Antoinette S. Peters

Long-term outcomes of the New Pathway Program at Harvard Medical School: a randomized controlled trial.

Purpose To evaluate the long-term effects of an innovative curriculum, the New Pathway (NP) Program, on behaviors and attitudes related to humanistic medicine, lifelong learning, and social learning. Method Long-term follow-up of Harvard Medical School students who participated in a randomized controlled trial. Descriptive study using 1998 telephone interviews of 100 1989 and 1990 graduates (50 who had studied the NP curriculum, 50 who had studied the traditional curriculum). The NP Program consisted of problem-based learning tutorials, with coordinated lectures, labs, experiences in humanistic medicine, and clinical experiences; the traditional program consisted of basic science lectures and labs. Results Of 22 measures on the survey, NP and traditional students differed significantly on only five (three humanism; two social learning): 40% of NP students and 18% of traditional students went on to practice primary care or psychiatry. NP students rated their preparation to practice humanistic medicine higher than did traditional students and expressed more confidence in their ability to manage patients with psychosocial problems. NP students were more likely than were traditional students to believe that faculty from the first two years continued to influence their thinking. NP students liked the pedagogic approaches of their program more than traditional students did. There was no difference between the groups on measures of lifelong learning. Conclusions Differences between NP and traditional students in the humanism domain first appeared during medical school and residency and remained significant well into practice, suggesting that humanistic medicine can be taught and learned.

Teaching and learning end-of-life care: evaluation of a faculty development program in palliative care.

Purpose To evaluate the effectiveness of the Program in Palliative Care Education and Practice (PCEP), an intensive faculty development program at Harvard Medical School. Method PCEP is a two-week program offered annually with two on-site sessions in Boston, MA, and an interim period distance-learning component. Training integrates palliative care clinical skill development, learning theory and teaching methods, and leadership and organizational change. Longitudinal surveys (preprogram, retrospective preprogram, and postprogram) of participants from 2000–03 assessed self-reported preparation in providing and teaching palliative care; teaching and patient care practices; and satisfaction with program. Results The response rate was 96% (n = 149) for Session I and 72% for both Session I and II (n = 113). Questionnaire responses demonstrated statistically significant improvements with large effect sizes (range 0.7–1.8) on nearly all measures. Preparation increased from 3.0 ± 1.1 to 4.2 ± 0.7 for providing end-of-life care (1 = not well prepared, 5 = very well prepared), and from 2.6 ± 1.0 to 4.3 ± 0.7 for teaching this topic. Respondents reported behavioral changes in patient care and teaching; e.g., after the program, 63% noted that, specifically as a result of attending the course, they encouraged learners to reflect on their emotional responses to dying patients, and 57% conducted experiential exercises (e.g., role-play). Eighty-two percent rated the experience as “transformative,” and many responses to open-ended items described powerful learning experiences. Participants rated the program highly (4.9 ± 0.1, 1 = lowest, 5 = highest rating). Conclusions Integrating clinical content with learning about educational methods is an efficient and effective approach to enhancing clinical faculty’s capacity to model and teach clinical care. This program offers an educational model that engages practitioners, stimulates changes in practice, and offers opportunities for reflection and professional revitalization.

Variation in predictors of primary care career choice by year and stage of training

CONTEXT: It is not known whether factors associated with primary care career choice affect trainees differently at different times or stages of medical education.OBJECTIVE: To examine how role models, encouragement, and personal characteristics affect career choice at different stages (medical school vs residency) and periods (1994 vs 1997) of training.DESIGN: A split-panel design with 2 cross-sectional telephone surveys and a panel survey in 1994 and 1997.PARTICIPANTS: A national probability sample of fourth-year students (307 in 1994, 219 in 1997), 645 second-year residents in 1994, and 494 third-year residents in 1997. Of the fourth-year students interviewed in 1994, 241 (78.5%) were reinterviewed as third-year residents in 1997.MAIN OUTCOME MEASURE: Primary care (general internal medicine, general pediatrics, or family medicine) career choice.RESULTS: Having a primary care role model was a stronger predictor of primary care career choice for residents (odds ratio [OR], 18.0; 95% confidence interval [95% CI], 11.2 to 28.8 in 1994; OR, 43.7; 95% CI, 24.4 to 78.3 in 1997) than for students (OR, 6.5; 95% CI, 4.3 to 10.2; no variation by year). Likewise, peer encouragement was more predictive for residents (OR, 5.4; 95% CI, 3.3 to 8.9 in 1994; OR, 16.6; 95% CI; 9.7 to 28.4 in 1997) than for students (OR, 2.1; 95% CI, 1.3 to 3.2; no variation by year). Orientation to the emotional aspects of care was consistently associated with primary care career choice across stages and years of training.CONCLUSIONS: The effect of peer encouragement and role models on career choice differed for students and residents and, in the case of residents, by year of training, suggesting that interventions to increase the primary care workforce should be tailored to stage of training.

A Self-instructional Model to Teach Systems-based Practice and Practice-based Learning and Improvement

BackgroundWhen mandated as resident competencies in 1999, systems-based practice (SBP) and practice-based learning and improvement (PBLI) were new concepts to many.ObjectiveTo describe and evaluate a 4-week clinical elective (Achieving Competence Today—ACT) to teach residents SBP and PBLI.DesignACT consisted of a four-week active learning course and follow-up teaching experience, guided and supported by web-based materials. The curriculum included readings, scheduled activities, work products including an improvement project, and weekly meetings with a non-expert preceptor. The evaluation used a before–after cross-comparison of ACT residents and their peers.ParticipantsSeventy-eight residents and 42 faculty in 18 US Internal Medicine residency programs participated between 2003 and 2005.Results and Main MeasurementsAll residents and faculty preceptors responded to a knowledge test, survey of attitudes, and self-assessment of competency to do 15 tasks related to SBP/PBLI. All measures were normalized to a 100-point scale. Each program’s principal investigator (PI) identified aspects of ACT that were most and least effective in enhancing resident learning. ACT residents’ gains in knowledge (4.4 on a 100-point scale) and self-assessed competency (11.3) were greater than controls’ (−1.9, −8.0), but changes in attitudes were not significantly different. Faculty preceptors’ knowledge scores did not change, but their attitudes became more positive (15.8). PIs found a ready-to-use curriculum effective (rated 8.5 on a 10-point scale).ConclusionsACT increased residents’ knowledge and self-assessment of their own competency and raised faculty’s assessment of the importance of residents’ learning SBP/PBLI. Faculty content expertise is not required for residents to learn SBP/PBLI.

Creating enduring change

BACKGROUND: Improved educational and evaluation methods are needed in continuing professional development programs.OBJECTIVE: To evaluate the long-term impact of a faculty development program in palliative care education and practice.DESIGN: Longitudinal self-report surveys administered from April 2000 to April 2005.PARTICIPANTS: Physician and nurse educators from North America and Europe. All program graduates (n=156) were invited to participate.INTERVENTION: Two-week program offered annually (2000 to 2003) with 2 on-site sessions and 6-month distance-learning period. Learner-centered training addressed teaching methods, clinical skill development, and organizational and professional development.MEASURES: Self-administered survey items assessing behaviors and attitudes related to palliative care teaching, clinical care, and organizational and professional development at pre-, postprogram, and long-term (6, 12, or 18 months) follow-up.RESULTS: Response rates: 96% (n=149) preprogram, 73% (n=114) follow-up. Participants reported increases in: time spent in palliative care practice (38% preprogram, 47% follow-up,P<.01); use of learner-centered teaching approaches (sum of 8 approaches used “a lot”: preprogram 0.7 ± 1.1, follow-up 3.1 ± 2.0,P<.0001); and palliative care topics taught (sum of 11 topics taught “a lot”: preprogram 1.6 ± 2.0, follow-up 4.9 ± 2.9,P<.0001). Reported clinical practices in psychosocial dimensions of care improved (e.g., assessed psychosocial needs of patient who most recently died: 68% preprogram, 85% follow-up,P=.01). Nearly all (90%) reported launching palliative care initiatives, and attributed their success to program participation. Respondents reported major improvements in confidence, commitment to palliative care, and enthusiasm for teaching. Eighty-two percent reported the experience as “transformative.”CONCLUSIONS: This evidence of enduring change provides support for the potential of this educational model to have measurable impact on practices and professional development of physician and nurse educators.

The effect of medical student teaching on patient satisfaction in a managed care setting.

OBJECTIVE: To measure the effect on patient satisfaction of medical student participation in care and the presence of medical student teaching.DESIGN: Prospective cohort study.SETTING: Eight outpatient internal medicine departments of a university-affiliated HMO in Massachusetts.PATIENTS: Two hundred seven patients seen on teaching days (81 patients who saw a medical student-preceptor dyad and 126 patients who saw the preceptor alone), and 360 patients who saw the preceptor on nonteaching days. Five hundred (88%) of 567 eligible patients responded.MEASUREMENTS AND MAIN RESULTS: Thirteen closed-response items on a written questionnaire, measuring satisfaction with specific dimensions of care and with care as a whole. Visit satisfaction was similar among patients on teaching and nonteaching days. Ninety-one percent of patients seeing a medical student, 93% of patients seeing the preceptor alone on teaching days, and 93% of patients on nonteaching days were satisfied or very satisfied with their visit; less than 2% of patients in each group were dissatisfied with their visit. Satisfaction on all measured dimensions of care was similar for patients seeing a medical student, patients seeing the preceptor alone on teaching days, and patients seeing the preceptor on nonteaching days.CONCLUSIONS: Medical student participation and the presence of medical student teaching had little effect on patient satisfaction. Concerns about patient satisfaction should not prevent managed care organizations from participating in primary care education.

50 years of publication in the field of medical education

Background: The advent of new medical education (ME) journals makes evident the growth of the field of ME. However, the nature and context of growth is undefined. Aim: To analyze the evolution of publication in ME. Methods: MEDLINE retrieval using medical subject headings was used to analyze patterns of ME publications from 1960–2010: changes in number of ME publications; number of journals publishing ME articles; co-topics occurring frequently in ME articles; differences among journals’ publication of co-topics. Results: Annual publication of ME articles increased from 279 in 1960 to 3760 in 2010. 81 531 articles were published in 4208 different journals. 104 journals published ME articles in 1960, 855 in 2010. Despite an increase in journals in all fields, ME journals now account for a larger proportion of all journals indexed in MEDLINE than in 1960. One-quarter of all ME articles were indexed as internship/residency; 16% as graduate ME; 15% as undergraduate ME; and 14% as continuing ME. The five journals that published the most ME articles distinguished themselves by publishing some topics with greater or less frequency. Conclusions: The increase in the number of ME publications and in the number of journals publishing ME articles suggests a supportive environment for a growing field; but variation in journals’ foci has implications for readers, editors and authors.

Evaluation of a faculty development program in managing care.

PURPOSE To evaluate a faculty development program that teaches quality improvement and cost—effectiveness. METHOD From October 2000 to February 2001, a two-part faculty development program was offered to 39 physicians from 19 U.S. medical schools supported by grants from the Partnerships for Quality Education (PQE) and Undergraduate Medical Education in the 21st Century (UME-21). Special features of the program included partnerships between academic and community physicians from each school, development of an educational innovation of interest to the participants, concurrent development of teaching skills and new medical knowledge, learning leadership skills (e.g., how to train colleagues to teach), and practice periods. The program focused on quality improvement and cost—effectiveness, but included other “managing care” topics. Prior to and after the course, participants assessed their knowledge of and competence to teach these topics, as well as other managing care topics. They also assessed their competence as medical educators and leaders. After the course, they indicated their progress in implementing their proposed educational innovations. RESULTS Thirty-two of the 39 physicians completed evaluations both before and after the program. Self-assessed knowledge and competence to teach quality improvement and cost—effectiveness were significantly higher at the end of the course, as were all self-assessed teaching and leadership skills. The largest change scores occurred in assessments of competency to teach the new topics and to teach in new ways. Participants who implemented their innovations rated their competencies to teach quality improvement and cost—effectiveness higher than did non—implementers. CONCLUSION Opportunities for faculty to learn how to teach a topic of stated importance to them, to practice what they have learned, and to work collaboratively with partners improved teaching skills.

How important is money as a reward for teaching

Purpose To examine the effect of increases in payment for teaching on retention of primary care faculty, and to compare those faculty members’ needs and rewards for teaching with objective data on retention. Method In 2006–2007, the authors compared retention rates of primary care clerkship preceptors at Harvard Medical School (1997–2006) when their stipends were raised from

Cooperative learning: a new application of problem-based learning in mental health training

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