant or near-significant improvement in several factors. However, male students in the intervention group, particularly those who encountered people with disabilities in a clinical context, had a tendency to more frequently agree with negative statements (ß = .628, p = .005). CONCLUSIONS: Exposure of medical students to a longitudinal curriculum for caring for people with disabilities led to significant improvement in several factors related to comfort and attitudes. The gender-related reinforcement of some negative attitudes merits further investigation and caution when implementing the curriculum in the future.

Reflective impressions of a precepted clinical experience caring for people with disabilities.

There is evidence that early and frequent encounters with people with disabilities can improve medical students' knowledge, skills, and attitudes about disability. As part of a 4-year integrated curriculum in caring for patients with disabilities, third-year medical students (n = 144) in a Family Medicine clerkship participated in a day-long precepted clinical experience at a medical facility serving people with disabilities, predominantly developmental disabilities, where they met patients and worked with clinicians. At the conclusion of the program, students completed a reflective survey about their experience. These data were analyzed qualitatively using a constructivist grounded-theory approach. Students' responses indicated that the experience improved their comfort levels in working with people with disabilities and increased their awareness of attitudinal factors that influence patient care. Responses also demonstrated that students achieved an awareness of technical accommodations and organizational adaptations that improve patient care.

Development of an instrument to measure medical students' attitudes toward people with disabilities.

As curricula to improve medical students' attitudes toward people with disabilities are developed, instruments are needed to guide the process and evaluate effectiveness. The authors developed an instrument to measure medical students' attitudes toward people with disabilities. A pilot instrument with 30 items in four sections was administered to 342 medical students. Internal consistency reliability and factor analysis were conducted. The Cronbach's alpha coefficient was 0.857, indicating very good internal consistency. Five components were identified: comfort interacting with people with disabilities, working with people with disabilities in a clinical setting, negative impressions of self-concepts of people with disabilities, positive impressions of self-concepts of people with disabilities, and conditional comfort with people with disabilities. The instrument appears to have good psychometric properties and requires further validation.

Attitudes of healthcare students and professionals toward patients with physical disability: a systematic review.

OBJECTIVE: Negative healthcare provider attitudes toward patients with physical disabilities may challenge the delivery of quality care to patients. The objective of this study was to systematically review published studies examining the attitudes of healthcare students and professionals toward patients with physical disabilities. DESIGN: In October 2011, we searched four electronic databases using the OVID platform. In addition, we screened citation lists. Independent reviewers completed the selection of articles and data abstraction by triplicate review using standardized and pilot tested forms. They resolved disagreements by discussion or with the help of an additional reviewer when necessary. Articles were included if they examined healthcare professionals' and students' attitudes toward patients with physical disabilities. We did not perform a meta-analysis because of the variation in instruments used and variables examined. We used a qualitative approach to identifying and reporting common findings across the studies. RESULTS: Results indicate that healthcare students and professionals have favorable attitudes toward persons with physical disabilities. More experience with persons with physical disabilities, both professionally and socially, was associated with more favorable attitudes. In addition, female healthcare students and professionals were found to have more positive attitudes toward patients with physical disabilities than do their male colleagues. Limited evidence exists examining the influence of age, race or ethnicity, and rank of student or professional on attitudes toward patients with physical disabilities. Finally, it was found that healthcare students and professionals reported overall more favorable attitudes than did individuals in non-healthcare professions. CONCLUSIONS: Overall, healthcare students' and professionals' attitudes toward persons with physical disabilities were favorable. However, some studies revealed the possibility that some healthcare providers demonstrate fear and anxiety with the challenge of caring for a patient with physical disabilities. Some of the factors associated with providers' attitudes toward patients with physical disabilities are potentially modifiable (e.g., experience) and could be the target of educational interventions to ameliorate this fear and facilitate higher quality care.

The effects of tracking responses and the day of mailing on physician survey response rate: three randomized trials.

BACKGROUND: The response rates to physician postal surveys remain modest. The primary objective of this study was to assess the effect of tracking responses on physician survey response rate (i.e., determining whether each potential participant has responded or not). A secondary objective was to assess the effects of day of mailing (Monday vs. Friday) on physician survey response rate. METHODS: We conducted 3 randomized controlled trials. The first 2 trials had a 2 x 2 factorial design and tested the effect of day of mailing (Monday vs. Friday) and of tracking vs. no tracking responses. The third trial tested the effect of day of mailing (Monday vs. Friday). We meta-analyzed these 3 trials using a random effects model. RESULTS: The total number of participants in the 3 trials was 1339. The response rate with tracked mailing was not statistically different from that with non-tracked mailing by the time of the first reminder (RR = 1.01 95% CI 0.84, 1.22; I²â€Š =  0%). There was a trend towards lower response rate with tracked mailing by the time of the second reminder (RR = 0.91; 95% CI 0.78, 1.06; I²  =  0%). The response rate with mailing on Mondays was not statistically different from that with Friday mailing by the time of first reminder (RR = 1.01; 95% CI 0.87, 1.17; I²â€Š =  0%), and by the time of the 2(nd) reminder (RR = 1.08; 95% CI 0.84, 1.39; I²  =  77%). CONCLUSIONS: Tracking response may negatively affect physicians' response rate. The day of mailing does not appear to affect physicians' response rate.

Validated instruments used to measure attitudes of healthcare students and professionals towards patients with physical disability: a systematic review.

BACKGROUND: Instruments to detect changes in attitudes towards people with disabilities are important for evaluation of training programs and for research. While we were interested in instruments specific for medical students, we aimed to systematically review the medical literature for validated survey instruments used to measure attitudes of healthcare students and professionals towards patients with physical disability. METHODS: We electronically searched Medline, EMBASE, PsycINFO, Health and Psychosocial Instruments. We included papers reporting on the development and/or validation of survey instruments to measure attitudes of healthcare students and professionals towards patients with physical disability. We excluded papers in which the attitudes were not measured in a provider-patient context. Two reviewers carried out titles and abstracts screening, full texts screening, and data abstraction in a duplicate and independent manner using standardized and pilot tested forms. RESULTS: We identified seven validated survey instruments used for healthcare students and professionals. These instruments were originally developed for the following target populations: general population (n = 4); dental students (n = 1); nursing students (n = 1); and rehabilitation professionals (n = 1). The types of validity reported for these instruments were content validity (n = 3), criterion-related validity (n = 1), construct validity (n = 2), face validity (n = 1), discriminant validity (n = 1), and responsiveness (n = 1). The most widely validated and used tool (ATDP) was developed in the late 1960s while the most recent instrument was developed in the early 1990s. CONCLUSION: Of the seven identified validated instruments, less than half were specifically designed for healthcare students and professionals and none for medical students. There is a need to develop and validate a contemporary instrument specifically for medical students.

A tool for self-assessment of communication skills and professionalism in residents.

BACKGROUND: Effective communication skills and professionalism are critical for physicians in order to provide optimum care and achieve better health outcomes. The aims of this study were to evaluate residents' self-assessment of their communication skills and professionalism in dealing with patients, and to evaluate the psychometric properties of a self-assessment questionnaire. METHODS: A modified version of the American Board of Internal Medicine's (ABIM) Patient Assessment survey was completed by 130 residents in 23 surgical and non-surgical training programs affiliated with a single medical school. Descriptive, regression and factor analyses were performed. Internal consistency, inter-item gamma scores, and discriminative validity of the questionnaire were determined. RESULTS: Factor analysis suggested two groups of items: one group relating to developing interpersonal relationships with patients and one group relating to conveying medical information to patients. Cronbach's alpha (0.86) indicated internal consistency. Males rated themselves higher than females in items related to explaining things to patients. When compared to graduates of U.S. medical schools, graduates of medical schools outside the U.S. rated themselves higher in items related to listening to the patient, yet lower in using understandable language. Surgical residents rated themselves higher than non-surgical residents in explaining options to patients. CONCLUSION: This appears to be an internally consistent and reliable tool for residents' self-assessment of communication skills and professionalism. Some demographic differences in self-perceived communication skills were noted.

A curriculum to teach medical students to care for people with disabilities: development and initial implementation.

BACKGROUND: Lack of knowledge and skills, and negative attitudes towards patients with disabilities, may adversely affect the services available to this group and negatively affect their health outcomes. The objective of this paper is to describe the development and initial implementation of a curriculum for teaching medical students to care for patients with disabilities. METHODS: We followed the six-step approach for developing curricula for medical education: general needs assessment, specific needs assessment, defining goals and objectives, determining the educational strategies, planning the implementation, and developing an evaluation plan. RESULTS: The curriculum has well defined goals and objectives covering knowledge, attitudes and skills. It employs both traditional and non-traditional teaching strategies. The implementation is planned over the four-year medical school curriculum in collaboration with a number of academic departments and specialized community-based agencies. The curriculum evaluation includes an attitudinal survey which is administered using a controlled design (pre- and post- exposure to the curriculum). The initial implementation of the curriculum has been very successful. CONCLUSION: We have developed a longitudinal curriculum to teach medical students to care for people with disabilities. A rigorous evaluation of the impact of the curriculum is needed.

Experiences promoting healthcare career interest among high-school students from underserved communities.

Promoting early interest in healthcare careers among youth from underserved areas is one promising strategy for addressing the health professional shortage in such communities, Most career choice studies try to predict outcomes using such traditional measures as grades and test scores, This study examines experiences influencing healthcare career interest among high-school students participating in health professions introductory programs in underserved communities. The opinions of parents and teachers regarding students' motivations are also considered. Seven focus groups (N=51) were conducted in one rural and two largely minority urban communities in New York State designated as health professional shortage areas. Qualitative data analysis involved a theory-driven, immersion and crystallization approach following the experiential learning model. Constructive experiences with the healthcare system, family role-modeling and support, interactive health-related school activities, the media, inspirational and accessible school staff, and strategic community partnerships, among other factors, facilitated student interest in health professions. Findings suggest that underserved and disenfranchised community environments still pose challenges for furthering healthcare career interest among youth.

Defining differences in the instructional styles of community preceptors.

BACKGROUND AND OBJECTIVES: Variability exists in the instructional experiences of medical students in clinical settings. As relationships between community-based physicians and medical students expand, it is important to promote instructional styles that enhance teaching and learning. This study identified attitudes and approaches toward teaching that distinguish preceptors with high student ratings from those with lower ratings. METHODS: Interviews were conducted with a purposive sample of 14 preceptors who had received either high or low scores from first-year students on the MedEd IQ, a standardized tool for assessing ambulatory clinical training experiences. Transcripts were analyzed using a qualitative approach. RESULTS: High-scoring preceptors were distinguished by six attributes: welcoming novice clinicians as legitimate participants in a community of practice, creating a central role for students in patient care and teaching, regularly engaging students in self-reflection to monitor their progress, helping students discover learning opportunities in routine patient encounters, using feedback to shape rather than evaluate student performance, and creating an environment where novices felt comfortable practicing new skills with patients. CONCLUSIONS: The results suggest that high-scoring preceptors provide a decidedly different experience through their approach to the challenge of training inexperienced students. These findings have implications for preceptor selection criteria and faculty development curricula.