Best practices in teaching echocardiography to cardiology fellows: a review of the evidence.

BACKGROUND: Best practices in the teaching of performance and interpretation of echocardiography to cardiology fellows are unknown, and thus, it has traditionally been performed through an apprenticeship model. This review summarizes the existing literature describing evidence-based teaching of echocardiography. METHODS: A comprehensive search of multiple scientific and educational databases included prospective studies describing an educational intervention for teaching echocardiography to physicians. A total of 288 articles were retrieved, and 10 articles were included in our review. The Medical Education Research Study Quality Instrument (MERSQI), a validated rubric designed to measure the methodological quality of educational research, was used to assign a comprehensive score to each paper. RESULTS: The articles were categorized by educational themes as follows: focused curriculum-based training, simulation, and assessment of competency. Individual study MERSQI scores varied from 8 to 13 (mean 10.55) on a scale of 18 points. The distribution of each group's median score (focused curriculum-based training 11.64; simulation 12.92; assessment of competency 9.39) was analyzed using boxplots with a 95% confidence interval. The median MERSQI score for the assessment of competency group was significantly lower than the others. CONCLUSIONS: A review of the data exploring best practices in teaching echocardiography shows only limited effects describing the curricular and assessment components of an overall educational system, rather than one-on-one clinical teaching. Future papers should explore application of point-of-care teaching and the impact of interventions on patient outcomes.

A tiered mentorship program improves number of students with an identified mentor.

BACKGROUND: Mentorship is critical to professional development and academic success. Unfortunately, only about 40% of medical students can identify a mentor. While group mentorship has been evaluated - the concept of a specialty specific, tiered group mentorship program (TGMP) has not. In the latter, each member of the group represents a unique education or professional level. PURPOSE: The purpose of this study was to investigate the ability of a specialty-specific, tiered group mentorship program to improve mentorship for students interested in emergency medicine. METHODS: Groups consisted of faculty members, residents, 4th-year students pursuing a career in Emergency Medicine, and junior (MS1, MS2, and MS3) medical students (13 total groups). Students completed confidential electronic surveys before and after completion of the program. RESULTS: Of 126 students, 85 completed the Course Evaluation Survey. At program onset, 11.4% of 1st-year students, 41.7% of 2nd-year students, 50% of 3rd-year students, and 28% of the total students could identify a mentor. After completion, 68.6% of 1st years, 83.3% of 2nd years, 90% of 3rd years, and 77.6% of the total reported they could identify a mentor. Faculty were rated most important members followed by the 4th-year student. CONCLUSION: A tiered group mentorship program improved the ability of students to identify a mentor. Students identified mentoring relationships from individuals at various professional levels.

Development and validation of a musculoskeletal physical examination decision-making test for medical students.

OBJECTIVE: Despite a renewed emphasis among educators, musculoskeletal education is still lacking in medical school and residency training programs. We created a musculoskeletal multiple-choice physical examination decision-making test to assess competency and physical examination knowledge of our trainees. DESIGN: We developed a 20-question test in musculoskeletal physical examination decision-making test with content that most medical students and orthopedic residents should know. All questions were reviewed by ratings of US orthopedic chairmen. It was administered to postgraduate year 2 to 5 orthopedic residents and 2 groups of medical students: 1 group immediately after their 3-week musculoskeletal course and the other 1 year after the musculoskeletal course completion. We hypothesized that residents would score highest, medical students 1 year post-musculoskeletal training lowest, and students immediately post-musculoskeletal training midrange. We administered an established cognitive knowledge test to compare student knowledge base as we expected the scores to correlate. SETTING: Academic medical center in the Midwestern United States. PARTICIPANTS: Orthopedic residents, chairmen, and medical students. RESULTS: Fifty-four orthopedic chairmen (54 of 110 or 49%) responded to our survey, rating a mean overall question importance of 7.12 (0 = Not Important; 5 = Important; 10 = Very Important). Mean physical examination decision-making scores were 89% for residents, 77% for immediate post-musculoskeletal trained medical students, and 59% 1 year post-musculoskeletal trained medical students (F = 42.07, p<0.001). The physical examination decision-making test was found to be internally consistent (Kuder-Richardson Formula 20 = 0.69). The musculoskeletal cognitive knowledge test was 78% for immediate post-musculoskeletal trained students and 71% for the 1 year post-musculoskeletal trained students. The student physical examination and cognitive knowledge scores were correlated (r = 0.54, p<0.001), but were not significantly different for either class. CONCLUSIONS: The physical examination decision-making test was found to be internally consistent in exposing the deficiencies of musculoskeletal education skills of our medical students and differentiated between ability levels in musculoskeletal physical examination decision-making (residents vs recently instructed musculoskeletal students vs 1 year post-musculoskeletal instruction).

The educational value of online mastery quizzes in a human anatomy course for first-year dental students.

The purpose of this study was to evaluate the effectiveness of online mastery quizzes in enhancing dental students' learning and preparedness for anatomy examinations. First-year dental students taking an integrated anatomy course at The Ohio State University were administered online mastery quizzes, made available for five days before each examination. The mastery quizzes were comprised of ten multiple-choice questions representative of the upcoming examination in content and difficulty. The students were allowed to access this resource as many times as they desired during the five-day window before each examination; the highest score for each student was added to his or her final course grade. The results indicate that almost all the students took advantage of this resource to reinforce content, clarify concepts, and prepare for the examinations. Statistical analyses of the students' exam performance showed that the mastery quizzes neither improved nor reduced their exam scores, but multiple regression analyses showed that the initial mastery quiz scores had a predictive value for their examination performance, suggesting a potential for mastery quizzes as an intervention tool for such a course. Online mastery quizzes, when used effectively, may be an effective resource to further engage dental and other students in educational endeavors and examination preparation and as a predictor of success.

The cognitive behavior survey: testing for factorial validity and time invariance across two years of medical school.

BACKGROUND: The Cognitive Behavior Survey (CBS) assesses learner behavior in healthcare-related fields. PURPOSE: The study aims were to evaluate the factorial validity of the CBS, which purports to measure three dimensions of learner behavior--conceptualization, reflection, and memorization--and propose and test an alternative model including its time invariance. METHODS: The CBS was administered to 3 cohorts of medical students upon matriculation and at the end of their 1st and 2nd year. RESULTS: Confirmatory factor analysis (CFA) did not support the original CBS model. Exploratory factor analysis (EFA) with an independent sample provided a new model. Retesting the EFA model using CFA with the original sample yielded a model with improved fit and time invariance. CONCLUSIONS: This study provides evidence for the original CBS 3-factor structure but requires alternative scoring for a time-invariant model.

Managing antidepressants in primary care: physicians' treatment modifications.

To examine antidepressant management practices in primary care, patients (N = 148) given an antidepressant for at least one month completed the Beck Depression Inventory (BDI-II), the Patient Health Questionnaire-9 (PHQ-9), and a demographic survey. Participants' mean age was 50.7 yr. and 80% were women. Patients' charts indicated whether physicians had made changes to prescribed antidepressants or dose either 6 wk. before or 6 wk. after study entry. For the 87% of participants whose depression status could be determined, 10% met dysthymic disorder criteria and only 33% had had a medication change in the previous month. Major depressive disorder occurred in 37% but only 18% had had a medication change. Co-existing dysthymic disorder and major depressive disorder were diagnosed in 34%, with 24% receiving a medication change. Participants not receiving a medication change had mean BDI-II scores indicating moderate depression. Lack of antidepressant adjustment suggests physicians may need to monitor depressive symptoms closely using protocols and prompts.

Impact of clinical pathway on quality of care in sickle cell patients.

Clinical pathways are disease specific and are designed to standardize care. They are intended to serve the purpose of improving quality of care and decreasing healthcare and societal costs. A retrospective cross-sectional study was conducted comparing sickle cell patients admitted to Mercy Children's Hospital (MCH) from June 1999 to November 2001 before the implementation of the clinical care pathway (n=66), to a similar group of patients admitted from December 2001 to July 2004 after pathway (n=121) implementation. The χ2 tests were used to compare categoric variables and independent t-tests for continuous variables. The results indicate improvement in compliance postpathway with specific care elements: incentive spirometry, pulse oximetry, ordering comfort measures, right dosage of pain medications, and achieving excellent nursing compliance in documenting pain scores. There was a significant decrease in the number of blood transfusions in postpathway patients. Though limited by sample size, the results suggest that clinical pathways are good tools for standardization of care in certain care elements and help to improve quality of care in sickle cell patients.

Coherence between physician diagnosis and patient self reports of anxiety and depression in primary care.

Mood and anxiety disorders complicate the care of patients with physical illness and pose challenges for primary care physicians. This study explored the coherence between a screening tool (PRIME-MD), a standardized questionnaire (Eysenck Personality Inventory), and physician diagnoses of anxiety and depression. Of 165 patients, 29% had diagnoses of depression, 21% had anxiety, and 59% had no mental health diagnosis. Patients who were younger, female, divorced/widowed, or unemployed with minimal education had highest prevalence of anxiety or depression. Scores on the self-report inventories were significantly higher in patients with physician-diagnosed anxiety or depression compared with those without these diagnoses. Medical use and chronic illness were highest in patients with anxiety or depression diagnoses. Despite the statistical agreement between the self-report inventories and physician diagnosis, the coherence among these measures was less than optimal. Use of self report tools is recommended to complement physician understanding of patient symptom description and management of anxiety and depression in primary care.

Antidepressant medication adherence: a study of primary care patients.

BACKGROUND: Nonadherence to antidepressant medication significantly contributes to the undertreatment of depression in primary care populations. The purpose of this study was to survey primary care patients' adherence to antidepressant medication to better understand factors associated with nonadherence. METHOD: Participants with a history of being prescribed an antidepressant for at least 4 weeks were recruited from a primary care research network. Subjects completed a demographic survey, the Patient Health Questionnaire (PHQ), the Beck Depression Inventory-II (BDI-II), the Medical Outcomes Study (MOS) 36-Item Short-Form Health Survey, the Interpersonal Support Evaluation List, the Stages of Change Scale, the Medication Adherence Scale, and the MOS measure of adherence. Differences between adherent and nonadherent patients were compared using chi(2) for discrete variables, independent t tests for continuous variables, and Mann-Whitney U tests for rank-ordered data. Data were collected from April 1, 2001 to April 1, 2004. RESULTS: Approximately 80% (N = 148) of individuals approached for this study agreed to participate. The overall sample was primarily white and female. The PHQ diagnoses at study entry were dysthymic disorder (8.8%, n = 13), major depressive disorder (31.8%, n = 47), "double depression" (both dysthymic disorder and major depressive disorder, 29.7%, n = 44), and no depression (16.2%, n = 24.) The mean BDI-II score for the total sample was 19.9. Nonadherent patients reported being more careless about taking their medications, were more worried about side effects, were less satisfied with their physicians, were under the age of 40 years, and were more likely to have asked for a specific antidepressant. Nonadherent patients also indicated being at lower stages of change. CONCLUSIONS: Individually tailoring education to patient preference and stage of change is recommended to promote adherence.

Primary care evaluation of mental disorders (PRIME-MD) screening for minor depressive disorder in primary care.

OBJECTIVE: Individuals visiting a primary care practice were screened to determine the prevalence of depressive disorders. The DSM-IV-TR research criteria for minor depressive disorder were used to standardize a definition for subthreshold symptoms. METHOD: Outpatients waiting to see their physicians at 3 community family medicine sites were invited to complete a demographic survey and the Primary Care Evaluation of Mental Disorders Patient Questionnaire (PRIME-MD PQ). Those who screened positive for depression on the PRIME-MD PQ were administered both the PRIME-MD Clinician Evaluation Guide (CEG) mood module and the Hamilton Depression Rating Scale (HDRS) by telephone. Data were collected over a 2-year period (1996-1998). RESULTS: 1,752 individuals completed the PRIME-MD PQ with 478 (27.3%) scoring positive for depression. Of these 478 patients, 321 received telephone follow-up using the PRIME-MD CEG mood module and the HDRS. PRIME-MD diagnoses were major depressive disorder (n = 85, 26.5%), dysthymia (n = 31, 9.6%), minor depressive disorder (n = 51, 15.9%), and no depression diagnosis (n = 154, 48.0%). The mean HDRS scores by diagnosis were major depressive disorder (20.3), dysthymia (12.9), minor depressive disorder (11.7), and no depression diagnosis (5.8). Post hoc analyses using Dunnett's C test indicated differences between each of the 4 groups at P ≤ .05, with the exception that dysthymia and minor depressive disorder were not significantly different. CONCLUSIONS: Minor depressive disorder was more prevalent than dysthymia and had similar symptom severity to dysthymia as measured by the HDRS. More research using standardized definitions and longitudinal studies is needed to clarify the natural course and treatment indications for minor depressive disorder.

The patient-physician relationship and medical utilization.

OBJECTIVE: The goal of this study was to (1) explore the relationship between medical utilization and characteristics of the patient-physician relationship and (2) evaluate the relationship between physician perception of patient difficulty, chronic medical problems, and patient somatizing tendencies. METHOD: Patients in an academic family practice center were asked to complete a demographic data sheet, the PRIME-MD Patient Questionnaire, and the Barrett-Lennard Relationship Inventory regarding their relationship with their physicians. Their physicians completed the Difficult Doctor-Patient Relationship Questionnaire. Patient charts were examined for number of office visits and phone calls in the previous year, as well as number of chronic problems and medications. The study was conducted from September 2000 to November 2001. RESULTS: Forms were completed by 165 patients and 20 physicians. Forty-three patients who were approached refused to participate. Patient ratings on the Barrett-Lennard Relationship Inventory were not related to utilization measures. Physician ratings of difficulty were significantly related to phone calls and visits (p < .05), as well as PRIME-MD Patient Questionnaire somatization tendencies (p < .05) but not to number of chronic problems. Patient and physician ratings were not significantly correlated. Gender (p < .001), marital status (p < .04), education (p < .03), and employment status (p < .002) were all related to utilization measures. CONCLUSION: Medical utilization was associated with somatizing tendencies of patients and the physicians' perception of patient difficulty. Physicians rated patients as difficult if they tended to somatize but not if they had a number of chronic problems.

Educating grade school children using a structured bicycle safety program.

BACKGROUND: Prevention is understudied in trauma care. Furthermore, the effectiveness of prevention outreach programs is not well documented. We attempted to verify that elementary school educational programs effectively create retained knowledge. METHODS: Three hundred fifty-one students (grades 1-3) viewed a bicycle safety videotape and then listened to a structured discussion of bicycle safety rules. Coded pretests were given before and identical posttests were given immediately after the session. Tests were readministered 1 month later to evaluate retained knowledge. Two hundred fifty-one students completed all three tests. RESULTS: Students showed significant (p < 0.01) improvement in retained knowledge about riding with traffic, wearing a bicycle helmet, warning pedestrians when riding on sidewalks, and stopping before riding into the street. CONCLUSION: We conclude that prevention programs are effective and result in retained knowledge. Further analysis is recommended to evaluate retained knowledge at greater intervals after the original education.

Patient-Physician Relationship and Service Utilization: Preliminary Findings.

BACKGROUND: Difficult physician-patient encounters pose a challenge in all aspects of health care. Characteristics of both physicians and patients affect the office encounter and utilization of services. The objectives of this study were to explore the impact of patients' characteristics and the patient-physician relationship on service utilization. METHOD: A sample of 22 family practice patients and their physicians completed questionnaires prior to and/or after an office visit. Chart review yielded demographic information and history. The number of office visits and phone calls were obtained from billing records. RESULTS: The number of patient-reported physical problems was correlated with negative affect (r = 0.63, p <.002), the number of phone calls to the office (r = 0.52, p <.02), and the difficulty of the encounter as perceived by the physician (r = 0.58, p <.005). The number of phone calls also correlated with the number of life events (r = 0.43, p <.05) and the patient's perception of the physician's warmth (r = 0.48, p <.03) and understanding (r = 0.44, p <.04). CONCLUSION: Life stress, negative affect, physical complaints, and the patients' perception of their physician impact utilization. Armed with information about patient characteristics prior to the office visit, the physician can increase efficiency and facilitate a more productive encounter.