A needs assessment for simulation-based training of emergency medical providers in Nebraska, USA.

BACKGROUND: Training emergency medical services (EMS) workforce is challenging in rural and remote settings. Moreover, critical access hospitals (CAHs) struggle to ensure continuing medical education for their emergency department (ED) staff. This project collected information from EMS and ED providers across Nebraska to identify gaps in their skills, knowledge, and abilities and thus inform curriculum development for the mobile simulation-based training program. METHODS: The needs assessment used a three-step process: (1) four facilitated focus group sessions were conducted in distinct geographical locations across Nebraska to identify participants' perceived training gaps; (2) based on the findings from the focus group, a needs assessment survey was constructed and sent to all EMS and ED staff in Nebraska; and (3) 1395 surveys were completed and analyzed. RESULTS: Thematic areas of training gaps included cardiopulmonary conditions, diabetes management, mass casualty incidents (MCI), maternal health and child delivery, patient assessment, pediatric care (PC), and respiratory emergency care. Gaps in non-clinical skills were related to crisis management such as maintaining effective teamwork. Participants frequently identified cardiopulmonary care, PC, and MCI as highly needed trainings. Other needs included life support-related retaining courses, sessions informing protocol updates, the availability of retraining tailored for rural areas, substance use-related emergencies, and farming-related injuries. CONCLUSION: EMS and ED staff identified several skill gaps and training needs in the provision of emergency services in rural communities. These results allow for the development of customized training curricula and, with the help of an on-site simulation-based program, can identify gaps in health professionals' skills, knowledge, and abilities and thus help them respond to acute healthcare needs of rural communities.

Student-Perceived Influences on Performance During Simulation.

BACKGROUND: Understanding the effect of the context of simulation to learning and performance is critical to ensure not only optimal learning but to provide a valid and reliable means to evaluate performance. The purpose of this study is to identify influences on performance from the student perspective and understand the contextual barriers inherent in simulation before using simulation for high-stakes testing. METHOD: This study used a qualitative descriptive design. Senior nursing students (N = 29) provided nursing care during simulation. Vocalized thoughts during simulation and reflective debriefing were digitally recorded and transcribed verbatim. Thematic analysis was conducted on transcribed data. RESULTS: Student performance during simulation was influenced by anxiety, uncertainty, technological limitations, and experience with the patient condition. Students had few previous simulation-based learning experiences that may have influenced performance. CONCLUSIONS: More needs to be understood regarding factors affecting simulation performance before pass-or-fail decisions are made using this technology. [J Nurs Educ. 2016;55(7):396-398.].

Influence of a rural family medicine rotation on residency selection: MS3 versus MS4.

BACKGROUND AND OBJECTIVES: Many family medicine educators feel that a required clinical rotation in family medicine has a positive influence on medical students' selection of family medicine residencies. We investigated the effect of a rural family medicine rotation on students' residency choices and examined the differences between a third-year and a fourth-year rotation. METHODS: We surveyed 1,260 students before and after they participated in a required rural family medicine rotation. RESULTS: The rotation had a small positive effect on student interest in family medicine. Over 20 years, there was a net gain of 4.7% (93 students) from before to after the rotation. Moving the rural rotation from the MS4 to the MS3 year resulted in a significant decline in the number of students who switched their preferences toward family medicine and ultimately matched to a family medicine residency. CONCLUSIONS: When the rotation occurs in the third year, there is more time following the rotation for other influences to exert an impact on a student's specialty choice, resulting in a small "bleed" away from family medicine. It might be useful to develop programs that continue to pique the interest in family medicine during their fourth year.

From professional silos to interprofessional education: campuswide focus on quality of care.

OBJECTIVES: The Institute of Medicine called for the integration of interprofessional education (IPE) into health professions curricula, in order to improve health care quality. In response, we developed, implemented, and evaluated a campus wide IPE program, shifting from traditional educational silos to greater collaboration. METHODS: Students (155) and faculty (30) from 6 academic programs (nursing, medicine, public health, allied health, dentistry, and pharmacy) engaged with a university hospital partner to deliver this program. The content addressed principles of IPE, teamwork development and 2 common quality care problems: hospital-acquired infections and communication errors. Pre-/post-surveys, the Readiness for Interprofessional Learning Scale, and the Interprofessional Education Perception Scale, were used for descriptive assessment of student learning. RESULTS: Students demonstrated increased understanding of health care quality and interprofessional teamwork principles and reported positive attitudes toward shared learning. While responses to the Readiness for Interprofessional Learning Scale grew more positive after the program, scores on the Interprofessional Education Perception Scale were more homogeneous. Both students and faculty highly evaluated the experience. CONCLUSION: This program was a first step in preparing individuals for collaborative learning, fostering awareness and enthusiasm for IPE among students and faculty, and demonstrating the feasibility of overcoming common barriers to IPE such as schedule coordination and faculty buy-in.

Reaching and teaching preceptors: limited success from a multifaceted faculty development program.

We conducted a six-pronged preceptor faculty development program that included a listserve and interactive Web-based teaching scenarios. A total of 144 preceptors in a required preceptorship program were offered traditional continuing medical education (CME), a preceptor listserve, an electronic clinical teaching discussion group, an orientation videotape, a CD-ROM on teaching skills, and technology support. On Web-based evaluation, 31% of participants responded. Eighty percent of preceptors allowed us to subscribe them to the listserve, and most agreed it was useful. One third of preceptors responded to an electronic clinical teaching case discussion, most rating it useful to their precepting. The listserve and electronic teaching cases hold promise for preceptor faculty development.

Preceptorship rurality does not affect medical students' shelf exam scores.

OBJECTIVE: This study's objective was to determine whether junior medical students' end-of-rotation shelf exam scores varied by the preceptorship county's rurality. METHODS: Student learning during rural preceptorship experiences, 1999 to 2005, was assessed using the students' scores on the National Board of Medical Examiners family medicine subject examination. Rurality was measured using both population density and the rural-urban continuum (RUC) codes. RESULTS: Exam scores were collected between January 1999 and May 2005 for 734 students. Mean scores did not vary significantly by rurality, although they did vary significantly by semester. Test scores of students in rural locations were not statistically significantly different from those of students in urban preceptorships. CONCLUSIONS: Students assigned to preceptorships in rural locations scored at the same levels as students in urban preceptorships. The finding that there were no differences in medical students' exam scores based on the rurality of their family medicine preceptorship site indicates a substantial degree of educational equivalency between urban and rural preceptorships.

Family medicine curriculum resource project: overview.

In 2000, the Health Resources and Services Administration, in the interest of fostering curriculum reform in medical schools, awarded a 4-year contract to the Society of Teachers of Family Medicine to develop a curricular resource. The contract directed development of a multi-part resource aimed at (1) preclerkship prerequisites for third-year clerkships in collaboration with internal medicine and pediatrics, (2) the family medicine clerkship, (3) post-clerkship preparation for residency training, and (4) specific special topic areas of importance to the government. The Family Medicine Curriculum Resource (FMCR) was produced by primary care educators, with day-to-day direction from an executive committee and overall oversight by an advisory committee. The FMCR was built around a theoretical framework to link medical student competencies with the Accreditation Council for Graduate Medical Education (ACGME) competencies for residency training. Considerable energy throughout development of the FMCR was devoted to obtaining input from potential end-user audiences through an active dissemination effort.

A proposal to address the curriculum for the M-4 medical student.

The unstructured and elective nature of the fourth-year medical student (M4) medical school curriculum has been recognized by medical educators as an area of concern. Few accepted guidelines exist for the M4 curriculum, and students exercise significant discretion over their experience. The Family Medicine Curriculum Resource Project post-clerkship resource was developed by the Society of Teachers of Family Medicine under contract from the Health Resources and Service Agency to support medical educators in the development of curricula and assessment of student needs for the M4 year of medical school. The post-clerkship resource defines competencies for graduation and contains educational resources as well as recommendations for faculty development and student evaluation in the M4 year.

Family Medicine Curriculum Resource Project: the future.

Under contract to the Health Resources and Services Administration (HRSA), the Society of Teachers of Family Medicine (STFM) created an undergraduate medical education curricular resource designed to train physicians to practice in the 21st century. An interdisciplinary group of more than 35 educators worked for 4 years to create the Family Medicine Curriculum Resource (FMCR). By consensus, the Accreditation Council for Graduate Medical Education (ACGME) competencies were adopted as the theoretical framework for this project. The FMCR provides materials for the preclerkship years, the third-year family medicine clerkship, the postclerkship year, and faculty development, as well as guidance for integrating topics of special interest to the federal government (such as, geriatrics, Healthy People 2010, genetics, informatics) into a 4-year continuum of medical education. There are challenges inherent in implementing each component of the FMCR. For example, can the ACGME competency-based approach be adapted to undergraduate medical education? Can the densely packed preclerkship years be adapted to include more focused effort on developing these competencies, and whose job is it anyway? What is "core" to being a competent clinician, and what information can be obtained when needed from medical informatics sources? Will family medicine educators embrace the FMCR recommendations for their third-year clerkships? Will exit assessment of the competency levels of graduating medical students be achieved, and can it make them more capable residents? Can faculty in different clinical and educational settings integrate the teaching of "how to learn" into their repertoire? How will faculty development innovation progress in a time of increasing emphasis on clinical productivity? Developing a common language and adoption of core competencies for all levels of medical education is imperative in a society that is focusing on improving health care quality and outcomes. The FMCR Project has developed a curricular resource to assist medical educators in this task. The challenge for the future is to measure how the FMCR is used and to ascertain if it has an influence on better patient and system outcomes.

The characteristics of successful family physicians in rural Nebraska: a qualitative study of physician interviews.

CONTEXT: In studying physician shortage issues, few studies have utilized individual interviews, allowing rural physicians to voice their own stories. PURPOSE: To explore rural physicians' unique characteristics affecting their decisions and satisfactions with practice in a rural area. METHODS: A qualitative interview study with 11 Nebraska family physicians practicing in rural (frontier) areas. FINDINGS: Previous experience and preference for a rural lifestyle, desire for autonomy, a wide scope of practice, and close relationships with patients defined those physicians choosing rural practice.

The effect of preceptorship rurality on students' self-perceived clinical competency.

OBJECTIVE: This study's objective was to determine whether students' learning experiences, as measured by the improvement in students' perceived competence in several clinical areas, varied by the preceptorship county's rurality. METHODS: Rural preceptorship experiences from 1990 to 2003 were assessed using pre- and post-preceptorship questionnaires regarding students' perceived levels of competence. Questionnaires addressed basic clinical skills, common diagnoses, and advanced clinical skills. Rurality was measured both as population density and using the Rural-Urban Continuum (RUC) codes. RESULTS: Primary analysis was completed using 1,037 sets of questionnaires; 231 questionnaires were unsuitable for analysis due to missing information. Mean perceived competency improved for all items. Students in rural locations, regardless of operationalization, had no statistically significant differences from students in urban locations in perceptions of their clinical skill or comfort with basic diagnoses. Individual item analyses revealed a gendered pattern. Women improved more than men on the technical skills; men improved more on women's health and psychosocial items. CONCLUSIONS: There were no differences in medical students' perceived competence based on the rurality of their family medicine preceptorship site. The preceptorship experience provides both women and men with a variety of experiences that lead to increased confidence in areas where they were least confident prior to the preceptorship.

Evidence-based and population-based medicine: national implementation under the UME-21 project.

BACKGROUND AND OBJECTIVES: The Undergraduate Medical Education for the 21st Century (UME-21) project developed and implemented innovations to medical school curricula at medical schools across the country. This report describes the development and implementation of innovative approaches to improving instruction in evidence-based medicine with a population-based perspective. METHODS: Each school participating in the UME-21 project designed, implemented, and evaluated its own unique curriculum initiatives. We examined these initiatives using data abstracted from written reports submitted to the project Executive Committee. Additional data were obtained by personal communication with project directors and evaluators at the various schools, student and preceptor comments, internal program evaluation at each school, and external evaluation by the UME-21 project leadership. The Association of American Medical Colleges Graduation Questionnaire was also used. RESULTS: Fourteen of 18 participating schools implemented a broad range of curricula to facilitate teaching and learning about evidence-based and population-based medicine. Common themes included the application of evidence to patient care, use of clinical practice guidelines and pathways, and the general incorporation of evidence-based techniques (literature searching, critical appraisal, etc) into the teaching of other content, such as clinical science and managed care. Teaching approaches included Web-based and other computer-based education, an emphasis on active and self-directed learning, use of small groups and workshops, and distribution of this content over multiple years. As an alternative to full-length evidence-based medicine courses, many schools incorporated an evidence-based approach into existing courses and clerkships. Data demonstrated an upward trend in student satisfaction with how topics were presented at UME-21 schools. CONCLUSIONS: These innovations successfully demonstrated that evidence-based and population-based medicine content can be introduced into medical school curricula. Introducing these constructs in ways that demonstrate their relevance to patient care facilitates student learning.

From library to discharge: a managing care student project.

BACKGROUND AND OBJECTIVES: The Patient Care Project (PCP) was a central component of the Undergraduate Medical Education for the 21st Century (UME-21) grant project at the University of Nebraska. With the primary goal of improving students' critical thinking skills, the PCP was directed more toward an understanding of managing care than the business aspects of managed care and emphasized written communication skills, clinical hypothesis testing, and exploring ways to solve medical and ethical questions. METHODS: All 239 students graduating in 2000 and 2001 were required to analyze the medical care received by one of their hospitalized patients. Using a criterion-based evaluation tool, students' written critiques were assessed in five specific areas, all of which required critical thinking skills. Students also received an overall grade for the project. The UME-21 Graduation Survey was used to assess changes in attitudes and behavior. Students graduating in 1999, prior to the institution of the PCP graduation requirement, served as a control group. RESULTS: The most frequently discussed topic of the PCPs was cardiovascular disease. The mean overall rating by the faculty for the PCPs was 3.7 and 3.8 in academic years 2000 and 2001, respectively (maximum=5). In a qualitative analysis of the PCPs, students demonstrated insight into their patients' overall medical care, including the use of evidence-based medicine (EBM), quality improvement, and cost containment. There were no statistically significant differences, however, between the PCP and control groups on the UME-21 Graduation Survey. Nonetheless, more students who had completed the PCP reported that they had identified the total cost of a patient's stay, designed a quality improvement loop, and obtained clinical evidence from an EBM computer database. On this same survey, all students agreed with the use of clinical practice guidelines and cost containment. CONCLUSIONS: The PCP appeared to be relevant to the students' learning needs, and they provided cogent critiques of the medical care they had rendered as well as critical analyses of their patients' discharge summaries and the cost of care including ways to reduce cost. On the other hand, we were unable to demonstrate any substantial differences in the results of the UME-21 Graduation Survey given to both the PCP and control groups. In spite of this lack of effect on students' attitudes, the PCP was perceived by the faculty to be valuable and has been incorporated into the required third-year family medicine clerkship at the University of Nebraska.

Do clerkship directors think medical students are prepared for the clerkship years?

PURPOSE: Educators have begun to question whether medical students are adequately prepared for the core clerkships. Inadequate preclerkship preparation may hinder learning and may be predictive of future achievement. This study assessed and compared the views of clerkship directors regarding student preparation for the core clinical clerkships in six key competencies. METHOD: In 2002, a national survey was conducted of 190 clerkship directors in internal medicine, family medicine, pediatrics, surgery, obstetrics/gynecology, and psychiatry from 32 U.S. medical schools. Clerkship directors were asked to report their views on the appropriate level of student preparation needed to begin the core clinical clerkships (none, minimal, intermediate, advanced), and the adequacy of that preparation (ranging from "much less" to "much more than necessary") in six key clinical competencies. RESULTS: A total of 140 clerkship directors responded (74%). The majority reported that students need at least intermediate ability in five of six competencies: communication (96%), professionalism (96%), interviewing/physical examination (78%), life-cycle stages (57%), epidemiology/probabilistic thinking (56%), and systems of care (27%). Thirty to fifty percent of clerkship directors felt students are less prepared than necessary in the six competencies. Views were similar across all specialties and generally did not differ by other clerkship director characteristics. CONCLUSIONS: Almost half of clerkship directors were concerned that students do not receive adequate preparation in key competencies before starting the core clinical clerkships. Many medical schools may need to give more attention to the preclerkship preparation of students in these high-priority areas.

Teaching the quality improvement process to junior medical students: the Nebraska experience.

To teach the continuous quality improvement (CQI) process to junior medical students at the University of Nebraska during their rural family medicine preceptorship, we designed and implemented a population health project in 1998. This project requires students to select a problem affecting a population in their preceptor's practice, analyze that problem, and suggest a solution or remediation using CQI principles. Support for the students during their project includes Web-based examples and readings. Results of this project have included national presentations and changes in several preceptors' practice patterns. This project has been well accepted by preceptors and students.