Listening with a narrative ear: Insights from a study of fall stories in older adults.

OBJECTIVE: To determine the value of adding a patient narrative to the clinical assessment of falls in the elderly. DESIGN: Qualitative study of interviews. SETTING: A fall prevention clinic in Calgary, Alta. PARTICIPANTS: Fifteen older adults on a wait list for assessment by the fall clinic and the physiotherapists who assessed them. METHODS: Participants' stories were audiorecorded and later transcribed and summarized. Stories were collected using open-ended questions, first inviting participants to tell the interviewer about themselves, and then the circumstances of their falls and their reflections on them. In a subsequent visit, transcriptions or summaries were returned to patients for member checking. Narratives were read and analyzed by all 4 investigators using a narrative approach and a close-reading technique. With the patients' additional consent, stories were shared with the fall prevention team for their insights and reactions. Interviews with physiotherapists were audiorecorded and transcribed. MAIN FINDINGS: The narrative analysis provided new insights into the attitudes about and perceptions of the causes of falls, their effects, and rehabilitation. Close reading exposed presentation of self, locus of control, and underlying social and emotional issues. CONCLUSION: The addition of patient narratives to clinical assessments offers clinicians an understanding of patients' perspectives, which can be used to better engage patients in rehabilitation.

Using visual art and collaborative reflection to explore medical attitudes toward vulnerable persons.

BACKGROUND: Vulnerable persons often face stigma-related barriers while seeking health care. Innovative education and professional development methods are needed to help change this. METHOD: We describe an interdisciplinary group workshop designed around a discomfiting oil portrait, intended to trigger provocative conversations among health care students and practitioners, and we present our mixed methods analysis of participant reflections. RESULTS: After the workshop, participants were significantly more likely to endorse the statements that the observation and interpretive skills involved in viewing visual art are relevant to patient care and that visual art should be used in medical education to improve students' observational skills, narrative skills, and empathy with their patients. Subsequent to the workshop, significantly more participants agreed that art interpretation should be required curriculum for health care students. Qualitative comments from two groups from two different education and professional contexts were examined for themes; conversations focused on issues of power, body image/self-esteem, and lessons for clinical practice. CONCLUSIONS: We argue that difficult conversations about affective responses to vulnerable persons are possible in a collaborative context using well-chosen works of visual art that can stand in for a patient.

Assessing outcomes through congruence of course objectives and reflective work.

INTRODUCTION: Course outcomes have been assessed by examining the congruence between statements of commitment to change (CTCs) and course objectives. Other forms of postcourse reflective exercises (for example, impact and unmet-needs statements) have not been examined for congruence with course objectives or their utility in assessing course outcomes. This study assessed the congruence of course objectives and statements of commitment to change, effects on practice, unmet-needs, and the utility of supplementing CTCs with other forms of reflective work in course evaluations. METHODS: A 3-module course on Alzheimer's disease and other dementias provided end-of-course CTC statements, follow-up data, and statements of effects on practice and unmet needs. Statements were aligned to module objectives and analyzed descriptively. RESULTS: Of the 932 physicians who registered for 1 of the 3 modules, 404 provided CTCs, 302 provided impact statements, and 265 provided unmet-needs statements. Sixty percent of the CTCs could be assigned to an objective for their module, and between 14% and 25% of CTCs were assigned to objectives for another module. Three-quarters of CTCs were fully or partially implemented. Physicians did not have an opportunity to implement the new content in 70% of nonimplemented CTCs. Fewer impact and unmet-needs statements were congruent with course objectives than CTCs. CONCLUSIONS: Commitment-to-change statements had more congruence with objectives than did impact or unmet-needs statements. These latter statements, particularly those that could not be assigned to an objective, may reinforce and supplement the information provided by CTC analyses.

The use of the opinion leader in continuing medical education.

This paper describes a process evaluation of an opinion leader (OL) project for a geriatric medical education program in dementia. Structured interviews with OLs were conducted to understand their experience as formal OLs from their initial training to the project's completion. Thirteen of 15 physicians involved in an OL project were interviewed. The adoption of a formal educational OL role was not an easy transition for most identified OLs. Some physicians struggled with the role and would have preferred more specific guidance. For this subject some content expertise was felt to be essential. Strong project leadership and some measures of success are important to sustain the OL commitment to a project. More attention needs to be devoted to the appropriate selection and training of OLs for educational projects to ensure that they have the relevant clinical expertise and skills to be effective and feel comfortable adopting a formal OL role.