Impact of a virtual coaching program for women physicians on burnout, fulfillment, and self-valuation.

BACKGROUND: Coaching has been demonstrated to be an effective physician wellness intervention. However, this evidence-based intervention has not yet been widely adopted in the physician community. Documentation and implementation research of interventions to address physician burnout in real world settings is much needed. OBJECTIVE: Assess the impact of a virtual physician coaching program in women physicians. DESIGN: Pre- and post-intervention surveys administered to participants enrolled in the program (N = 329). Effect size was calculated comparing pre- and post-intervention paired data (N = 201). PARTICIPANTS: 201 women physicians from 40 states in the United States of America and 3 international participants. INTERVENTIONS: Participants were given access to an 8 week virtual coaching program including eight individual, six small group, and 24 large group sessions. MAIN MEASURES: Stanford Professional Fulfillment Inventory (PFI) containing categories for assessing professional fulfillment, burnout, and the Clinician Self-Valuation (SV) Scale (a measure of self-compassion). KEY RESULTS: Burnout was found in 77.1% (N = 155) of participants at baseline, which reduced to 33.3% (N = 67) at completion with large effect size (Cohen's d 1.11). The percentage of participants who endorsed significant professional fulfillment started at 27.4% (N = 55) and improved to 68.2% (N = 137) with a large effect size (Cohen's d 0.95). Self-valuation improved from 17.9% (N = 36) of the participants endorsing a compassionate self-improvement perspective to 64% of the same participants eight weeks later. The self-valuation metric showed a very large effect size (Cohen's d 1.28). CONCLUSIONS: Virtual physician coaching programs led by physician coaches can decrease burnout, improve professional fulfillment, and increase self-compassion. Non-institution-based opportunities for coaching available to any physician across the United States and internationally can facilitate access to effective physician well-being interventions.

Implementation and Outcomes of a Community Assessment Service-Learning Activity Within Academic Learning Communities.

A community needs assessment and engagement activity was implemented in 2013 in the core preclinical curriculum as part of the doctoring course within Academic Communities at UC San Diego School of Medicine. This required educational experience included curricular learning objectives as well as goals to strengthen community service within academic communities. This activity was implemented and sustained within the academic communities with each community serving a different community of San Diego. Survey data from preclinical students from 2014 to 2017 consistently reported that the community assessment activity helped sustain or develop a service project in the academic community (67.1%-79.6% strongly agree or agree) and increased students' knowledge of the needs in the assigned San Diego community (76.3%-80.6% strongly agree or agree). Students felt that the community assessment and engagement activity was a valuable learning experience (62.5%-77.8% strongly agree or agree). As a result of this educational intervention, 14 projects were implemented in the community. A subset of particularly interested and motivated medical students then took on leadership roles in these projects. Student-led scholarly assessment of the impact of some of these interventions resulted in 2 peer-reviewed publications thus far and 9 national presentations at the time of this publication. These assessments demonstrate not only educational impact, but health-system-level changes and meaningful change in patient outcomes.

Implementation and Evaluation of a Recurring Interdisciplinary Community Health Fair in a Remote U.S.-Mexico Border Community.

The purpose of this project was to design, implement, and assess a recurring interdisciplinary community health fair in an underserved border town. University of California San Diego (UCSD) medical and pharmacy students, under faculty supervision, worked alongside community partners in Calexico, California to implement a health fair two miles from the U.S.-Mexico border. Demographic and screening data were described from 293 participants from 2014 to 2016. Over 90% (269/293) listed Mexico as their country of birth, 82.9% (243/293) were monolingual Spanish speakers, 75.4% (221/293) had an annual household income of ≤ $20,000, and 58.7% (172/293) described their health as fair or poor. Screening revealed 91.1% (265/291) were overweight or obese, 37.8% (109/288) had hypertension, 9.3% (27/289) had elevated blood sugar, and 11.4% (33/289) had elevated total cholesterol levels. This model could be replicated in other training settings to increase exposure to border health issues and connect patients to local health services.

Addressing Food Insecurity in Family Medicine and Medical Education.

BACKGROUND AND OBJECTIVES: Food insecurity is associated with poor health outcomes, yet is not routinely addressed in health care. This study was conducted to determine if education regarding food insecurity as a health issue could modify knowledge, attitudes, and clinical behavior. METHODS: Educational sessions on food insecurity and its impact on health were conducted in 2015 at three different family medicine residency programs and one medical school. A pre/post survey was given immediately before and after this session. Attendees were encouraged to identify and implement individual and system-based changes to integrate food insecurity screening and referrals into their clinical practices. Participants completed follow-up surveys approximately 1 year later, and the authors obtained systems-level data from electronic health records and databases. Pre/post means (SD) were compared using t-tests. The numbers of patients screened and referred were calculated. RESULTS: Eighty-five participants completed the pre/post survey during the educational sessions (51 medical students, 29 residents, 5 faculty). Self-reported knowledge of food insecurity, resources, and willingness to discuss with patients increased (P<0.0001 for all). Each program identified a feasible systems-based change. Follow-up surveys demonstrated increased discussion of food insecurity during clinical visits and referrals to food resources. Over 1,600 patients were screened for food insecurity as a result of systems-based changes. CONCLUSIONS: Educational interventions focused on the role of food insecurity in health can produce improvements in knowledge and attitudes toward addressing food insecurity, increase discussions with patients about food insecurity, and result in measurable patient and systems-level changes.

Small group activities within academic communities improve the connectedness of students and faculty.

BACKGROUND: The University of California, San Diego, School of Medicine implemented a curriculum change that included reduction of lectures, incorporation of problem-based learning and other small group activities. Six academic communities were introduced for teaching longitudinal curricular content and organizing extracurricular activities. METHODS: Surveys were collected from 904 first- and second-year medical students over 6 years. Student satisfaction data with their sense of connectedness and community support were collected before and after the implementation of the new curriculum. In a follow-up survey, medical students rated factors that contributed to their sense of connectedness with faculty and students (n = 134). RESULTS: Students' perception of connectedness to faculty significantly increased following implementation of a curriculum change that included academic communities. Students ranked small group clinical skills activities within academic communities significantly higher than other activities concerning their sense of connectedness with faculty. Students' perception of connectedness among each other was high at baseline and did not significantly change. Small group activities scored higher than extracurricular activities regarding students' connectedness among themselves. CONCLUSIONS: The implementation of a new curriculum with more small group educational activities including academic communities enhanced connectedness between students and faculty and resulted in an increased sense of community.

Longitudinal Hypertension Outcomes at Four Student-Run Free Clinic Sites.

BACKGROUND AND OBJECTIVES: Student-Run Free Clinics (SRFCs) play a significant role in medical education yet there is minimal information about patient outcomes over time in this setting. The purpose of this study was to assess longitudinal outcomes of hypertension management during routine care at four SRFC sites, while comparing control rates with national standards, and examining for characteristics independently associated with uncontrolled hypertension. METHODS: The authors conducted a retrospective medical record review of visits from January 2004 through April 2016 with an initial visit for hypertension and a follow-up visit 9 to 15 months later. Hypertension control was analyzed using descriptive statistics, paired t tests, logistic regression, and a longitudinal linear mixed-effects model. RESULTS: This study included 496 patients and 4,798 visits. The mean age was 50.9 (SD 10.8) years old, 71.2% (346) were Latinos, 63.3% (314) were Spanish speaking, and 15.5% (72) were homeless. Mean blood pressure was reduced from 141.6 (SD 21.8)/85.1 (SD 13.2) to 132.1 (SD 17.3)/79.4 (SD10.8), a decrease of 9.5 (CI 7.4, 11.5)/5.7 (CI 4.4, 7.0) mmHg. Blood pressure was significantly reduced within the first month of treatment, and this reduction was sustained throughout the follow-up period. Using the National Health and Nutrition Examination Survey (NHANES) definition (<140/<90), blood pressure was controlled in 59.7% (296/496) of patients. No significant differences in control were noted based on gender, ethnicity, language, housing status, or clinic site. CONCLUSIONS: SRFCs can provide effective long-term hypertension management and achieve rates of control that exceed national averages despite serving those least likely to be controlled.

Implementation of a food insecurity screening and referral program in student-run free clinics in San Diego, California.

Food insecurity is associated with many poor health outcomes yet is not routinely addressed in clinical settings. The purpose of this study was to implement a food insecurity screening and referral program in Student-run Free Clinics (SRFC) and to document the prevalence of food insecurity screening in this low-income patient population. All patients seen in three SRFC sites affiliated with one institution in San Diego, California were screened for food insecurity using the 6-item United States Department of Agriculture (USDA) Food Security Survey between January and July 2015 and referred to appropriate resources. The percentage of patients who were food insecure was calculated. The screening rate was 92.5% (430/463 patients), 74.0% (318/430) were food insecure, including 30.7% (132/430) with very low food security. A food insecurity registry and referral tracking system revealed that by January 2016, 201 participants were receiving monthly boxes of food onsite, 66 used an off-site food pantry, and 64 were enrolled in the Supplemental Nutrition Assistance Program (SNAP). It is possible to implement a food insecurity screening and referral program into SRFCs. The prevalence of food insecurity in this population was remarkably high yet remained largely unknown until this program was implemented. Other health care settings, particularly those with underserved patient populations, should consider implementing food insecurity screening and referral programs.

Medical Student Perceptions of the Learning Environment: Learning Communities Are Associated With a More Positive Learning Environment in a Multi-Institutional Medical School Study.

PURPOSE: Many medical schools have implemented learning communities (LCs) to improve the learning environment (LE) for students. The authors conducted this study to determine whether a relationship exists between medical student perceptions of the LE and presence of LCs during the preclerkship years. METHOD: Students from 24 schools participating in the American Medical Association Learning Environment Study completed the 17-item Medical Student Learning Environment Survey (MSLES) at the end of their first and second years of medical school between 2011 and 2013. Mean total MSLES scores and individual item scores at the end of the first and second years in schools with and without LCs were compared with t tests, and effect sizes were calculated. Mixed-effects longitudinal models were used to control for student demographics and random school and student effects on the relationship between LC status and MSLES score. RESULTS: A total of 4,980 students (81% of 6,148 matriculants) from 18 schools with LCs and 6 without LCs participated. Mean [SD] MSLES scores were significantly higher in LC schools compared with non-LC schools at the end of year one (3.72 [0.44] versus 3.57 [0.43], P < .001) and year two (3.69 [0.49] versus 3.42 [0.54], P < .001). The effect size increased from 0.35 (small) at the end of year one to 0.53 (medium) at the end of year two. CONCLUSIONS: This large multi-institutional cohort study found that LCs at medical schools were associated with more positive perceptions of the LE by preclerkship students.

The Effect of Community Health Center (CHC) Density on Preventable Hospital Admissions in Medicaid and Uninsured Patients.

Community health centers (CHCs) are expected to play a major role in expanding primary care access under the Affordable Care Act (ACA). Although benefits of such health centers among Medicaid populations have been documented, little is known about their impact on the uninsured. Additionally, the effect of health center density on preventable hospitalizations is unknown. This study calculated health center density within five miles of California hospitals using geocoding and Haversine distance formula. Using the 2010 California inpatient dataset, rates of preventable hospitalizations were classified by Prevention Quality Indicators (PQIs). After adjusting for patient and community covariates, we found that as health center density increased, the odds ratio of preventable hospitalizations decreased in both Medicaid and uninsured patients. (OR 0.79 and 0.86 for Medicaid and uninsured respectively p<.001,.044) These findings suggest health centers are contributing to lowering preventable hospitalizations and supports plans to expand such health centers.

Longitudinal hyperlipidemia outcomes at three student-run free clinic sites.

BACKGROUND AND OBJECTIVES: Student-run free clinics (SRFC) aim to improve health outcomes of vulnerable populations by providing care to those who have difficulty accessing the traditional health care safety net. Reducing low density lipoprotein (LDL) is known to improve health outcomes, yet uninsured patients remain especially susceptible to poor control. This study describes hyperlipidemia control over time among patients who received care at three University of California San Diego Student-Run Free Clinic Project (SRFCP) sites. METHODS: The authors performed a retrospective review of clinic visits from August 2006--November 2010 from three sites of the SRFCP. Patients with a new diagnosis of hyperlipidemia, a baseline LDL level, and at least one follow-up LDL drawn between 6 weeks and 18 months were included in this study (n=96). Hyperlipidemia control was analyzed using descriptive statistics, Fisher's exact tests, paired t tests, and binary logistic regression. RESULTS: At the last visit, 58.3% (56/96) of patients had achieved LDL goal. LDL decreased from a baseline mean of 135.8 mg/dL to 101.3mg/dL among the cohort (P<.001). Statins were used in 86.5% (83/96) of patients. No significant differences were noted when stratified by language, gender, diabetes comorbidity, homelessness, or clinic site. When comparing Hispanics and Caucasians only, Hispanic patients had better LDL control than Caucasians. CONCLUSIONS: This study demonstrates that a SRFC can effectively manage hyperlipidemia over time, and rates of control can exceed national standards.

Universal depression screening, diagnosis, management, and outcomes at a student-run free clinic.

OBJECTIVE: Student-run free clinics (SRFCs) are now present at most medical schools. Reports regarding SRFCs have focused on the infrastructure of established clinics, characteristics of the patient populations served, and their contribution to patient care. Few studies discuss their role in preventive medicine and even fewer discuss mental health care. This study examined the outcomes of a medical student-run universal depression screening, diagnosis, and management program at two SRFC sites. METHODS: Medical students implemented a universal depression screening, diagnosis, and management program within the electronic health record during routine adult primary care visits utilizing the Patient Health Questionnaire-2 (PHQ-2) as an initial screening tool, with a protocol to administer the Patient Health Questionnaire-9 (PHQ-9) if the PHQ-2 score was ≥3. This is a retrospective medical record review of visits from August 13, 2013, through February 13, 2014, to assess this program. RESULTS: Overall, 95.8 % (206/215) of the patients received either the PHQ-2 or the PHQ-9. Among the 174 patients without a previous diagnosis of depression, 166 were screened (95.4 %), of which 33 (19.9 %) had a positive PHQ-2 score of ≥3; 30 (of 33; 90.9 %) appropriately received a PHQ-9. Nineteen (of 166 screened; 11.4 %) previously undiagnosed patients were confirmed to have depression. Fourteen patients had two or more PHQ-9 tests at least 4 weeks apart and eight (57.1 %) had a clinically significant improvement, defined as PHQ-9 score decrease of ≥5. The prevalence of depression diagnosed prior to the implementation of this program in this cohort was 19.1 % (41/215) and after was 27.9 % (60/215). CONCLUSIONS: This study demonstrated that medical students with faculty supervision can successfully implement a universal depression screening, diagnosis, and management program at multiple SRFC sites, identify previously undiagnosed depression, and work with interdisciplinary support services to provide treatment options, leading to a clinically significant improvement in depression severity.

The effect of involvement in a student-run free clinic project on attitudes toward the underserved and interest in primary care.

METHODS: The authors designed a survey instrument to examine the effect of involvement in a student-run free clinic project (SRFCP) on medical student self-reported attitudes toward the underserved and interest in primary care. From 2001-2010, first-and second-year medical students in an introductory service-learning elective course rated each of 15 statements on a seven-point Likert scale pre/post survey. Wilcoxon's signed rank test was performed on all matched pairs and an intent-to-treat analysis included unmatched pairs. RESULTS: The response rate was 97.9%, with 914 of 934 students enrolled participating. Significant increases were seen in each of the 15 items in matched pre/post survey pairs, N = 433 (47.4%), or with an intent-to-treat analysis, N = 914 (p ≤ .002 for all). CONCLUSIONS: This study found that medical student involvement in a SRFCP improved student knowledge, skills, attitudes and self-efficacy with the underserved, interest in work with the underserved after graduation, and interest in primary care.

The growth of learning communities in undergraduate medical education.

PURPOSE: To determine the presence and characteristics of learning communities (LCs) in undergraduate medical education. METHOD: The authors updated an earlier Web-based survey to assess LCs in medical education. Using a cross-sectional study design, they sent the survey to an LC leader or dean at each Association of American Medical Colleges member medical school (n = 151) between October 2011 and March 2012. The first survey item asked respondents to indicate if their institution had LCs. Those with LCs were asked to provide details regarding the structure, governance, funding, space, curricular components, extracurricular activities, and areas addressed as part of the LCs. Those without LCs were asked only if they were considering developing them. The full survey instrument contained 35 items including yes/no, multiple-choice, and open-ended questions. The authors analyzed data using descriptive statistics and examined open-ended responses for recurrent themes. RESULTS: The response rate was 83.4% (126/151). Sixty-six schools (52.4%) had LCs. Of the 60 remaining schools without LCs, 29 (48.3%) indicated that they were considering creating them. Of the 52 schools that provided the year their LCs were established, 27 (51.9%) indicated they began in 2007 or later. LC characteristics varied widely. CONCLUSIONS: The number of medical schools with LCs is increasing rapidly. LCs provide an opportunity to transform medical education through longitudinal relationships and mentoring. Further study is needed to document outcomes and best practices for LCs in medical education.

Clinical outcomes of diabetic patients at a student-run free clinic project.

OBJECTIVES: Our objective was to determine if the quality of care of diabetic patients at a Student-Run Free Clinic Project (SRFCP) meets the standard of care, is comparable with other published outcomes, and whether pertinent diabetic clinical indicators improve over time. METHODS: The authors conducted a retrospective chart review of diabetic patients at three University of California-San Diego (UCSD) SRFCP sites from December 1, 2008 to December 1, 2009 (n=182), calculated the percentage who received recommended screening tests, percent at goal, and compared these to published outcomes using Fisher's exact tests. Baseline measures were compared to most recent values using paired t tests. RESULTS: The percentage of patients who received recommended screening tests (process measures) was blood pressure (BP) 100%, HbA1c 99.5%, creatinine 99.5%, LDL 93%, HDL and triglycerides 88%, microalbumin/creatinine ratio 80%, and ophthalmology exam 32%. Intermediate outcomes included: 70% of patients were at LDL goal <100, 70% had microalbumin/creatinine ratio <30, 61% of males were at HDL goal %gt;40, 47% of females at HDL goal>50, 52% with triglycerides <150, 45% had BP <130/80, and 30% of patients had HbA1c <7. Mean HbA1c, LDL, HDL, triglycerides and blood pressure improved significantly over time. CONCLUSIONS: Diabetic patients at UCSD SRFCP reached goals for both process measures and intermediate outcomes at rates that meet or exceed published outcomes of insured and uninsured diabetics on nearly all measures, with the exception of ophthalmology screening. Glycemic control, cholesterol levels, and blood pressure improved significantly during care at the UCSD SRFCP.

Medical student perceptions of the educational value of a student-run free clinic.

BACKGROUND AND OBJECTIVES: Many medical schools have student-run free clinics (SRFCs), yet their educational value has not been well studied. We performed a one-time cross-sectional survey to assess medical student perceptions of the educational value of an SRFC at their institution. METHODS: The authors designed and validated a survey instrument including six statements on a 5-point Likert-scale. The questionnaire was distributed from February through May 2010 to all students enrolled at the University of California San Diego (UCSD) School of Medicine as part of a larger yearly, anonymous, internet-based survey regarding their experiences at the institution. RESULTS: The response rate was 66.5% with 347 of 522 eligible students participating. Ninety percent agreed or strongly agreed that the SRFC was a valuable educational experience, mean score: 4.51 on a scale of 5. Eighty-two percent agreed or strongly agreed that the teaching was excellent, mean score: 4.23. Students agreed or strongly agreed that the SRFC improved attitudes toward working with underserved patients (72%, mean score 3.99), helped students stay connected to sense of purpose, (71%, mean score 3.98), improved overall sense of well-being (67%, mean score 3.88), and influenced their decision to come to UCSD (52%, mean score 3.37). Eighty-four percent of qualitative responses in a free text comment box were positive (46 of 55). CONCLUSIONS: To the authors' knowledge, this is the first study to report the perceptions of an entire medical student body of a SRFC at their institution. The majority felt that this was a valuable educational experience.

Applying eye movement miscue analysis to the reading patterns of children with language impairment.

This paper presents a research report on an investigation into the reading eye movements of a bilingual 10-year, 10-month old girl with language impairment secondary to Downs Syndrome. Eye movement miscue analysis (Paulson, 2000) was employed to evaluate the visual sampling and oral productions of this child as she read from complete texts presented in Spanish and English. Results are presented in relationship to misconceptions manifest in the clinical practice of intervention providers. Based upon the research and this data, readers do not fixate on every word and the miscues they produce are not the result of failing to fixate on the text.