Amanda Kost

Socrates was not a pimp: changing the paradigm of questioning in medical education.

The slang term “pimping” is widely recognized by learners and educators in the clinical learning environment as the act of more senior members of the medical team publicly asking questions of more junior members. Although questioning as a pedagogical practice has many benefits, pimping, as described in the literature, evokes negative emotions in learners and leads to an environment that is not conducive to adult learning. Medical educators may employ pimping as a pedagogic technique because of beliefs that it is a Socratic teaching method. Although problems with pimping have previously been identified, no alternative techniques for questioning in the clinical environment were suggested. The authors posit that using the term “pimping” to describe questioning in medical education is harmful and unprofessional, and they propose clearly defining pimping as “questioning with the intent to shame or humiliate the learner to maintain the power hierarchy in medical education.” Explicitly separating pimping from the larger practice of questioning allows the authors to make three recommendations for improving questioning practices. First, educators should examine the purpose of each question they pose to learners. Second, they should apply historic and modern interpretations of Socratic teaching methods that promote critical thinking skills. Finally, they should consider adult learning theories to make concrete changes to their questioning practices. These changes can result in questioning that is more learner centered, aids in the acquisition of knowledge and skills, performs helpful formative and summative assessments of the learner, and improves community in the clinical learning environment.

Clinical Decisions Made in Primary Care Clinics Before and After Choosing Wisely

Background: The Choosing Wisely™ campaign encourages physicians to avoid low-value care. Although widely lauded, no study has examined its impact on clinical decisions made in primary care settings. Methods: We compared clinical decisions made for 5 Choosing Wisely recommendations over two 6-month time periods before and after the campaign launch and an educational intervention to promote it at 3 primary care residency clinics. Results: The rate of recommendations adherence was high (93.2%) at baseline but did significantly increase to 96.5% after the launch. These findings suggest primary care physicians respond to training and publicity in low-value care, though further research is needed. Conclusion: Given that even small decreases of physician test ordering can produce large cost savings, the Choosing Wisely project may help achieve the health care triple aim.

Primary care residency choice and participation in an extracurricular longitudinal medical school program to promote practice with medically underserved populations.

Purpose In 2006, the University of Washington School of Medicine (UWSOM) launched the Underserved Pathway (UP), an extracurricular longitudinal experience supporting student interest in caring for underserved populations. This study examined the association between UP participation and residency choice. Method The study population was 663 UWSOM graduates who matched to a residency from 2008 to 2011; 69 were UP participants. Outcomes included matching to primary care residencies (family medicine, internal medicine, pediatrics, or medicine–pediatrics). The authors calculated graduate rates and odds of UP participants versus nonparticipants matching to primary care residencies overall and to residencies in individual primary care specialties. This analysis included all graduates and 513 graduates who had dual interest in primary care and underserved care at matriculation. Of 336 graduates matching to primary care, the authors calculated rates of entering the individual specialties with respect to UP participation. Results UP participants matched at significantly higher rates than nonparticipants to primary care (72.5% versus 48.1%, adjusted odds ratio [OR] 2.2) and family medicine residencies (33.3% versus 15.0%, adjusted OR 2.9). Of graduates with dual matriculation interest in primary care and underserved care, 73.4% of participants versus 53.5% of nonparticipants matched to primary care (adjusted OR 1.9), and 31.2% of participants versus 18.0% of nonparticipants matched to family medicine (adjusted OR 2.1). Of primary care matched graduates, 46.0% of participants versus 31.1% of nonparticipants entered family medicine. Conclusions Supporting student interest in underserved careers is associated with higher rates of graduates entering primary care residencies, specifically family medicine.

The WWAMI Targeted Rural Underserved Track (TRUST) Program: An Innovative Response to Rural Physician Workforce Shortages.

PROBLEM Too few physicians practice in rural areas. To address the physician workforce needs of the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region, the University of Washington School of Medicine developed the Targeted Rural Underserved Track (TRUST) program in August 2008. TRUST is a four-year curriculum centered on a clinical longitudinal continuity experience with students repeatedly returning to a single site located in a rural community or small city. APPROACH The overarching theme of TRUST is one of linkages. Students are strategically linked to a rural community, known as their TRUST continuity community (TCC). The program begins with a targeted admission process and combines new and established programs and curricular elements to form a cohesive educational experience. This experience includes repeated preclinical visits, clerkships, and electives at a students TCC, and rural health courses, the Underserved Pathway, and the Rural Underserved Opportunities Program (which includes a community-oriented primary care scholarly project). OUTCOMES TRUST was piloted in Montana in 2008. With the matriculating class of 2015, every state in the WWAMI region will have TRUST students. From 2009 (the year targeted admissions began) to 2015, 123 students have been accepted into TRUST. Thirty-three students have graduated. Thirty (90.9%) of these graduates have entered residencies in needed regional specialties. NEXT STEPS Next steps include implementing a robust evaluation program, obtaining secure institutional programmatic funding, and further developing linkages with regional rural residency programs. TRUST may be a step forward in addressing regional needs and a reproducible model for other medical schools.

Seasonal Affective Disorder, Grief Reaction, and Adjustment Disorder

Seasonal affective disorder is a subtype of other affective disorders. The most studied treatment is light therapy, although second-generation antidepressants are also an option. Grief reactions are normal for patients experiencing loss, and primary care providers (PCPs) should be aware of both the expected course of grief and the more severe symptoms that indicate complex grief. Adjustment disorder is a time-limited abnormal response to a stressor. PCPs can manage patients with adjustment disorder by arranging counseling, screening for suicidality, assessing for substance abuse, and ruling out other psychiatric diagnoses. At present there are no reliable data to suggest medication management.

Building a Pipeline to Equity

The US health care system is full of broken promises. Education is supposed to be the great equalizer, yet for many students a medical education remains out of reach. Over 10 years ago the Association of American Medical Colleges looked at the economic diversity of medical students by parental

Response: Re: Clinical Decisions Made in Primary Care Clinics Before and After Choosing Wisely™

To the Editor: We thank Dr. Gladwell for his thoughtful comments regarding our article about the impact of the Choosing Wisely campaign on clinical decisions made in primary care clinics. As he notes, achieving value in health care is a critical component of improving our health care system. Thus it

The Underserved Pathway—Fostering Medical Student Interest in the Care of Vulnerable Populations

The Underserved Pathway at the University of Washington School of Medicine helps prepare future physicians to work with underserved populations by providing a foundation of practical knowledge and real-world experiences.