The effect of incorporating women's health into a PBL curriculum on students' tendencies to identify learning issues in an ambulatory care setting.

PURPOSE: To investigate whether the incorporation of women's health into problem-based learning (PBL) cases affects students' tendency to identify learning issues related to women's health as they encounter patients in an ambulatory care setting. METHOD: Students in the PBL curriculum at the Allegheny University of the Health Sciences, MCP-Hahnemann School of Medicine, participate in a nine-week primary care practicum at the end of their first year, during which they spend three half-days per week in an ambulatory setting examining patients and completing patient logs that include any learning issues identified. Patient logs from 23 first-year PBL students who had not been exposed to a new women's health education program prior to their practicum in 1993 and from 22 first-year PBL students who had been exposed to the program prior to their practicum in 1994 were reviewed. For each women's health learning issue identified, the sex of the student and the sex, specialty, and practice setting of the student's preceptor were recorded. Data were analyzed with several statistical methods. RESULTS: There was no statistically significant difference in the numbers of men and women students or preceptors between the two years. In 1993 an average of 59% of the patients seen per student were women; in 1994 the average was 61%. The mean numbers of total learning issues identified (including women's health learning issues) were similar in the two years, but the mean percentage of clinical women's health learning issues identified increased significantly between 1993 and 1994, as did the mean percentage of community/preventive health women's health learning issues identified. There was a significant student-sex-by-preceptor-sex interaction for the total number of women's health learning issues identified (p = .024): for both years, the students paired with a preceptor of the same sex identified a higher number of women's health learning issues than did the students paired with a preceptor of the opposite sex. CONCLUSION: The results suggest that PBL is an effective way to increase students' awareness of women's health issues in a primary care clinical setting. More studies are needed to define the effect of PBL on the kind of reading and learning students will do when they get to the clinical setting.

Applying practical preventive skills in a preclinical preceptorship.

Learning primary care medicine includes learning to apply practical, preventive medicine skills during everyday encounters with patients. The authors relate their experiences with implementing a voluntary, preventive diabetic foot-care program within the Texas Statewide Family Practice Preceptorship Program (TSFPPP). They explain the background of the TSFPPP and their rationale for introducing prevention and selecting diabetic foot care as a first preventive training module. The program's structure, educational materials, and evaluations are described. Of the 158 students and 88 preceptors who were exposed to the program, the authors received evaluations from 86 preceptors and 110 students. Students documented that they had screened and provided foot-care education to 321 diabetic patients. On average, students saved their preceptors 5-10 minutes each time they examined a diabetic patient's feet or provided foot-care education. The students said that the wide variety of preceptors' practices, the time constraints placed upon the preceptors, and the preceptors' own guidelines for the voluntary preceptorship all posed challenges to completing the preventive activities. The preceptors reported that preclinical students could play an important preventive role in their practices; however, to get optimum results from a preventive module, it may be important for students and preceptors to determine which topics are introduced. Using the preceptor's suggestions, the authors are developing a smoking-cessation module.

Implementing a comprehensive approach to managing faculty roles, rewards, and development in an era of change.

The current environment in which medicine is taught and practiced requires that medical schools pay increased attention to the faculty member's roles, rewards, career development, and productivity. Medical schools must make strategic decisions about the allocation of resources that can nurture their faculties and support the activities in academic and community settings in which faculty are involved. From 1993 to 1995 Allegheny University of the Health Sciences (formerly Medical College of Pennsylvania and Hahnemann University) designed a comprehensive system for the professional development of faculty. This system is based upon expanded categories of faculty academic activity and scholarship. New programs were implemented to reorient faculty toward conducting and documenting the expanded array of scholarly activities. The main characteristics of the new system are the establishment of formally defined performance expectations, the vertical alignment of the individual faculty member's objectives with the department's mission and the school's mission, and an increasing emphasis upon faculty interdependence, accountability, and use of sound business practices. The authors describe these and other aspects of the design of the new system in detail and report initial results and lessons learned from the system's implementation, evaluation, and dissemination throughout the university. The long-term success of this comprehensive professional development program will be assessed over time by observing how this institution advances its mission in a well-planned and cost-effective manner that retains talented, productive, and professionally fulfilled faculty.

Use of a paper-cut as an adjunct to teaching the Whipple procedure by video.

BACKGROUND: Medical students often experience difficulty comprehending anatomic relationships of complex operations to which they are exposed during surgical clerkship. Pancreaticoduodenectomy, the Whipple procedure, is one such operation. Although video recordings are available to facilitate the learning of the Whipple procedure, commercially available tapes are not self-explanatory to the uninitiated. Since we have previously demonstrated that third-year medical students could learn the operative steps of inguinal herniorraphy by a paper-cutting exercise, we set out to determine whether an exercise of similar design could enhance a student's comprehension of the Whipple procedure. METHODS: Using Adobe Illustrator 5.5 for MacIntosh, an exercise was developed on a 8.5 x 11-inch paper that could be distributed to students for self-administration. The exercise was performed using a #15 scalpel or an iris scissors. Thirty-seven students were randomized into two groups. Each student received a pretest of questions focusing on the Whipple procedure. Group I was shown an 18-minute commercially available teaching video on the Whipple procedure. Group II was given the Whipple origami exercise, which required 20 minutes to complete. A first posttest was administered to each group. Next, the groups switched exercises, and a second posttest was administered. RESULTS: There was no significant difference between the groups' pretest scores (two-tailed t test, P = 0.290). Group I improved its score from an average of 64.21 (SD 14.27) to 67.89 (SD 13.16) after watching the video, and further to 77.89 (SD 14.37) after completing the paper-cut exercise. Group II improved from 60.00 (SD 9.43) to 78.95 (SD 11.00) after performing the paper-cut, but derived no additional measurable benefit from watching the video, average score 74.74 (SD 18.37). After the first exercise, students who performed the paper-cut showed a significantly greater improvement in test scores compared with students who saw the video (P = 0.0035 by Mann-Whitney U). After both groups had completed the exercises, the mean changes from baseline were no longer significantly different (P = 0.58 by Mann-Whitney U). CONCLUSION: As a single educational intervention, the paper-cut exercise was a more effective teaching device than the video in the given time frame. The origami model may be generalized to a variety of surgical procedures and appears to be a valuable adjunct to traditional teaching.

The medical record and the medical interview: an evaluation of student case histories.

This study assessed the results of a second-year family medicine course designed to improve student abilities in writing complete assessments and plans from interviews with standardized patients. Sixty-six students attended lectures on the patient's perception of the symptoms of the major causes of death, learned techniques of medical interviewing, saw a model interview by their tutor, received model faculty histories based on American Board of Family Practice Office Record Review Criteria, and received critiques of their own histories. Students in the highest decile recorded twice as much information as those in the lowest decile and recorded as many history items as the faculty member who recorded the most history items. The faculty, however, recorded a more complete list of diagnoses, differential diagnoses, and investigations. Students in the lowest decile recorded the least information and the least number of assessments and plans and did not respond to written critiques. Students in the lowest decile could improve if they were identified early in the course and worked intensively with role models.

Designing and evaluating an episodic, problem-based geriatric curriculum.

BACKGROUND: Medical school geriatric training has been directed primarily at improving students' attitudes and knowledge about elderly patients. This study evaluated a clinical problem-based geriatric course for medical students. METHODS: The two-semester geriatric course was presented to 136 second-year medical students. Faculty taught students about clinical reasoning in ambulatory geriatrics using written cases, patient-actors, literature reviews, lectures, and discussions. At the end of the course, students' clinical activity was evaluated using audiotaped interviews with standardized geriatric patients. A questionnaire examined students' knowledge, attitudes, and their evaluation of the course. RESULTS: All 136 students completed the post-course standardized patient interview, and 105 (77%) completed questionnaires. Students rated the course favorably and had high confidence scores for ability to assess geriatric problems. Students' knowledge increased during the course compared to a precourse examination (P less than .05). Evaluation of post-course standardized patient interviews revealed that students who scored higher on the knowledge test tended to ask more psychosocial questions during the interview (r = 0.38). Students who scored higher on the attitude test spent more time eliciting patients' feelings during the interview (r = 0.38). Those with lower scores on the attitude test spent more time asking factual, nonpsychosocial questions (r = 0.28). CONCLUSIONS: A clinical problem-based geriatric course for preclinical medical students can be successful in improving students' knowledge. Attitudes and knowledge effect the questions a student asks during the medical interview.

Specialty career decision making of third-year medical students.

Medical Students who are deciding which specialty to enter sometimes do not choose the one they actually prefer. The purposes of this study were to compare specialty preferences of students with their choices, as well as to identify the factors on which decisions about entering family medicine are based. Of North Carolina's 429 third-year medical students, 59% responded in 1985 to a career preferences questionnaire that assessed the process of specialty decision making. Internal medicine was the most frequently chosen specialty when another was preferred. The frequency with which family practice was the career choice was affected little by differences between preferences and choices. Six factors were identified, with the curriculum as the major factor separating those who chose family practice from those who chose other primary care or non-primary care specialties. Based on these results, six suggestions are offered for medical school administrators and faculty desiring to increase the number of students selecting family practice.

Bringing a family practice model of health to the People's Republic of China.

The health care system in the People's Republic of China (PRC) is undergoing a major transition that has made the government revise its approach to how medicine is taught and practiced. Family medicine, which provides a generalist approach to medical care, is at the forefront of this transition. This article reviews the recent history of medical education in the PRC, including the establishment of the discipline of family medicine in the mid 1980s, and factors promoting development of family medicine. These include the movement away from government-subsidized health care in hospital settings, the aging population, increased urbanization, increasing incidence of infectious diseases, and rising health care costs. We conclude from observations made in the PRC and from a review of secondary sources that family medicine in China is in its infancy. The value of understanding the role that family medicine plays within China's changing health care system is that we gain a broader perspective of the variety and growing international importance of family practice as a profession.

Management of problem patients with multiple chronic diseases.

Residents in a university-based family medicine program perceived patients with diabetes mellitus, hypertension, and obesity as problem patients. The residents' perceptions of 166 patients were compared with information from a chart audit. A resident questionnaire outlined the goals, obstacles, and strategies pertaining to management of these patients as well as residents' perceptions of patient expectations. The results prompted a shift in focus from the problem patient to the problem patient-physician relationship and brought forth improved strategies that hold potential for making a difference in patient and physician satisfaction and outcome of care.

Strategies to expand the definition of scholarship for the health professions.

Standards for promotions and tenure for health professions faculty must require the same intellectual and methodologic rigor as those in other academic areas. The challenge is to expand the traditional view of scholarship as research to include scholarship of teaching, application, and integration and to develop methods for documenting these. This article describes four strategies instituted by Allegheny University of the Health Sciences to address this challenge. Results of two of the strategies, a workshop for appointments and promotions and tenure committee members, and a workshop for preparing junior faculty for academic advancement are discussed. The four strategies described are intended to serve as models to stimulate discussion and innovation at other institutions.

Training and evaluating teams of simulated patients.

The purpose of this study was to train and evaluate teams of standardized (simulated) patients as part of a required course in family medicine for second-year medical students. During three hours of training, six women were trained to play the same person. These standardized teams played four roles during the 12-week course. Each simulator was interviewed by three student interviewers who were part of six groups of ten to 12 students, each group led by a physician. All sessions were audiotaped, and a coding system was developed. The completeness of response, new unscripted items, and accuracy of information provided by the simulators were measured using the audiotape sessions as sources of data. In addition, the degree of accuracy of the affect of each simulator was assessed by faculty and students in written case histories. The results of the study show that multiple simulators are an effective way of promoting active learning and of teaching basic clinical concepts and skills. Teams of standardized patients give students a consistent learning experience when there are constraints of student group size, time, and scheduling simulations within a traditional curriculum.

Faculty development for family medicine: a status report.

Stability in family medicine residency program growth has resulted in a trend to redefine faculty development in terms of changing needs. Recent literature has indicated these needs to be in the areas of increased research, improved clinical skills, reassessment of content and methods of faculty development, and changes in educational methods. To identify the status of faculty development programs in 1985, 126 family medicine university-based programs were surveyed. Data were obtained regarding the content of faculty development programs, the perceived competence of faculty in six clinical teaching areas and three academic areas, and the importance of eight areas of faculty development. The most frequent activity reported by the 74 respondents was in the area of teaching and evaluation. Research was the academic area listed in which directors noted a particular lack of competence. In the clinical content area, both procedural skills and critical care stood out as areas of faculty needs. Results suggested that more than one track of faculty development should be provided to meet complex and changing faculty development needs.

Defining and accomplishing clinically related objectives in an eight-hour oncology course for first-year medical students.

Designing a clinically relevant cancer curriculum for freshmen attending medical schools with a traditional curriculum poses the following challenges: (1) there is limited curriculum time; (2) the subject matter is complex. The authors defined some of the responsibilities of the general physician in regard to cancer and six related objectives that first-year students could accomplish in an eight-hour multidisciplinary oncology course. A case-based, modified essay examination required students to demonstrate that they could begin to integrate principles of prevention, screening, diagnosis and staging, and treatment modalities. Ninety percent of the students accomplished the objectives. However, in working up the cancer case, 70% of the students did not mention the physical examination and 53% forgot multidisciplinary consultation. In a curriculum with limited objectives, first-year students can begin to deal efficiently with the complexities of cancer. Evaluation data revealed those objectives and related physician responsibilities requiring reinforcement in subsequent training.

Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency.

CONTEXT: Medical educators have had a growing sense that proficiency in physical diagnostic skills is waning, but few data have examined the question critically. OBJECTIVE, DESIGN, AND SETTING: To compare the cardiac auscultatory proficiency of medical students and physicians in training. A multicenter cross-sectional assessment of students and house staff. A total of 8 internal medicine and 23 family practice programs of the mid-Atlantic area. PARTICIPANTS: A total of 453 physicians in training and 88 medical students. INTERVENTIONS: All participants listened to 12 cardiac events directly recorded from patients, which they identified by completing a multiple-choice questionnaire. MAIN OUTCOME MEASURES: scores were expressed as the percentage of participants, for year and type of training, who correctly identified each event. Cumulative scores were expressed as the total number of events correctly recognized. An adjusted score was calculated whenever participants selected not only the correct finding but also findings that are acoustically similar and yet absent. RESULTS: Trainees' cumulative scores ranged between 0 and 7 for both internal medicine and family practice residents (median, 2.5 and 2.0, respectively). Internal medicine residents had the highest cumulative adjusted scores for the 6 extra sounds and for all 12 cardiac events tested (P=.01 and .02, respectively). On average, internal medicine and family practice residents recognized 20% of all cardiac events; the number of correct identifications improved little with year of training and was not significantly higher than the number identified by medical students. CONCLUSIONS: Both internal medicine and family practice trainees had a disturbingly low identification rate for 12 important and commonly encountered cardiac events. This study suggests a need to improve the teaching and assessment of cardiac auscultation during generalists' training, particularly with the advent of managed care and its search for more cost-effective uses of technology.