Catheterized urine color change.

What caused the abrupt change in color of catheterized urine after several days of Foley catheter placement?

Curricular Recommendations for a National Family Medicine Subinternship: A Qualitative Analysis From Multiple Stakeholders.

BACKGROUND AND OBJECTIVES: The 2011 Alliance for Clinical Education panel recommended the development of a specialty-specific curriculum for all subinternships (sub-Is). A 2019 CERA survey found that 58% of family medicine clerkship directors agreed that a standardized curriculum would be helpful. The goal of this study was to explore attitudes and preferences regarding a national family medicine sub-I curriculum among a broad set of stakeholders. METHODS: Focus groups were conducted with medical students, residents, residency faculty, and undergraduate medical education faculty at the 2020 STFM Conference on Medical Student Education. Focus groups were transcribed, and a qualitative analysis was conducted with participants' responses about the benefits and characteristics of a family medicine sub-I, recommendations for core sub-I skills/objectives, likelihood of using a national curriculum, and preferred student and program evaluation methods. RESULTS: There were four focus groups with a total of 24 participants. The following main themes emerged: the family medicine sub-I has distinctive characteristics from other sub-Is and provides unique benefits for students and residency programs, a standardized curriculum should allow for adaptability and flexibility, and the sub-I evaluation for the students and program should be specific and experience-focused. These themes were classified into specific subthemes. CONCLUSIONS: The stakeholder emphasis on themes of uniqueness, adaptability, and specificity within evaluation will help educators structure a comprehensive framework for national recommendations for the sub-I curriculum. A well-designed family medicine sub-I may provide rigorous educational training for students and may also encourage career commitment to the discipline.

Forward Feeding in Graduate Medical Education: Results of a National Survey.

BACKGROUND AND OBJECTIVES: "Forward feeding" is defined as the sharing of information regarding learner behaviors and performance outside of formal institutional committee structures. The purpose of this study was to establish baseline opinions and policies of forward feeding in family medicine residency programs. METHODS: Data for this study were obtained as part of the 2015 CERA Program Directors Fall Survey. Program directors indicated whether they felt that faculty should and do engage in forward feeding. Respondents were asked to rate the importance of various types of information about learners (academic performance, clinical performance, professionalism, physical health, and mental health), reasons for promoting, and concerns regarding forward feeding on a 5-point Likert scale. RESULTS: The overall response rate was 49% (227/461). Most agreed that faculty should (87%) and do (83%) engage in forward feeding. Concerns regarding professionalism and clinical performance were reported as most important to share. The most important reason identified for forward feeding was the early identification of struggling residents, followed by the ability to direct teaching to the resident's specific needs, and improving the quality of feedback. Fear of creating bias was the most commonly cited concern for engaging in forward feeding, followed by fear of violating confidentiality and difficulty maintaining confidentiality. Fear of litigation was the least common concern. CONCLUSIONS: Despite concerns, the majority of program directors feel that faculty should and do engage in forward feeding. Our study confirms the importance of clinical performance and professionalism as two important themes of information shared by attendings about residents.

Technology Use to Deliver Faculty Development: A CERA Study.

INTRODUCTION: Technology provides a platform to help address individualized training needs for community preceptors who are separated from the campus and pressured to achieve clinical productivity goals. This study explores technology use and support for delivering faculty development to community preceptors. METHODS: This cross-sectional study was part of the 2017 Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) annual survey of family medicine clerkship directors in the United States and Canada. RESULTS: The majority of respondents (n=62, 68.9%) agreed or strongly agreed that "using technology is critical to the successful delivery of faculty development to community preceptors." Only one-third (n=31) agreed or strongly agreed that their institution offers them adequate support to create and deliver technology-mediated faculty development or offers adequate support to community preceptors for accessing and using technology. CONCLUSIONS: Clerkship directors need institutional support to provide effective faculty development to preceptors via technology. The opportunity exists for institutions, national organizations, and professions to collaborate across disciplines and health professions on technology-based faculty development to support a level of quality and engagement for faculty development that is consistent with the levels we bring to student education.

Institutional NIH Research Funding and a Culture of Support for Family Medicine-Their Relationship to Family Medicine Specialty Choice.

BACKGROUND AND OBJECTIVES: The United States suffers from a low proportion of medical students pursuing family medicine (FM). Our objective was to examine institutional characteristics consistent with a focus on National Institutes of Health (NIH) research, institutional support for FM education, and the proportion of medical students choosing FM. METHODS: The 2015 CERA Survey of Family Medicine Clerkship Directors was merged with institutional NIH funding data from 2014 and medical student specialty choice in 2015. Institutional educational support was operationalized as (1) clerkship director's perception of medical school environment toward FM, and (2) amount of negative comments about FM made by faculty in other departments. The outcome was the percentage of students selecting FM. Bivariate statistics were computed. RESULTS: As NIH funding increases, the proportion of students entering FM decreases (r=-.22). Institutions with higher NIH funding had lower clerkship director perceptions of medical school support toward FM (r=-.38). Among private institutions, the negative correlation between NIH funding and the proportion of students entering FM strengthens to r=-.48, P=.001. As perceptions of support for FM increase, the proportion of students entering FM increase (r=.47). Among private schools, perceptions of support toward family medicine was strongly positively correlated with the proportion of students entering FM (r=.72, P=.001). CONCLUSIONS: Higher institutional NIH funding is associated with less support for FM and lower proportions of students choosing FM. These issues appear to be even more influential in private medical schools. Understanding how to integrate the goals of NIH-level research and increasing primary care workforce so that both can be achieved is the next challenge.

Creating a Centralized Infrastructure to Facilitate Medical Education Research.

PURPOSE: Building research capacity and increasing scholarly productivity are identified needs of the specialty of family medicine. The Accreditation Council for Graduate Medical Education (ACGME) has increased the scholarly requirements for residency programs, placing even more pressure on faculty to be productive in the scholarly realm. The Council of Academic Family Medicine Educational Research Alliance (CERA) was created by volunteer members of the specialty with shared interests in overcoming barriers and increasing scholarly production. METHODS: CERA has developed the infrastructure and expertise to regularly conduct omnibus surveys of key family medicine educational leaders. Proposals are centrally collected and competitively chosen. The omnibus survey process includes collaboration with experienced mentors, centralized institutional review board clearance, pilot testing, and centralized data collection. The survey results are disseminated back to research teams for presentation and publication of the findings. RESULTS: To date, over 115 research teams have had their projects included in CERA omnibus surveys. Projects have been led by research teams from across the country and with a wide variety of research experience. This collaborative work has resulted in more than 75 scientific presentations and over 55 peer-reviewed papers in the medical literature. The raw data are now available online and serve as a repository for future secondary analysis and as an educational resource. CONCLUSIONS: The CERA infrastructure has allowed a large number of research teams to conduct meaningful scholarship at a fraction of the typical cost in terms of time and energy. CERA has expanded family medicine research by removing barriers for teams with limited experience or resources.

Text Messaging as a Teaching Tool in a Family Medicine Clerkship Rotation.

INTRODUCTION: Today's learners use multiple forms of social communication, such as text messaging, that offer a promising teaching tool for medical education. The purpose of this study was to evaluate a diabetes care curriculum delivered through text messages for third-year medical students on a rural family medicine clerkship. METHODS: A pilot study of 119 participants were compared in a parallel group randomized controlled trial evaluating medical student learning and satisfaction with text messages throughout rotation compared to an email with the same content in their first week of rotation. Participants completed a 10-question multiple-choice test and six survey questions upon completing the rotation. The primary outcome was a difference between test scores among the two groups, and student satisfaction with the educational intervention was a secondary outcome. RESULTS: A total of 85 participants successfully completed the study protocol (34 text messages and 51 email) and were included in a per protocol analysis. The average number of correct responses per test was 3.32 (SD 1.29) in the texting group and 3.69 (SD 1.53) in the email group (P=0.259). Student satisfaction with text messages was 3.68 (SD 0.87) compared to email at 2.02 (SD 0.95) when rating the educational intervention on a 1 to 5 Likert scale (1=poor, 3=average, and 5=excellent). CONCLUSIONS: Participant knowledge on a challenging posttest was not improved with text messages compared to an email in this pilot study. Satisfaction with text messages was primarily positive. Further study is needed to determine the effectiveness of this content delivery method.

Faculty Development for Medical School Community-Based Faculty: A Council of Academic Family Medicine Educational Research Alliance Study Exploring Institutional Requirements and Challenges.

PURPOSE: Community-based faculty play a large role in training medical students nationwide and require faculty development. The authors hypothesized that positive relationships exist between clerkships paying preceptors and requiring faculty development, and between protected clerkship directors' time and delivering face-to-face preceptor training, as well as with the number or length of community-based preceptor visits. Through under standing the quantity, delivery methods, barriers, and institutional support for faculty development provided to community-based preceptors teaching in family medicine clerkships, best practices can be developed. METHOD: Data from the 2015 Council of Academic Family Medicine's Educational Research Alliance survey of Family Medicine Clerkship Directors were analyzed. The cross-sectional survey of clerkship directors is distributed annually to institutional representatives of U.S. and Canadian accredited medical schools. Survey questions focused on the requirements, delivery methods, barriers, and institutional support available for providing faculty development to community-based preceptors. RESULTS: Paying community-based preceptors was positively correlated with requiring faculty development in family medicine clerkships. The greatest barrier to providing faculty development was community-based preceptor time availability; however, face-to-face methods remain the most common delivery strategy. Many family medicine clerkship directors perform informal or no needs assessment in developing faculty development topics for community-based faculty. CONCLUSIONS: Providing payment to community preceptors may allow schools to enhance faculty development program activities and effectiveness. Medical schools could benefit from constructing a formal curriculum for faculty development, including formal preceptor needs assessment and program evaluation. Clerkship directors may consider recruiting and retaining community-based faculty by employing innovative faculty development delivery methods.

How we teach U.S. medical students to negotiate uncertainty in clinical care: a CERA study.

BACKGROUND AND OBJECTIVES: The patient relies on the physician to help negotiate medical evidence, particularly when experts disagree. For shared decision making to be most effective, the physician must disclose personal uncertainty. This study proposes to describe how uncertainty management is intentionally and systematically taught to medical students. METHODS: A cross-sectional survey was administered to all family medicine clerkship directors (FM CDs) at U.S. allopathic medical schools. Items evaluated the teaching of uncertainty in two domains (instruction and modeling). RESULTS: Eighty-six of 134 (64.18%) FM CDs surveyed completed the survey. Overall, an average of 2.6 hours was devoted to learning about clinical guidelines. The teaching objective addressed least by this sample was discussing uncertainty with the patient. Most curricula do not engage the medical students in how to discuss uncertainty with patients. Hypothesis testing revealed that the clerkship's general attitude toward the importance of teaching students how to deal with competing medical evidence is associated with both instruction and modeling behavior. DISCUSSION: FM CDs demonstrate a positive attitude toward teaching students how to deal with competing evidence. Clerkships do provide students with the opportunity to see faculty engage in uncertainty discussions with patients. Opportunities exist to improve medical student competence in discussing uncertainty in a productive manner. Clerkship directors influence curriculum development and implementation but through their attitude also construct a culture that can be positively aligned with teaching medical students how to negotiate uncertainty in clinical care.

Contemporary teaching strategies of exemplary community preceptors--is technology helping?

BACKGROUND AND OBJECTIVES: Many schools rely upon community preceptors for office-based education of medical students. These preceptors struggle to balance clinical care with the learning needs of students. We aim to gain a deeper understanding of the teaching rewards and challenges of current community preceptors. METHODS: Five schools' family medicine clerkship directors conducted in-depth interviews of two exemplary preceptors at each of their programs. Following qualitative analysis of the interviews, three directors conducted one focus group at their school. The individual and group interviews were recorded, transcribed, and analyzed using grounded theory. RESULTS: Exemplary community preceptors described strategies to improve the learning environment and specific teaching approaches. Well-known teaching strategies such as role modeling, adjusting instruction to the learner's needs, and selecting patients appropriate for a specific student were used. They also described newer techniques such as co-learning and integrating technology, for example, accessing online, current practice guidelines together with the student. They detailed challenges to teaching, including time constraints and too much content to cover and provided advice about teaching tools. CONCLUSIONS: While challenged by clinical demands, preceptors enjoyed teaching and found it rewarding. They used time-proven teaching strategies as well as technology and online resources to facilitate ambulatory teaching. Community preceptors continue to struggle to integrate learners and the priorities of the medical school curriculum into the clinical environment. Further development of electronic tools and other resources to support the teaching needs of preceptors may contribute to learning and help minimize preceptor burden.

Assessing oral health curriculum in US family medicine residency programs: a CERA study.

BACKGROUND AND OBJECTIVES: During the past decade, national initiatives have called for improved oral health training for physicians. We do not know, however, how family medicine residency programs have answered this call. METHODS: Family medicine residency directors completed a survey that asked how many hours of oral health teaching are included in their programs in addition to what topics are covered and the perceived barriers to this education. The response rate was 35%. RESULTS: A total of 72% of respondents agreed that oral health is an important topic, but only 32% are satisfied with their residents' competency in oral health. Barriers to this education included competing priorities (85%), inadequate time (69%), and lack of faculty expertise (52%). CONCLUSIONS: The findings suggest that programs are including more hours than in previous years, yet continued efforts are needed to cover core oral health topics and increase the competency of family medicine residents. Awareness of STFM's Smiles for Life and use of its modules were associated with increased hours of training.

A collaborative model for developing and maintaining virtual patients for medical education.

There is great interest in using computer-assisted instruction in medical education, but getting computer-assisted instruction materials used broadly is difficult to achieve. We describe a successful model for the development and maintenance of a specific type of computer-assisted instruction - virtual patients - in medical education. The collaborative model's seven key components are described and compared to other models of diffusion of innovation and curriculum development. The collaborative development model that began in one medical discipline is now extended to two additional disciplines, through partnerships with their respective clerkship director organizations. We believe that the ability to achieve broad use of virtual patients, and to transition the programs from successfully relying on grant funding to financially self-sustaining, resulted directly from the collaborative development and maintenance process. This process can be used in other learning environments and for the development of other types of computer-assisted instruction programs.

Creating a multi-institutional family medicine clerkship examination: lessons learned.

BACKGROUND AND OBJECTIVES: Multiple choice examinations assess learners' attainment of medical knowledge. Developing multiple choice examinations that discriminate among learners is difficult and time-consuming. Many institutions avoid this effort by using the National Board of Medical Examiners (NBME) subject examinations, which can also provide comparisons to a national norm. The family medicine subject examination has been criticized, however, because the test's content does not reflect the learning expected during the clerkship. Additionally, the test results cannot guide clerkship directors sufficiently to help students study or to improve the curriculum. METHODS: Family medicine clerkships at three different institutions used a common 75-item examination based on the textbook Essentials of Family Medicine, Fifth Edition, for one academic year. Data were pooled and analyzed. The Raush Item Response Theory assessed student and item performance. RESULTS: A total of 451 students took the examination. Across the three schools: (1) item separations (Rasch) were high (8.64), indicating good spread in item difficulty, (2) person separations were lower (1.65), indicating that medical students are likely a relatively homogeneous group, (3) Rasch item reliabilities were strong (ranging from .96-.99), and (4) Rasch person reliabilities (.54-.73) were lower. True internal consistencies across items as measured by the Kuder-Richardson 20 (KR-20) reliabilities were just adequate at .71-.77. CONCLUSIONS: By pooling resources, clerkship directors can share the creation and implementation of a written examination that has acceptable reliability and greater face validity than the NBME subject examination. They also have more control over examination content and can guide students' learning and curriculum improvements more accurately.