Direct correlation of radiologic and cadaveric structures in a gross anatomy course.

BACKGROUND: Radiologic imaging is increasingly utilized as supplemental material in preclinical gross anatomy courses, but few studies have investigated its utility as a fully integrated instructional tool. AIMS: Establish the benefit of a teaching method that simultaneously correlates cadaveric and radiologic structures for learning human anatomy. METHOD: We performed a mixed-methods randomized controlled trial and one-way cross-over study comparing exam grades and subjective student perception in a gross anatomy course. The intervention consisted of daily direct correlation small group sessions in which students simultaneously identified and correlated radiologic and cadaveric structures. The control method utilized identical laboratory and teaching conditions but students did not simultaneously correlate structures. Spatial relationships of structures within each respective media (gross or radiologic) were emphasized in both groups. RESULTS: No significant differences in radiology, gross, or written exam scores were observed between the intervention and control groups. The cross-over group preferred the intervention and control methods equally. The correlation teaching sessions ranked equally with active dissection as the most important instructional components of the course. CONCLUSION: Direct, simultaneous correlation of radiologic and cadaveric structures did not affect exam scores or student preference but helped students understand anatomical concepts in comparison with other course components.

Patient and provider determinants of nephrology referral in older adults with severe chronic kidney disease: a survey of provider decision making.

BACKGROUND: Although chronic kidney disease (CKD) disproportionately affects older adults, they are less likely to be referred to a nephrologist. Factors that influence the referral decisions of primary care providers (PCPs) specifically for older CKD patients have been incompletely described. Patient factors such as dementia, functional disability, and co-morbidity may complicate the decision to refer an older adult. This study evaluated the role of patient and PCP factors in the referral decisions for older adults with stage 4 CKD. METHODS: We administered a two-part survey to study the decisions of practicing PCPs. First, using a blocked factorial design, vignettes systematically varied 6 patient characteristics: age, race, gender, co-morbidity, functional status, and cognitive status. CKD severity, patient preferences, and degree of anemia were held constant. Second, covariates from a standard questionnaire included PCP estimates of life expectancy, demographics, reaction to clinical uncertainty, and risk aversion. The main outcome was the decision to refer to the nephrologist. Random effects logistic regression models tested independent associations of predictor variables with the referral decision. RESULTS: More than half (62.5%) of all PCP decisions (n = 680) were to refer to a nephrologist. Vignette-based factors that independently decreased referral included older patient age (OR = 0.27; 95% CI, 0.15 to 0.48) and having moderate dementia (OR = 0.14; 95%CI, 0.07 to 0.25). There were no associations between co-morbidity or impaired functional activity with the referral decision. Survey-based PCP factors that significantly increased the referral likelihood include female gender (OR = 7.75; 95%CI, 2.07 to 28.93), non-white race (OR = 30.29; 95%CI, 1.30 to 703.73), those who expect nephrologists to discuss goals of care (OR = 53.13; 95%CI, 2.42 to 1168.00), those with higher levels of anxiety about uncertainty (OR = 1.28; 95%CI, 1.04 to 1.57), and those with greater risk aversion (OR = 3.39; 95%CI, 1.02 to 11.24). CONCLUSIONS: In this decision making study using hypothetical clinical vignettes, we found that the PCP decision to refer older patients with severe CKD to a nephrologist reflects a complex interplay between patient and provider factors. Age, dementia, and several provider characteristics weighed more heavily than co-morbidity and functional status in PCP referral decisions. These results suggest that practice guidelines should develop a more nuanced approach to the referral of older adults with CKD.

The role of radiology in preclinical anatomy: a critical review of the past, present, and future.

RATIONALE AND OBJECTIVES: Radiology has been an increasingly important component of preclinical anatomy instruction since the 1960s. The global status of medical imaging pedagogies and radiologists' roles in medical anatomy education is not well established but is important in determining the specialty's contribution to undergraduate medical education. MATERIALS AND METHODS: PubMed was searched with various combinations of MeSH terms including "radiology," "undergraduate medical education," and "anatomy." Articles were reviewed for relevance, and referenced articles of possible relevance were hand-traced to ensure a wide capture of articles. RESULTS: Although more medical schools around the world are using medical imaging to teach anatomy, some regions, such as the United States, show a decline in the proportion of imaging taught by radiologists. Lectures, small group discussions, and self-instruction remain the mainstay of current pedagogies and have witnessed dramatic changes over the past few decades with respect to the types of imaging used. Newer pedagogies use contextual and hands-on experiences to improve spatial and application principles. Qualitative and quantitative studies report somewhat mixed results of pedagogical efficacies but demonstrate generally high acceptance by students and instructors and often significant exam score improvement. Radiology as a specialty must overcome several challenges for it to become more involved in anatomy education, including teaching incentives and protected academic time. CONCLUSIONS: As anatomy instruction and clinical medicine grow increasingly digital, it is ever more important that radiologists continue to develop new anatomy pedagogies and contribute to anatomy education in greater roles.

Driving deeper learning by assessment: an adaptation of the Revised Bloom's Taxonomy for medical imaging in gross anatomy.

RATIONALE AND OBJECTIVES: As medical imaging continues to grow as a central modality by which physicians of all specialties visualize anatomy, so, too, is its role in medical student education. However, no study to our knowledge has attempted to categorize the necessary cognitive skills. Here, we assess a tool to identify those skills and their possible hierarchical nature that reflects deeper understanding of radiological anatomy. MATERIALS AND METHODS: We adapted the revision of Bloom's Taxonomy of Educational Objectives to create examination questions and teaching points for normal radiological anatomy in a medical anatomy course in 2008. All six previously established levels of cognitive processes were adapted, ranging from Remembering to Create. Reliability and validity were assessed. RESULTS: Of 102 eligible students, 98 (98%) consented to participate, and 108 examination questions were assessed. Cronbach α assessing reliability ranged from poor (.197) to moderate (.571) with most categories being moderate. Score means for the levels of cognitive processes were statistically distinct [F(4, 102) = 180.63, P < .001] and tended to decrease as the level of cognitive process increased [Spearman ρ(5) = -.800, P = .104], consistent with a valid hierarchical structure. CONCLUSIONS: A radiological anatomy adaptation of the revised taxonomy demonstrated generally adequate reliability and acceptable validity to establish evaluations that test different depths of cognitive processes. This is a critical first step to create a fundamental curricular tool by which medical imaging education-both normal and pathological-may be taught and assessed in the future.

The minority student voice at one medical school: lessons for all?

PURPOSE: Although the minority population of the United States is projected to increase, the number of minority students in medical schools remains stagnant. The University of Chicago Pritzker School of Medicine (PSOM) matriculates students underrepresented in medicine (URM) above the national average. To identify potential strategies through which medical schools can support the success of URM medical students, interviews with URM students/graduates were conducted. METHOD: Students/recent graduates (within six years) who participated in this study self-identified as URMs in medicine and were selected for participation using random quota sampling. Participants completed a semistructured, qualitative interview in 2009-2010 about their experiences at PSOM. Key themes were identified and independently analyzed by investigators to ensure intercoder agreement. RESULTS: Participants identified five facets of their medical school experiences that either facilitated or hindered their academic success. Facilitators of support clustered in three categories: the collaborative learning climate at PSOM, the required health care disparities course, and student body diversity. Inhibitors of support clustered in two categories: insufficiently diverse faculty; and expectations-from self and others-to fulfill additional responsibilities, or carry a disproportionate burden. CONCLUSIONS: Intentional cultivation of a collaborative learning climate, formal inclusion of health care disparities curriculum, and commitment to fostering student body diversity are three routes by which PSOM has supported URM students. Additionally, recognizing the importance of building a diverse faculty and extending efforts to decrease the disproportionate burden and stereotype threat felt by URM students are institutional imperatives.

Improved understanding of human anatomy through self-guided radiological anatomy modules.

RATIONALE AND OBJECTIVE: To quantifiably measure the impact of self-instructed radiological anatomy modules on anatomy comprehension, demonstrated by radiology, gross, and written exams. MATERIALS AND METHODS: Study guides for independent use that emphasized structural relationships were created for use with two online radiology atlases. A guide was created for each module of the first year medical anatomy course and incorporated as an optional course component. A total of 93 of 96 eligible students participated. All exams were normalized to control for variances in exam difficulty and body region tested. An independent t-test was used to compare overall exam scores with respect to guide completion or incompletion. To account for aptitude differences between students, a paired t-test of each student's exam scores with and without completion of the associated guide was performed, thus allowing students to serve as their own controls. RESULTS: Twenty-one students completed no study guides; 22 completed all six guides; and 50 students completed between one and five guides. Aggregate comparisons of all students' exam scores showed significantly improved mean performance when guides were used (radiology, 57.8% [percentile] vs. 45.1%, P < .001; gross, 56.9% vs. 46.5%, P = .001; written, 57.8% vs. 50.2%, P = .011). Paired comparisons among students who completed between one and five guides demonstrated significantly higher mean practical exam scores when guides were used (radiology, 49.3% [percentile] vs. 36.0%, P = .001; gross, 51.5% vs. 40.4%, P = .005), but not higher written scores. CONCLUSIONS: Radiological anatomy study guides significantly improved anatomy comprehension on radiology, gross, and written exams.

The seventh element of quality: the doctor-patient relationship.

BACKGROUND AND OBJECTIVES: National experts have defined the elements of quality health care, but community-based physicians have not been systematically asked their opinions about quality. This study explored primary care clinicians' beliefs about the elements of quality care. METHODS: Responses from structured interviews with 12 primary care clinicians and open-ended comments in a subsequent survey of 85 clinicians, all employed by a large urban federally qualified community health center, were coded independently by two researchers and analyzed for major themes. After discovering that these themes resembled the six elements advanced by the Institute of Medicine, the data were recoded to identify additional perceptions about quality. RESULTS: Clinicians believe that the relationship with patients is a core element of quality health care. They also reconfirm the elements of quality advanced by the Institute of Medicine--safety, timeliness, effectiveness, efficiency, equity, and patient centeredness, with safety mentioned infrequently. The clinicians also emphasized preventive care. CONCLUSIONS: While primary care clinicians' beliefs about quality are generally consistent with experts' definitions, they emphasize relationships and rarely mention safety. Successful efforts to promote quality in primary care should be consistent with clinicians' beliefs about what constitutes high quality.