A social ecological approach to promote learning health disparities in the clinical years: impact of a home-visiting educational program for medical students.

BACKGROUND: There is consensus that medical schools have a duty to educate students about social determinants of health (SDOH) and equip them with skills required to ameliorate health disparities. Although the National Academy of Medicine (NAM) urged the development of experiential long term programs, teaching is usually conducted in the pre-clinical years or as voluntary courses. ETGAR a required health disparities course, based on the social ecological model, was initiated to answer the NAM call. This study aimed to ascertain the course impact on students learning of SDOH and health disparities. METHODS: Students during their first clinical year cared for four patients in their transition from hospital back home, one patient in each internal medicine, surgery, pediatrics and obstetrics/gynecology rotation. The students home-visited their patients after meeting them in hospital and preparing a plain language discharge letter. Training session prior to the course, a tutorial in each rotation, and structured feedback gave the educational envelope. Mixed methodology was employed to evaluate the course impact. Quantitative data collected by students during the home-visit: patients' characteristics and quality and safety of the transition back home using the Medication Discrepancy Tool and Care Transition Measure questionnaire. Stakeholders' views were collected via interviews and focus groups with students representing all affiliated hospitals, and interviews with heads of departments most involved in the course. RESULTS: Three hundred six students in three academic years, between October 2016-July 2019, completed home visits for 485 disadvantaged patients with improvement in patients' knowledge of their treatment (3.2 (0.96) vs 3.8 (0.57), Z = -7.12, p < .0001) and identification of medication discrepancies in 42% of visits. Four themes emerged from the qualitative analysis: contribution to learning, experience-based learning, professional identity formation, and course implementation. CONCLUSIONS: ETGAR was perceived to complement hospital-based learning, making students witness the interaction between patients' circumstances and health and exposing them to four patients' environment levels. It provided a didactic framework for promoting awareness to SDOH and tools and behaviors required to ameliorate their impact on health and health disparities. The course combined communication and community learning into traditionally bio-medical clinical years and serves as a model for how social-ecology approaches can be integrated into the curriculum.

Teaching plain language to medical students: improving communication with disadvantaged patients.

BACKGROUND: Low health literacy underpins health inequality and leads to poor adherence to medical care and higher risk of adverse events and rehospitalization. Communication in plain language, therefore, is an essential skill for health professionals to acquire. Most medical education communication skill programs focus on verbal communication, while written communication training is scarce. ETGAR is a student delivered service for vulnerable patients after hospital discharge in which, amongst other duties, students 'translate' the medical discharge letters into plain language and share them with patients at a home visit. This study ascertains how this plain language training impacted on students' written communication skills using a tool designed for purpose. METHODS: Students, in pairs, wrote three plain language discharge letters over the course of a year for patients whom they encountered in hospital. The students handed over and shared the letters with the patients during a post-discharge home visit. Structured feedback from course instructors was given for each letter. An assessment tool was developed to evaluate students' ability to tell the hospitalization narrative using plain and clear language. First and last letters were blindly evaluated for the entire cohort (74 letters; 87 students). RESULTS: Students scored higher in all assessment categories in the third letters, with significant improvement in overall score 3.5 ± 0.8 vs 4.1 ± 0.6 Z = -3.43, p = 0.001. The assessment tool's reliability was high α = 0.797, it successfully differentiated between plain language categories, and its score was not affected by letter length or patient's medical condition. CONCLUSIONS: Plain language discharge letters written for real patients in the context of experience-based learning improved in quality, providing students with skills to work effectively in an environment where poor health literacy is prevalent. ETGAR may serve as a model for learning written communication skills during clinical years, using the assessment tool for formative or summative evaluation.

Learning social determinants of health through a home visiting course in the clinical years.

OBJECTIVE: The purpose of this study was to assess the impact of a new experience-based educational program aiming to teach social determinants of health (SDH) and health disparities, through a post-discharge home-visit conducted with patients recruited in hospital. METHODS: 105 clinical-year students visited 177 patients living in disadvantaged circumstances. Their home-visit reports were analyzed employing mixed methodology. Content analysis was conducted for classifying issues raised by students, and quantitative analysis to compare reports by level of elaboration, gender and class. RESULTS: Fifteen taxonomy items were identified. Social support and patients' medical conditions were most prevalent, followed by personal-related and community-related issues. Analysis demonstrated students' understanding of the relationship between SDH and patient health, and challenges patients face following discharge. Women and mixed couples provided more elaborate reports, which contained significantly greater critique of medical care. CONCLUSIONS: Meeting patients both in hospital and at home enhanced awareness of SDH. Students learned to view the patient comprehensively, and to understand the diverse factors affecting their health. Students, who had essentially sole responsibility for the home-visit, successfully integrated their skills to take action when needed. PRACTICE IMPLICATIONS: The ETGAR experience provided a means for effective learning about how social determinants impact on health.

[COMPETENCY-BASED TRAINING AS A WAY TO CREATE ORGANIZATIONAL CHANGE AND IMPROVE PROFESSIONALISM: A REVIEW OF THE PROCESS OF IMPLEMENTING A COMPETENCY-BASED MEDICAL EDUCATION (CBME) TRAINING PROGRAM IN NEONATOLOGY FELLOWSHIP IN ISRAEL].

INTRODUCTION: Competency-based medical education (CBME) is a model aimed to address certain challenges and shortcomings attributed to the contemporary models of medical education and the medical profession in general. The CBME model has been used mainly in the education of undergraduate medical students with no continuation to residency, fellowship, or independent practice. In this review, we present a program based on the CBME model for the design and implementation of a new fellowship program in neonatology in Israel. As part of the program, we propose a mentorship program as a means to facilitate the implementation and acceptance of the program in the different wards. We designed assessment tools that can help the mentor track the fellow's development over time as well as to examine the impact of the proposed program on performance and on all stakeholders' satisfaction over time. We aim to evaluate the benefits and effectiveness of this CBME training not only on the fellows' abilities and performance outcomes, but also on the accompanying general organizational changes that can lead to general improvement in the neonatal profession in Israel.

[SIMULATION AS A TRAINING AND ASSESSMENT TOOL FOR COMPETENCY BASED MEDICAL EDUCATION - A REGULATORY CHALLENGE].

INTRODUCTION: Competency Based Medical Education (CBME) is an educational approach that occupies a central place in medical education. Medical education is accountable for the graduates' professional level, ensuring they are skilled and competent in all key areas of their profession. Adopting CBME underscores the importance of simulation-based training. Experiential training provides, among other things: standardization of training, controlled exposure to extreme events and soft skills, such as patient-caregiver communication and teamwork training. Unlike the traditional apprentice approach, accountability reinforces the choice of a preliminary encounter with simulated patients prior to real-life care, as a complimentary tool for improving patient safety. Incorporating a practical exam is self-evident in CBME because of the need to ensure that the examinees are competent to provide unsupervised safe and quality care. Implementation of a national CBME program, likewise, incorporating simulation into national training programs, requires involvement and supervision on health system regulators. In this paper, we describe simulation-based national training programs that to date integrate competency-based training in the various medical sectors. As national programs, they are implemented under the guidance and in cooperation with the regulators. On the one hand, CBME is a new approach and its implementation will require time and the cooperation of many stakeholders. On the other hand, simulation is an existing, well-established training and assessment tool that can be used as an anchor around which you can start building the competency-based training programs.

Cost-Effectiveness Evaluation of EHR: Simulation of an Abdominal Aortic Aneurysm in the Emergency Department.

Health care organizations have installed electronic systems to increase efficiency in health care. Empirically assessing the cost-effectiveness of technologies to the health care system is a challenging and complex task. This study examined cost-effectiveness of additional clinical information supplied via an EHR system by simulating a case of abdominal aortic aneurysm devised and acted professionally by the Israel Center of Medical Simulation. We conducted a simulation-based study on physicians who were asked to treat a simulated patient for the prevalent medical scenario of hip and leg pain that actually corresponded to an abdominal aortic aneurysm. Half of the participating physicians from the Department of Emergency Medicine at Tel-Hashomer Hospital - Israel's largest - had access to an EHR system that integrates medical data from multiple health providers (community and hospitals) in addition to the local health record, and half did not. To model medical decision making, the results of the simulation were combined with a Markov Model within a decision tree. Cost-effectiveness was analyzed by comparing the effects of the admission/discharge decision in units of quality adjusted life years (QALYs) to the estimated costs. The results showed that using EHR in the ED increases the QALY of the patient and improves medical decision-making. The expenditure per patient for one QALY unit as a result of using the EHR was $1229, which is very cost-effective according to many accepted threshold values (less than all these values). Thus, using the EHR contributes to making a cost-effective decision in this specific but prevalent case.