From Cheerleader to Coach: The Developmental Progression of Bedside Teachers in Giving Feedback to Early Learners.

BACKGROUND: Medical students learn clinical skills at the bedside from teaching clinicians, who often learn to teach by teaching. Little is known about the process of becoming an effective clinical teacher. Understanding how teaching skills and approaches change with experience may help tailor faculty development for new teachers. Focusing on giving feedback to early learners, the authors asked: What is the developmental progression of clinician-teachers as they learn to give clinical skills feedback to medical students? METHOD: This qualitative study included longitudinal interviews with clinician-teachers over five years in a new clinical skills teaching program for preclinical medical students. Techniques derived from grounded theory were used for initial analyses. The current study focused on one theme identified in initial analyses: giving feedback to students. Transcript passages were organized by interview year, coded, and discussed in year clusters; thematic codes were compared and emergent codes developed. RESULTS: Themes related to giving feedback demonstrated a dyadic structure: characteristic of less experienced teachers versus characteristic of experienced teachers. Seven dominant dyadic themes emerged, including teacher as cheerleader versus coach, concern about student fragility versus understanding resilience, and focus on creating a safe environment versus challenging students within a safe environment. CONCLUSIONS: With consistent teaching, clinical teachers demonstrated progress in giving feedback to students in multiple areas, including understanding students' developmental trajectory and needs, developing tools and strategies, and adopting a dynamic, challenging, inclusive team approach. Ongoing teaching opportunities with targeted faculty development may help improve clinician-teachers' feedback skills and approaches.

Empowering fourth-year medical students: the value of the senior year.

In this issue of Academic Medicine, Wolf et al explore the purposes and value of the senior year of medical school as viewed by graduating students at their institution. Using data from student focus groups and questionnaires, they report that students all found there to be significant value in but identified different purposes for the fourth year. The authors of this commentary believe that study adds to the discussion of fourth-year curriculum reform an important voice that has been lacking-that of students.Previous articles focusing on the perceived lack of clarity of educational purpose in the senior year curriculum have reflected a faculty perspective and have led some to call for increasing the structure of, decreasing the elective time in, or even completely eliminating the fourth year. In this commentary, the authors ask for a pause in this debate to consider the implications of the student perspective as well as important trends in the medical education continuum that affect the senior student (e.g., milestones that will set new expectations for first-year residents, increasing pressure associated with matching to a residency). They propose that providing students with time for career exploration and for focusing on areas of interest would allow them to individualize their preparation for residency and to be more sure of their career choices. They share the University of Washington School of Medicine's planned new fourth-year approach as an example of a flexible, individualized senior year curriculum.

Challenges and opportunities in building a sustainable rural primary care workforce in alignment with the Affordable Care Act: the WWAMI program as a case study.

The authors examine the potential impact of the Patient Protection and Affordable Care Act (ACA) on a large medical education program in the Northwest United States that builds the primary care workforce for its largely rural region. The 42-year-old Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) program, hosted by the University of Washington School of Medicine, is one of the nation's most successful models for rural health training. The program has expanded training and retention of primary care health professionals for the region through medical school education, graduate medical education, a physician assistant training program, and support for practicing health professionals.The ACA and resulting accountable care organizations (ACOs) present potential challenges for rural settings and health training programs like WWAMI that focus on building the health workforce for rural and underserved populations. As more Americans acquire health coverage, more health professionals will be needed, especially in primary care. Rural locations may face increased competition for these professionals. Medical schools are expanding their positions to meet the need, but limits on graduate medical education expansion may result in a bottleneck, with insufficient residency positions for graduating students. The development of ACOs may further challenge building a rural workforce by limiting training opportunities for health professionals because of competing demands and concerns about cost, efficiency, and safety associated with training. Medical education programs like WWAMI will need to increase efforts to train primary care physicians and increase their advocacy for student programs and additional graduate medical education for rural constituents.

What are the benefits of early patient contact?--A comparison of three preclinical patient contact settings.

BACKGROUND: Despite increasing attention to providing preclinical medical students with early patient experiences, little is known about associated outcomes for students. The authors compared three early patient experiences at a large American medical school where all preclinical students complete preceptorships and weekly bedside clinical-skills training and about half complete clinical, community-based summer immersion experiences. The authors asked, what are the relative outcomes and important educational components for students? METHODS: Medical students completed surveys at end of second year 2009-2011. In 2009, students compared/contrasted two of three approaches; responses framed later survey questions. In 2010 and 2011, students rated all three experiences in relevant areas (e.g., developing comfort in clinical setting). Investigators performed qualitative and quantitative analyses. RESULTS: Students rated bedside training more highly for developing comfort with clinical settings, one-on-one clinical-skills training, feedback, active clinical experience, quality of clinical training, and learning to be part of a team. They rated community clinical immersion and preceptorships more highly for understanding the life/practice of a physician and career/specialty decisions. CONCLUSIONS: Preclinical students received different benefits from the different experiences. Medical schools should define objectives of early clinical experiences and offer options accordingly. A combination of experiences may help students achieve clinical and team comfort, clinical skills, an understanding of physicians' lives/practices, and broad exposure for career decisions.

Teachers as learners: the effect of bedside teaching on the clinical skills of clinician-teachers.

PURPOSE: To assess the impact on full-time faculty's own clinical skills and practices of sustained clinical skills bedside teaching with preclerkship students. METHOD: This was a longitudinal, qualitative study of faculty who provide dedicated ongoing bedside clinical skills teaching for preclerkship medical students. Interviews were conducted during 2003 to 2007 with 31 faculty of the Colleges program at University of Washington School of Medicine. Content analyses of interview transcripts were performed. RESULTS: Teachers perceived a strong positive impact of teaching on their own clinical skills. Six themes were associated with the influence of bedside teaching on teachers' skills and practices. One related to deterrents to change (e.g., reliance on tests/specialists) that narrowed teachers' practice skills prior to starting bedside teaching. Three related to expansion of the process of clinical care resulting from bedside teaching: expanded knowledge and skills, deconstructing the clinical experience (e.g., deepening, broadening, slowing one's practice), and greater self-reflection (e.g., awareness of being a role model). Two were perceived outcomes: improved clinical skills (e.g., physical examination) and more mindful practices (e.g., self-confidence, patient-centered). CONCLUSIONS: Teachers perceived profound positive impact on their clinical skills from teaching preclerkship students at the bedside. Further studies are needed, including comparing teaching preclerkship students with teaching advanced students and residents, to assess whether teaching at other levels has this effect.

Measuring the quality of end-of-life care.

CONTEXT: Although there is a documented need to improve end-of-life care, there are few validated and brief questionnaires that are available as outcome measures for use in improving that care. OBJECTIVES: To examine the measurement characteristics of the Quality of End-of-Life Care (QEOLC) questionnaire. METHODS: In a multisite, cross-sectional study of a mailed questionnaire, patients with life-limiting illnesses, their families, and nurses completed the QEOLC questionnaire. Patients and nurses were identified by physicians, and families were identified by participating patients. Physicians included general internists, oncologists, cardiologists, and pulmonologists from the Southeast and Pacific Northwest of the United States. RESULTS: Eight hundred one patients, 310 of their families, and 885 nurses were identified by 85 physicians. Using structural equation modeling techniques corrected for clustering under physicians, we identified a patient-specific factor based on 11 items, a family-specific factor based on 22 items, a nurse-specific factor based on 11 items, and a common single-factor solution based on 10 items. Construct validity was supported by significant associations in the hypothesized direction between the identified QEOLC factors and each of the following: physician palliative care knowledge, patients' and families' ratings of overall quality of care, and patients' levels of symptom distress. CONCLUSION: Although continued testing in heterogeneous samples is necessary, the current study supported the construct validity of the QEOLC questionnaire to assess physician skill at end-of-life care, thereby providing valid measures of quality end-of-life care. Furthermore, this approach is a model for development and validation of patient- and family-centered assessments of quality of care.

The language of prognostication in intensive care units.

UNLABELLED: Rationale. Although misunderstandings about prognosis are common in intensive care units (ICUs), little is known about how physicians actually communicate prognostic information. OBJECTIVES: The authors sought to 1) develop a framework to describe the language physicians use to disclose prognosis, 2) determine whether physicians frame prognostic statements as estimates for populations or estimates for individual patients, and 3) determine whether physicians use the recommended ''ask-tell-ask'' approach when discussing prognosis. METHODS: The authors conducted a multicenter, cross-sectional study of 51 audiotaped physician-family conferences about life support decisions in ICUs. They identified each prognostic statement and used grounded theory methods to develop a framework to understand the language physicians use to communicate prognosis. MAIN RESULTS: Physicians prognosticated in 50 of 51 conferences. When discussing prognosis, physicians used qualitative probability statements in 72% (36/50) of conferences, numeric statements in 20% (10/50), absolute statements in 13% (4/32), and nonprobabilistic statements in 40% (20/50). Physicians exclusively used population-based language in 10% (5/50) of conferences, single-event probability statements in 62% (31/50), and both in 28% (14/ 50). In only 2% (1/50) of conferences did physicians ask whether the family wished to hear prognostic information prior to discussing it, and in only 14% of conferences (7/50) did physicians check to verify that families understood the prognostic information. CONCLUSIONS: There is considerable variability in the language used by physicians to disclose prognosis, with only 20% of physicians using quantitative terms. Very few physicians checked whether families understood prognostic information. These findings may provide potential targets for interventions to improve communication about prognosis in ICUs.

Learning professionalism: perspectives of preclinical medical students.

PURPOSE: To identify and examine how students respond to and engage with formal professionalism teaching strategies, and what factors outside the formal curriculum may influence professional development. METHOD: Individual semistructured interviews were conducted with 56 students completing the preclinical curriculum at the University of Washington School of Medicine in 2004 and 2005. Interviews were recorded, transcribed, and analyzed using qualitative methods. RESULTS: Students identified role modeling as an important modality for learning professionalism, even during their preclinical years. Role models included classroom faculty and peers, in addition to physicians in clinical settings. Small-group discussions and lectures helped some students identify and analyze the professional behaviors they observed, but they elicited negative responses from others. Students believed their professionalism derived from values, upbringing, and experiences prior to medical school. Some students reflected on their evolving professionalism while working directly with patients. CONCLUSIONS: Medical schools should ensure that students are exposed to excellent role models-ideally, faculty who can articulate the ideals of professionalism and work with students longitudinally in clinical settings. Lectures about professionalism may alienate rather than inspire students. Students' premedical experiences and values influencing professionalism should be acknowledged and appreciated. Bedside teaching and reflection on students' inner experience as they begin to work directly with patients deserve further exploration as opportunities to teach professionalism.

Impact of a pre-clinical clinical skills curriculum on student performance in third-year clerkships.

BACKGROUND: Research on the outcomes of pre-clinical curricula for clinical skills development is needed to assess their influence on medical student performance in clerkships. OBJECTIVE: To better understand the impact of a clinical-skills curriculum in the pre-clinical setting on student performance. DESIGN: We conducted a non-randomized, retrospective, pre-post review of student performance evaluations from 3rd-year clerkships, before and after implementation of a clinical-skills curriculum, the Colleges (2001-2007). MAIN RESULTS: Comparisons of clerkship performance data revealed statistically significant differences favoring the post-Colleges group in the Internal Medicine clerkship for 9 of 12 clinical-skills domains, including Technical Communication Skills (p < 0.023, effect size 0.16), Procedural Skills (p < 0.031, effect size 0.17), Communication Skills (p < 0.003, effect size 0.21), Patient Relationships (p < 0.003, effect size 0.21), Professional Relationships (p < 0.021, effect size 0.17), Educational Attitudes (p < 0.001, effect size 0.24), Initiative and Interest (p < 0.032, effect size 0.15), Attendance and Participation (p < 0.007, effect size 0.19), and Dependability (p < 0.008, effect size 0.19). Statistically significant differences were identified favoring the post-Colleges group in technical communication skills for three of six basic clerkships (Internal Medicine, Surgery, and Pediatrics). CONCLUSIONS: Implementation of a pre-clinical fundamental skills curriculum appears to be associated with improved clerkship performance in the 3rd year of medical school, particularly in the Internal Medicine clerkship. Similar curricula, focused on teaching clinical skills in small groups at the bedside with personalized mentoring from faculty members, may improve student performance. Continued efforts are needed to understand how to best prepare students for clinical clerkships and how to evaluate outcomes of similar pre-clinical skills programs.

Abandonment at the end of life from patient, caregiver, nurse, and physician perspectives: loss of continuity and lack of closure.

BACKGROUND: Surveys and anecdotes suggest that patients and family members sometimes feel abandoned by their physicians at the transition to end-of-life care. To our knowledge, no prior studies describe abandonment prospectively. METHODS: We conducted a longitudinal, qualitative study of patients, family caregivers, physicians, and nurses using a community-based sample. Using a purposive strategy, we recruited 31 physicians who identified 55 patients with incurable cancer or advanced chronic obstructive pulmonary disease, 36 family caregivers, and 25 nurses. Eligible patients met the prognostic criterion that their physician "would not be surprised" if death occurred within a year. Qualitative, semistructured interviews were performed at enrollment, 4 to 6 months, and 12 months and were audiotaped, transcribed, and coded by an interdisciplinary team. When asked to talk about hope and prognostic information, participants spontaneously raised concerns about abandonment, and we incorporated this topic into our interview guide. RESULTS: Two themes were identified: before death, abandonment worries related to loss of continuity between patient and physician; at the time of death or after, feelings of abandonment resulted from lack of closure for patients and families. Physicians reported lack of closure but did not discuss this as abandonment. CONCLUSIONS: The professional value of nonabandonment at the end of life consists of 2 different elements: (1) providing continuity, of both expertise and the patient-physician relationship; and (2) facilitating closure of an important therapeutic relationship. Framing this professional value as continuity and closure could promote the development of interventions to improve this aspect of end-of-life care.

Lexicon creation to promote faculty development in medical communication.

OBJECTIVE: Most medical educators have little or no training in teaching and assessing medical communication, and they are not consistent in what they teach. The authors set out to reach consensus in our educational community on a lexicon of communication terms for use in teaching physician-patient communication skills to second-year medical students. METHODS: An interdisciplinary medical school physician-patient communication committee assembled 23 important terms and agreed on definitions for each term. Thirty core preclinical faculty representing nine medical specialties reviewed the lexicon. Faculty were surveyed about lexicon definitions, barriers to use, and methods of using during educational encounters. RESULTS: All preclinical faculty members agreed on 19 out of 23 definitions and most respondents agreed on the definitions of the remaining four terms. Sixty-nine percent of respondents said they used the terms during their teaching encounters. CONCLUSION: Implementing a process to create a shared language around physician-patient communication may help unify and enhance faculty educational efforts. We were able to establish that medical educators can agree on the content of a medical communication lexicon for use with students. The use of defined and consistently used terms in multiple venues may reduce ambiguity, standardize teaching, enhance recognition of communication skills, and promote effective reinforcement and remediation by faculty. PRACTICE IMPLICATIONS: Evidence suggests that most medical educators have little or no training in teaching and assessing medical communication and that they are not consistent in what they teach. Asking a community of faculty to share responsibility for creating a communication lexicon may be an efficient and effective way to educate faculty and unify their educational effort.

Responding to families' questions about the meaning of physical movements in critically ill patients.

BACKGROUND: Families may have questions about the meaning of physical movement in critically ill patients for whom movements are likely involuntary. If unresolved, these questions may contribute to difficult communication around end-of-life care. This study used qualitative methods to describe physicians' responses to families' questions about the meaning of patients' movements in critically ill patients. METHODS: Fifty-one family conferences in which withdrawal of life support or discussion of bad news was addressed were audiotaped and analyzed with a limited application of grounded theory techniques. Patients were identified from intensive care units in 4 Seattle area hospitals. Two hundred twenty-seven family members and 36 physicians participated in the study. RESULTS: Family members' questions indicating lack of resolution about the meaning of patients' movements that were likely involuntary occurred in 6 (12%) of the 51 conferences. Physicians used 3 approaches to respond to the following questions: (1) providing clinical information, (2) acknowledging families' emotions, and (3) exploring the meaning of families' emotions. Physicians were most likely to provide clinical information in these situations and infrequently explored the meaning of families' emotions. CONCLUSIONS: Physicians' responses to family questions indicating lack of resolution about the meaning of patients' movements that were likely involuntary can be categorized into 3 types. Physicians may be better able to respond to and resolve these questions by using all 3 types of communication approaches. Future studies should determine if such responses can improve families' experiences and other outcomes.

Transitions regarding palliative and end-of-life care in severe chronic obstructive pulmonary disease or advanced cancer: themes identified by patients, families, and clinicians.

BACKGROUND: Classic trajectories of illness at end of life (EOL) suggest different care needs for patients with cancer versus chronic obstructive pulmonary disease (COPD) and may lead to different experiences of transitions over the course of a life-limiting illness. Patients may experience transitions in different ways than clinicians. No prior studies have examined this issue from patients', families', and clinicians' perspectives. OBJECTIVES: We sought to explore transitions, defined as experiences that patients and family members viewed as milestones in the evolution of their illnesses and therapies, and compare these perceptions with the perspectives of the patient's physician and nurse to provide insights about communication concerning EOL care. METHODS: We conducted a qualitative study using grounded theory to examine participants' perspectives on the experiences of key transitions in the context of living with advanced COPD or cancer. In-depth interviews with patients, family members, nurses, and physicians were conducted by experienced interviewers. RESULTS: Six themes were identified regarding participants' experiences with transitions. Themes that defined transitions among both patients with COPD and those with cancer included: new or different treatments and no more treatments available. Themes unique to patients with COPD were activity limitations due to functional decline and initiation of oxygen therapy. One theme unique to clinicians was acute exacerbation of illness or hospitalization. CONCLUSIONS: This study identified differences in the meaning of transitions for patients versus clinicians and for patients with COPD versus those with cancer. These findings may offer clinicians the opportunity to provide a more patient-centered approach to communication about end-of-life care by acknowledging and addressing transitions in palliative care from the perspective of the patient and family.

An approach to understanding the interaction of hope and desire for explicit prognostic information among individuals with severe chronic obstructive pulmonary disease or advanced cancer.

BACKGROUND: Physicians often report that they are reluctant to discuss prognosis for life-threatening illnesses with patients and family out of concern for destroying their hope, yet there is little empirical research describing how patients and family incorporate their needs for hope with desires for prognostic information. OBJECTIVE: We conducted a qualitative study to examine the perspectives of patients, family, physicians, and nurses on the simultaneous need for supporting hope and discussing prognosis. METHODS: We conducted in-depth longitudinal qualitative interviews with patients with either advanced cancer or severe chronic obstructive pulmonary disease (COPD), along with their family, physicians, and nurses. We used principles of grounded theory to analyze the transcripts and evaluated a conceptual model with four diagrams depicting different types of approaches to hope and prognostic information. RESULTS: We interviewed 55 patients, 36 family members, 31 physicians, and 25 nurses representing 220 hours of interviews. Asking patients directly "how much information" they wanted was, by itself, not useful for identifying information needs, but in-depth questioning identified variability in patients' and family members' desires for explicit prognostic information. All but 2 patients endorsed at least one of the diagrams concerning the interaction of hope and prognostic information and some patients described moving from one diagram to another over the course of their illness. Respondents also described two different approaches to communication about prognosis based on the diagram selected: two of the four diagrams suggested a direct approach and the other two suggested a cautious, indirect approach. CONCLUSIONS: This study found important variability in the ways different patients with life-limiting illnesses approach the interaction of wanting support for hope and prognostic information from their clinicians. The four-diagram approach may help clinicians understand individual patients and families, but further research is needed to determine the utility of these diagrams for improving communication about end-of-life care.

Meeting physicians' responsibilities in providing end-of-life care.

Despite many clinical examples of exemplary end-of-life care, a number of studies highlight significant shortcomings in the quality of end-of-life care that the majority of patients receive. In part, this stems from inconsistencies in training and supporting clinicians in delivering end-of-life care. This review describes the responsibilities of pulmonary and critical care physicians in providing end-of-life care to patients and their families. While many responsibilities are common to all physicians who care for patients with life-limiting illness, some issues are particularly relevant to pulmonary and critical care physicians. These issues include prognostication and decision making about goals of care, challenges and approaches to communicating with patients and their family, the role of interdisciplinary collaboration, principles and practice of withholding and withdrawing life-sustaining measures, and cultural competency in end-of-life care.

Prognostication during physician-family discussions about limiting life support in intensive care units.

OBJECTIVE: Prognostic information is important to the family members of incapacitated, critically ill patients, yet little is known about what prognostic information physicians provide. Our objectives were to determine the types of prognostic information provided to families of critically ill patients when making major end-of-life treatment decisions and to identify factors associated with more physician prognostication. DESIGN: Multiple-center, cross-sectional study. SETTING: ICUs of four hospitals. SUBJECTS: Thirty-five physicians, 51 patients, and 169 family members. INTERVENTIONS: We audiotaped 51 physician-family conferences in which there were deliberations about major end-of-life treatment decisions at four hospitals in 2000-2002. Conferences were coded to identify the types of prognostic information provided by physicians. We used a mixed-effects regression model to identify factors associated with more prognostication by physicians. MEASUREMENTS AND MAIN RESULTS: The mean number of prognostic statements per conference was 9.4+/-6.4 (range 0-29). Eighty-six percent of conferences contained discussion of the patient's anticipated functional status or quality of life, compared with 63% in which the chances for survival were discussed (p=.01). There were significantly more statements about prognosis for functional outcomes per conference compared with statements about prognosis for survival (median 4 [interquartile range 2-8] vs. 1 [interquartile range 0-3]; p<.001). Increasing educational level of the family was independently associated with more prognostic statements by physicians (p<.001) as was the degree of physician-family conflict about withdrawing life support (p<.001) and the physician's race being white (p=.009). CONCLUSIONS: Prognostication occurred frequently during physician-family deliberations about whether to forego life support, but physicians did not discuss the patient's prognosis for survival in more than one third of conferences. Less educated families received less information about prognosis. Future studies should address whether these observations partially explain the high prevalence of family misunderstandings about prognosis in intensive care units.

Competing professionalism values among community-based family physicians.

BACKGROUND: Professionalism has received considerable attention in recent years, mostly within academic settings. Little attention has been given to the perspectives of practicing physicians on professionalism. This study was designed to determine whether prevailing definitions of and guidelines for professionalism accurately reflect the perspectives and experiences of practicing community-based family physicians. METHOD: Eighteen practicing family physicians in Seattle were recruited from nonacademic settings to participate in focus groups during 2003. Transcripts were analyzed for content themes related to professionalism. RESULTS: Analysis revealed several tensions among values that the physician participants described balancing in their practices. Balancing organizational expectations and individual physician or patient values was a major source of tension. CONCLUSIONS: Practicing family physicians describe various tensions as they attempt to balance their own values with competing values of their patients, the organizations for which many work, and stated values of their profession. Such tensions among values have seldom been described in past literature and should be considered in designing medical curricula at all levels.