Anne Mounsey

Do students develop better motivational interviewing skills through role-play with standardised patients or with student colleagues?

Objective  Smoking is the leading cause of preventable death in the USA and reducing the number of smokers by 50% is among the goals of the Healthy People 2010 initiative. Despite its importance, few medical students receive formal training in smoking cessation counselling. Motivational interviewing is a patient‐centred, but directive, method of counselling that has been found to be more effective than giving brief advice for motivating smokers to quit. We wanted to determine whether using standardised patients to teach this skill to Year 3 medical students would be more effective than using student role‐plays.

Teaching students behavior change skills: description and assessment of a new Motivational interviewing curriculum

Background: One of the US government health goals outlined in the Healthy People 2010 document (2000) is to increase the number of physicians who counsel their patients regarding unhealthy behaviors. Studies have shown a low rate of physicians provide smoking cessation counseling. We introduced a motivational interviewing curriculum into our medical school for first and third year students and then evaluated the effect of this curriculum on third year students counseling skills. Methods: The motivational interviewing curriculum was comprised of a lecture series and small group teaching with practice in role plays. The effectiveness of the curriculum was evaluated by student performance in a videotaped interview with a standardized patient who portrayed a smoker. The interview was rated using the Motivational Interviewing Treatment Integrity scoring tool (MITI). The MITI assesses 6 criteria: empathy, MI spirit (autonomy, evocation and collaboration), MI adherence (asking permission, affirmation, emphasis of control and support), MI non adherence (advise, confront and direct), the types of questions (open or closed) and the number of reflections. Secondary outcomes included a knowledge exam related to motivational interviewing and students’ evaluations of the effectiveness of the motivational interviewing curriculum. Results: Analysis of the MITI scores showed that students reached a proficiency level on the rate of reflections, were just below proficiency in assessment of empathy and motivational interviewing spirit and substantially below proficiency in the percent of open ended questions. These proficiency scores were for professional counselors but nevertheless provided us with information on the effectiveness of the new curriculum and where the focus of our teaching should be. On the optional evaluation of the first-year MI curriculum by 112 students, 83% felt that the MI curriculum had helped them be more comfortable in discussing behavior change with patients and 98% felt it was an important skill for physicians to have.

A randomized controlled trial of two different types of web-based instructional methods: one with case-based scenarios and one without.

Background: Computer-based learning (CBL) is an effective form of medical education. Educators have developed recommendations for instructional design but there is only minimal research that evaluates these recommendations. Aim: To evaluate the effect of case-based questions contained in computer modules on learning efficacy. Methods: The authors conducted a randomized controlled trial in 124 medical students of two CBL PowerPoint modules-based on Medicare. The modules were identical except one contained 11 case-based scenarios followed by multiple choice questions. The primary outcome measurement was a previously validated, 11-item knowledge test taken at the end of the module and at the end of the academic year to test retention. Results: The students who studied the module with case-based questions answered one more item correctly in the first test (8.9 vs. 10.00 correct answers, p = 0.001). This difference had disappeared by the time of the second test (4.2 vs. 4.7, p = 0.095). Conclusions: This study shows that computer modules with case-based questions enhance learning in the short-term but at the expense of increased time and so decreased learning efficiency. This learning benefit was not maintained.

Strongyloides as a Cause of Fever of Unknown Origin

Strongyloides is endemic in parts of the United States. Most often it is asymptomatic but it has a wide range of clinical presentations. Because of the unusual capacity of strongyloides for autoinfection, it can cause hyperinfection, when it effects the pulmonary and gastrointestinal systems, or disseminated infection, when other organs are involved. Both hyperinfection and disseminated strongyloides usually occur in immunosuppressed patients. We report a case of hyperinfection with strongyloides in a man presenting with fever of unknown origin who was not immunosuppressed.

Hepatitis C for Primary Care Physicians

Hepatitis C is a common cause of cirrhosis, hepatocellular carcinoma, and liver transplant. Although it is usually asymptomatic, new screening recommendations will lead to increased recognition by primary care physicians. Rapidly evolving treatment recommendations are making this a treatable infection for many patients. Recognition of the infection and initiation of treatment for appropriate patients will decrease the likelihood of progression to cirrhosis and hepatocellular carcinoma. Primary care physicians have the difficult task of managing comorbid conditions, such as chronic pain and hyperlipidemia, in patients with hepatitis C, as well as a potential for treating hepatitis C.

Molar pregnancy after tubal ligation in a patient with neuroendocrine tumour: when a rare condition coincides with an unexpected diagnosis

A 40-year-old woman with a history of bilateral tubal ligation and a recent diagnosis of metastatic neuroendocrine tumour in the liver presented with severe nausea, vomiting, diarrhoea and dehydration. She had an inconclusive urine pregnancy test in the emergency department that was followed by an extremely high serum β-human chorionic gonadotropin. Transvaginal ultrasound, MRI and subsequent pathology from a dilation and curettage (D&C) revealed that the patient had a complete molar pregnancy. This is a case of an unusual patient who reminds us that one person can have a rare diagnosis and an unexpected obstetrical outcome. We could find no evidence in the medical literature of a causal link between these two diagnoses but present this case report of a reproductive age woman with neuroendocrine tumour and complete molar pregnancy. This case also serves as an example of the phenomenon of the ‘hook effect.’