Medical Students' Perceptions of American Indian-Focused Educational Experiences.

INTRODUCTION: American Indians are burdened with a myriad of health disparities. As South Dakota's largest minority population, increasing medical students' experiences with the healthcare of American Indians can play a significant role in helping to alleviate American Indians' health disparities as these future physicians will be better able to predict, detect, and treat the health care needs of this population. METHODS: Survey data from 103 medical students at the University of South Dakota Sanford School of Medicine (SSOM) was collected and analyzed. Demographic information and perceived levels of being informed about American Indians and populations on reservations were collected. Furthermore, medical students' insights on how the SSOM can improve its students' educational experiences with American Indian populations were also collected. RESULTS: Compared to their perceived knowledge of American Indians prior to beginning medical school (26.2 percent), responding medical students believe they became more informed regarding American Indians (61.2 percent) as they progressed through medical school. Fifty-one of the 64 students (80 percent) who answered the open-ended question noted that their medical training would benefit from increased opportunities (including required) with American Indian people, culture, and reservation-based communities. CONCLUSION: There is a desire amongst medical students to increase and require more cultural information and clinical experiences with American Indian people and populations on reservations. Future research is needed to obtain medical student feedback on the newly implemented curriculum and elective opportunities.

Understanding mothers' perception of child's illness: Adapting the CONNECT Instrument for pediatrics.

AIMS AND OBJECTIVES: To adapt the CONNECT Instrument for use in the paediatric population, to assess validity of this instrument after its adaptation and to assess concordance between mothers' perception of their child's illness and providers' understanding of mothers' perceptions. BACKGROUND: The CONNECT Instrument (Patient Education and Counseling, 73, 2008, 232-239) was validated in an adult outpatient population to characterise both patients' perspectives and physicians' understanding of their patients' perspectives for several dimensions of the illness experience. However, this did not include the paediatric population or advanced practice providers. DESIGN: A two-part prospective, cross-sectional, observational study to assess the validity of CONNECT for Pediatrics and to assess perception of illness. METHODS: The CONNECT Instrument (Patient Version) was adapted from its original form and modified to CONNECT for Pediatrics to facilitate use in the inpatient paediatric population. Eighty-five participants were enrolled including mothers, advanced practice providers and physicians from 2013-2014 during a child's scheduled admission to a paediatric epilepsy monitoring unit. Principal components analysis and inter-item reliability were analysed, and differences in the six mean domain scores were assessed using repeated measures analysis of variance (RM-ANOVA). Reporting of this research adheres to the STROBE guidelines (See Appendix S1). RESULTS: Our analysis indicated that the modifications made provided a relatively valid and reliable instrument. There were overall statistically significant differences between the mother and physician groups, specifically in the domains of meaning and preference for partnership. CONCLUSIONS: Paediatric advanced practice providers and physicians do have an understanding of mothers' perception of illness. RELEVANCE TO CLINICAL PRACTICE: The ability of physicians and advanced practice providers to understand mothers' perceptions of illness is increasingly important in a changing healthcare environment. CONNECT for Pediatrics facilitates the identification of mothers' perception of their child's illness and provides the opportunity for paediatric advanced practice providers and physicians to understand parents' perception of illness.

Brief educational intervention improves content of intern handovers.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires residency programs to ensure safe patient handovers and to document resident competency in handover communication, yet there are few evidence-based curricula teaching resident handover skills. OBJECTIVE: We assessed the immediate and sustained impact of a brief educational intervention on pediatrics intern handover skills. METHODS: Interns at a freestanding children's hospital participated in an intervention that included a 1-hour educational workshop on components of high-quality handovers, as well as implementation of a standardized handover format. The format, SAFETIPS, includes patient information, current diagnosis and assessment, patient acuity, a focused plan, a baseline exam, a to-do list, anticipatory guidance, and potential pointers and pitfalls. Important communication behaviors, such as paraphrasing key information, were addressed. Quality of intern handovers was evaluated using a simulated encounter 2 weeks before, 2 weeks after, and 7 months after the workshop. Two trained, blinded, independent observers scored the videotaped encounters. RESULTS: All 27 interns rotating at the Children's Hospital consented to participate in the study, and 20 attended the workshop. We included all participant data in the analysis, regardless of workshop attendance. Following the intervention, intern reporting of patient acuity improved from 13% to 92% (P < .001), and gains were maintained 7 months later. Rates of key communication behaviors, such as paraphrasing critical information, did not improve. CONCLUSIONS: A brief educational workshop promoting standardized handovers improved the inclusion of essential information during intern handovers, and these improvements were sustained over time. The intervention did not improve key communication behaviors.

Assessing learning outcomes and cost effectiveness of an online sleep curriculum for medical students.

OBJECTIVE: Sleep disorders are highly prevalent across all age groups but often remain undiagnosed and untreated, resulting in significant health consequences. To overcome an inadequacy of available curricula and learner and instructor time constraints, this study sought to determine if an online sleep medicine curriculum would achieve equivalent learner outcomes when compared with traditional, classroom-based, face-to-face instruction at equivalent costs. METHOD: Medical students rotating on a required clinical clerkship received instruction in 4 core clinical sleep-medicine competency domains in 1 of 2 delivery formats: a single 2.5-hour face-to-face workshop or 4 asynchronous e-learning modules. Immediate learning outcomes were assessed in a subsequent clerkship using a multiple-choice examination and standardized patient station, with long-term outcomes assessed through analysis of students' patient write-ups for inclusion of sleep complaints and diagnoses before and after the intervention. Instructional costs by delivery format were tracked. Descriptive and inferential statistical analyses compared learning outcomes and costs by instructional delivery method (face-to-face versus e-learning). RESULTS: Face-to-face learners, compared with online learners, were more satisfied with instruction. Learning outcomes (i.e., multiple-choice examination, standardized patient encounter, patient write-up), as measured by short-term and long-term assessments, were roughly equivalent. Design, delivery, and learner-assessment costs by format were equivalent at the end of 1 year, due to higher ongoing teaching costs associated with face-to-face learning offsetting online development and delivery costs. CONCLUSIONS: Because short-term and long-term learner performance outcomes were roughly equivalent, based on delivery method, the cost effectiveness of online learning is an economically and educationally viable instruction platform for clinical clerkships.

U.S. attitudes and perceived practice for noninvasive ventilation in pediatric acute respiratory failure.

OBJECTIVE: Few pediatric studies exist regarding the use of noninvasive positive-pressure ventilation for acute respiratory failure; however, those that do suggest a role. This study seeks to describe attitudes and perceived practices of pediatric intensivists regarding the use of noninvasive positive-pressure ventilation in children with acute respiratory failure. DESIGN: Electronic survey. SETTING: Medical institutions. PARTICIPANTS: Of the 932 physicians approached, 353 (38%) responded to the survey. Respondents included U.S. physicians practicing pediatric critical care (90%), pediatric anesthesia critical care (4%), pediatric pulmonary critical care (4%), and other disciplines (2%). INTERVENTIONS: Survey. MEASUREMENTS AND MAIN RESULTS: The survey contained questions regarding 1) practitioner demographics, 2) patient characteristics, and 3) clinical cases designed to assess noninvasive positive-pressure ventilation use in certain patient scenarios. Noninvasive positive-pressure ventilation was used by 99% of the respondents, with 60% using noninvasive positive-pressure ventilation as initial support >10% of the time. Respondents reported use of noninvasive positive-pressure ventilation for acute respiratory failure in lower airway disease (70%), asthma (51%), acute lung injury/acute respiratory distress syndrome (43%), and upper airway obstruction (31%). In clinical scenarios, respondents reported that the factors associated with nonuse of noninvasive positive-pressure ventilation as initial support were disease process (31%), oxygenation (19%), ventilation severity (15%), expectation that the patient was likely to worsen (12%), and age or inability to cooperate (11%). CONCLUSIONS: Noninvasive positive-pressure ventilation is widely used and most frequently utilized in patients with acute lower airway disease. Factors such as severe defects in oxygenation and ventilation, disease progression, and patient tolerability decreased the likelihood of use. These findings may help direct further studies of noninvasive positive-pressure ventilation in children with acute respiratory failure.

Evaluation of a tool to teach medical students direct ophthalmoscopy.

INTRODUCTION: With declining exposure to the ophthalmologic examination in medical school, medical students and their instructors need a simple, effective method for teaching direct ophthalmoscopy. OBJECTIVE: Evaluation of canisters as direct ophthalmoscopy teaching aids for medical students. METHODS: Two ounce plastic canisters were designed to simulate an eye with 35 mm fundus photographs placed at the base and an 8mm hole drilled in the center of the cap to simulate a dilated pupil. These tools were used as an optional supplement to the instruction of ophthalmoscopy. Participants included 102 second-year medical students from the Medical College of Wisconsin and 11 residents and instructors from The Eye Institute in Milwaukee, Wis. RESULTS: Effectiveness and ease of use of the canisters were assessed by analyzing questionnaires completed by the medical students and instructors. According to 76% of students and 93% of instructors, the canisters "supplemented their learning/teaching." Most students (90%) and instructors (88%) found them "easy to use." CONCLUSION: This device is a simple and effective tool for teaching direct ophthalmoscopy to medical students.

A survey of inner city youth and their parents about participation in sports.

BACKGROUND: Several studies have explored motivating factors for sports participation for youth, but limited data is available regarding factors motivating inner-city children to participate in sports. METHODS: A consecutive sample of parents (n=100 parents) and children (n=138 children) attending a health fair in an inner-city community were surveyed regarding motivating factors for enrolling in a team sport (or enrolling their child in a team sport). Parents and children indicated the importance of 10 factors (1=not very important to 4=very important) on separate but similar written surveys. RESULTS: "Developing healthy habits" and "Becoming physically fit and healthy" received the highest mean rankings from both parents and children. "Helping my child gain or lose weight" received one of the lowest rankings from parents. CONCLUSIONS: To encourage sports participation by inner-city children, health care professionals and others should emphasize identified motivational factors for children and their parents.

Student competence in fluid and electrolyte management: the impact of various teaching methods.

OBJECTIVE: The goal of this study was to evaluate 1) the competency of junior medical students (M3s) in fluid and electrolyte management upon completion of their pediatric clerkship; 2) the frequency and perceived helpfulness of fluid and electrolyte management-based interactions with the following sources of education: a lecture, first-year residents (PL1s), senior residents (PL3s), and faculty; and 3) the relationship between points 1 and 2. METHODS: Upon completion of the clerkship, M3 competency was evaluated by a quiz with multiple-choice questions and a clinical vignette concerning the intravenous fluid (IVF) management of a dehydrated child. Junior medical students completed a survey to identify the fluid and electrolyte management case-based practice frequency with PL1s, PL3s, and faculty, and the perceived helpfulness of the lecture, PL1s, PL3s, and faculty, rated on a 10-point Likert scale. RESULTS: One hundred eighty-seven M3s took the quiz and 180 completed surveys. The mean clinical vignette score was 7.0 (range, 0-12). Eighty-one percent of M3s wrote inadequate IVF orders for a dehydrated infant. The median-perceived helpfulness for each source was lecture, 9 points; PL1, 5 points; PL3, 4 points; and faculty, 3 points. In multivariate regression, only a higher perceived helpfulness rating for the lecture was significantly associated with higher clinical vignette scores (r = 0.43; P < .001). When asked for ideas to improve fluid and electrolyte management education, 47% of M3s recommended more practice problems. CONCLUSIONS: Most M3s lacked adequate fluid and electrolyte management competency. Junior medical students rated the lecture the most helpful source of fluid and electrolyte management education. Improvements in fluid and electrolyte management education of M3s may result from providing practice problems with immediate feedback and formal training to increase the fluid and electrolyte management educational skills of PL1s, PL3s, and faculty.

Pediatric residents address critical child health issues in the community.

BACKGROUND: Practicing pediatricians are challenged to look beyond the clinical settings for local resources to address health threats to children and families. Pediatric residents' perceptions of the realities faced by families that they frequently see in the emergency room and outpatient or inpatient units are inadequate. OBJECTIVES: The Community Pediatrics Training Initiative (CPTI) is a national initiative within the American Academy of Pediatrics designed to prepare future pediatricians to serve families from traditionally underserved communities. The three unique components of this CPTI at Children's Hospital of Wisconsin (CHW) and the Medical College of Wisconsin (MCW) support child health improvement through (1) interactive discussions with families, (2) exposure to programs in community agencies, and (3) community initiatives. METHODS: Pediatric residents, along with community partners, have implemented more than 25 community initiatives in the areas of access to care, adolescent health, child advocacy, and environmental and public health. RESULTS: The immediate assessment from our CPTI curriculum demonstrates community experiences significantly promote their competencies in child advocacy and system-based practice while expanding their knowledge of the impact of poverty. In 2005, a survey of 84 postgraduates (75% response rate) assessed the effectiveness of community pediatrics training. All graduates self-reported that they are moderately to greatly prepared to respond to children's culture, age, gender, and disabilities. Of the 43 (68%) graduates who are currently in practice, 10 (23%) are working directly with underserved populations. CONCLUSIONS: The development of community initiatives by pediatric residents in partnership with community stakeholders greatly expanded residents' competencies in child health improvement.

The Medical College of Wisconsin Senior Mentor Program: experience of a lifetime.

The Medical College of Wisconsin (MCW) Senior Mentor Program (SMP) has been offered to a small group of first and second year medical students as a course alternative to the traditional physician mentor program. The program links students with healthy older adult mentors and includes mentor/student visits, didactic sessions, written assignments, and shadowing experiences. The goals of the course are to increase positive attitudes about aging and geriatrics and to teach basic assessment and interviewing skills in geriatric content areas. A course evaluation including questionnaires, focus groups, and content analysis found that students experienced positive attitude change about geriatric patient care, increased knowledge about geriatrics, and satisfaction with the mentor/student relationship. Students have reported gains in their knowledge of geriatric and gait assessment, ADL evaluation, and mental health screening, among other issues. Further, students report being excited, more comfortable, and less fearful caring for and interacting professionally with older adults as a result of the SMP. The SMP is an effective and meaningful method of geriatric education for preclinical students. It may be an alternative at medical schools that cannot support a large-scale multi-year senior mentor program.

Objective Structured Video Examinations (OSVEs) for geriatrics education.

The Medical College of Wisconsin (MCW) and the Wisconsin Geriatric Education Center (WGEC) are committed to developing educational materials for primary care physicians in training. In response to the opportunity created by the Accreditation Council for Graduate Medical Education (ACGME) competency mandate, an MCW-led interdisciplinary working group has developed competency-linked video-based assessment tools for use in primary care residency training programs. Modeled after the Objective Structured Clinical Examinations (OSCE), used as part of the medical licensing examination process, we created geriatric-focused Objective Structured Video Examinations (OSVEs) as a strategy to infuse geriatrics into residency training. Each OSVE tool contains a 1-3 minute video trigger that is associated with a series of multiple choice and/or constructed response questions (e.g., fill in the blank). These questions assess residents' understanding of video-demonstrated ACGME competencies including professionalism, systems-based practice, communication, and practice-based learning. An instructor's guide and scoring key are provided for each tool. Response to the OSVEs has been overwhelmingly enthusiastic including greater than 90% commitment by statewide faculty to use the tools in residency training.

Multiple variables influence the educational value of surgical clerkship sites.

BACKGROUND: Students' satisfaction with the educational quality of a surgical clerkship is influenced by their experiences at assigned clinical sites. We sought to identify key variables perceived by students to be associated with educationally valued clerkship sites. METHODS: Between 1998 and 2002, third-year medical students completed a surgery site survey for each of the 2 sites on which they rotated during their required 2-month surgery rotation, representing a total of 16 sites. Students rated each site using a Likert scale on 8 educational variables as well as the overall educational value of the site. Students recorded the hours per week of direct instructional contact with attendings and, in the 2001/2002 academic year, provided narrative comments regarding site-specific strengths and weaknesses. The relationship between site variables and overall educational value across all sites was examined by stepwise multiple regression analysis. Content analysis of narrative responses was performed to surface major strengths and weaknesses associated with site-specific educational value. RESULTS: From 1,377 completed surveys, representing an 87% completion rate, a statistically significant relationship was identified between sites' overall educational value and 6 variables. The most significant variables were as follows: "direct instructional contact with attendings in the operating room" and "quality of house staff teaching" (accounted for 33% and 13% of the total variance in educational value, respectively). Content analysis from 359 narrative responses, representing a 92% response rate, revealed 5 major categories, with operating room experience receiving the most "strength" comments (28.8%). CONCLUSIONS: Specific variables influencing the perceived educational quality of clerkship sites can be identified. The single largest influence emerging independently from both the quantitative and qualitative analyses was the students' experiences in the operating room. Emphasis on the educational experience in the operating room should be a priority when seeking to improve the educational value of clerkship sites.

The 360-degree evaluation: increased work with little return?

OBJECTIVE: To test a 360-degree resident evaluation tool on our trauma/critical care services to determine if multiple raters yielded equivalent information compared with traditional faculty evaluations. DESIGN: Prospective evaluation. PARTICIPANTS: Residents, nurses, faculty, and staff at an academic medical center. METHODS: The evaluation tool was developed based on extensive qualitative analysis of 13 major medical specialties' Residency Review Committee (RRC) criteria relative to the ACGME competencies and then revised with content specific to surgery. The evaluation contained 19 items divided into ACGME competency areas. Each item was scored on a 1 to 9 Likert scale: 1 = not meeting expectations and 9 = exceeding expectations. Residents on the trauma and surgical intensive care unit rotations evaluated themselves, and they were also evaluated by chief residents, surgical intensive care unit fellows, faculty, surgical intensive care unit nurses, trauma nurse clinicians, and nurse practitioners. Multiple analyses of variance were used to compare ratings by rater groups. RESULTS: Ten residents were evaluated on the trauma service from April to August 2003. Between 74 and 106 evaluations were obtained per resident per competency area. Average scores across the competencies were remarkably similar, ranging from 6.18 for practice-based learning and systems-based practice to 6.54 for professionalism. Although there was variability within rater groups, ratings were not statistically different between groups for any ACGME competency. CONCLUSIONS: The 360-degree evaluation provide limited new information compared with traditional faculty ratings. Follow-up studies are required to confirm this finding with larger samples of residents and surgical specialties.

Meeting the Accreditation Council for Graduate Medical Education competencies using established residency training program assessment tools.

BACKGROUND: Most existing residency evaluation tools were constructed to evaluate the Accreditation Council for Graduate Medical Education (ACGME) competencies. METHODS: Before ACGME's six competency based assessment requirements for resident performance were developed, we created a residency evaluation tool with 5 domains important to successful surgical resident performance. Reliability was determined after 6 months of use. Factor analysis assessed whether the evaluation tool was a construct-valid measure of the ACGME competencies. RESULTS: Three hundred forty-three evaluations for 36 surgical residents were tested. The original evaluation tool was highly reliable with an overall reliability of 0.97. Factor analysis defined 4 new combinations of questions analogous to 4 of the ACGME competencies: professionalism (reliability 0.95), patient care (reliability 0.93), medical knowledge (reliability 0.92), and communication (reliability 0.92). The new competency clusters were correlated with each other to a moderate degree. CONCLUSIONS: Our locally developed tool demonstrated high reliability and construct validity for 4 of 6 ACGME competencies. The correlation between factors suggests overlap between competencies.

Outcomes results from the evaluation of the APA/HRSA Faculty Scholars Program.

BACKGROUND: The goal of the Ambulatory Pediatric Association/Health Resources and Services Administration National Faculty Development Scholars Program was to improve primary care education in the pediatric setting. The program evaluation focused on four stake-holder objectives: 1) increase the educational skills of community and generalist faculty; 2) create pediatric leadership focused on changing the culture within the medical community to support primary care education; 3) develop an infrastructure that supports sustained faculty development efforts at the local, regional, and national level; and 4) include content areas consistent with Health Resources and Services Administration contract requirements. METHODS: A multimethod evaluation plan, focused on the 107 completing scholars, was implemented utilizing six evaluation instruments. RESULTS: Key outcomes from both quantitative and qualitative outcome measures reveal that all evaluation objectives were achieved. Scholars presented 438 local workshops and 161 regional/national workshops focused on pediatric education with a combined attendance of 7939 participants. More than half of the scholars have now assumed a leadership position in education associated with program participation. Ninety-three percent of the scholars reported organizational/infrastructure changes associated with their program participation ranging from increased numbers of community teaching sites to specific resource allocations to support of faculty development. CONCLUSIONS: The outcomes of this evaluation reveal that the faculty development program achieved its objectives, with participants leading workshops, impacting faculty development infrastructure, advancing their own careers, and being strategically positioned in leadership roles with the skills to improve primary care education in the ambulatory setting.

Primary care residents self assessment skills in dementia.

The ability to accurately self-assess is a critical component of professionalism and is included in the newly required Accreditation Council of Graduate Medical Education (ACGME) core competencies. To assess residents' ability to accurately self-assess their competencies related to a commonly presenting problem in geriatrics, a Standardized Patient, portraying an individual with early signs of dementia, was inserted into family medicine residents' clinic schedules. Immediately post the encounter, each resident self-assessed his/her performance using a four category (Communication, History of Present Illness, Social History, Functional Assessment), 17-item behavioral checklist. The items in each category highlighted items specific to a dementia-screening interview (e.g., HPI: Used a standardized exam which includes orientation, memory, recall and registration). Resident ratings were compared to ratings from two faculty assessors who independently viewed the videotape of each resident's SP interview. While statistically significant differences between the self-assessment and expert assessors appeared in only one of the four major checklist categories (functional assessment), item specific analysis revealed significant differences on discrete items within the dementia screening interview. Implications for teaching and assessment consistent with the ACGME required competency assessment category of professionalism are discussed.

Experienced clinical educators improve their clinical teaching effectiveness.

OBJECTIVES: To determine if experienced clinical educators (CEs) can improve their teaching by incorporating 4 literature-based teaching methods into their instruction. METHODS: We trained 7 experienced CEs on the teaching methods during a monthly faculty development program. Each CE recorded use of these methods during 10 months on a personal digital assistant. We compared the CEs' teaching evaluations with those of nonparticipating faculty by analysis of variance at baseline, during the study period, and for 1 year after the study. RESULTS: Reported use of 2 teaching methods (priming and feedback) increased significantly over use at baseline; use of 2 other methods (teaching in the patient's presence and 1-2 focal teaching points) remained constant. Scores on the CEs' teaching evaluations were significantly higher during the study period on 1 item, whereas the comparison group showed no changes. The changes persisted during the follow-up period. CEs reported that the teaching methods focused the learner and teacher, making subsequent encounters more productive. They also found that the act of entering data daily prompted them to reflect on their teaching. CONCLUSIONS: Experienced teachers can be persuaded to incorporate new methods into their daily teaching. Reflection on teaching is enhanced with group support and daily reminders. With these interventions, teaching effectiveness of these experienced educators improved.

A longitudinal women's health curriculum: a multi-method, multiperspective needs assessment.

OBJECTIVES: To define critical competencies in women's health for medical student education and to assess the degree to which they are taught. STUDY DESIGN: A set of competencies in women's health was developed. A multi-method needs assessment was implemented. RESULTS: Faculty and student evaluations revealed no major areas of disagreement but did identify major deficits in the basic sciences including the physiologic influence of estrogen on nongynecologic organ systems and of androgen on various organ systems, nutrition, and alternative medicine and the difference between the sexes in disease processes, presentation, and treatment. In the clinical years, there are important deficits in the teaching of diseases unique to women, limited attention to psychosocial aspects of women's health, and no cohesive teaching of a gender-specific approach to clinical evaluation. CONCLUSION: In the medical school curriculum, gender's effect on disease is inadequately addressed. An integrated longitudinal approach to gender-specific medicine is needed.

Personal digital assistant for "real time" assessment of women's health in the clinical years.

OBJECTIVE: To assess in "real time" the degree to which women's health competencies are addressed in the clinical curriculum by using a personal digital assistant. STUDY DESIGN: Competencies for women's health were developed. Twelve students were supplied with a personal digital assistant, pre-loaded with a patient log system, for use in assessment of the inclusion of these competencies in the clinical arena. The students received instruction on completing the log for each patient for whom they were primarily responsible. RESULTS: There were 2690 total encounters. In clerkships other than obstetrics and gynecology, gender was discussed in 10% to 20% of encounters. Other than obstetrics and gynecology diagnostic categories, no more than 15% of diagnoses included gender discussion. CONCLUSION: Student recording of patient encounters reveals a minimal amount of women's health discussion in the clinical years; however, the personal digital assistant is an effective tool with which to monitor curriculum content in the clinical setting.