Student Clinical Experiences in Cross-Cultural Education.

OBJECTIVES: Education in cultural competence is critical to training medical students to care for patients from all backgrounds, but it is unclear what experience students have in the clinical learning environment. We describe the medical student experience in directly observed cross-cultural encounters within two clinical clerkships, and we identify areas of need for further resident and faculty training in providing high-quality feedback following these encounters. METHODS: We collected direct observation feedback forms from third-year medical students in the Internal Medicine and Pediatrics clerkships. The observed cross-cultural skill was categorized, and the quality of feedback given to students was quantified using a standardized model. RESULTS: Students were observed using an interpreter more frequently than any other skill. Positive feedback received the highest quality scores, averaging 3.34 out of 4 coded elements. Corrective feedback quality only averaged 2.3 out of 4 coded elements, and quality correlated with the frequency of cross-cultural skill observation. CONCLUSIONS: Significant variability exists in the quality of feedback provided to students following the direct observation of cross-cultural clinical skills. Faculty and resident training to improve feedback should focus on corrective feedback in less commonly observed cross-cultural skills.

Development and initial validation of an instrument for video-based assessment of technical skill in ERCP.

BACKGROUND AND AIMS: The accurate measurement of technical skill in ERCP is essential for endoscopic training, quality assurance, and coaching of this procedure. Hypothesizing that technical skill can be measured by analysis of ERCP videos, we aimed to develop and validate a video-based ERCP skill assessment tool. METHODS: Based on review of procedural videos, the task of ERCP was deconstructed into its basic components by an expert panel that developed an initial version of the Bethesda ERCP Skill Assessment Tool (BESAT). Subsequently, 2 modified Delphi panels and 3 validation exercises were conducted with the goal of iteratively refining the tool. Fully crossed generalizability studies investigated the contributions of assessors, ERCP performance, and technical elements to reliability. RESULTS: Twenty-nine technical elements were initially generated from task deconstruction. Ultimately, after iterative refinement, the tool comprised 6 technical elements and 11 subelements. The developmental process achieved consistent improvements in the performance characteristics of the tool with every iteration. For the most recent version of the tool, BESAT-v4, the generalizability coefficient (a reliability index) was .67. Most variance in BESAT scores (43.55%) was attributed to differences in endoscopists' skill, indicating that the tool can reliably differentiate between endoscopists based on video analysis. CONCLUSIONS: Video-based assessment of ERCP skill appears to be feasible with a novel instrument that demonstrates favorable validity evidence. Future steps include determining whether the tool can discriminate between endoscopists of varying experience levels and predict important outcomes in clinical practice.

Identification of foundational non-clinical attributes necessary for successful transition to residency: a modified Delphi study with experienced medical educators.

BACKGROUND: We aimed to identify foundational non-clinical attributes expected of medical school graduates to be successful in residency. METHODS: We conducted a three-round modified Delphi study with snowball sampling of experienced medical educators. In Round 1, respondents rated 28 attributes identified from a literature search. Additional attributes were proposed through invited comments. In Round 2, respondents expressed their agreement with advanced attribute definitions and examples. Consensus on final definitions and examples was obtained in Round 3. RESULTS: Sixty-four percent (105/163) of invited educators participated in Round 1. There was broad representation of educational focus (undergraduate, graduate, and continuing medical education) and field of practice (primary care, sub-specialty, medical, and surgical). Thirteen attributes were advanced to Round 2. Ninety-seven of 105 (92%) respondents participated in Round 2, with greater than 92% agreement for all attributes. Three pairs were consolidated. In Round 3, 88% (85/97) of educators expressed greater than 92% agreement about definitions and representative examples. The final 10 foundational attributes are: communication skills, critical thinking, emotional intelligence, ethical behavior, intellectual curiosity, organizational skills, resilience, self-improvement, teamwork, and vocational commitment. CONCLUSION: Through a consensus-building process of medical educators, we identified and defined 10 foundational non-clinical attributes for a medical student's successful transition to residency.

Using Ultrasound to Enhance Medical Students' Femoral Vascular Physical Examination Skills.

OBJECTIVES: To determine whether the addition of ultrasound to traditional physical examination instruction improves junior medical students' abilities to locate the femoral pulse. METHODS: Initially, 150 second-year medical students were taught the femoral pulse examination using traditional bedside teaching on standardized patients and online didactic videos. Students were then randomized into 2 groups: group 1 received ultrasound training first and then completed the standardized examination; and group 2 performed the standardized examination first and then received ultrasound training. On the standardized patients, the femoral artery was marked with invisible ink before the sessions using ultrasound. Compared to these markers, students were then evaluated on the accuracy of femoral artery pulse palpation and the estimated location of the femoral vein. All students completed a self-assessment survey after the ultrasound sessions. RESULTS: Ultrasound training improved the students' ability to palpate the femoral pulse (P= .02). However, ultrasound did not facilitate correct estimation of the femoral vein's anatomic location (P = .09). Confidence levels in localizing the femoral artery and vein were equal between groups at baseline, and both increased after the ultrasound sessions. CONCLUSIONS: The addition of ultrasound teaching to traditional physical examination instruction enhanced medical student competency and confidence with the femoral vascular examination. However, understanding of anatomy may require emphasis on precourse didactic material, but further study is required.

An innovative approach to teaching cross-cultural communication among dental students.

Introduction There is a lack of concordance in demographics between dental professionals and their patients. Professional organisations have recognised the necessity of cultural competency training in dental education. This study sought to employ and evaluate a novel intervention in cultural competency training on cross-cultural communication for undergraduate dental students.Material and methods The session employed dyad training, roleplaying, Kleinman's Explanatory Model and introduced the new 'Model for Negotiating Across Cultures', applied to patients' cultures. Learners included 24 first-year and 27 third-year dental students. Evaluation compared pre- and post-intervention responses to the modified Health Belief Attitudes Survey (HBAS). Paired t-tests were conducted to determine difference in pre- and post-intervention scores.Results For first-year students, the mean difference improvement between the pre- and post-intervention surveys for each HBAS domain was statistically significant (p <0.05). For the third-year students, improvement was significant in all domains except for quality (p = 0.083).Discussion Dental students were found to have improved cultural competency scores by the HBAS. Implementation of this educational intervention demonstrates a paradigm that could be implemented for cross-cultural communication.Conclusion The intervention can be utilised as a resource for cross-cultural communication education for dental students and could be expanded for all health professional students.

Training internal medicine residents in outpatient HIV care: a survey of program Directors.

BACKGROUND: The care of patients with HIV is increasingly focused on outpatient chronic disease management. It is not known to what extent internal medicine residents in the US are currently being trained in or encouraged to provide primary care for this population of patients. OBJECTIVE: To survey internal medicine residency program directors about their attitudes regarding training in outpatient HIV care and current program practices. DESIGN: Program directors were surveyed first by email. Non-responding programs were mailed up to two copies of the survey. SUBJECTS: All internal medicine residency program directors in the US. MAIN MEASURES: Program director attitudes and residency descriptions. KEY RESULTS: Of the 372 program directors surveyed, 230 responded (61.8 %). Forty-two percent of program directors agreed that it is important to train residents to be primary care providers for patients with HIV. Teaching outpatient-based HIV curricula was a priority for 45.1%, and 56.5% reported that exposing residents to outpatient HIV clinical care was a high priority. Only 46.5% of programs offer a dedicated rotation in outpatient HIV care, and 50.5% of programs have curricula in place to teach about outpatient HIV care. Only 18.8% of program directors believed their graduates had the skills to be primary providers for patients with HIV, and 70.6% reported that residents interested in providing care for patients with HIV pursued ID fellowships. The strongest reasons cited for limited HIV training during residency were beliefs that patients with HIV prefer to be seen and receive better care in ID clinics compared to general medicine clinics. CONCLUSIONS: With a looming HIV workforce shortage, we believe that internal medicine programs should create educational experiences that will provide their residents with the skills and knowledge necessary to meet the healthcare needs of this population.

Impact of participation in a community-based intimate partner violence prevention program on medical students: a multi-center study.

BACKGROUND: Physicians are generally poorly trained to recognize, treat or refer adolescents at risk for intimate partner violence (IPV). Participation in community programs may improve medical students' knowledge, skills, and attitudes about IPV prevention. OBJECTIVE: To determine whether the experience of serving as educators in a community-based adolescent IPV prevention program improves medical students' knowledge, skills, and attitudes toward victims of IPV, beyond that of didactic training. PARTICIPANTS: One hundred and seventeen students attending 4 medical schools. DESIGN: Students were randomly assigned to didactic training in adolescent IPV prevention with or without participation as educators in a community-based adolescent IPV prevention program. Students assigned to didactic training alone served as community educators after the study was completed. MEASUREMENT: Knowledge, self-assessment of skills and attitudes about intimate partner violence and future plans to pursue outreach work. RESULTS: The baseline mean knowledge score of 10.25 improved to 21.64 after didactic training (p

Student body racial and ethnic composition and diversity-related outcomes in US medical schools.

CONTEXT: Many medical schools assert that a racially and ethnically diverse student body is an important element in educating physicians to meet the needs of a diverse society. However, there is limited evidence addressing the educational effects of student body racial diversity. OBJECTIVE: To determine whether student body racial and ethnic diversity is associated with diversity-related outcomes among US medical students. DESIGN, SETTING, AND PARTICIPANTS: A Web-based survey (Graduation Questionnaire) administered by the Association of American Medical Colleges of 20,112 graduating medical students (64% of all graduating students in 2003 and 2004) from 118 allopathic medical schools in the United States. Historically black and Puerto Rican medical schools were excluded. MAIN OUTCOME MEASURES: Students' self-rated preparedness to care for patients from other racial and ethnic backgrounds, attitudes about equity and access to care, and intent to practice in an underserved area. RESULTS: White students within the highest quintile for student body racial and ethnic diversity, measured by the proportion of underrepresented minority (URM) students, were more likely to rate themselves as highly prepared to care for minority populations than those in the lowest diversity quintile (61.1% vs 53.9%, respectively; P < .001; adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 1.13-1.57). This association was strongest in schools in which students perceived a positive climate for interracial interaction. White students in the highest URM quintile were also more likely to have strong attitudes endorsing equitable access to care (54.8% vs 44.2%, respectively; P < .001; adjusted OR, 1.42; 95% CI, 1.15-1.74). For nonwhite students, after adjustment there were no significant associations between student body URM proportions and diversity-related outcomes. Student body URM proportions were not associated with white or nonwhite students' plans to practice in underserved communities, although URM students were substantially more likely than white or nonwhite/non-URM students to plan to serve the underserved (48.7% vs 18.8% vs 16.2%, respectively; P < .001). CONCLUSION: Student body racial and ethnic diversity within US medical schools is associated with outcomes consistent with the goal of preparing students to meet the needs of a diverse population.

Student body diversity: relationship to medical students' experiences and attitudes.

BACKGROUND: Multiple studies of undergraduate college students have demonstrated the effects of cross-cultural interaction and exposure to diverse ideas on a variety of educational outcomes. The current study was designed to extend this work into medical education, examining student body diversity and school-supported cross-cultural experiences on students' attitudes about diversity. METHOD: Four-hundred forty-one rising fourth-year medical students from three schools with differing levels of student body diversity completed a 55-item questionnaire on their background, experiences, and attitudes related to cross-cultural diversity. RESULTS: Medical students' attitudes about culture and health and their perspectives on societal issues related to diversity were influenced by their medical school experiences. Informal instructional interactions seem to have been most influential in shaping these beliefs. DISCUSSION: The opportunity for students from diverse backgrounds to interact as part of the curriculum is an important means of promoting positive attitudes toward diversity in educational and social environments.

The Impact of an Academy of Medical Educators on the Culture of an American Health Sciences Campus.

PURPOSE: During the last two decades in the United States, academies of medical educators (AMEs) have proliferated as formal organizations within faculties of health professions education to recognize teaching excellence, support faculty development, and encourage scholarly activity. AMEs have been effective at rewarding faculty for educational excellence and providing faculty development. However, the impact of an AME on campus culture remains unclear. METHOD: A qualitative case study asked, How has an AME shaped organizational culture? The authors investigated the University of Colorado health sciences campus AME given its clear mandate to impact organizational culture. The authors interviewed a purposeful sample of 26 AME members and non-AME campus faculty and educational leaders during the 2014-2015 academic year. Two reviewers employed content analysis to code the transcripts. RESULTS: The AME has positively impacted organizational culture by being a symbol of institutional commitment to the educational mission, and by asserting education as an evidence-based practice. At the faculty member level, the AME's impact includes creating a home and community for educators to network. Individual faculty influence departments and programs across campus through teaching and interpersonal connections. However, the AME has not impacted all of campus, due to only reaching self-identified educators, and the siloed nature of departments on campus. CONCLUSIONS: Although limited to a single campus and an early established AME, this study contributes significant insight by describing how an AME as a structural unit impacts individual faculty members, who in turn impact organizational campus culture regarding the educational mission.

Evaluation of the role of training in the implementation of a depression screening and treatment protocol in 2 academic outpatient internal medicine clinics utilizing the electronic medical record.

Systematic approaches to depression identification and management are effective though not consistently implemented. The research team implemented a depression protocol, preceded by training, in 2 faculty-resident practices. Medical assistants used the Patient Health Questionnaire (PHQ)-2 for initial screening; providers performed the PHQ-9. These were documented in the electronic medical record. Logistic regression was performed to assess the association of provider type, clinic site, and training attendance with documentation of PHQ-9 after positive PHQ-2s, and with repeat PHQ-9s after positive PHQ-9s. In logistic regression analysis, training attendance was positively associated with documentation of PHQ-9 after a positive PHQ-2 (odds ratio [OR] = 2.4 [confidence interval (CI) = 1.3-4.3]) and repeated documentation of a PHQ-9 after a positive PHQ-9 (OR = 2.5 [CI = 1.1-5.3]). This study describes the successful implementation of a stepped-care approach to depression care. The positive association of training with compliance with protocol procedures indicates the importance of training in the implementation of practice change.

Using fresh tissue dissection to teach human anatomy in the clinical years.

PURPOSE: Gross anatomy is taught in medical school with textbooks, cadaver dissection, plastic models, and multimedia illustration, but all lack the reality of color and texture that is possible with fresh tissue dissection. The authors studied the use of fresh tissue dissection of the thorax and abdomen of the rat to teach human anatomy. METHOD: In a half-day exercise, 52 fourth-year medical students paired off and completed an exercise to dissect in less than three hours the thorax and abdomen of a euthanized rat. Observation of organs was augmented by active manipulation such as passing a tube down the esophagus, cannulating the trachea and inflating the lungs, injecting dye in the kidney to trace the ureter and bladder, and pulling the testis through the inguinal canal. Comparison of the rat and human was emphasized to enhance the education. The exercise ended with practice suturing fresh tissue. RESULTS: Students rated the exercise to teach anatomy as 4.9 positive on a 5.0 (high) scale. The significant positive structures (p <.05) for texture were heart, liver, lungs and trachea; for color they were lungs and spleen; for location and size they were adrenal gland and urinary bladder; and for function they were adrenal gland and esophagus. CONCLUSION: Fresh tissue dissection of the thorax and abdomen of the rat is a valuable tool for human anatomy education. The dissonances in human and rat anatomy enhance abstraction and transfer of knowledge. Active manipulation of organs promotes retention of knowledge, and suturing provides a "clinical" context. Fresh tissue dissection is an efficient innovative method to provide a global review of anatomy of the thorax and abdomen during the busy clinical years of medical education.

Effective feedback strategies for teaching in pediatric and adolescent gynecology.

The clinical setting of pediatric and adolescent gynecology poses complex tasks for the physician with its numerous procedures and the communication demands of interacting with an adolescent and/or guardian. Needless to say, teaching within this setting is highly demanding. Regardless of the level of learner or the professional role (e.g., nurse, medical student, resident, physician assistant) represented, clinical teaching requires that the instructor provide feedback in ways that benefit the student. Recent research on feedback suggests a more complex understanding of feedback than in the past. This article highlights key research and its implication for effective feedback by presenting a three part framework; know your learner, understand what is to be learned, and plan for improvement.

Students' perspectives on the fourth year of medical school: a mixed-methods analysis.

PURPOSE: Little is known about the purpose and value of the fourth year of medical school from the perspective of medical students. In this study, the authors systematically explored the year's purpose and value as determined by students. METHOD: In April 2011, the authors conducted semistructured focus groups with graduating fourth-year students at the University of Colorado School of Medicine to understand their perspectives on the purpose of the fourth year. Using results of a thematic analysis of the focus group data, the authors developed and administered a 10-item questionnaire to all graduating fourth-year medical students in May 2011. Questionnaire data were analyzed using descriptive statistics and exploratory factor analysis. RESULTS: A total of 17 students participated in two focus groups. Six themes related to the purpose of the fourth year emerged from the focus group data: career development and preparation, pursuing personal interests, career identification, exploration of diverse practice settings, influence of emotion, and flexibility and individualization. The questionnaire was completed by 134 of 148 students (91% response rate). Factor analysis of the questionnaire data identified five factors: strengthening one's residency application, developing skills, pursuing personal interests, exploring diverse practice settings, and identifying a career. CONCLUSIONS: Medical students uniformly identified the fourth year of medical school as having purpose and value, but their views on the fourth year's purpose differed. This finding underscores the importance of the individualization of the fourth year. Students' perspectives should inform any decisions made about modifying fourth-year curricula and structure.

Measuring pediatric resident competencies in adolescent medicine.

PURPOSE: To compare third-year pediatric resident competence on an adolescent medicine with competence in treating younger children. METHODS: The participants were third-year residents (2010 [n = 24] and 2011 [n = 23]) at University of Colorado School of Medicine. Resident competence was measured in the domains of professionalism, communication, and history-taking skills in a multicase Objective Structured Clinical Examination. RESULTS: Percent correct scores in professionalism, history-taking, and communication skills on the adolescent case ranked in the bottom half of cases in both years. T-tests comparing mean score difference between the adolescent case and pediatric cases combined were statistically significant for professionalism (79.57 ± 4.15 vs. 89.51 ± 14.14, p = .01) and history taking (66.27 ± 11.02 vs. 75.10 ± 18.40, p = .05). CONCLUSIONS: Resident's history taking addressed immediate issues but not public health issues with adolescents. The professionalism findings suggest that residents engage in less patient-centered care when caring for adolescents, even while their communication skills remain on par.

Time and cost of teaching cataract surgery.

PURPOSE: To compare the differences in the time of completion of cataract surgery for residents and attending surgeons and to assign a dollar cost. SETTING: University of Colorado teaching hospital, Aurora, Colorado, USA. DESIGN: Comparative case series. METHODS: Cataract cases were divided into 3 levels of difficulty for comparison. Main outcome measures were total case time (incision to patch) and degree of difficulty. RESULTS: Nine residents and 6 attending surgeons participated in the study. Case times were collected for 324 resident cases and 319 attending surgeon cases. The mean attending surgeon case time was 25.75 minutes ± 12.32 (SD) and the mean resident case time, 46.35 ± 16.75 minutes. There was no significant difference in the degree of difficulty between resident cases and attending surgeon cases. Approximately 600 total cases were performed by 4 residents during 3 years of residency training. Taking into account the mean time of case completion for attending surgeons versus residents, the total difference in time if attending surgeons had performed 600 cataracts would be 12,360 minutes. Using a dollar cost of approximately $11.24 per minute at the institution, the cost difference was calculated to be $138,926.40. CONCLUSION: There was a significant time and dollar cost incurred in teaching cataract surgery. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Validation of the colorado psychiatry evidence-based medicine test.

BACKGROUND: Evidence-based medicine (EBM) has become an important part of residency education, yet many EBM curricula lack a valid and standardized tool to identify learners' prior knowledge and assess progress. OBJECTIVE: We developed an EBM examination in psychiatry to measure our effectiveness in teaching comprehensive EBM to residents. METHODS: We developed a psychiatry EBM test using the validated EBM Fresno Test of Competence for family medicine. The test consists of case scenarios with open-ended questions. We also developed a scoring rubric and obtained reliability with multiple raters. Fifty-seven residents provided test data after completing 3, 6, 25, or 31 EBM sessions. The number of sessions for each resident was based on their length of training in our program. RESULTS: The examination had strong interrater reliability, internal reliability, and item discrimination. Many residents showed significant improvement on their examination scores when data were compared from tests taken before and after a sequence of teaching sessions. Also, a threshold for the level of expert on the examination was established using test data from 5 EBM teacher-experts. CONCLUSIONS: We successfully developed a valid and reliable EBM examination for use with psychiatry residents to measure essential EBM skills as part of a larger project to encourage EBM practice for residents in routine patient care. The test provides information on residents' knowledge in EBM from entry level concepts through expert performance. It can be used to place incoming residents in appropriate levels of an EBM curriculum and to monitor the effectiveness of EBM instruction.

Evaluating nonphysician staff members' self-perceived ability to provide multisource evaluations of residents.

BACKGROUND: Multisource evaluations of residents offer valuable feedback, yet there is little evidence on the best way to collect these data from a range of health care professionals. OBJECTIVE: This study evaluated nonphysician staff members' ability to assess internal medicine residents' performance and behavior, and explored whether staff members differed in their perceived ability to participate in resident evaluations. METHODS: We distributed an anonymous survey to nurses, medical assistants, and administrative staff at 6 internal medicine residency continuity clinics. Differences between nurses and other staff members' perceived ability to evaluate resident behavior were examined using independent t tests. RESULTS: The survey response rate was 82% (61 of 74). A total of 55 respondents (90%) reported that it was important for them to evaluate residents. Participants reported being able to evaluate professional behaviors very well (62% [36 of 58] on the domain of respect to staff; 61% [36 of 59] on attire; and 54% [32 of 59] on communication). Individuals without a clinical background reported being uncomfortable evaluating medical knowledge (60%; 24 of 40) and judgment (55%; 22 of 40), whereas nurses reported being more comfortable evaluating these competencies. Respondents reported that the biggest barrier to evaluation was limited contact (86%; 48 of 56), and a significant amount of feedback was given verbally rather than on written evaluations. CONCLUSIONS: Nonphysician staff members agree it is important to evaluate residents, and they are most comfortable providing feedback on professional behaviors. A significant amount of feedback is provided verbally but not necessarily captured in a formal written evaluation process.