Culture and physician-patient communication: a qualitative exploration of residents' experiences and attitudes.

BACKGROUND: Increasing evidence suggests that communication plays a central role in effective clinical care. To facilitate effective instruction in this domain, this study seeks to understand how pediatric residents approach the challenge of cross-cultural communication. METHODS: A convenience sample of 29 pediatric residents participated in five focus groups that were jointly facilitated by a clinical and a process expert. Discussion was stimulated using two video scenarios of pediatric cross-cultural communication challenges. RESULTS: Seven dominant categories were evident in the discussions: characteristics of culture, beliefs about culture, attitudes towards culture, opinions about how to build expertise in communication, cultural conflict, insights regarding prejudice, and comments about interview technique. Residents tended to view culture and difference as residing in patients (not in themselves), reflecting their assumption that western medicine is acultural. CONCLUSIONS: Residents believe that lack of knowledge about other cultures causes their communication difficulties. Our findings suggest, however, that more basic issues may underlie their difficulties. Residents may recognize prejudice in the abstract but fail to see it in their environment, and they may spend minimal time reflecting on their professional culture and beliefs.

Conversations with parents of medically ill children: a study of interactions between medical students and parents and pediatric residents and parents in the clinical setting.

BACKGROUND: The traditional remedies applied by medical schools to the perennial problem of teaching "caring competence" have been unsuccessful. PURPOSE: Our purpose was to design and evaluate a simple and effective method for helping students maintain affective contact with their patients. METHODS: Third-year medical students and pediatric residents were given the opportunity to talk informally with parents of medically ill children and reflect on the value of this experience for their learning. Trainees' opinions of the experience were measured with focus groups and a questionnaire. RESULTS: Trainees were delighted with the experience, particularly with the following aspects: the opportunity to hear a personally relevant story told in a sincere manner, the realization that they could have an authentic interaction "even" in a medical setting, and the usefulness of the information they derived from the conversation. CONCLUSIONS: We concluded that something unique to the conversational experience has educational value.

Typical and atypical Carney's triad presenting with malignant hypertension and papilledema.

This report encourages clinicians to consider a diagnosis of Carney's triad in patients with multifocal gastric stromal sarcoma, extraadrenal paraganglioma (predominantly mediastinal), or pulmonary chondroma. The authors conducted a retrospective 20-year survey at the Hospital for Sick Children and identified two children with Carney's triad. One child, presenting atypically with papilledema and fundal hemorrhages from malignant hypertension and benign intracranial hypertension from chronic iron-deficiency anemia, is the second patient ever to date be described with the complete Carney's triad of neoplasms at diagnosis. Another child presented more typically with gastric stromal sarcoma and pulmonary chondroma without paraganglioma. Carney's triad is a rare differential diagnosis for "idiopathic" hypertension or iron-deficiency anemia from chronic gastrointestinal bleeding. If missed, patients with Carney's triad may have the debilitating physical and mental consequences of chronic iron deficiency and may die of untreated prolonged hypertension and metastatic leiomyosarcoma.

Clinical teaching: maintaining an educational role for doctors in the new health care environment.

CONTEXT AND OBJECTIVES: Good clinical teaching is central to medical education but there is concern about maintaining this in contemporary, pressured health care environments. This paper aims to demonstrate that good clinical practice is at the heart of good clinical teaching. METHODS: Seven roles are used as a framework for analysing good clinical teaching. The roles are medical expert, communicator, collaborator, manager, advocate, scholar and professional. RESULTS: The analysis of clinical teaching and clinical practice demonstrates that they are closely linked. As experts, clinical teachers are involved in research, information retrieval and sharing of knowledge or teaching. Good communication with trainees, patients and colleagues defines teaching excellence. Clinicians can 'teach' collaboration by acting as role models and by encouraging learners to understand the responsibilities of other health professionals. As managers, clinicians can apply their skills to the effective management of learning resources. Similarly skills as advocates at the individual, community and population level can be passed on in educational encounters. The clinicians' responsibilities as scholars are most readily applied to teaching activities. Clinicians have clear roles in taking scholarly approaches to their practice and demonstrating them to others. CONCLUSION: Good clinical teaching is concerned with providing role models for good practice, making good practice visible and explaining it to trainees. This is the very basis of clinicians as professionals, the seventh role, and should be the foundation for the further development of clinicians as excellent clinical teachers.

A review of the evaluation of clinical teaching: new perspectives and challenges.

PURPOSE: This article discusses the importance of the process of evaluation of clinical teaching for the individual teacher and for the programme. Measurement principles, including validity, reliability, efficiency and feasibility, and methods to evaluate clinical teaching are reviewed. CONTEXT: Evaluation is usually carried out from the perspective of the learner. This article broadens the evaluation to include the perspectives of the teacher, the patient and the institutional administrators and payers in the health care system and recommends evaluation strategies. RESULTS: Each perspective provides specific feedback on factors or attributes of the clinical teacher's performance in the domains of medical expert, professional, scholar, communicator, collaborator, patient advocate and manager. Teachers should be evaluated in all domains relevant to their teaching objectives; these include knowledge, clinical competence, teaching effectiveness and professional attributes. CONCLUSIONS AND IMPLICATIONS: Using this model of evaluation, a connection can be made between teaching and learning about all the expected roles of a physician. This can form the basis for systematic investigation into the relationship between the quality of teaching and the desired outcomes, the improvement of student learning and the achievement of better health care practice. It is suggested that the extent of effort and resources devoted to evaluation should be commensurate with the value assigned to the evaluation process and its outcomes.

The use of an objective structured clinical examination with postgraduate residents in pediatrics.

OBJECTIVE: To evaluate the usefulness of an objective structured clinical examination (OSCE) for assessing and providing feedback to postgraduate residents in pediatrics. DESIGN: A 5-station OSCE given in 1996, based on the educational objectives of a general pediatric training program. Each station assessed the residents' interviewing and history-taking skills with a standardized patient. The results were correlated with those of the in-training evaluation reports. SETTING: The Department of Paediatrics, University of Toronto Faculty of Medicine, Toronto, Ontario. PARTICIPANTS: Forty-three of 61 pediatric residents: 14 first-year, 12 second-year, 8 third-year, and 9 fourth-year residents. MAIN OUTCOME MEASURES: Scores for each of the 5 stations were broken down into 15 points for the check-list, 5 for the global assessment, and 10 for the written postencounter question, for a total score of 150. The in-training evaluation report ratings were converted to a 5-point numerical scale, ranging from 1 (unsatisfactory) to 5 (outstanding). RESULTS: The mean OSCE score for the 43 pediatric residents was 104.9. Although the residents in their senior year scored higher, there was no statistically significant difference among the 4 years for the total OSCE score or for any of the 5 stations. The fourth-year residents' scores on the postencounter questions were significantly (P < .05) higher than the first-year residents' scores. Two residents scored less than 60%. The internal consistency of the 5-station OSCE was limited (r = 0.69). Residents received verbal feedback at the conclusion of the OSCE, and they received their scores when they were calculated. The mean overall in-training evaluation report score for all 61 pediatric residents was 3.9. There was a moderate, but statistically significant, correlation between the overall mean OSCE results and the overall mean in-training evaluation report scores (r = 0.45). CONCLUSION: The OSCE can provide a useful formative evaluation of postgraduate residents, but the usefulness of the evaluation data and the feedback must be balanced with the logistic difficulties and expense.

Ethics teaching and learning in pediatric training: development of a curriculum.

The Royal College of Physicians and Surgeons of Canada has stated that residency programs "must provide opportunities for residents to gain an understanding of the basic principles of biomedical ethics as it relates to the specialty." This article presents the steps taken to develop a curriculum for teaching and learning biomedical ethics in Canadian pediatric residency programs, and to provide a model for teaching ethics in this context. Using literature reviews, and opinion surveys of departmental chairpersons, pediatric residents, and practising pediatricians across Canada, we have developed a teachers' handbook to help faculty members in teaching ethics. It can also be used as a tool to enhance faculty development in ethics. The manual is to be distributed to all pediatric training programs throughout Canada in 1997, and its use will be evaluated over the subsequent year. It offers a prototype that is adaptable to Royal College programs other than pediatrics.

Do child and/or parent bereavement programs work?

Bereavement programs for children and parents are becoming popular since there are more and more neonatal intensive care programs, pediatric oncology programs and pediatric intensive care programs offering these services. This paper addresses the following question: Do bereavement programs work? An overview of the literature dating back to 1964 was undertaken. Only papers dealing with treatment were reviewed. Randomized controlled trials were selected as presenting the best evidence for or against program effectiveness. Methodologic features such as description of the sample, comparability of treatment and control groups, description of the intervention, use of objective, valid, reproducible and blinded outcome measures, sample size calculations, thoroughness of follow-up and attention to clinical as well as statistical significance were assessed. Four randomized controlled trials were found in the literature search. Two of the studies showed benefit, two did not. All four suffered significant methodologic flaws. At this time it is unclear as to whether or not bereavement programs help families. Given the high costs of health care, it is important that studies be done to determine which families are likely to benefit from bereavement programs and what type of program is effective.

Oxybutynin efficacy in the treatment of primary enuresis.

The effectiveness of oxybutynin in the treatment of primary enuresis was evaluated in a double-blind study. A total of 30 children (25 boys, five girls), at least 6 years of age, with primary enuresis and no daytime incontinence or history of other urinary tract problems were selected at random from an enuresis clinic population. The study was explained to the families and they were told how to keep records of nocturnal bed-wetting episodes and side effects. The patients were treated with a 10 mg of oxybutynin at suppertime for 28 days. Before or after the treatment period, all children received an identical placebo for 4 weeks. Two-sided paired t tests were used to compare frequency of nocturnal enuresis. Frequency during the drug regimen did not differ significantly from that during the placebo study. There were no differences in findings between boys and girls or between children who had previously taken imipramine and those who had not. The study showed no evidence that oxybutynin is effective in treating primary enuresis.

Clinical, laboratory, and epidemiologic features of a viral gastroenteritis in infants and children.

We studied 27 infants admitted to the hospital with acute diarrhea caused by human rotavirus (HRV) and obtained additional data on fecal excretion from ten outpatients with the same infection. The disease was characterized by watery diarrhea with fever and vomiting at the onset, isotonic dehydration, compensated metabolic acidosis, and increased concentrations of sodium and chloride but low concentrations of sugar in stools. Diarrhea usually ceased in three to four days when oral feedings were reduced or stopped but recurred mildly in four patients. Of 57 household contacts, 12 were symptomatic, 6 had HRV in their stools, and 19 had significantly increased serum HRV antibody titers. These features of the disease accord with available information on the pathogenesis of HRV infection. Knowledge of the clinical pattern of this newly diagnosable infection should help physicians to recognize and treat quickly this highly infectious, potentially dangerous illness.