Senior student goal setting during subinternship: a mixed-methods study.

BACKGROUND: New developments in Subinternship curricula attempt to establish self-directed learning skills that will translate into the 1st year of residency. However, we know little about how well senior medical students' self-directed learning goals match with what is expected of them in residency. PURPOSES: We designed a mixed-methods study to examine the goals set by senior students at Georgia Health Sciences University on Pediatric Subinternship and to determine how those goals relate to the 6 Accreditation Council for Graduate Medical Education (ACGME) competencies. METHODS: We used an iterative process to categorize self-directed learning goals on Pediatric Subinternships (n=188 goals generated by 57 senior students) by (a) the 6 ACGME competencies and (b) general or specific goals. We used tests of association and multivariate modeling to compare goal categories by clinical site and time of year. RESULTS: There were 56.3% of goals addressing patient care. Professionalism and systems-based practice goals were rare. Of the goals, 72% were general, but goals written by students at the newborn nursery and neonatal intensive care unit sites were significantly more likely to be specific than goals written by students on the general inpatient subinternship. CONCLUSIONS: The overwhelming majority of senior medical student goals on a Pediatric Subinternship are general and related to patient care. Students may need assistance with developing more specific goals in all 6 competencies. Our findings suggest that understanding and incorporating students' learning goals may be important for enhancing the potential effectiveness of transition-to-residence curricula.

Disparate patterns of prenatal care utilization stratified by medical and psychosocial risk.

To evaluate patterns of prenatal care utilization stratified by medical and psychosocial risk. A retrospective cohort of 786 pregnant women who subsequently delivered live births from 1999 to 2003 at the University of Michigan were classified into high medical, high psychosocial, high medical and high psychosocial (dual high risk) and low-risk pregnancies. Chi-square and logistic regression analyses assessed the association between risk and prenatal care utilization using the Kotelchuck Index. Of 786 pregnancies, 202 (25.7%) were high medical risk, 178 (22.7%) were high psychosocial risk, 227 (28.9%) were dual high risk and 179 (22.8%) were low-risk. Over 31% of dual high risk and 25% of high medical risk pregnancies received "adequate plus" prenatal care versus 10% of high psychosocial risk pregnancies. In multivariate analyses, adjusted for risk, race and insurance, high psychosocial risk pregnancies (OR = 1.69; 95% CI 1.06-2.72) were significantly more likely to receive inadequate prenatal care than care of greater intensity. Many high psychosocial risk pregnancies do not receive adequate prenatal care.

Measuring health professions students' orientation toward lifelong learning.

OBJECTIVE: Lifelong learning is considered to be an element of professionalism for healthcare professionals. Accreditation standards for health professions educational programs require that lifelong learning be promoted in the curriculae; however, tools to assess whether these standards are met are sparse. This study evaluated the internal structure of student responses on a transdisciplinary adaptation of the Jefferson Scale of Physician Lifelong Learning-Medical Students Version (JeffSPLL-MS). METHODS: The Jefferson Scale of Lifelong Learning-Health Professions Students Version (JeffSPLL-HPS) was administered to 180 students in eight entry-level health professions programs. Confirmatory factor analyses were performed to investigate internal structure. RESULTS: JeffSPLL-MS and JeffSLL-HPS mean scores were similar. Cronbach's alpha for the JeffSLL-HPS was 0.85. Results of the confirmatory factor analysis revealed a three-factor structure of the JeffSLL-HPS that was consistent with that of the JeffSPLL-MS. The Cronbach's alphas for the three factors on the JeffSLL-HPS were 0.78, 0.73, and 0.62. CONCLUSIONS: The JeffSLL-HPS's internal structure is similar to that of the JeffSPLL-MS. The tool may be valuable for faculty and administrators in health professions programs for assessing their goal of meeting accreditation standards and to assess the extent to which their students value the importance of lifelong learning.

Effectiveness and feasibility of utilizing E4D technology as a teaching tool in a preclinical dental education environment.

Recent efforts have been directed towards utilizing CAD/CAM technology in the education of future dentists. The purpose of this pilot study was to investigate the feasibility of implementing CAD/CAM technology in instruction on preparing a tooth for restoration. Students at one dental school were assigned access to CAD/CAM technology vs. traditional preparation methods in a randomized, crossover design. In a convenience sample of a second-year class, seventy-six of the seventy-nine students volunteered to participate, for a response rate of 96 percent. Two analyses were performed on this pilot data: a primary effectiveness analysis comparing students' competency exam scores by intervention group (intention-to-treat analysis) and a secondary efficacy analysis comparing competency exam scores among students who reported using CAD/CAM versus those who did not. The effectiveness analysis showed no difference in outcomes by intervention group assignment. While student survey results indicated interest in utilizing the technology, the actual utilization rate was much less than one might anticipate, yielding a sample size that limited statistical power. The secondary analysis demonstrated higher mean competency exam scores for students reporting use of CAD/CAM compared to those who did not use the technology, but these results did not reach statistical significance (p=0.075). Prior research has investigated the efficacy of CAD/CAM in a controlled educational trial, but this study adds to the literature by investigating student use of CAD/CAM in a real-world, self-study fashion. Further studies should investigate ways in which to increase student utilization of CAD/CAM and whether or not increased utilization, with a larger sample size, would yield significant outcomes.

Measuring psychological flexibility in medical students and residents: a psychometric analysis.

PURPOSE: Psychological flexibility involves mindful awareness of our thoughts and feelings without allowing them to prohibit acting consistently with our values and may have important implications for patient-centered clinical care. Although psychological flexibility appears quite relevant to the training and development of health care providers, prior research has not evaluated measures of psychological flexibility in medical learners. Therefore, we investigated the validity of our learners' responses to three measures related to psychological flexibility. METHODS: Fourth-year medical students and residents (n=275) completed three measures of overlapping aspects of psychological flexibility: (1) Acceptance and Action Questionnaire-II (AAQ-II); (2) Cognitive Fusion Questionnaire (CFQ); and (3) Mindful Attention and Awareness Questionnaire (MAAS). We evaluated five aspects of construct validity: content, response process, internal structure, relationship with other variables, and consequences. RESULTS: We found good internal consistency for responses on the AAQ (α=0.93), MAAS (α=0.92), and CFQ (α=0.95). Factor analyses demonstrated a reasonable fit to previously published factor structures. As expected, scores on all three measures were moderately correlated with one another and with a measure of life satisfaction (p<0.01). CONCLUSION: Our findings provide preliminary evidence supporting validity of the psychological flexibility construct in a medical education sample. As psychological flexibility is a central concept underlying self-awareness, this work may have important implications for clinical training and practice.

Mental health, substance use and intimate partner problems among pregnant and postpartum suicide victims in the National Violent Death Reporting System.

OBJECTIVES: Suicide during pregnancy and postpartum is a tragic event for the victim and profoundly impacts the baby, the family and the community. Prior efforts to study risks for pregnancy-associated suicide have been hampered by the lack of data sources which capture pregnancy and delivery status of victims. Introduction of the United States National Violent Death Reporting System (NVDRS) offers new insights into violent deaths by linking multiple data sources and allowing better examination of psychosocial risk factors. METHODS: The analysis used data from 17 states reporting to the NVDRS from 2003 to 2007 to evaluate suicide patterns among pregnant, postpartum, and nonpregnant or postpartum women. Demographic factors, mental health status, substance use, precipitating circumstances, intimate partner problems and suicide methods were compared among groups. RESULTS: The 2083 female suicide victims of reproductive age demonstrated high prevalence of existing mental health diagnosis and current depressed mood, with depressed mood significantly higher among postpartum women. Substance use and presence of other precipitating factors were high and similar among groups. Intimate partner problems were higher among pregnant and postpartum victims. Postpartum women were more likely to die via asphyxia as cause of death compared to poisoning or firearms. CONCLUSIONS: These findings describe important mental health, substance use and intimate partner problems seen with pregnancy-associated suicide. The study highlights mental health risk factors which could potentially be targeted for intervention in this vulnerable population.

Internet message boards for pregnancy loss: who's on-line and why?

BACKGROUND: Pregnancy loss is common, but its significance is often minimized by family, friends, and the community, leaving bereaved parents with unmet need for support. This study sought to describe demographics, usage patterns, and perceived benefits for women participating in Internet pregnancy loss support groups. METHODS: We requested permission to post an anonymous Internet survey on large and active United States Internet message boards for women with miscarriages and stillbirths. The study purposefully oversampled stillbirth sites and included both closed- and open-ended questions. The University of Michigan Institutional Review Board approved the study. Closed-ended questions were summarized and evaluated with bivariate analysis. We performed a qualitative analysis of open-ended data using an iterative coding process to identify key themes. RESULTS: Of 62 sites queried, 15 granted permission to post the survey on 18 different message boards. We collected 1,039 surveys, of which 1,006 were complete and eligible for analysis. Women were typically white, well educated, and frequent users. They noted message boards helped them to feel less isolated in their loss and grief and they appreciated unique aspects of Internet communication such as convenience, access, anonymity, and privacy. Pregnancy loss message boards are an important aspect of support for many bereaved mothers. African-American women seem to be substantially underrepresented on-line despite being at higher risk for stillbirth. CONCLUSION: Internet message boards serve a unique function in providing support for women with miscarriage and stillbirth. The benefits are often significantly different from those encountered in traditional face-to-face bereavement support.

Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System.

OBJECTIVE: To estimate the rates of pregnancy-associated homicide and suicide in a multistate sample from the National Violent Death Reporting System, to compare these rates with other causes of maternal mortality, and to describe victims' demographic characteristics. METHODS: We analyzed data from female victims of reproductive age from 2003 to 2007. We identified pregnancy-associated violent deaths as deaths attributable to homicide or suicide during pregnancy or within the first year postpartum, and we calculated the rates of pregnancy-associated homicide and suicide as the number of deaths per 100,000 live births in the sample population. We used descriptive statistics to report victims' demographic characteristics and prevalence of intimate-partner violence. RESULTS: There were 94 counts of pregnancy-associated suicide and 139 counts of pregnancy-associated homicide, yielding pregnancy-associated suicide and homicide rates of 2.0 and 2.9 deaths per 100,000 live births, respectively. Victims of pregnancy-associated suicide were significantly more likely to be older and white or Native American as compared with all live births in National Violent Death Reporting System states. Pregnancy-associated homicide victims were significantly more likely to be at the extremes of the age range and African American. In our study, 54.3% of pregnancy-associated suicides involved intimate partner conflict that appeared to contribute to the suicide, and 45.3% of pregnancy-associated homicides were associated with intimate-partner violence. CONCLUSION: Our results indicate that pregnancy-associated homicide and suicide are important contributors to maternal mortality and confirm the need to evaluate the relationships between sociodemographic disparities and intimate-partner violence with pregnancy-associated violent death.

OB CARES--The Obstetric Clinics and Resources Study: providers' perceptions of addressing perinatal depression--a qualitative study.

OBJECTIVE: We conducted a qualitative study to understand how prenatal care providers perceive influences on their delivery of perinatal depression care. Given that depression screening protocols were in place at the clinics where we sampled providers, we hypothesized that clinic- and system-level factors such as resources, training opportunities and coordination would be dominant in influencing provider decisions. METHODS: We conducted semistructured interviews with 20 prenatal care providers from six obstetric clinics. We performed a thematic analysis, including within-case and cross-case comparisons, and built a conceptual model of provider decision making from the data. RESULTS: Although depression screening protocols were in place at our study clinics, we found that decisions to address perinatal depression were largely made at the level of the individual provider and were undefined on a clinic level, resulting in highly variable practice patterns. In addition, while providers acknowledged externally derived influences, such as logistical resources and coordination of care, they spoke of internally derived influences, including familiarity with consultants, personal engagement styles and perceptions of role identity, as more directly relevant to their decision making. CONCLUSION: Our results highlight the pivotal role of internal factors in decisions to deliver perinatal depression care. Future interventions in obstetric settings should target the intrinsic motivations of providers.

Lengthened predelivery stay and antepartum complications in women with depressive symptoms during pregnancy.

UNLABELLED: Abstract Background: It is crucial to understand the timing and mechanisms behind depression's effect on peripartum stay because attempts to intervene will vary based on the time period involved. We designed this study to compare predelivery and postdelivery length of stay in women with and without elevated depressive symptoms during pregnancy. METHODS: This study involved secondary data analysis of a larger study exploring antepartum depression. Each subject completed the Center for Epidemiological Studies Depression Scale (CES-D) during pregnancy at a mean of 25.8 weeks' gestation. We used time-stamped data to compare total peripartum, predelivery, and postdelivery lengths of stay in women with and without elevated depressive symptoms during pregnancy. In addition, we used a Cox proportional hazards regression model to evaluate potential mechanisms for depression's effect on length of stay. RESULTS: The study sample included 802 pregnant women. Overall, 18% of study subjects scored ≥16 on the CES-D. Bivariate analyses demonstrated a significant association between elevated depressive symptoms and longer predelivery stays (time from admission to delivery). Interaction analyses demonstrated a significant interaction effect between depressive symptoms and parity, such that depressive symptoms were significantly associated with predelivery length of stay in multiparas but not so in primiparous subjects. In a multivariate model of multiparous subjects, depression's effect on length of stay was partially influenced by sociodemographic confounders but remained significant until antepartum complications were added to the model. CONCLUSIONS: Depressive symptoms during pregnancy are significantly associated with a subsequent increase in predelivery length of stay, and this association is mediated in part by antepartum complications, even after controlling for sociodemographic factors. These longer hospital stays can present significant burdens to the patient, her family, and the healthcare system. Future studies should evaluate whether interventions for depression during pregnancy can impact this relationship among depressive symptoms during pregnancy, antepartum complications, and extensive predelivery hospitalizations.