Clerkship directors' perceptions of the effects of managed care on medical students' education.

PURPOSE: Little is known about the effect of managed care on medical students' education. Because clerkship directors (CDs) are especially well positioned to observe any changes, this study surveyed CDs from six medical specialties about their perceptions of the effects of managed care on medical students' education. METHOD: Anonymous questionnaires were mailed to 808 CDs from departments of six medical specialties at 125 U.S. allopathic medical schools between October 1997 and March 1998. Among other questions, respondents were asked whether they had observed changes in 19 different aspects of medical students' education, whether these changes were beneficial or detrimental, and whether they believed the changes were due to managed care and/or to other factors. Results were analyzed to determine perceptions of the overall magnitude and source(s) of changes, the perceived positive versus negative effect of managed care, and whether these outcomes were statistically associated with the perceived degree of managed care's market penetration. RESULTS: Five hundred questionnaires (61.9%) were returned. For full-time and voluntary faculty teaching, faculty availability for educational administration, directors' clinical responsibilities, and quality of professional life, the most common response was that managed care had an adverse effect. For faculty's enthusiasm for teaching, directors' administrative and educational duties, and clerkship training sites, the second most common response after "not changed" was that managed care had a negative effect. The majority of respondents held negative opinions of managed care and thought that medical students did not understand it. CONCLUSIONS: CDs in six medical specialties perceived that managed care has negatively affected medical students' education. These perceptions may influence medical students' education. Measures must be taken to ensure excellent education through adequate resources and training in the context of high-quality medical care.

The administrative colloquium: developing management and leadership skills for faculty.

OBJECTIVE: Development of leadership competencies has become a priority for many academic health science centers. However, traditional faculty development has focused almost exclusively on improving teaching skills. The process and outcomes of developing leadership skills for academic health science center faculty has not been extensively studied. METHODS: The University of Nebraska Medical Center (UNMC) created a year-long course, called the Administrative Colloquium, as a means to enhance faculty leadership skills. Completion of the course required attendance at 8 half-day workshop sessions, each devoted to teaching a leadership competency (eg, leading with vision, managing change) and completing a project with a project report (oral or poster presentation). Course evaluation was multifaceted. Attendees were queried multiple times by a pre- and poststrategy and retrospective pre- and poststrategy concerning their perceptions about knowledge obtained during the course. Paired t testing was used to determine statistical differences between the mean pre- versus postvalues and the retrospective pre- versus postvalues. Project content was qualitatively analyzed for themes. RESULTS: All comparisons of pre- and postdata and retrospective pre- and postdata were statistically significant (P <.05). Three themes arose from the analysis of projects: change, management, and interpersonal communications. CONCLUSIONS: The pre- and postknowledge data and the retrospective pre- and postknowledge data demonstrate that learning was significant as well as sustained. Qualitative analysis of the project content demonstrates that the participants were applying the course content to solving real-world problems. These results give preliminary support to the conclusion that the Administrative Colloquium has had an impact on faculty leadership development at UNMC.

A comparison of clinical pediatric patient encounters in university medical center and community private practice settings.

BACKGROUND: Growing numbers of medical students complete clerkships in community private practice (CPP) settings instead of the more traditional university-based clinics, yet few empirical studies have evaluated how setting type impacts clinical experiences, skill development, and student satisfaction. OBJECTIVE: This study compared the pediatric patient encounters seen by third-year medical students in university medical center (UMC) and CPP settings. METHODS: Third-year medical students were required to keep a log of all patients seen during their 8-week pediatric clerkship. Logbook entries were coded and then analyzed for differences in the number and distribution of the primary diagnostic categories between settings. RESULTS: CPP students reported, on the average, seeing over 3 times more patients than UMC students. The case mix distribution also differed significantly by setting. In general, CPP students reported seeing proportionately more routine illnesses, whereas UMC students reported seeing proportionately more uncommon disorders. Because CPP students saw more patients overall, they averaged more cases in almost all diagnostic categories. CONCLUSION: CPP students received more clinical patient exposure than UMC students, except for patients in a few diagnostic categories.

Teaching quality measurement and improvement, cost-effectiveness, and patient satisfaction in undergraduate medical education: the UME-21 experience.

BACKGROUND: The health care system in the United States is changing at an ever-increasing rate. Recent reports by the Institute of Medicine raising concerns regarding rates of medical errors and suggesting the need for reengineering of the health care delivery system have focused attention on the need for quality measurement and improvement. METHODS: We abstracted data from final written reports submitted by 18 Undergraduate Medical Education for the 21st Century (UME-21) schools, as well as other materials available from participating UME-21 schools. Specific curricular innovations developed and implemented were identified. Additionally, senior medical students' responses to the annual Graduation Questionnaire administered by the Association of American Medical Colleges (AAMC) were available for analysis. The change from 1999 to 2001 in the proportion of seniors rating instruction in quality assurance as adequate was compared among four groups of UME-21 schools and the other 107 US medical schools. RESULTS: Eleven of the 18 schools specifically addressed the content areas of quality measurement and improvement, including utilization management (27% of schools), cost-effectiveness (45% of schools), use of clinical practice guidelines (73% of schools), and patient satisfaction assessment (45% of schools). Each school developed unique approaches and educational materials pertinent to the content area. Overall, the percentage of seniors rating the relative amount of instructional time devoted to quality assurance in medicine by their school's curriculum as adequate or better rose from 49% to 66% between 1999 and 2001 at the 11 UME-21 schools that introduced initiatives in quality improvement into their curricula. This change was significantly higher than the pattern at other US medical schools between 1999 and 2001, at which seniors' ratings rose only from 43% to 56%. CONCLUSIONS: Curriculum development and implementation addressing quality improvement in medical practice accelerate improvement of students' perception that their education has adequately addressed this subject area. This article summarizes some of the experiences, curricular approaches, successes, failures, and lessons learned in quality improvement by schools participating in the UME-21 project.

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.

Setting a personal career direction.

In summary, we believe that both you and your organization should have a set of core values, a well-defined mission (core purpose), and a vision of the future. Ideally, your projects and activities should be congruent with your mission and values, you should be pursuing your vision, and all of this should be congruent with the organization mission and values. Practically speaking, most individuals we have worked with over the years find themselves in two different groups at this point in the exercise. The minority find that their personal mission is not at all similar to the mission of their current organization and they find it necessary to seriously reevaluate their personal career direction. Sometimes, this results in them finding some other place to work. On the other hand, the majority discover their personal mission is in reasonable agreement with that of their organization. For both, this exercise has helped them clarify and better manage their personal career direction.

Clinical experience and examination performance: is there a correlation?

CONTEXT: The Liaison Committee on Medical Education (LCME) requires there to be: '...comparable educational experiences and equivalent methods of evaluation across all alternative instructional sites within a given discipline'. It is an LCME accreditation requirement that students encounter similar numbers of patients with similar diagnoses. However, previous empirical studies have not shown a correlation between the numbers of patients seen by students and performance on multiple-choice examinations. OBJECTIVE: This study examined whether student exposure to patients with specific diagnoses predicts performance on multiple-choice examination questions pertaining to those diagnoses. METHODS: The Department of Pediatrics at the University of Nebraska Medical Center has collected patient logbooks from clerks since 1994. These contain information on patient demographics and students' roles in patient care. During week 7 of an 8-week course, students took an examination intended to help them prepare for their final examination. Logbooks and pre-examination questions were coded using standard ICD-9 codes. Data were analysed using Minitab statistical software to determine dependence between patient encounters and test scores. Subjects comprised a convenience sample of students who completed the clerkship during 1997-2000. RESULTS: Our analysis indicates that performance on a multiple-choice examination is independent of the number of patients seen. CONCLUSIONS: Our data suggest knowledge-based examination performance cannot be predicted by the volume of patients seen. Therefore, too much emphasis on examination performance in clinical courses should be carefully weighed against clinical performance to determine the successful completion of clerkships.

Experience with a program of faculty development.

The authors describe the faculty development program at the University of Nebraska Medical Center. Faculty needs were identified in instructional skill development, academic socialization and mentoring. Committees with campus-wide representation designed the instructional activities. Among the total 749 faculty, 59% attended at least one faculty development offering consisting of one and two-day institutes or two-hour luncheon workshops in the past five years. Evaluations ranked each event highly for quality, relevance, impact on teaching and usefulness. Experiences in creating a successful faculty development program at an academic medical center are reported. Success was measured by attendee numbers and increased participation of faculty in teaching and mentoring. Factors contributing to this success include generous financial support by leadership, broad-based planning and administrative support.