A theory-based faculty development program for clinician-educators.

This essay describes the development, implementation, and evaluation of a theory-based faculty development program for physician-educators in medicine and pediatrics at The Cleveland Clinic. The program comprises a 12-hour course (focused on skills in precepting, bedside teaching, leading small-group discussions, giving lectures, designing curricula, and giving effective feedback); onsite coaching of teaching (on wards, in outpatient clinics, or in formal lectures); and innovative projects in clinical medical education. The program advocates and demonstrates a tailored-teaching approach combined with learner-centered, interactive, experiential, and reflective teaching strategies. The evaluation of the program includes satisfaction ratings, self-assessment of teaching competencies, and independent ratings of teaching effectiveness by the participants' trainees (medical students, residents, and fellows). The program is rated highly, shows significant improvements in teaching skills as measured by both participants' self assessments and independent ratings by participants' trainees, and is ongoing.

Developing and testing an instrument to measure the effectiveness of clinical teaching in an academic medical center.

PURPOSE: Instruments that rate teaching effectiveness provide both positive and negative feedback to clinician-educators, helping them improve their teaching. The authors developed the Clinical Teaching Effectiveness Instrument, which was theory-based and generic across their entire academic medical center, The Cleveland Clinic Foundation. They tested it for reliability, validity, and usability. METHOD: In 1997, using an iterative qualitative development process involving key stakeholders, the authors developed an institution-wide instrument to routinely evaluate clinical faculty. The resulting instrument has 15 questions that use a five-point evaluation scale. The instrument, which was administered to medical students, residents, and fellows over a 20-month period, produced data that were rigorously tested for instrument characteristics, reliability, criterion-related and content validity, and usability. RESULTS: This instrument, implemented in all departments across the institution, produced data on a total of 711 clinician-educators. Correlation coefficients among the items were high (.57 to .77). The scores were reliable (g coefficient of 0.935), and the instrument had both content and criterion-related validity. CONCLUSIONS: The Cleveland Clinic's Clinical Teaching Effectiveness Instrument is reliable and valid, as well as usable. It can be used as an evaluation tool for a wide variety of clinical teaching settings.

Educating residents for managed care: report on a multidisciplinary conference.

A growing number of residency programs are preparing their graduates for the realities of managed care practice. In 1996, The Cleveland Clinic Foundation, a private, nonprofit academic medical center, hosted a two-day conference on managed care education to develop innovative instructional and evaluative approaches that, where appropriate, would build on existing expertise. The conference was attended by invited national experts who had a stake in residents' education: clinical faculty, residents, medical educators, executives of managed care organizations, and representatives of other interested organizations. Participants spent much of their time in four small break out groups, each focusing on one of the following topics that were judged particularly relevant to managed care: preventive and population-based medicine, appropriate utilization of resources, clinician-patient communication, and interdisciplinary team practice. Participants shared existing materials, discussed teaching goals and objectives, and generated ideas for teaching methods, teaching materials, and evaluative methods for their respective topics. The authors summarize the recommendations from the four groups, with an overview of the issues that emerged during the conference concerning curriculum development, integration of managed care topics into existing curricula, staging of the curriculum, experiential teaching methods, negative attitudes and resistance, evaluation of trainees and profiling, program assessment, faculty development, and cooperation between academic medical centers and managed care organizations.

Patient education through teaching for conceptual change.

It is not enough for clinicians to gather good patient information and then dictate management plans. If patient education is to be successful, attention must be paid to tailoring educational input to the patient's particular needs. If the conceptual change approach is followed, patient differences due to factors such as age and culture will be taken into account. Likewise, the different types of patient education described earlier can be accommodated, since the patient and his or her particular needs are always the focus of all medical conversations. The conceptual change approach for patient education potentially can help clinicians avoid the temptation to ignore patients' perspectives and provide instruction tailored to patient needs, thereby reducing the possibility of educational negligence.

Traditional healers in southern Africa.

One task of medical anthropologists is to search for similarities and differences among cultural conceptions of illness and healing. This search may identify common, if not universal, characteristics of healing and effective patient care. This paper describes traditional healing practices in southern Africa as related by six traditional healers. Despite the seemingly exotic nature of their practice, the traditional healers' underlying strategies (probing deeply into the psychological, spiritual, and social contexts of illness and using healing ceremonies and natural medicinal preparations) seem to be effective in certain circumstances. Perhaps more important, these strategies can leave both patient and practitioner with a sense of connection and satisfaction. A study of these strategies reveals some general qualities of the healing process that are more apparent in the absence of sophisticated technology.

Reflection in clinical teaching: an analysis of reflection-on-action and its implications for staffing residents.

In order to improve clinical teaching in the ambulatory care setting, clinical teachers need to know the range of instructional strategies available to them. One potentially useful strategy is that of reflection. In this paper, reflective practice will be described in the context of the professional training of physicians, with the purpose of improving clinical teaching. An example of reflective practice--a transcript of a video tape of an attending physician and a resident in a general internal medicine clinic--will be analyzed. In this transcript, reflective comments by both the attending physician and resident are integrated into the original dialogue.

Giving feedback in medical education: verification of recommended techniques.

OBJECTIVE: We investigated naturally occurring feedback incidents to substantiate literature-based recommended techniques for giving feedback effectively. SETTING: A faculty development course for improving the teaching of the medical interview, with opportunities for participants to receive feedback. PARTICIPANTS: Seventy-four course participants (clinician-educators from a wide range of medical disciplines, and several behavioral scientists). MEASUREMENTS AND MAIN RESULTS: We used qualitative and quantitative approaches. Participants provided narratives of helpful and unhelpful incidents experienced during the course and then rated their own narratives using a semantic-differential survey. We found strong agreement between the two approaches, and congruence between our data and the recommended literature. Giving feedback effectively includes: establishing an appropriate interpersonal climate; using an appropriate location; establishing mutually agreed upon goals; eliciting the learner's thoughts and feelings; reflecting on observed behaviors; being nonjudgmental; relating feedback to specific behaviors; offering the right amount of feedback; and offering suggestions for improvement. CONCLUSIONS: Feedback techniques experienced by respondents substantiate the literature-based recommendations, and corrective feedback is regarded as helpful when delivered appropriately. A model for providing feedback is offered.

An inventory to improve clinical teaching in the general internal medicine clinic.

The increasing occurrence of outpatient medical care has led to the need for more and better medical education in the clinic. the Wisconsin Inventory of Clinic Teaching (WICT) was developed to improve the teaching of attending doctors in a general internal medicine clinic. The items on the inventory were derived from interviews with residents and attending doctors. The inventory was shown to have validity, and to be reliable with internal consistency correlations. We found an interesting disparity between attending doctors' and residents' expectations concerning clinical teaching. The instrument is in use as part of a teaching improvement programme for attending doctors in a general internal medicine clinic.

Conceptual frameworks in preclinical and clinical textbooks.

This is an exploratory attempt to investigate the organization of knowledge in preclinical and clinical textbooks. A theoretical framework to understand the role of textbooks in medical education is developed. An analysis of preclinical and clinical textbooks indicates that preclinical textbooks organize the same field of knowledge differently to clinical ones. In clinical textbooks two different types of organization are indicated. The implication of these findings is discussed.

What's the use of faculty development? Program evaluation using retrospective self-assessments and independent performance ratings.

BACKGROUND: The assessment of the effectiveness of faculty development programs is increasingly important in medical schools and academic medical centers but is difficult to accomplish. PURPOSE: We investigated the usefulness of retrospective self-assessments by program participants in combination with independent ratings of teaching performance by their trainees. METHODS: We used a single sample, prepost intervention design using multiple measures. Our assessment instruments were based on our institution's accepted teaching competencies. We measured participants' self-assessments of their teaching competencies before the program and their retrospective self-assessed improvements in these competencies after the program. We also used independent ratings of the participants' teaching competencies before and after their involvement in the program, as rated by their own trainees (fellows, residents, and medical students). Selected teaching competencies comprised the intended learning outcomes of the faculty development program. RESULTS: Participants' preprogram self-assessments showed that the program was appropriately matched to several topics identified as needy, but also included topics that participants did not identify as needs. The retrospective self-assessments showed improvements in teaching skills that previously were identified as needs, as well as those in which participants originally felt quite competent. The independent ratings by trainees showed overall positive improvements (some significantly). The retrospective self-assessed improvements correlated positively with the independent ratings by their trainees (p < .01). CONCLUSIONS: This evaluation strategy showed that the faculty development program improved the teaching competencies of the participants. Both the program participants' retrospective self-assessments and the independent ratings by their trainees showed postprogram improvements and were positively intercorrelated. The use of these multiple measures is a viable approach to evaluate the impact of a faculty development program. Potentially either approach could be used, but in combination, they provide a feasible, valid, and reliable evaluation.

Successful lecturing: a prospective study to validate attributes of the effective medical lecture.

OBJECTIVE: In a study conducted over 3 large symposia on intensive review of internal medicine, we previously assessed the features that were most important to course participants in evaluating the quality of a lecture. In this study, we attempt to validate these observations by assessing prospectively the extent to which ratings of specific lecture features would predict the overall evaluation of lectures. MEASUREMENTS AND MAIN RESULTS: After each lecture, 143 to 355 course participants rated the overall lecture quality of 69 speakers involved in a large symposium on intensive review of internal medicine. In addition, 7 selected participants and the course directors rated specific lecture features and overall quality for each speaker. The relations among the variables were assessed through Pearson correlation coefficients and cluster analysis. Regression analysis was performed to determine which features would predict the overall lecture quality ratings. The features that most highly correlated with ratings of overall lecture quality were the speaker's abilities to identify key points (r =.797) and be engaging (r =.782), the lecture clarity (r =.754), and the slide comprehensibility (r =.691) and format (r =.660). The three lecture features of engaging the audience, lecture clarity, and using a case-based format were identified through regression as the strongest predictors of overall lecture quality ratings (R2 = 0.67, P = 0.0001). CONCLUSIONS: We have identified core lecture features that positively affect the success of the lecture. We believe our findings are useful for lecturers wanting to improve their effectiveness and for educators who design continuing medical education curricula.

Evaluation of resident performance in an outpatient internal medicine clinic using standardized patients.

OBJECTIVE: To observe and evaluate the performance of primary care internal medicine residents within the outpatient clinic milieu. DESIGN: Longitudinal descriptive study. PATIENTS/PARTICIPANTS: 48 internal medicine resident encounters with two standardized patients at the University of Wisconsin General Internal Medicine Clinics. INTERVENTION: Residents were rated by the standardized patients with a medical skills checklist and an interpersonal skills checklist, and by the staffing physician with a clinical reasoning skills checklist. The investigators reviewed audiotapes of the standardized patient encounters for strategic management skills. MAIN RESULTS: Resident performance on these scales was examined for improvement with years of training; when considered separately, no such effect was seen for either standardized patient case. When the cases were grouped together, however, there was significant improvement on the Clinical Reasoning Instrument. The grouped standardized patient data were compared with data from inpatient faculty evaluations of the residents. Faculty evaluations correlated with standardized patient evaluations of resident performance only on the medical checklist. Finally, comparison of the four assessment scales demonstrated a significant correlation between interpersonal skills, as assessed by the patient, and strategic management skills. CONCLUSION: Resident outpatient performance, measured in a blinded setting, does not improve with year of training. Faculty inpatient assessments of residents correlate with medical "thoroughness" as measured by a medical skills checklist, and interpersonal skills as rated by standardized patients correlate with resident use of strategic medical management.

Strategies for managing uncertainty and complexity.

OBJECTIVES: To identify strategies involved in the diagnosis and treatment plans of primary care problems that are uncertain and complex. METHODS: In this exploratory study we observed primary care physicians encountering standardized patients who portrayed typical primary care problems involving uncertainty and complexity. First, we analyzed 10 tapes of nine physicians with a range of clinical experience (first-year residents through faculty physicians) interacting with four standardized patient cases (headache, back pain, hypertension, and abdominal pain). We analyzed the 10 tapes to determine the regular occurrence of physician behavior patterns that we later described as strategies. Then, using a written questionnaire, 19 general internal medicine faculty physicians from our hospital and from an affiliated hospital rated the perceived importance of these strategies for clinical practice in general. Finally, we checked the incidence of the strategies: (1) across a range of six cases (headache, back pain, hypertension, abdominal pain, fatigue, and well-adult care) using six first-year residents (a total of 19 encounters), and (2) across different levels of clinical experience using the standardized patient case of headache involving eight physicians (first-year residents through faculty physicians). RESULTS: Nine strategies were identified, and each was rated as important to primary care clinical practice. The strategies were: (1) defines the context of the diagnosis and explains the signs and symptoms as part of the expected spectrum of the disease; (2) eliminates alternative diagnoses by dealing with patient fears, giving reasons in the context of the patient's belief system; (3) describes the prognosis in terms of the likely course of the disease and expectations of treatment; (4) negotiates key problems or issues that are important to both patient and physician; (5) negotiates the plan and ensures patient understands, and is willing and able to comply, given his/her particular context; (6) keeps diagnostic options open by making provisional diagnoses while keeping alternatives in mind; (7) is circumspect and takes action to minimize the possibility of missing other critical diagnoses; (8) plays for time by allowing signs and symptoms to develop to help clarify the diagnosis; and (9) plans for contingencies by providing appropriate if/then statements concerning situations requiring further action. The strategies were used in each of the six cases, and by physicians with all levels of clinical experience. CONCLUSIONS: The nine strategies led to the generation of a construct we termed "strategic medical management," which refers to the management (diagnosis and proposed treatment) of uncertain and complex medical problems in primary care. The construct provides a more elaborated framework in which to view clinical decision making and integrates recent ideas concerning doctor-patient communication into this process. Strategic medical management appears to be based on tacit knowledge that is seldom explicity articulated or taught. It has potential implications for enhancing instruction and assessment in medical education.