Learning styles and perceptions of the value of various learning modalities before and after a 2nd-year course in microbiology and infectious diseases.

BACKGROUND: The authors' 4-week course in microbiology and infectious diseases consists of lectures, small-group sessions, interactive computer-assisted learning (CAL), and textbook readings. PURPOSE: To determine how individual learning style influenced learners' value assessment of these teaching modalities. METHODS: A Kolb Learning Style Inventory and questionnaire to assess enthusiasm for each teaching modality were administered before the course. At course end, a 2nd questionnaire assessed the perceived usefulness of each teaching modality. RESULTS: Learners with a relative preference for experiential learning rather than abstraction initially favored small groups (R2 = .06, p = .004) and CAL (R2 = .06, p = .005). Similarly, learners with a preference for reflective observation rather than active experimentation favored lectures (R2 = .05, p = .01). However, at course end, Kolb learning style did not predict the value assessment of any modality. CONCLUSIONS: Kolb learning style influenced the initial attractiveness but not the retrospective assessment of learning modalities; hence, quality and content superseded learning style as determinants of value after course completion.

Using a multimedia tool to improve cardiac auscultation knowledge and skills.

OBJECTIVE: Today's medical school graduates have significant deficits in physical examination skills. Medical educators have been searching for methods to effectively teach and maintain these skills in students. The objective of this study was to determine if an auscultation curriculum centered on a portable multimedia CD-ROM was effective in producing and maintaining significant gains in cardiac auscultatory skills. DESIGN: Controlled cohort study. PARTICIPANTS: All 168 third-year medical students at 1 medical school in an academic medical center. INTERVENTIONS: Students were tested before and after exposure to 1 or more elements of the auscultation curriculum: teaching on ward/clinic rotations, CD-ROM comprehensive cases with follow-up seminars, and a CD-ROM 20-case miniseries. The primary outcome measures were student performance on a 10-item test of auscultation skill (listening and identifying heart sound characteristics) and a 30-item test of auscultation knowledge (factual questions about auscultation). A subset of students was tested for attenuation effects 9 or 12 months after the intervention. RESULTS: Compared with the control group (1 month clinical rotation alone), students who were also exposed to the CD-ROM 20-case miniseries had significant improvements in auscultation skills scores (P < .05), but not knowledge. Additional months of clerkship, comprehensive CD-ROM cases, and follow-up seminars increased auscultation knowledge beyond the miniseries alone (P < .05), but did not further improve auscultation skills. Students' auscultation knowledge diminished one year after the intervention, but auscultation skills did not. CONCLUSION: In addition to the standard curriculum of ward and conference teaching, portable multimedia tools may help improve quality of physical examination skills.

Teaching the one-minute preceptor. A randomized controlled trial.

OBJECTIVE: The One-Minute Preceptor (OMP) model of faculty development is used widely to improve teaching, but its effect on teaching behavior has not been assessed. We aim to evaluate the effect of this intervention on residents' teaching skills. DESIGN: Randomized controlled trial. SETTING: Inpatient teaching services at both a tertiary care hospital and a Veterans Administration Medical Center affiliated with a University Medical Center. PARTICIPANTS: Participants included 57 second- and third-year internal medicine residents that were randomized to the intervention group (n = 28) or to the control group (n = 29). INTERVENTION: The intervention was a 1-hour session incorporating lecture, group discussion, and role-play. MEASUREMENTS AND MAIN RESULTS: Primary outcome measures were resident self-report and learner ratings of resident performance of the OMP teaching behaviors. Residents assigned to the intervention group reported statistically significant changes in all behaviors (P <.05). Eighty-seven percent of residents rated the intervention as "useful or very useful" on a 1-5 point scale with a mean of 4.28. Student ratings of teacher performance showed improvements in all skills except "Teaching General Rules." Learners of the residents in the intervention group reported increased motivation to do outside reading when compared to learners of the control residents. Ratings of overall teaching effectiveness were not significantly different between the 2 groups. CONCLUSIONS: The OMP model is a brief and easy-to-administer intervention that provides modest improvements in residents' teaching skills.

Perceived symptoms and health-related quality of life reported by uncomplicated hypertensive patients compared to normal controls.

OBJECTIVES: This study compared the prevalence and intensity of symptoms and the health-related quality of life (HQL) of patients taking antihypertensive medications and patients without disease. METHODS: This cross-sectional study used surveys mailed to patient's homes. All consecutive patients over age 30 years attending either a general medicine or hypertension clinic during 3 months were eligible (n = 437). Hypertension group (HTN-G) patients were diagnosed with primary hypertension, prescribed antihypertensive medications, and had no other symptomatic conditions or drug therapies. Control group (CNTL-G) patients were seen in the general medicine clinic and had no chronic symptomatic conditions or drug therapies. Measures included the Symptom Distress Checklist (SDC, list of 51 symptoms, frequency, and level of distress), the Medical Outcomes Study Short Form-36 (SF-36), medications, blood pressures, and other data obtained from medical records and patient self-report. RESULTS: A total of 222 patients responded (46% CNTL-G, 55% HTN-G). HTN-G patients were somewhat older (59.0 +/- 11.2 vs 48.5 +/- 11.7 years, P = 0.001) and had a higher percent of minorities (24.8% vs 13.5%, P = 0.02), but otherwise similar. After adjusting for age and race differences, HTN-G patients reported significantly more symptoms (8.8 +/- 7.8 vs 4.7 +/- 4.8, P = 0.001) and related distress (32.2 +/- 4.2 vs 12.0 +/- 18.2, P = 0.001) as well as lower scores (reduced HQL) for most of the SF-36 domains. In general, hypertensive patients had more physical, but not mental symptoms than control patients. CONCLUSIONS: Hypertensive patients receiving antihypertensive medications have more symptoms and lower HQL. Differences were detected by both a brief, general HQL instrument and a detailed, disease-specific instrument. Routine screening of treated hypertensive patients using a brief HQL questionnaire to detect physical symptoms may prove feasible and useful.

Assessing medical students' awareness of and sensitivity to diverse health beliefs using a standardized patient station.

PURPOSE: To assess students' performances on a health-beliefs communication OSCE station to determine whether there were differences in cultural competence based on the students' ethnic backgrounds. METHOD: A total of 71 students completed a health-beliefs communication OSCE station in which they were required to address the health beliefs and cultural concerns of a standardized patient (SP) portraying an African American woman with diabetes. The SPs rated students' performances on a ten-item interview assessment checklist. Scores on the station were standardized within SPs to adjust for differences in their use of the rating scale. A factor analysis was performed to determine conceptual constructs on the interview assessment checklist. Subscale means were computed for each student. T-tests of these subscale scores were conducted to investigate gender and ethnic differences between subgroups of students. The underrepresented minority (URM) students (five African Americans and three Mexican Americans) were compared with all other students, and the white students were compared with all others. To assess the magnitudes of the differences between subgroups, effect sizes (ES(m)) were computed for means comparisons. RESULTS: Factor analysis formed two factors: Disease Beliefs and Management, and Cultural Concerns. Two remaining items loaded on a third factor that had reliability too low to support further analysis. Meaningful differences were found in cultural sensitivity based on students' ethnic backgrounds. The URM students performed better than did all other students in addressing the patient's concerns about altering culturally-based dietary behaviors for diabetes self-care [URM students' mean standardized score (SD) = 0.42 (0.15); all others = -0.01 (0.67); ES(m) = 1.05]. White students performed better than did all other students in assessing the patient's concerns about using insulin to control her blood sugar levels [white students' mean standardized score (SD) = 0.13 (0.40); all others = -0.10 (0.64); ES(m) = 0.4]. CONCLUSION: Cultural competency deficits and differences were measurable using a health-beliefs communications station, and these differences were meaningful enough to warrant faculty discussion and research about how to ensure that students master this competency.

Is there a relationship between attending physicians' and residents' teaching skills and students' examination scores?

PURPOSE: Faculty development programs and faculty incentive systems have heightened the need to validate a connection between the quality of teaching and students' learning. This study was designed to determine the association between attending physicians' and residents' teacher ratings and their students' examination scores. METHOD: From a database of 362 students, 138 faculty, and 107 residents in internal medicine, student-faculty (n = 476) and student-resident (n = 474) pairs were identified. All students were in their third year, rotating on inpatient general medicine and cardiology services, July 1994 through June 1996, at a single institution. The outcome measure for students' knowledge was the NBME Subject Examination in internal medicine. To control for students' baseline knowledge, the predictors were scores on the USMLE Step 1 and a sequential examination (a clinically-based pre- and post-clerkship examination). Teaching abilities of faculty and residents were rated by a global item on the post-clerkship evaluation. Faculty's ratings used only scores from prior to the study period; residents' ratings included those scores students gave during the study period. RESULTS: Multivariate analyses showed faculty's teaching ratings were a small but significant predictor of the increase in students' knowledge. Residents' teaching ratings did not predict an increase in students' knowledge. CONCLUSION: Attending faculty's clinical teaching ability has a positive and significant effect on medical students' learning.

The influence of task formats on the accuracy of medical students' self-assessments.

PURPOSE: Accurate self-assessment is an essential skill for the self-directed learning activities and appropriate patient referral decisions of practicing physicians. However, many questions about the characteristics of self-assessment remain unanswered. One is whether self-assessment is a generalizable skill or dependent on the characteristics of the task. This study examines the self-assessment skills of medical students across two task formats: performance-based and cognitive-based. METHOD: In 1997 and 1998, fourth-year medical students at the University of Michigan assessed their own performances on ten stations of a clinical examination. The examination used two formats: performance tasks (the examination or history taking of standardized patients) and cognitive tasks (interpreting vignettes or test results and then answering paper-and-pencil questions). Three measures of self-assessment accuracy were used: a bias index (average difference between the students' estimates of their performances and their actual scores), a deviation index (average absolute difference between estimate and actual score), and an actual score-estimate-of-performance correlation (the correlation between the estimate and actual scores). RESULTS: The student bias and deviation indices were similar on the cognitive and the performance tasks. The correlations also indicated similarity between the two types of tasks. CONCLUSION: The results indicate that the format of the task does not influence students' abilities to self-assess their performances, and that students' self-assessment abilities are consistent over a range of skills and tasks. The authors also emphasize the importance of sampling tasks while conducting self-assessment research.

Medical students' self-assessments and their allocations of learning time.

PURPOSE: To investigate the impact of self-assessed diagnostic strengths and weaknesses on medical students' allocation of learning time (one indicator of self-directed learning) during a third-year internal medicine clerkship. METHOD: In 1997-98, 107 students at the University of Michigan Medical School self-assessed their diagnostic skills in 14 clinical areas before and after the clerkship and reported the relative amounts of time spent learning about these topics during the clerkship. RESULTS: Individual-level analyses indicated that, for the average student, self-assessed strengths and weaknesses did not correlate with allocation of educational time, but that time allocation was positively related to changes in self-assessed skill. Considerable variations in these relationships, however, suggest a need for closer study. CONCLUSION: Although individual students evidenced different levels of self-directed learning, this study suggests overall that students at this level of training are neophytes in applying both information generated through self-assessment and principles of self-directed learning in their clinical education. Attempts to advance students beyond this level depend on many factors, including the extent to which the learning environment encourages or even permits self-directed learning, the progression and time frame through which students become self-directed practitioners, and the impact of educational interventions to promote this development.

The influence of treatment modality and ethnicity on attitudes in type 2 diabetes.

OBJECTIVE: The study examines diabetes attitude differences by treatment modality (insulin vs. no insulin), race/ethnicity, and the interaction of these two variables for people with type 2 diabetes. RESEARCH DESIGN AND METHODS: Data were collected with the Diabetes Care Profile (DCP), an instrument that assesses psychosocial factors related to diabetes. Participants (n = 672) were recruited in the metropolitan Detroit, Michigan, area from 1993 to 1996. A total of 68% of these participants were African-Americans with type 2 diabetes, and 32% were Caucasians with type 2 diabetes. Analyses of covariance were performed to examine the effects of race/ethnicity, treatment, and their interaction for each DCP scale. RESULTS: The four patient categories (two ethnicities by two treatment modalities) differed by age, years with diabetes, education, and sex distribution. Treatment modality had a significant effect on 6 of the 16 DCP scales (Control, Social and Personal Factors, Positive Attitude, Negative Attitude, Self-Care Ability, and Exercise Barriers). Ethnicity was a significant effect for three scales (Control, Support, and Support Attitudes). The interaction of race/ethnicity and treatment modality was a significant effect for two related attitude scales (Positive Attitude and Negative Attitude). CONCLUSIONS: The results suggest that attitudes toward diabetes are similar for African-American and Caucasian patients with type 2 diabetes. The results also suggest that treatment modality has a greater effect on attitudes than either race/ethnicity or the interaction effect. However, Caucasian patients using insulin differed from the other patient groups by having the least positive and the most negative attitudes regarding diabetes.

Evaluating the usefulness of computerized adaptive testing for medical in-course assessment.

PURPOSE: This study investigated the feasibility of converting an existing computer-administered, in-course internal medicine test to an adaptive format. METHOD: A 200-item internal medicine extended matching test was used for this research. Parameters were estimated with commercially available software with responses from 621 examinees. A specially developed simulation program was used to retrospectively estimate the efficiency of the computer-adaptive exam format. RESULTS: It was found that the average test length could be shortened by almost half with measurement precision approximately equal to that of the full 200-item paper-and-pencil test. However, computer-adaptive testing with this item bank provided little advantage for examinees at the upper end of the ability continuum. An examination of classical item statistics and IRT item statistics suggested that adding more difficult items might extend the advantage to this group of examinees. CONCLUSIONS: Medical item banks presently used for incourse assessment might be advantageously employed in adaptive testing. However, it is important to evaluate the match between the items and the measurement objective of the test before implementing this format.

The third version of the Diabetes Attitude Scale.

OBJECTIVE: The objective of this study was to develop a third version of the Diabetes Attitude Scale (DAS-3) that is congruent with current scientific knowledge about diabetes, has improved subscale internal reliability scores, and is shorter than the earlier versions of this instrument. RESEARCH DESIGN AND METHODS: The second DAS was revised and rewritten by a panel of diabetes experts, including patients, associated with the University of Michigan Diabetes Research and Training Center. The revised version of the instrument was sent to physicians, nurses, dietitians, and patients with diabetes. Completed and usable questionnaires were obtained from 384 patients with diabetes, 321 physicians, 540 nurses, and 569 dietitians. The total number of surveys used for these analyses was 1,814. RESULTS: The study resulted in a revised DAS with 33 items and five discrete subscales. The subscales were attitudes toward the following: 1) need for special training to provide diabetes care, 2) seriousness of type 2 diabetes, 3) value of tight glucose control, 4) pyschosocial impact of diabetes, and 5) attitude toward patient autonomy. Overall, the subscale reliabilities of the DAS-3 were superior to the earlier versions of the scale. CONCLUSIONS: The DAS-3 is a valid and reliable general measure of diabetes-related attitudes and is most suitable for comparisons across different groups of health care professionals and/or patients. The DAS-3 is also suitable for the evaluation of patient and/or professional education programs if those programs focus on the specific topic areas measured by the five DAS-3 subscales.

Training students in education of the hypertensive patient: enhanced performance after a simulated patient instructor (SPI)-based exercise.

The process whereby a physician explains to the ill patient what has gone wrong and what can be done about it can be taught and evaluated by simulated patients (SPIs). This study was designed to determine whether a training experience in educating a diabetic SPI improves subsequent performance with a hypertensive SPI. Competence in educating a hypertensive SPI by students who had no prior training experience (n = 26) was compared to that of an experimental group (n = 20) that had a prior training session. Performance was assessed with a counseling skills scale and a case-specific content checklist (1 = poor to 5 = excellent). Students in the experimental group performed better than controls in both counseling skills (4.46 v 3.86, P < .01) and completeness of coverage of content (3.28 v 2.65, P < .01). Students in both groups focused more on clinical features and treatment than on laboratory testing and follow-up. The ability to counsel "patients" with hypertension can be enhanced by a prior learning experience with a diabetic SPI. Clinical application of knowledge about hypertension can be assessed by SPIs.

The reliability of the Diabetes Care Profile for African Americans.

The Diabetes Care Profile (DCP) is an instrument used to assess social and psychological factors related to diabetes and its treatment. The reliability of the DCP was established in populations consisting primarily of Caucasians with type 2 diabetes. This study tests whether the DCP is a reliable instrument for African Americans with type 2 diabetes. Both African American (n = 511) and Caucasian (n = 235) patients with type 2 diabetes were recruited at six sites located in the metropolitan Detroit area. Scale reliability was calculated by Cronbach's coefficient alpha. The scale reliabilities ranged from .70 to .97 for African Americans. These reliabilities were similar to those of Caucasians, whose scale reliabilities ranged from .68 to .96. The Feldt test was used to determine differences between the reliabilities of the two patient populations. No significant differences were found. The DCP is a reliable survey instrument for African American and Caucasian patients with type 2 diabetes.

Implications of cognitive research for ambulatory care education.

Research in cognitive psychology has led to changes in how educators conceptualize thinking and approach improving students' thinking processes. As medical education moves into ambulatory care settings, there is an opportunity for educators to consider the implications of cognition theories for the ambulatory case curriculum. In this paper, the author briefly explains four major concepts of cognitive theory-the importance of context; students' need for transferable knowledge; the importance of balancing depth and breadth of knowledge; and the role of prior knowledge in problem solving- and discusses the possible implications of each concept for ambulatory care educations.

A predictive model of student satisfaction with the medical school learning environment.

PURPOSE: To examine differences in attitudes toward the medical school learning environment among student subgroups based on gender and race-ethnicity, to identify the most influential predictors of student satisfaction with the learning environment, and to create a model of student satisfaction with the learning environment. METHOD: Three years of survey data (1992-93 to 1994-95) from first-year students at the University of Michigan Medical School were combined. The total sample consisted of 430 respondents, broken into two sets of subgroups: women (n = 171) and men (n = 259), and whites (n = 239) and underrepresented minorities (n = 74). Asian students were removed from analyses when comparisons were made by race-ethnicity, but were included in the analyses for all students and those comparing men and women. Student's t-tests were used to identify differences between gender and racial-ethnic groups in mean responses to seven survey items, and effect sizes were used to characterize the magnitudes and practical significances of the differences. Forward stepwise regression was conducted to determine the best predictive models for each student subgroup and for the total sample; the subgroup models were compared with each other as well as with the total-sample model. RESULTS: Cross-validation of the gender and race-ethnicity models showed that the men's satisfaction and the women's satisfaction were predicted equally well using either subgroup's model, and that the white students' satisfaction and the underrepresented-minority students' satisfaction were predicted equally well using either subgroup's model. Furthermore, the total-sample model, employing a subset of five predictors, was similar in its predictive power to the subgroup models. CONCLUSION: The study's findings suggest that curriculum structure (timely feedback and the promotion of critical thinking) and students' perceptions of the priority faculty place on students' education are prominent predictors of student satisfaction (across all subgroups) with the learning environment. In contrast, students' perceptions of the learning environment as a comfortable place for all gender and racial-ethnic groups, although less prominent predictors of satisfaction, will discriminate among the subgroups.

Teaching skills for accessing and interpreting information from systematic reviews/meta-analyses, practice guidelines, and the Internet.

Skills and practice related to accessing and interpreting clinical information from systematic reviews/meta-analyses, practice guidelines, and the Internet have been integrated into a new senior year elective designed to teach medical students how to critically appraise information from a variety of sources and evaluate it's applicability to patient care. Small groups of senior medical students under the direction of a multidisciplinary team (behavioral scientist, information specialist, physician) facilitate discussions of clinical articles using checklists designed to evaluate their quality. The central feature of the course is a demonstration of the Cochrane Database of Systematic Reviews (CDSR), an electronic journal distributed by BMJ Publishing, and the requirement that students conduct a literature review on a topic of their choice and present an oral and written summary in the form of a "draft" meta-analysis. Students are provided with strategies to "surf" the Internet/WWW for information, e.g., practice guidelines/treatment protocols, descriptions of on-going clinical trials. A total of 52 students have participated to date. Students have selected project topics across a wide range of medical disciplines, including internal medicine, family practice, OB/GYN, pediatrics, surgery, neurology, emergency medicine, and psychiatry. The course is one of the most favorably evaluated of all senior electives and rated more favorably than the overall mean ratings for all electives combined on 8 of 9 scales, including "Quality of course overall" (4.39 vs. 3.92 on 5-point scale).