Do clerkship experiences affect medical students' attitudes toward chronically ill patients?

PURPOSE: To measure changes in medical students' attitudes toward chronically ill patients, and to identify experiences, specifically during clerkships, that contributed to students' attitudes. METHOD: A cohort of students from five U.S. medical schools voluntarily participated in three surveys longitudinally administered before and after required clinical rotations. The first two questionnaires were identical and asked for demographic information and pre-matriculation experiences with chronically ill patients. The third was modified to include questions about clinical experiences with chronically ill patients. Responses from the first and third questionnaires were linked for analysis. RESULTS: A total of 502 of 695 students (69%) completed both the first and the third questionnaires. Many students (36%) had had pre-matriculation experiences with chronic illness. After clinical training, 25% of the respondents stated that they would seek another career specialty if the incidence of chronically ill patients increased in their chosen field, compared with the 9% who responded so before clinical training (p <.001). While 73% of the students had favorable perceptions toward chronically ill patients, and 91% felt involved in care, significantly fewer students (p <.01) had had positive patient care experiences when working with residents (57%) and attendings (59%). Gender, age, prior experiences, and school site were not associated with attitudinal changes. CONCLUSION: Students begin medical school with positive attitudes toward caring for chronically ill patients, but this perception depreciates with clinical experience, which may affect specialty decisions. Contributing factors may include adequate role modeling by residents and attendings and a perceived discrepancy in the quality of care patients receive.

Communicating bad news: a pediatric department's evaluation of a simulated intervention.

OBJECTIVE: To determine if pediatric residents and emergency department (ED) fellows could improve their ability to counsel and inform standardized patients (SPs) about bad news. METHODOLOGY: A crossover, self-controlled design in which trainees were their own control individuals, and SPs provided feedback after the first interview. The setting was the consultation room in the ED of a large children's hospital. The outcome measures included examining the counseling and informing skills of study participants. RESULTS: Trainees improved their informing skills after being provided feedback in the broad areas of communication and follow-up and in the total number of content areas asked. Their counseling skills improved in two areas: 1) promoting more trust and 2) making parents feel less dependent. Those trainees who scored higher on counseling skills discussed more total and critical content issues with SPs in the study. Trainee feedback revealed a very high rating of the educational process, and the trainees also felt much more confident about their skills after the first and second sessions. CONCLUSIONS: Using SPs to teach residents and ED fellows to give bad news is an effective educational process that provides trainees with interactions that simulate real-life experience

Teaching telephone management skills to pediatric residents in a pilot program using a standardized patient.

BACKGROUND: Pediatricians spend a significant amount of time on the telephone but receive little formal training in telephone management skills. We found only two previous reports in the literature using a randomized controlled trial (RCT) that documented the effectiveness of a telephone management program for residents. METHODS: The goals of this pilot study were (1) to provide second year pediatric residents (PL-2s) an experimental telephone management educational program, using a standardized patient (SP); (2) to assess the PL-2s' affective skills and ability to address relevant content on a series of simulated telephone calls; and (3) to determine whether feedback to the experimental group would improve their telephone management skills. RESULTS: In this small pilot RCT using an SP intervention, no improvement was found in PL-2s' short-term or long-term telephone management skills. CONCLUSION: Further studies involving larger number of residents and revised study design are needed in planning effective approaches to teaching these important skills to pediatric residents in our training program.

Teaching physicians how to break bad news: a 1-day workshop using standardized parents.

OBJECTIVE: To evaluate the effectiveness of a training program using standardized parents (SPs) to improve the performance of pediatric intensive care fellows in communicating bad news to parents. DESIGN: Self-controlled crossover design. SETTING: Tertiary pediatric intensive care unit in a university-affiliated children's hospital. PARTICIPANTS: Seven pediatric intensive care fellows and 4 trained volunteers (2 sets of SPs) participated in the study. METHODS: Two case scenarios of children admitted to the intensive care unit with a near-fatal diagnosis were used for the fellow's interactions with the SPs. The SPs had received 15 hours of training in role playing, performance evaluation, and giving feedback to the physicians. At the end of the first session, SPs provided feedback to the physicians under each of the 5 following categories: communication skills, content issues, support systems, interventions, and parent perceptions. During the second session, the parent meeting was repeated with a new but similar case scenario and a different set of SPs. Both sessions were videotaped, and a rater blinded to the order of the sessions used a weighted scale based on a checklist to score changes in physician performance. RESULTS: The performance by the fellows showed a significant mean (+/-SEM) improvement in scores of 18.1 (+/-5.2) points (P = .007) between the first and the second sessions. Ranking of session scores revealed that physician performance improved significantly during the second session (Wilcoxon signed rank test, P = .002). CONCLUSIONS: To our knowledge this is the first study that demonstrates short-term improvement in physician performance in conveying bad news in a pediatric intensive care setting using SPs in a 1-day workshop.

Clinical teaching improvement: past and future for faculty development.

Faculty development programs have focused on the improvement of clinical teaching for several decades, resulting in a wide variety of programs for clinical teachers. With the current constraints on medical education, faculty developers must reexamine prior work and decide on future directions. This article discusses 1) the rationale for providing faculty development for clinical teachers, 2) the competencies needed by clinical teachers, 3) the available programs to assist faculty to master those competencies, and 4) the evaluation methods that have been used to assess these programs. Given this background, we discuss possible future directions to advance the field.

Home health care: pediatric education in the community.

The purpose of this paper is to describe a curricular innovation involving a community home health care (HHC) experience for third-year medical students as an integral part of a pediatric clerkship. Students at George Washington University are required to participate in an afternoon of HHC visits, one of which requires their reviewing a patient's record before the visit. They then do a pertinent history and a focused physical examination, followed by an assessment and plan, and provide integrated care with the home health care professional. They record this information on a consultation form that is reviewed and evaluated by the clerkship director. Most students have rated this experience positively. A questionnaire before and after the HHC experience and a wrap-up session at the conclusion of the rotation revealed that students are becoming more informed about aspects of home health care and have more positive attitudes about their identified role as future physicians in this important area.

Assessing student performance on a pediatric clerkship.

OBJECTIVE: To determine whether any of 4 parameters used as evaluation methods in the pediatric clerkship at Children's National Medical Center, Washington, DC, could predict a student's performance, as measured by the final grade. DESIGN: A retrospective study in which the following data were collected: (1) a record of the diagnoses and total number of patients seen during the rotation, (2) clinical performance grade, (3) the National Board of Medical Examiners (NBME) pediatric shelf test score, (4) case presentation grade, and (5) the final clerkship grade for overall performance. SETTING: Third-year pediatric clerkship in the 1987-1988 academic year at Children's National Medical Center, the George Washington University School of Medicine. RESULTS: A total of 128 students had complete data. Correlations among the clinical parameters, ie, number of patients seen, clinical grade, case grade, and the NBME shelf test score were all statistically nonsignificant. In addition, multiple regression modeling of NBME test scores, using measures such as clinical grade, average case grade, and number of patients seen, was unsuccessful, with only clinical performance entering the regression model. In contrast, modeling of the final clerkship grade resulted in explaining almost 80% of the variation on a student's final grade (R2 = 0.79). Variables submitted to the model were number of patients seen, clinical grade, average case presentation grade, and ordered examination score. Last, a highly significant relationship (chi 2 = 15.98, P < .001) was noted between students receiving a final grade of honors and an "A" on their case grade. CONCLUSIONS: Results confirmed that there is no single best predictor of performance on a pediatric clerkship. While there was only a weak correlation between each single measure and the final grade, together these accounted for 80% of the variation in students' scores. Based on the study data, the use of varied evaluative methods to determine a student's final grade is recommended.

Learning preference and personality type: their association in paediatric residents.

The objective of this study was to determine if there is a relationship between the learning preferences and personality types of residents in paediatrics. As part of a study to teach residents in paediatrics how to teach, the authors administered the Learning Preference Inventory (LPI) and Fundamental Interpersonal Relationship Orientation (FIRO-B) instruments to 55 residents in paediatrics at all three levels of training. The instruments provided data that were used to provide feedback to residents on their learning preferences and interaction styles, as well as how these factors might affect teaching and learning in the clinical setting. The Pearson correlation coefficient was used to determine relationships between the LPI and the FIRO-B. Fifty-two of the 55 residents (95%) completed the instruments. The results revealed that residents' learning preferences were significantly related to their personality types. For example, residents with high inclusion and affection scores on the FIRO-B preferred learning with others, which was significantly related to their high interpersonal scores on the LPI. Residents with low inclusion and affection scores were more likely to prefer independent learning (high individual and student-structured scores on the LPI) and abstract learning at statistically significant levels. The scores obtained by residents in paediatrics on the LPI were strongly correlated with those obtained on the FIRO-B. These data may have important implications for the way in which staff recruit, counsel and teach residents. The fact that the LPI is easy to administer and does not purport to measure personality styles makes it an acceptable educational tool that can be used in many areas of training.

Improving the way we educate medical students: a priority for the 1990s.

The repeated calls for change in the last 80 years regarding how we educate medical students have met with resistance and inertia. Position papers on why change should occur and what the outcomes should be have been presented since the 1930s, but the missing essential ingredient in each of those documents has been how to implement change within the context of the medical school organization and environment. Recognizing this deficiency, the Association of American Medical Colleges convened a task force, which, among other things, surveyed medical school administrators to determine how they were effecting change in their own institutions. Based on results from respondents, the task force published the ACME--TRI report, an acronym for assessing change in medical education--the road to implementation. This article offers suggestions on how to implement parts of the ACME--TRI report.

Medical students' experiences with and perceptions of chronic illness prior to medical school.

Concerns have been expressed about the failure of the medical curriculum to address the health-care needs of the chronically ill. It has been shown in the literature that medical students develop cynicism and negative feelings towards chronic illness as they progress through their training, perhaps as a result of the attitudes and frustrations of their teachers. What has been inadequately addressed are the experiences with and perceptions about chronic illness that medical students have before entering medical school. Some recommendations are made for curriculum changes based on the findings reported.