Improving outcomes in adults with diabetes through an interprofessional collaborative practice program.

In 2014, the Midwest Interprofessional Practice, Education and Research Center partnered with a Federally Qualified Health Center (FQHC) to implement an interprofessional collaborative practice (IPCP) education program to improve the health of adult patients with diabetes and to improve practice efficiency. This partnership included integrating an interprofessional team of students with the practice team. Twenty-five students and 20 staff engaged in the IPCP program, which included completion of educational modules on IPCP and implementation of daily huddles, focus patient visits, phone calls, team-based case presentations, medication reconciliation, and student-led group diabetes education classes. This study used a sequential mixed methods design. Tools used for collecting data from staff and students included demographic forms, the Interdisciplinary Education Perception Scale (IEPS), the Entry-level Interprofessional Questionnaire, the Collaborative Practice Assessment Tool, and pre/post module knowledge tests completed at baseline and at one-year post implementation. Patient clinical indicators included HgbA1c, glucose, lipid panel laboratory assessments, body mass index, blood pressure, and documentation of annual dental, foot, and eye examinations. Practice efficiency was measured by the average number of patients seen per provider per hour. Both students and staff showed significant knowledge gains in IPCP on Team Dynamics and Tips for Behavioural Changes knowledge tests (p < .05). Patients who had an HgbA1c of ≥ 7% significantly decreased their HgbA1c (p < .05) and glucose (p < .01). However, BMI and annual dental and eye examinations did not improve. Providers demonstrated an increase in the number of patients seen per hour. This IPCP intervention showed improvement in practice efficiencies and select patient outcomes in a family practice clinic.

Issues in Nutrition: Dietary Considerations in Select Chronic Conditions.

Chronic diseases that affect the gastrointestinal tract also tend to affect nutrition. The incidence of chronic liver disease is increasing. As the prevalence of obesity rises, so do the incidences of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. Patients with chronic liver disease usually have some degree of malnutrition. In the absence of encephalopathy, patients with chronic liver disease should consume more protein than that in the average diet. There is some controversy about whether diet plays a role in the development of inflammatory bowel disease. Patients with ulcerative colitis and Crohn disease frequently present with weight loss as a symptom, and require careful nutritional assessment. Exclusive enteral nutrition plays an important role in inducing remission in children with Crohn disease but the same is not true in adults. Celiac disease is a relatively common enteropathy characterized by an autoimmune response in the intestinal lining. Patients with celiac disease should avoid eating gluten, which is found in wheat, soy, and barley. There is no evidence that gluten avoidance results in improved health outcomes in patients who are not gluten intolerant.

Issues in Nutrition: Nutritional Assessment of Adults.

The assessment of nutritional status in adults should begin with a complete history, including intake of fruits and vegetables, sources of fat, and added sugar (eg, sugar-sweetened beverages). The history should include social factors that may impede a patient's ability to obtain food, as well as any factors that might interfere with preparing, chewing, and digesting food and absorbing nutrients. The physical examination should include measurement of height and weight and calculation of body mass index. It also may include measurements of waist circumference and waist to hip ratio, and an evaluation of strength. Laboratory evaluation should include measurement of albumin, prealbumin, and other markers of total body protein stores. No biomarker is completely sensitive or specific. With a range of dietary patterns, it is possible for nutritional gaps specific to those patterns to develop. Identification of a single nutrient deficiency typically reflects an overall weakness in the diet. The Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets have the most evidence to support them as healthy diets.

Issues in Nutrition: Dietary Supplements.

The majority of American adults report use of one or more dietary supplements every day or occasionally. The Dietary Supplement Health and Education Act of 1994 defines dietary supplements and regulates their manufacture and distribution. One of the most commonly used supplements is vitamin D. Measurement of serum levels of vitamin D must be undertaken with the caveats that different laboratories define normal levels differently, and that there is rarely a clinical correlation with the actual level. Patients should understand that supplements should not be used to excess, as there are toxicities and other adverse effects associated with most of them. There currently is considerable research being performed on probiotics and how the gut microbiome affects health and disease states. Protein supplements may be useful in reducing mortality rates in elderly patients but they do not appear to increase quality of life. If used, protein supplements should contain essential amino acids. Casein and whey supplements, derived from dairy sources, help transport essential amino acids to tissues. Although there have been many studies investigating the role of vitamin supplements in disease prevention, there have been few conclusive positive results.

Issues in Nutrition: Carbohydrates.

Carbohydrates include sugars, starches, and dietary fibers. Resistant starches resemble fiber in their behavior in the intestinal tract, and may have positive effects on blood glucose levels and the gut microbiome. Fibers are classified as soluble and insoluble, but most fiber-containing foods contain a mixture of soluble and insoluble fiber. Soluble fiber has been shown to lower low-density lipoprotein cholesterol levels. Many artificial sweeteners and other sugar substitutes are available. Most natural sources of sweeteners also are energy sources. Many artificial sweeteners contain no kilocalories in the amounts typically used. Sugar alcohols may have a laxative effect when consumed in large amounts. Glycemic index and glycemic load are measurements that help quantify serum glucose response after ingestion of particular foods. These measurements may be affected by the combination of foods consumed in a given meal, and the glycemic index may vary among individuals eating the same meal. Eating foods with a low glycemic index may help prevent development of type 2 diabetes. There is no definitive evidence to recommend low-carbohydrate diets over low-fat diets for long-term weight loss; they are equally effective.

Student performance on smoking cessation counseling with standardized patients.

BACKGROUND AND OBJECTIVES: Gaps in medical school education exist for the leading preventable cause of morbidity and mortality in the United States--cigarette smoking. This report is on an innovative medical student curriculum of smoking cessation with a high-stakes required performance assessment during a third-year clerkship in family medicine addressing the following questions: (1) Can medical students consistently achieve high levels of performance providing smoking cessation advice with standardized patients and (2) Is the performance on standardized patients associated with other concurrent cognitive test performance on comprehensive topics relevant to family medicine? METHODS: From 1997--2002 (Cohort 1), 470 students completed a focused assessment with standardized patients on smoking cessation counseling. From 2003--2007, 277 students completed a revised, complex shared decision making assessment on smoking cessation with standardized patients. Associations between student performance on standardized patients and concurrent cognitive examinations were analyzed. RESULTS: High levels of student performance were sustained on standardized patients and were inconsistently associated with other concurrent (written and oral) cognitive examinations. CONCLUSIONS: These findings further substantiate a need for broadening the range of assessing medical student competency beyond cognitive evaluations alone. Medical students can consistently achieve high levels of smoking cessation counseling with standardized patients regardless of the complexity of approach or performance on other concurrent examinations.

Using a formative simulated patient exercise for curriculum evaluation.

BACKGROUND: It is not clear that teaching specific history taking, physical examination and patient teaching techniques to medical students results in durable behavioural changes. We used a quasi-experimental design that approximated a randomized double blinded trial to examine whether a Participatory Decision-Making (PDM) educational module taught in a clerkship improves performance on a Simulated Patient Exercise (SPE) in another clerkship, and how this is influenced by the time between training and assessment. METHODS: Third year medical students in an internal medicine clerkship were assessed on their use of PDM skills in an SPE conducted in the second week of the clerkship. The rotational structure of the third year clerkships formed a pseudo-randomized design where students had 1) completed the family practice clerkship containing a training module on PDM skills approximately four weeks prior to the SPE, 2) completed the family medicine clerkship and the training module approximately 12 weeks prior to the SPE or 3) had not completed the family medicine clerkship and the PDM training module at the time they were assessed via the SPE. RESULTS: Based on limited pilot data there were statistically significant differences between students who received PDM training approximately four weeks prior to the SPE and students who received training approximately 12 weeks prior to the SPE. Students who received training 12 weeks prior to the SPE performed better than those who received training four weeks prior to the SPE. In a second comparison students who received training four weeks prior to the SPE performed better than those who did not receive training but the differences narrowly missed statistical significance (P < 0.05). CONCLUSION: This pilot study demonstrated the feasibility of a methodology for conducting rigorous curricular evaluations using natural experiments based on the structure of clinical rotations. In addition, it provided preliminary data suggesting targeted educational interventions can result in marked improvements in the clinical skills spontaneously exhibited by physician trainees in a setting different from which the skills were taught.

Medical students, clinical preventive services, and shared decision-making.

OBJECTIVE: Improving access to preventive care requires addressing patient, provider, and systems barriers. Patients often lack knowledge or are skeptical about the importance of prevention. Physicians feel that they have too little time, are not trained to deliver preventive services, and are concerned about the effectiveness of prevention. We have implemented an educational module in the required family practice clerkship (1) to enhance medical student learning about common clinical preventive services and (2) to teach students how to inform and involve patients in shared decision making about those services. DESCRIPTION: Students are asked to examine available evidence-based information for preventive screening services. They are encouraged to look at the recommendations of various organizations and use such resources as reports from the U.S. Preventive Services Task Force to determine recommendations they want to be knowledgeable about in talking with their patients. For learning shared decision making, students are trained to use a model adapted from Braddock and colleagues(1) to discuss specific screening services and to engage patients in the process of making informed decisions about what is best for their own health. The shared decision making is presented and modeled by faculty, discussed in small groups, and students practice using Web-based cases and simulations. The students are evaluated using formative and summative performance-based assessments as they interact with simulated patients about (1) screening for high blood cholesterol and other lipid abnormalities, (2) screening for colorectal cancer, (3) screening for prostate cancer, and (4) screening for breast cancer. The final student evaluation is a ten-minute, videotaped discussion with a simulated patient about screening for colorectal cancer that is graded against a checklist that focuses primarily on the elements of shared decision making. DISCUSSION: Our medical students appear quite willing to accept shared decision making as a skill that they should have in working with patients, and this was the primary focus of the newly implemented module. However, we have learned that students need to deepen their understanding of screening services in order to help patients understand the associated benefits and risks. The final videotaped interaction with a simulated patient about colorectal cancer screening has been very helpful in making it more obvious to faculty what students believe and know about screening for colorectal cancer. As the students are asked to discuss clinical issues with patients and discuss the pros and cons of screening tests as part of the shared decision-making process, their thinking becomes transparent and it is evident where curricular changes and enhancements are required. We have found that an explicit model that allows students to demonstrate a process for shared decision making is a good introductory tool. We think it would be helpful to provide students with more formative feedback. We would like to develop faculty development programs around shared decision making so that more of our clinical faculty would model such a process with patients. Performance-based assessments are resource-intensive, but they appear to be worth the added effort in terms of enhanced skills development and a more comprehensive appraisal of student learning.

The Web-based worksheet: an opportunity for prompt, consistent, and expert feedback in a community-based hospice experience.

We faced a challenge in providing a consistent high-quality learning experience in hospice care, especially because our community-based medical school has students rotating in hospices in six separated communities and the number of faculty with expertise in palliative care is limited. To address these concerns, a Web-based worksheet with interaction with a central campus faculty member was designed for use in a hospice module in a family practice clerkship.