Calvin L. Chou

Characterizing the Patient-centeredness of Hidden Curricula in Medical Schools: Development and Validation of a New Measure

Purpose The “hidden curriculum” has a powerful influence in shaping medical students’ attitudes and behaviors toward patient care. The purpose of this project was to develop and test a tool (the C3 Instrument) to help educators characterize and understand the hidden curriculum at their own institutions. Method In 2000, the authors developed survey items to measure three content areas of the hidden curriculum with respect to patient-centered care. These content areas include role modeling, students’ patient-care experiences, and perceived support for students’ own patient-centered behaviors. The survey was distributed to third- and fourth-year students at ten medical schools in the United States. Using factor analysis, the authors selected items for the final version of the C3 Instrument. To examine validity, they compared instrument scores to results of a poll of members of two organizations devoted to teaching patient-centered care. Results A total of 890 students completed the survey. The mean age of students was 27 (SD 3). Fifty-two percent of students were women, and 70% were white. Twenty-nine items were selected for the C3 Instrument, with internal consistency measures ranging from .67 to .93 for instrument subdimensions. In the validation analysis, summary scores for all three content areas of the C3 Instrument were consistent with results of the poll of patient-centered organizations. Conclusion Despite some issues that still need to be resolved, the C3 Instrument proved to be a reliable and valid tool that characterizes a medical schools hidden curriculum with respect to patient-centered care. It can be used to guide educational interventions by addressing the context that exists around formal teaching activities. It also makes possible the study of hidden curricula across multiple medical schools. Further research on the hidden curriculum should be aimed at developing a greater understanding of the dynamics between formal teaching activities and school culture.

Not the same everywhere: Patient-centered learning environments at nine medical schools

BACKGROUND: Learning environments overtly or implicitly address patient-centered values and have been the focus of research for more than 40 years, often in studies about the “hidden curriculum.” However, many of these studies occurred at single medical schools and used time-intensive ethnographic methods. This field of inquiry lacks survey methods and information about how learning environments differ across medical schools.OBJECTIVE: To examine patient-centered characteristics of learning environments at 9 U.S. medical schools.DESIGN: Cross-sectional internet-based survey.PARTICIPANTS: Eight-hundred and twenty-three third- and fourth-year medical students in the classes of 2002 and 2003.MEASUREMENTS: We measured the patient-centeredness of learning environments with the Communication, Curriculum, and Culture (C3) Instrument, a 29-item validated measure that characterizes the degree to which a medical school’s environment fosters patient-centered care. The C3 Instrument contains 3 content areas (role modeling, students’ experiences, and support for students’ patient-centered behaviors), and is designed to measure these areas independent of respondents’ attitudes about patient-centered care. We also collected demographic and attitudinal information from respondents.RESULTS: The variability of C3 scores across schools in each of the 3 content areas of the instrument was striking and statistically significant (P values ranged from .001 to .004). In addition, the patterns of scores on the 3 content areas differed from school to school.CONCLUSIONS: The 9 schools demonstrated unique and different learning environments both in terms of magnitude and patterns of characteristics. Further multiinstitutional study of hidden curricula is needed to further establish the degree of variability that exists, and to assist educators in making informed choices about how to intervene at their own schools.

Surgery in the patient with liver disease

Management of the surgical patient with liver disease begins with a careful preoperative assessment (Fig. 1). Any clues to liver disease on history and physical examination should be investigated to ascertain the cause of the clinical finding. More data on surgical patients with unexpected liver disease are now available. Patients undergoing emergent surgery are at significant risk of developing liver dysfunction. Childs class still correlates strongly to postoperative complications. Cornerstones of perioperative management in these patients are medical treatment of complications of chronic liver disease, such as ascites; coagulopathy; prevention of encephalopathy; and rapid treatment of dangerous postoperative complications, such as acute acalculous cholecystitis. Evolving knowledge of the effects of anesthesia, improving surgical techniques, and use of better diagnostic tests will help in the reduction of perioperative complications in these patients.

Improving residents' interviewing skills by group videotape review.

OBJECTIVE Internal medicine residency training programs typically emphasize biomedical learning, but relatively few provide opportunities for residents to improve outpatient interviewing skills or to address challenging patient encounters. Even fewer programs provide resources to assess patient-resident relationship skills. To address these issues, we developed a curriculum that is designed to enhance patient-centered interviewing techniques in residents. DESCRIPTION At the UCSF-VA PRIME residency program, interns on ambulatory block attend three didactic sessions that introduce basic medical interviewing techniques, including elicitation of patient concerns and mutual agenda setting, biopsychosocial interviewing, and conflict resolution in the patient-physician relationship. These sessions are taught using role-play exercises and interactive, case-based discussions. Second- and third-year residents on ambulatory block participate in an ongoing small-group seminar in which they present videotapes of their interviews with patients. To make these tapes, residents arrange to see patients in a clinic room where a videotape recorder is mounted on the wall. Patients who consent to be videotaped complete a form stating that the tapes are to be used solely for educational purposes. Twice a year, each of our 16 residents selects one encounter that highlights personal learning goals related to interviewing and presents those learning goals with associated videotape clips in a 90-minute seminar. Each seminar is devoted to two residents, who facilitate a discussion of the effectiveness of the interview and solicit feedback about potential methods for improvement. DISCUSSION When the seminars were originally developed, we anticipated that this innovative combination of traditional individual videotape review with small-group learning would encourage self-directed learning. Indeed, over the last three years, residents have become more confident with their interviewing capabilities and less self-conscious about showing their own videotaped interviews. As a result, the seminars have unexpectedly evolved into a highly sophisticated series of learning modules, in which residents seek their most challenging patient encounters to videotape and show to the group. Residents have presented complicated scenarios involving critical patient-physician conflicts, somatizing patients, cross-cultural communication difficulties, overzealous family members, patients with substance abuse, and bad-news interviews. These dilemmas represent fundamental management challenges that are difficult to discuss in a more didactic format, and the immediate case-based nature of the interviews makes these often-emotional issues come alive. The group videotape reviews also give residents opportunities to reflect on their own interviewing encounters, to observe other interviewing styles and techniques, and to provide support to their fellow residents after particularly emotional interviews. An ancillary benefit of these exercises is that we have now developed a library of challenging interviews, which are easily accessible for further teaching seminars. Our residents consider this learning experience to be one of the most positive of their residency and valuable for their professional development. Residents report that this small-group seminar series has markedly improved their communication with patients, and they now clamor for the opportunity to present interviewing dilemmas. We believe that similar curricula can be readily instituted at other residency programs.

Caring attitudes in medical education: perceptions of deans and curriculum leaders.

BACKGROUNDSystems of undergraduate medical education and patient care can create barriers to fostering caring attitudes.OBJECTIVEThe aim of this study is to survey associate deans and curriculum leaders about teaching and assessment of caring attitudes in their medical schools.PARTICIPANTSThe participants of this study include 134 leaders of medical education in the USA and Canada.METHODSWe developed a survey with 26 quantitative questions and 1 open-ended question. In September to October 2005, the Association of American Medical Colleges distributed it electronically to curricular leaders. We used descriptive statistics to analyze quantitative data, and the constant comparison technique for qualitative analysis.RESULTSWe received 73 responses from 134 medical schools. Most respondents believed that their schools strongly emphasized caring attitudes. At the same time, 35% thought caring attitudes were emphasized less than scientific knowledge. Frequently used methods to teach caring attitudes included small-group discussion and didactics in the preclinical years, role modeling and mentoring in the clinical years, and skills training with feedback throughout all years. Barriers to fostering caring attitudes included time and productivity pressures and lack of faculty development. Respondents with supportive learning environments were more likely to screen applicants’ caring attitudes, encourage collaborative learning, give humanism awards to faculty, and provide faculty development that emphasized teaching of caring attitudes.CONCLUSIONSThe majority of educational leaders value caring attitudes, but overall, educational systems inconsistently foster them. Schools may facilitate caring learning environments by providing faculty development and support, by assessing students and applicants for caring attitudes, and by encouraging collaboration.

Predicting failing performance on a standardized patient clinical performance examination: the importance of communication and professionalism skills deficits.

Background The purpose is to determine which assessment measures identify medical students at risk of failing a clinical performance examination (CPX). Method Retrospective case-control, multiyear design, contingency table analysis, n = 149. Results We identified two predictors of CPX failure in patient–physician interaction skills: low clerkship ratings (odds ratio 1.79, P = .008) and student progress review for communication or professionalism concerns (odds ratio 2.64, P = .002). No assessments predicted CPX failure in clinical skills. Conclusions Performance concerns in communication and professionalism identify students at risk of failing the patient–physician interaction portion of a CPX. This correlation suggests that both faculty and standardized patients can detect noncognitive traits predictive of failing performance. Early identification of these students may allow for development of a structured supplemental curriculum with increased opportunities for practice and feedback. The lack of predictors in the clinical skills portion suggests limited faculty observation or feedback.

Clinical skills-related learning goals of senior medical students after performance feedback

Medical Education 2011: 45: 878–885

Teaching Feedback to First-year Medical Students: Long-term Skill Retention and Accuracy of Student Self-assessment

ABSTRACTBACKGROUNDGiving and receiving feedback are critical skills and should be taught early in the process of medical education, yet few studies discuss the effect of feedback curricula for first-year medical students.OBJECTIVESTo study short-term and long-term skills and attitudes of first-year medical students after a multidisciplinary feedback curriculum.DESIGNProspective pre- vs. post-course evaluation using mixed-methods data analysis.PARTICIPANTSFirst-year students at a public university medical school.INTERVENTIONSWe collected anonymous student feedback to faculty before, immediately after, and 8 months after the curriculum and classified comments by recommendation (reinforcing/corrective) and specificity (global/specific). Students also self-rated their comfort with and quality of feedback. We assessed changes in comments (skills) and self-rated abilities (attitudes) across the three time points.MEASUREMENTS AND MAIN RESULTSAcross the three time points, students’ evaluation contained more corrective specific comments per evaluation [pre-curriculum mean (SD) 0.48 (0.99); post-curriculum 1.20 (1.7); year-end 0.95 (1.5); p = 0.006]. Students reported increased skill and comfort in giving and receiving feedback and at providing constructive feedback (p < 0.001). However, the number of specific comments on year-end evaluations declined [pre 3.35 (2.0); post 3.49 (2.3); year-end 2.8 (2.1)]; p = 0.008], as did students’ self-rated ability to give specific comments.CONCLUSIONTeaching feedback to early medical students resulted in improved skills of delivering corrective specific feedback and enhanced comfort with feedback. However, students’ overall ability to deliver specific feedback decreased over time.

Physical Examination Education in Graduate Medical Education—A Systematic Review of the Literature

ABSTRACTOBJECTIVESThere is widespread recognition that physical examination (PE) should be taught in Graduate Medical Education (GME), but little is known regarding how to best teach PE to residents. Deliberate practice fosters expertise in other fields, but its utility in teaching PE is unknown. We systematically reviewed the literature to determine the effectiveness of methods to teach PE in GME, with attention to usage of deliberate practice.DATA SOURCESWe searched PubMed, ERIC, and EMBASE for English language studies regarding PE education in GME published between January 1951 and December 2012.STUDY ELIGIBILITY CRITERIASeven eligibility criteria were applied to studies of PE education: (1) English language; (2) subjects in GME; (3) description of study population; (4) description of intervention; (5) assessment of efficacy; (6) inclusion of control group; and (7) report of data analysis.STUDY APPRAISAL AND SYNTHESIS METHODSWe extracted data regarding study quality, type of PE, study population, curricular features, use of deliberate practice, outcomes and assessment methods. Tabulated summaries of studies were reviewed for narrative synthesis.RESULTSFourteen studies met inclusion criteria. The mean Medical Education Research Study Quality Instrument (MERSQI) score was 9.0 out of 18. Most studies (n = 8) included internal medicine residents. Half of the studies used resident interaction with a human examinee as the primary means of teaching PE. Three studies “definitely” and four studies “possibly” used deliberate practice; all but one of these studies demonstrated improved educational outcomes.LIMITATIONSWe used a non-validated deliberate practice assessment. Given the heterogeneity of assessment modalities, we did not perform a meta-analysis.CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGSNo single strategy for teaching PE in GME is clearly superior to another. Following the principles of deliberate practice and interaction with human examinees may be beneficial in teaching PE; controlled studies including these educational features should be performed to investigate these exploratory findings.

Near-peer teaching in a formative clinical skills examination.

Context and setting Games as Active Learning Strategies was 1 of 7 active learning workshops offered to faculty at the College of Medicine, University of Saskatchewan, Saskatoon, Canada. The workshop was interactive and conducted in a computer laboratory. Why the idea was necessary There is evidence to show that games, defined by some as fun with a purpose , foster active learning, allow for interactivity, promote collaboration, peer-learning and teamwork, and increase motivation. Despite their potential to enhance learning, there is very little use of games in the teaching and learning of medicine. We therefore designed and developed a workshop that would enable participants to create a game using selfgenerated questions. What was done A literature review was completed to identify: the rationale for using games; different types of games available; and the use and examples of games in medicine. We then designed and developed the 2.5-hour interactive workshop. The objectives were to: